SPLE Review 2022 Diagnostic Exam
INSTRUCTIONS: Select the correct answer for each of the following questions. Mark only one answer for each item.
You are given 2 1/2 hours to answer this 250-item Diagnostic Exam.
Goodluck!!!
INSTRUCTIONS: Select the correct answer for each of the following questions. Mark only one answer for each item.
You are given 2 1/2 hours to answer this 250-item Diagnostic Exam.
Goodluck!!!
Situation: Nicole is a nurse in the emergency room. He is aware that the effective nursing intervention is dependent upon appropriate assessment and identification of risk factors thus preventing further complication.
1. Nicole is performing a neurological assessment on a client with history of head injury. He wants to assess the patient’s level of consciousness using the Glasgow Coma Scale (GCS). Which of the following responses would yield a score of 9?
a. Eye opens to verbal command, flexes and withdraws extremities, makes incomprehensible sound.
b. Open eye when pinched, extremities are abnormally flexes (decorticate), does not reply when talked to.
c. Eyes remain close, extremities are extended abnormally (decerebrate), makes incomprehensible sound.
d. Eye opening is spontaneous, follows command, converses with the nurse.
2. Nicole will collect clean-voided urine specimen from a male client. All of the following should be done by Nurse Nicole EXCEPT:
a. Collect first voided specimen in the morning.
b. Collect at least 10 ml of urine
c. Delegate the nursing aide to collect the urine specimen
d. Instruct the client to squat over a toilet and hold the urine container between legs.
3. Time urine specimen will be collected from another client to evaluate the ability of her kidney to concentrate and dilute urine. All of the following are correct statements about timed urine specimen, EXCEPT:
a. Timed urine specimens are refrigerated to prevent bacterial growth or decomposition urine components.
b. In timed urine specimens, each voiding of urine is collected in a small clean container and emptied immediately into a large refrigerated bottle.
c. The client should be provided with a saline container to collect urine.
d. At the end of the collection period, the client should be instructed to completely empty the bladder and save this voiding as part of the specimen.
4. Nurse Nicole is planning to take the vital signs of her clients. She reviewed the record of Paulo and noted that he had a previous blood pressure reading of 130/70 mmHg and a pulse rate of 70. How long will it take Nurse Nicole to release the blood pressure cuff if she will get Paulo’s BP measurement again?
a. 10-15 seconds
b. 15-30 seconds
c. 30-45 seconds
d. 45-60 seconds
5. Nurse Nicole performs breast examination for Lorena. Which of the following physical assessment findings would require that Karen refer Lorena for evaluation of breast cancer?
a. Freely moveable breast lesions
b. Breast tenderness during or before menstruation
c. Breast lesions with difficult to define edges
d. Bilateral breast lesions
Situation: One of the vital responsibilities of the nurse is to be equipped with sufficient knowledge on drug pharmacology to keep away from any forms of legal suits and liabilities of malpractice and negligence.
6. Polyethylene glycolelectrolyte solution (GoLYTELY) is ordered for a client before a colonoscopy. The physician’s office nurse explains to the client how to take the solution. Which of the following statements, if made by the client, indicates the need for further instruction?
a. “I need to drink 4 liters of the solution.”
b. “If I drink it ice cold, it won’t taste as bad.”
c. “Once I finish drinking the solution, I can drink only water.”
d. “I can use tap water to reconstitute the powder.”
7. Joey D, a 43 year-old businessman has been receiving cimetidine (Tagamet) 300 mg qid for several weeks. During an office visit the physician gives him an additional prescription for aluminum hydroxide (Amphojel) 600 mg qid. Which of the following instructions, if given by the nurse, is BEST?
a. Take the Tagamet and Amphojel together after meals and at bedtime for combined effect.
b. Take the Amphojel with meals and before bed and the Tagamet 1 hour after meals and before bed.
c. Take the Tagamet 2 hours before meals and before bed and the Amphojel 2 hours after meals and at bedtime.
d. Take the Tagamet with meals and 1 hour before bed and take the Amphojel 1 hour after meals and at bedtime.
8. Mrs. Divinigracia, a 46-year old client has an order for aminophylline PO. The nurse should withhold the medication and notify the physician if the client makes which of the following statements?
A. “I am allergic to Neomycin.”
B. “I am taking Isuprel.”
C. “I have trouble breathing when I exercise.”
D. “I have had several urinary tract infections.”
9. A 60-year-old woman receives Thiethylperazine maleate (Torecan) 10 mg IM after surgery for repair of a hernia. The ordered activity is up ad lib. One half-hour after administration of the medication, the patient has to void. The nurse should:
A. Accompany the patient to the bathroom.
B. Obtain a bedside commode for the patient to use.
C. Obtain an order to catheterize the patient.
D. Place the patient on the bedpan.
10. A client with a Hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have:
A. Constipation
B. Weight gain
C. Anorexia
D. Diarrhea
11. The nurse is caring for a patient the second day after an appendectomy. The patient is a 23- year-old exchange student from Japan. Which of the following observations by the nurse would suggest that the patient is experiencing pain?
A. The patient’s pulse is 74, BP 104/66.
B. The patient’s dressing has a small amount of serosanguinous drainage.
C. The patient repeatedly rubs his hands together.
D. The patient’s skin is cool and dry.
12. The family members of an 85-year-old report to the nurse that they suspect that their father is masturbating. Which of the following responses by the nurse is BEST?
A. “I understand your concern because this is not a normal part of aging.”
B. “Don’t worry because I think that he will stop soon.”
C. “This is considered a normal behavior for men.”
D. “The best thing you can do is talk to your father about this behavior.”
13. Nurse Janine explains the use of transcutaneous electrical nerve stimulation (TENS) to a client with Sciatica. Which of the following actions, if performed by the patient, would indicate that further teaching is necessary?
A. The client applies a conducting gel before applying the electrodes.
B. The client places the electrodes on the side of the body opposite to the painful area.
C. The client turns up the voltage until he feels a prickly “pins and needles” sensation.
D. The client adjusts the voltage based on the relief of pain he experiences.
14. Mr. Doctora, a client who had an appendectomy 4 days ago complains of severe abdominal pain. During the initial assessment he states, “I have had two almost-black stools today.” Which of the following nursing actions is MOST important?
A. Start an IV with D5W at 125 cc/h.
B. Insert a nasogastric tube.
C. Notify the physician.
D. Obtain a stool specimen.
15. The nurse is caring for a patient following a right adrenalectomy. During the immediate postoperative period, it is MOST important for the nurse to observe for which of the following?
A. Fluid and electrolyte imbalance
B. Temperature fluctuation
C. Respiratory atelectasis
D. Blood pressure alteration
16. A client on continuous mechanical ventilation desires to go home. In order to determine the client’s ability for homecare, the nurse should
A. Assess the ability of others in the home to be trained to provide appropriate care for the client.
B. Confer with the client’s physician and discuss the feasibility of the client’s request.
C. Assess the number of people in the home and the adequacy of space to care for the client.
D. Examine the client’s reasons for wanting to go home, and discuss the implications of homecare.
17. Prior to helping a client out of bed on the first day after an anterior cervical fusion, the nurse should:
A. Remove the client’s cervical collar.
B. Raise the head of the bed.
C. Position the client supine at the edge of the bed.
D. Ask the client to fold both arms across his chest.
18. On the morning after surgery to repair a fractured hip, the nurse finds a 66-year-old woman struggling to get out of bed. The client tells the nurse, “I have to clean the kitchen now.” Which of the following actions, if taken by the nurse, is MOST appropriate?
A. Obtain blood gas studies.
B. Instruct the client to remain in bed.
C. Take the client’s blood pressure.
D. Ask the family to remain with the client.
19. The nurse reading an EKG rhythm strip determines that there are 8 QRS complexes in 30 large squares for a 6-second strip. The nurse calculates the heart rate to be which of the following?
A. 60
B. 70
C. 80
D. 120
Situation: Regardless of specialty or work setting, nurses perform basic duties that include treating patients, educating patients and the public about various medical conditions, and providing advice and emotional support to patients' family members.
20. When explaining the initiation the initiation of IV therapy to a 2 year-old child, the nurse should:
A. Ask the child, “Do you want me to start the IV now?”
B. Give simple directions shortly before the IV therapy is to start
C. Tell the child, “This treatment is for your own good.”
D. Inform the child that the needle will be in place for 10 days
21. After having an IV line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the site reveals that it is warm and erythematous. This usually indicates:
A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
22. The nurse must administer Terazocin hydrochloride (Hytrin) 5mg PO but is unsure of the average dosage. The most appropriate nursing action would be to:
A. Page the physician’s assistant
B. Ask another nurse in the unit
C. Look through the 1986 issues of the Philippine Journal of Nursing
D. Refer to the unit’s copy of an annual drug update
23. Christy, a patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:
A. Withhold the medication and notify the physician
B. Administer the medication and notify the physician
C. Administer the medication with an antihistamine
D. Apply corn starch soaks to the rash
24. All of the following nursing interventions are correct when using the Z-track method of drug injection except:
A. Prepare the injection site with alcohol
B. Use a needle that’s at least 1” long
C. Aspirate for blood before injection
D. Rub the site vigorously after the injection to promote absorption.
25. The correct method for determining the vastus lateralis site for an IM injection is to:
A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into the thirds, and select the middle third on the anterior of the thigh
Situation: Mr. Nismal has been admitted to the hospital with iron deficiency anemia. The physician orders a blood transfusion STAT.
26. In whole blood transfusions, the nurse must do all of the following except:
A. Assess the venipuncture site for evidence of hematomas
B. Prepare the blood transfusion using microdrip tubing
C. Make sure the drip chamber of the IV tubing is partially filled with blood
D. Assess the patient closely for any reactions
27. The physician orders the addition of 40mEq of potassium chloride to the blood transfusions by IV piggyback. The nurse should:
A. Check the latest laboratory tests results before administering the medication
B. Replace the blood with an isotonic solution, such as normal saline solution
C. Check the patient’s temperature before adding the potassium chloride
D. Not carry out the order and check with the physician immediately
28. If Mr. Nismal exhibits a severe blood transfusion reaction, the priority nursing intervention is to:
A. Monitor vital signs every ½ hour
B. Discontinue the blood transfusion, begin infusing normal saline solution, and notify the physician
C. Start an IV infusion of dextrose 10% in water at 100ml/hour
D. Monitor and record the patient’s fluid intake and output
29. Mr. Nismal has just received two units of packed RBC. Which of the following laboratory tests should reflect his response to this therapy?
A. BUN level
B. Hematocrit level
c. Potassium level
D. Calcium Level
30. The main purpose of packed RBC therapy for Mr. Nismal would be to:
A. Improve vital signs
B. Raise the white blood cell count
C. Correct anemia
D. Assist with clotting factors
31. The nurse is caring for a client recovering from lower bowel surgery. The nurse determines that teaching has been successful if the client selects which of the following menus?
A. Milk, green beans, whole-wheat bread.
B. Creamed chicken soup, broccoli, pudding.
C. Baked chicken, buttered rice, plain gelatin.
D. Cabbage salad, fried chicken, applesauce.
32. The nurse is caring for a teenage boy in Buck’s traction. It is MOST important for the nurse to take which of the following actions?
A. Check the pin sites for bleeding or infection.
B. Apply topical or antibiotic ointment as ordered.
C. Assess that the elastic bandages are not too loose or too tight.
D. Remove the bandages daily to lubricate the skin.
33. A 32-year-old male with acute lymphocytic leukemia is admitted with shortness of breath, anemia, and tachycardia. The MOST appropriately stated nursing diagnosis would be
A. Altered protection, immunosuppression: leukemia.
B. Impaired gas exchange related to decreased RBCs.
C. Risk for infection related to altered immune system.
D. Risk of injury related to decreased platelets.
34. An order has been received to obtain a stool specimen and test for occult blood. The nurse would be MOST concerned if the client made which of the following statements?
A. “I take Feosol every day.”
B. “My physician prescribed Vicodin.”
C. “I’ve been taking Lomotil.”
D. “I sometimes take Motrin.”
35. A 62-year-old man is undergoing peritoneal dialysis at a hemodialysis center. The nurse notices that the fluid outflow is inadequate. Which of the following activities, if performed by the nurse, would be best INITIALLY?
A. Place the man in low-Fowler’s position.
B. Position the drainage bag at the level of the man’s heart.
C. Close the clamp to the drainage tubing for one-half hour, and then reopen.
D. Milk the drainage tubing firmly every 20 minutes.
36. The nurse prepares a 56-year-old woman for insertion of a subclavian triple lumen catheter to be used for administration of total parenteral nutrition (TPN). The nurse should position the client:
A. In high-Fowler’s position with the client’s head in a neutral position
B. In semi-Fowler’s position with the client’s head extended
C. In supine with the client’s head low and turned away from the insertion site
D. In left lateral with the client’s head turned toward the insertion site
37. The nurse cares for a 44-year-old man in the clinic. The physician’s orders read: sulindac (Clinoril) 200 mg PO bid for 14 days. The nurse should instruct the man to report which of the following symptoms IMMEDIATELY to the physician?
A. Nervousness.
B. Photophobia.
C. Ecchymosis of the extremities.
D. Slight edema of the feet.
38. An 82-year-old female client is diagnosed with a vitamin K deficiency due to dietary malabsorption. Which of the following is an appropriate nursing intervention for this client?
A. Encourage the client to remain in bed.
B. Carefully check the client’s arm after taking her blood pressure.
C. Increase dietary intake of fruits and fiber.
D. Observe the client for signs of angina or cardiac dysrhythmia.
39. A 12-year-old client is admitted to the pediatric unit in vaso-occlusive crisis from sickle cell anemia. As the nurse prepares the plan of care, which of the following orders should the nurse correct?
A. Bedrest with bathroom privileges.
B. 2 liters oxygen via nasal cannula.
C. Maintain IV at keep open rate.
D. Administer analgesics as ordered.
40. The nurse supervises a nurse’s aide administer a soapsuds enema to a patient prior to abdominal surgery. Which of the following actions, if performed by the aide, would require an intervention by the nurse?
A. The aide holds the irrigation set 30 inches above the patient’s rectum.
B. The aide inserts the irrigation tube 3 inches into the patient’s rectum.
C. The aide positions the patient in Sims’ position.
D. The aide warms the water to 105°F (40°C).
41. The nurse is assessing a child with cystic fibrosis. The nurse would be MOST concerned if which of the following was observed?
A. The child is expectorating thick yellow mucus.
B. There is increased mucus production with postural drainage.
C. Exertional dyspnea increases during the day.
D. The child complains about difficulty breathing.
42. The nurse is caring for a patient admitted to the unit 3 days ago with second- and third-degree burns over 30% of her body. It would be MOST important for the nurse to report which of the following observations to the next shift?
A. CVP reading of 12 cm water pressure
B. General muscle weakness and lethargy
C. Heart rate of 100 beats per minute
D. Systolic blood pressure of 105
43. An adult male client complains of hearing loss. While the nurse is irrigating his ear to remove cerumen for better observation of the tympanic membrane, the client comments that he is getting dizzy. The nurse would stop the procedure and:
A. Notify the physician immediately
B. Monitor for changes in intracranial pressure
C. Warm the irrigant and resume the procedure
D. Explore the canal with a cotton applicator
44. The nurse is caring for a patient 3 days after a spinal cord injury at the level of T-5. The patient complains of a pounding headache, and the nurse notes profuse sweating on the patient’s forehead. Which of the following actions, if taken by the nurse, is BEST?
A. Determine the patency of the Foley catheter.
B. Place ice packs on the neck and head.
C. Elevate the head of the bed.
D. Apply a rigid cervical collar.
45. A young Hispanic client who speaks little English is admitted to a medical-surgical unit with an increased temperature. Prior to performing a physical assessment, which of the following is the MOST appropriate nursing action?
A. Attempt to prepare the client with hand signals.
B. Show the client pictures of the physical exam process.
C. Contact an employee who speaks Spanish to translate.
D. Speak slowly to explain the physical assessment.
46. A 67-year-old man is returned to his room following a bronchoscopy. The client complains of thirst and requests ice chips. The physician has left an order for the patient to resume his regular diet. The nurse should
A. Touch the back of the client’s throat with a tongue depressor.
B. Observe the client while he sucks on a few ice chips.
C. Provide clear fluids to the client and advance to soft foods.
D. Assess the client’s tissue turgor and intake and output.
47. The nurse is performing health screening at a shelter for the homeless. Which of the following nursing observations would most likely indicate the need for teaching about personal hygiene?
A. Fruity breath odor
B. Foul-smelling stools
C. Vaginal itching
D. Red, swollen gums
48. A 74-year-old woman is returned while checking the patency of a Salem sump tube, the nurse finds stomach contents draining from the air vent. Which of the following nursing actions is MOST appropriate?
A. Insert water through the air vent.
B. Pull the sump tube back 2–3 inches.
C. Insert 30 cc air through the air vent.
D. Insert a new nasogastric tube.
49. The home health nurse has been making home visits to follow the progress of a two-year-old boy with Tetralogy of Fallot. When the nurse visits the home, the child is found diaphoretic and short of breath. What should the nurse do FIRST?
A. Give the boy oxygen at 2 liters via nasal cannula
B. Place the boy in the knee-chest or squatting position
C. Administer morphine 0.1 mg/kg SQ to the boy
D. Lay the boy in bed flat with his head elevated
50. The nurse is caring for a client with a three-chamber water-seal drainage system (Pleur-evac). While assisting the man from the bed to the chair, the drainage tubing becomes disconnected from the Pleur-evac. The nurse should:
A. Insert the tubing in a container of sterile saline solution.
B. Cut the tubing two inches from the end and clamp securely.
C. Reconnect the tubing to the Pleur-evac container.
D. Connect the tubing to a new Pleur-evac container.
Situation: Mr. Santana is admitted to the hospital with vomiting, diarrhea, fever, and a 5 lb weight loss. The nursing diagnosis reads Fluid volume deficit related to vomiting and diarrhea.
51. Which of the following laboratory values can the nurse expect to find on Mr. Santana’s chart?
A. Increased hematocrit level
B. Normal Serum chloride level
C. Decreased urine specific gravity
D. Elevated serum potassium level
52. Nurse Ethan’s first priority in assessing the patient’s status should be to check his:
A. Tendon reflexes, cardiac rhythm, and muscle ability
B. Neck veins, visual acuity, and state of consciousness
C. Respirations (for wheezing), nail color, and pedal pulses
D. Skin, mucous membranes, and urine output
53. Which of the following IV solutions would most likely be ordered to replace Mr. Santana’s fluids?
A. 1000 ml of sterile water at 75 ml/hour
B. 1000 ml of 0.45% sodium chloride at 100 ml/hour
C. 1000 ml of dextrose 5% in normal saline solution at 125 ml/hour
D. 1000 ml of 5 % sodium chloride at 150 ml/hour
Situation: Mrs. Hortelano is admitted to the hospital with a diagnosis of hyponatremia and hypokalemia. She has been on diuretic therapy at home.
A. Take the patient’s vital signs
B. Restrict the patient’s oral fluid intake
C. Record the patient’s daily weight
D. Force oral fluids
55. When assessing Mrs. Hortelano for signs and symptoms of hypokalemia, the nurse would expect to find:
A. Hyperactive deep tendon reflexes
B. Positive Chvostek’s sign
C. Leg cramps
D. Tetany
56. Nurse Carissa should assess Mrs. Hortelano for which of the following classic signs and symptoms of severe hyponatremia?
A. Muscle weakness, constipation, and paralytic ileus
B. Elevated temperature, pulse, and BP
C. Nervousness, confusion, and seizures
D. Thirst, hypotension and cyanosis
57. A nurse observes a dazed and apparently confused co-worker taking two diazepam(Valium) tablets by mouth as the co-worker is about to pour medications. What should the nurse do?
A. Call the head nurse immediately before the co-worker pours and administers the medications
B. Pour the medications for the co-worker while she goes for a cup of coffee
C. Report the co-worker to hospital security because she may be addicted to drugs
D. Watch the co-worker closely and report the incident to the head nurse at the end of the day
58. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do?
A. Discourage them from making a decision until their grief has eased
B. Listen to their concerns and answer their questions honestly
C. Encourage them to sign the consent form right away
D. Tell them the body will not be available for a wake or funeral
59. A new head nurse on a unit is distressed about the poor staffing on the 11pm-to-7am shift, what should she do?
A. Complain to her fellow nurses
B. Wait until she knows more about the unit
C. Discuss the problem with her supervisor
D. Inform the staff that they must volunteer to rotate
Situation: A nurse assigned to Mr. Martin, a 75-year-old newly diagnosed diabetic patient, is beginning to write objectives for the teaching plan.
60. Written objectives do all of the following except:
A. Help to organize teaching plans
B. Ensure communication among staff
C. Document the quality of care
D. Ensure learning
61. Which of the following objectives is written in behavioral terms?
A. Mr. Martin’s younger sister should learn about Diabetes mellitus
B. Mr. Martin’s wife needs to understand the side effects of insulin
C. Mr. Martin’s will be able to determine his insulin requirements base on blood glucose levels obtained from glucometer by next week
D. Mr. Martin will know about Diabetes-related foot care and the techniques and equipment necessary to carry it out.
62. Before Mr. Martin is discharged from the hospital, his sister will demonstrate how to correctly use the glucometer, obtaining the same accurate results as the nurse. This is an example of:
a. Cognitive objective
B. Affective objective
C. Psychomotor objective
D. All of the above
63. The nurse can best recognize the patient is learning by:
A. His ability to repeat what was taught immediately after the discussion
B. A positive change in his behavior
C. Constant verbal reaffirmations that he understands
D. Non-verbal acknowledgements that he understands, such as nodding
64. All of the following teacher behaviors are barriers to learning except:
A. Constant use of technical words
B. Drawing the person into the discussion
C. Loosely structured teaching sessions
D. Detailed, lengthy explanations
65. Which of the following clinical manifestations would lead the nurse to suspect that the client has psoriasis?
A. Profuse, erythematous scales often covering large areas of the body
B. Patchy eruptions with possible hair loss and nail shedding
C. Widespread bullae on the skin and mucous membranes
D. Shedding of large sheets of epidermis along with toenails and eyebrows
66. Which of the following instructions should be included in the teaching plan for the client receiving oral prednisone as treatment for an inflammatory skin disorder?
A. Taking the medication at night to prevent nocturia
B. Instructing not to discontinue the medication abruptly
C. Notifying the physician if the client loses weight
D. Instructing to stop the medication when the inflammation is gone
67. Which of the following outcomes is expected when evaluating adequate fluid replacement in burn client based on the Parkland formula for fluid resuscitation?
A. The client received 2 ml/kg body weight x TSBA burned over the first 24 hours after the burn.
B. The client received 4 ml/kg body weight x %TBSA burned over the first 36 hours after the burn.
C. The client received 1 ml/kg body weight x %TBSA burned over the first 24 hours after the burn.
D. The client received 4 ml lactated Ringer’s solution x % TBSA burn x kg body weight over the first 24 hours after the burn
68. Before debriding a second-degree burn wound on the left lower leg, Nurse Jacky should do which of the following?
A. Apply lindane (Kwell) to the affected area
B. Medicate the client with narcotic analgesic
C. Administer acyclovir (Zovirax) intravenously
D. Apply a topical antimicrobial ointment
69. Nursing interventions for preventing pressure ulcers would include which of the following?
A. Turning the client every 8 hours
B. Avoiding the use of a life sheet
C. Using pressure-relieving devices
D. Keeping the head of the bed flat
70. A client asks the nurse, “What is toxic epidermal necrolysis?” Which of the following is the nurse’s best response?
A. “A rare, potentially fatal skin disorder causing reddened, necrotic, eroded skin.”
B. “An autoimmune disease that causes blisters on the skin and mucous membranes.”
C. “An inflammatory condition affecting the sebaceous follicles”
D. “An acute viral infection that causes markedly painful skin eruptions”
71. The client with acne vulgaris says “I try to keep my skin clean. I scrub my face every night, but the blackheads will not go away.” Which of the following would be the nurse’s best response?
A. “Why do you scrub your face?”
B. “You need a stronger soap when you scrub.”
C. “You want the blackheads to go away.”
D. “Not being clean is not the problem with acne.”
72. Which of the following would the health care provider suspect after noticing a loosely adherent, honey-yellow colored lesion around the client’s nose?
A. Impetigo
B. Folliculitis
C. Furuncle
D. Carbuncle
73. When evaluating the effectiveness of client teaching about health promotion and maintenance behaviors regarding skin care, which of the following actions demonstrates that the client understood the teaching?
A. Stays unprotected in the sun between noon and 4 pm
B. Avoids excessive sun exposure if the client is middle-aged
C. Is exposed to repeated low-dose radiation
D. Avoids repeated exposure to irritants and allergens
74. Which of the following instructions would be appropriate for a client diagnosed with tinea pedis?
A. Wear white cotton socks
B. Use your own comb or brush
C. Use a clean towel and wash cloth daily
D. Avoid wearing tight-fitting clothing
75. At the scene of burn injury, the first priority in treating a client who has sustained a partial-thickness burn to the left hand is which of the following?
A. Applying ice packs to the burned area
B. Applying petroleum jelly to the burned area
C. Immersing the client’s left hand in cool water
D. Immediately taking the client to the emergency department
76. Which of the following would be the nurse’s best response when the client asks, “What does it mean if I have a first-degree burn?”?
A. “You have destroyed your dermis and epidermis.”
B. “You have destroyed your skin and the underlying subcutaneous tissue.”
C. “You have superficial tissue destruction involving the epidermis only.”
D. “You will probably have some scarring after healing process.”
77. Which of the following nursing interventions would be appropriate for the client who has had an electrical burn?
A. Monitoring the client for arrhythmias for at least 24 hours
B. Flushing the burned area with copious amounts cool water
C. Supporting pulmonary function through early incubation
D. Administering 100% oxygen based on arterial blood gas results
Situation: Mr. Borres, age 18, is admitted to the hospital with a fractured nose and other minor abrasions sustained in a biking accident. The physician orders an ice pack to be applied over the patient’s nose.
78. Nurse Angelu should tell Mr. Borres that the ice pack will help him:
A. Maintain alignment of the fracture
B. Prevent skin maceration at the injury site
C. Reduce pain by enhancing vasodilation
D. Relieve or prevent edema by reducing local blood flow
79. After 30 minutes, the nurse removes the ice pack and explains to Mr. Borres that it will be replaced later. The most important rationale for this nursing action is that:
A. Cold can retard edema and bleeding after injury
B. Cold anesthetizes underlying tissues
C. Ice needs to be replenished about every 30 minutes
D. Prolonged exposure to cold can cause tissue ischemia
80. Nurse Angelu must be knowledgeable that cold application is often done to treat:
A. Open wounds
B. Impaired circulation
C. A fever
D. A sprained ankle
Situation: Mr. Warren is admitted to the hospital with dyspnea, an unproductive cough, and a pulse rate of 90beats/minute. His hemoglobin level is 14 g/dl and serum sodium level, 150mEq/liter. The physician orders oxygen therapy as part of Mr. Warren’s medical plan.
81. An appropriate nursing diagnosis for Mr. Warren is:
A. Impaired gas exchange related to anemia
B. Impaired gas exchange related to tachycardia
C. Impaired airway clearance related to oxygenation
D. Impaired gas exchange related to inability to move secretions
82. Which of the following nursing interventions should the nurse implement based on Mr. Warren’s nursing diagnosis?
A. Encourage the patient to change position every 2 hours, and assist him as necessary
B. Maintain the patient in the orthopneic position, and encourage coughing and deep-breathing exercises
C. Provide adequate hydration, and measure the patient’s fluid intake and output
D. All of the above
83. The physician informs Mr. Warren that he may use a salt substitute but that he must undergo a monthly blood test to monitor his:
A. Magnesium level
B. Potassium level
C. Calcium level
D. Hemoglobin level
84. The nurse makes an error while recording her assessment findings on Mr. Warren’s chart. How should she correct the information without jeopardizing the chart’s legality?
A. Cross out the error and initial the word
B. Draw a line through the incorrect statement, write the word “error”, and sign her name
C. Use an ink eraser or correction fluid to maintain the chart’s neatness
D. Erase the error, write “error”, and sign her name
85. After Mr. Warren is discharge, his room must be prepared for the next patient. This is accomplished through:
A. Universal Precaution
B. Autoclaving
C. Terminal disinfection
D. Gas sterilization
Situation: Nurses with specialized skills and advanced knowledge of anesthetic s can expect to find opportunities in a variety of clinical settings.
86. General anesthetics potentiate the effects of which of the following group of drugs?
A. Depolarizing agents
B. Skeletal muscle relaxants
C. Volatile liquids
D. Inhalation anesthetics
87. During surgery, there is an increased potential for arrhythmias when cathecolamines are given with:
A. halothane (Fluothane)
B. digoxin (Lanoxin)
C. bupivacaine (Marcaine)
D. lidocaine ( Xylocaine)
88. The most dangerous metabolic side effects of general anesthesia that can occur during surgery is:
A. Hyperglycemia
B. Hyperthermia
C. Hypoglycemia
D. Hypothermia
89. A client who will be undergoing surgery with general anesthesia should be given which of the following instructions pre-operatively?
A. Eat a big breakfast
B. Expect to be incontinent of urine postoperatively
C. Double your medication doses
D. Expect nausea, vomiting, shivering, and pain postoperatively
90. Every nurse must be knowledgeable that local and regional anesthetics act by:
A. Inhibiting depolarization
B. Increasing depolarization
C. Producing a semiconscious state
D. Inhibiting motor movement
Situation: Nurses have a key role to play in caring for a patient receiving chemotherapy.
91. A client on chemotherapy has the following CBC results: WBC 5000/mm3, RBC platelet 10,000/mm3. Which of the following is he at risk for?
A. Infection
B. Bleeding
C. Angina
D. None of the above
92. A client on chemotherapy with a history of cardiac disease is at risk for cardiac complications because:
A. White blood cells are reduced.
B. Oxygen-carrying capacity may be reduced.
C. Sodium levels may rise meaning fluid overload.
D. Hematocrit is lowered.
93. Which of the following is the priority nursing diagnosis for a client undergoing chemotherapy?
A. Decreased cardiac output
B. Fear
C. Altered Nutrition
D. Anxiety
94. Which of the following nursing interventions is essential to prevent deterioration during the course of chemotherapy?
A. Administration of pain medications
B. Administration of antiemetics
C. Grief counseling
D. Antibiotic therapy
95. Which of the following is a priority in ensuring adequate nutrition during the course of chemotherapy?
A. Preventing stomatitis
B. Serving foods that the client likes
C. Providing small, frequent meals
D. Providing adequate fluids
Situation: Jefferson, a student nurse, is reviewing his notes on Pharmacology. He is aware that nurses should be knowledgeable about the drugs they administer to their patients.
96. Which group of drugs mimics parasympathetic activity?
A. Cholinergic agents
B. Anticholinergic agents
C. Adrenergic agents
D. Antiadrenergic agents
97. Jefferson had read that cholinergic agents are used to:
A. Produce miosis
B. Facilitate neuromuscular blockade
C. Synergize neuromuscular blockers
D. Facilitate tricyclic activity
98. Which laboratory test is altered by use of cholinergic agents?
A. Serum sodium
B. Serum potassium
C. Serum amylase
D. Serum creatinine
99. Which of the following metabolic effects may be a consequence of administration of adrenergic agents?
A. Hypoglycemia
B. Metabolic acidosis
C. Hyperglycemia
D. Respiratory alkalosis
100. Adrenergic blockers are contraindicated in:
A. Hypertension
B. Pheochromocytoma
C. Migraines
D. Obstructive airway disease
Situation: Shamcey, 23 year old woman who was first diagnosed with partial complex seizures at age 7. Despite multiple trials of various anti-epileptic drugs the seizures were difficult to control.
101. Nurse Derek is caring for the client. He knows that anti-epilpetic drugs act to suppress seizure activity of the client by all of the following mechanisms except:
A. Altering ionic conductance
B. Altering neuronal membrane potentials
C. Altering levels of neurotransmitters
D. Eliminating the epileptogenic focus
102. Nurse Derek is aware that Fetal Hydantoin syndrome is associated with all of the following findings except:
A. Microcephaly
B. Hypoplastic heart
C. Cleft Palate
D. Hypertelorism
103. When administering IV phenytoin (Dilantin), Nurse Derek should do which of the following actions:
A. Administer it at a rate of 100mg/min.
B. Protect the drug from light exposure
C. Mix the drug in dextrose solution
D. Mix the drug in saline solution
104. Shamcey is receiving phenytoin and warfarin (Coumadin), the nurse would expect which of the following drug-drug interactions?
A. Decreased effectiveness of warfarin
B. Increased effectiveness of phenytoin
C. Increased effectiveness warfarin
D. Decreased effectiveness phenytoin
105. Which of the following antiepileptics induces its own metabolism and requires close monitoring of therapeutic levels because of the potential for wide swings in serum levels?
A. phynetoin
B. Valproic acid
C. carbamazepine (Tegretol)
D. ethosuximide (Zarontin)
Situation: Mr. Manny was rushed to the emergency room of Don Benito hospital complaining of chest pain while watching a boxing event.
106. On your initial assessment of a patient with an Acute Myocardial Infarction you would expect the vital signs to be:
A. hypotension, tachycardia
B. hypertension, irregular heart rhythm
C. fever, tachycardia
D. hypotension, tachypnea
107. Mr. Manny’s chest pain is not ceasing. Which is the most important finding when assessing hi chest pain? The pain:
A. Increases with inspiration
B. Lasts longer than 30 min.
C. Is relieved with one nitroglycerin tablet
D. Is relieved with rest
108. Your patient is 1 hour post-endomyocardial biopsy (EMB) surgery. Which of the following assessment findings is the most important?
A. Pericardial friction rub and dysrhythmia
B. Muffled heart sounds and decreased blood pressure
C. Sudden spiking fever, chills, and abdominal pain
D. Angina exacerbated with movement
109. A priority nursing intervention for a patient with an aneurysm of the superior vena cava would be to:
A. Increase nitroprusside infusion rate
B. Administer an extra dose of Valium
C. Assess flank for pain and ecchymosis
D. Assess respiratory status and prepare for possible intubation
110. In a patient with hypertropic cardiomyopathy, which of the following drugs would be contraindicated?
A. digoxin, positive inotropic
B. Inderal, negative inotropic
C. heparin, anticoagulant
D. verapamil, calcium channel blocker
111. Bernadette, a 35 year old client was prescribed a corticosteroid by her physician. Corticosteroid therapy is indicated in all of the following conditions except:
A. osteoarthritis
B. Rheumatoid arthritis
C. Systemic lupus erhythematosus
D. Acute spinal cord injury
112. The nurse should be aware that oral steroids are prescribed on a taper in order to:
A. Achieve optimal serum levels
B. Ensure drug reliability
C. Ensure compliance
D. Prevent steroid withdrawal syndrome
113. Alliyah, a 34 year old client who has been taking steroids for rheumatoid arthritis over several years presents with a compression vertebral fracture. This fracture is due to:
A. An entirely separate condition
B. The osteoporotic effect of long-term steroid use
C. Deterioration in rheumatoid arthritis
D. An excessively high dose of steroids
114. Noddy, a 21 year old client is admitted into the emergency department with an acute spinal cord injury. Methylprednisolone is contraindicated for treatment when the injury:
A. Is high cervical lesion
B. Occurred less than 4 hours ago
C. Occurred less than 8 hours ago
D. Occurred more than 8 hours ago
115. Which of the following statements about intravenous administration of steroids is true?
A. Steroids administered intravenously must be diluted.
B. Steroids administered intravenously can be either in diluted or undiluted form.
C. Steroids should be given IV push only.
D. Intravenous administration of steroids is contraindicated in acutely ill clients.
Situation: Mr. Yee, a 76 years old comatose client with tracheostomy, was assigned to a new staff nurse in the unit. The new nurse is making a plan of care for Mr. Yee and is reviewing important principles in tracheostomy care.
116. Which of the following principles of tracheostomy suctioning would the nurse consider correct?
A. To ensure removal of a larger amount of secretions, suction should be on continuously when entering and leaving the respiratory tract.
B. The maximum amount of time for the procedure is 15 seconds going in and 15 seconds coming out.
To ensure consistent removal of secretions, the catheter should be withdrawn straight out, without twisting.
D. To minimize hypoxia, the entire suctioning procedure should not exceed 15minutes.
117. Which one of the following nursing actions is most helpful in reducing chronically thick respiratory tract secretions of Mr. Yee?
A. Maintaining continuous oxygen therapy
B. Keeping the patient in semi-fowler’s position as much as possible
C. Maintaining an adequate fluid intake for the patient
D. instilling 3 mL of NSS intratracheally before suctioning.
118. Which of the following presents the most appropriate reason for suctioning a patient?
A. Suctioning once per shift is part of the routine nursing assessment.
B. The patient is unconscious and unable to cough up secretions.
C. The patient has a capped tracheostomy.
D. The physician has ordered suctioning every hour.
19. Which one of the following groups of signs indicates that Mr. Yee is experiencing early hypoxia?
A. bradypnea, dyspnea, cyanosis
B. bradycardia, lethargy, disorientation
C. hypotension, dyspnea, pulse deficit
D. restlessness, tachycardia, diaphoresis
120. Respiratory failure occurs when the respiratory system and heart are unable to:
A. Maintain adequate oxygenation
B. Retain adequate CO2
C. Maintain a PaO2 of 80mmHg
D. Maintain a PaCO2 of less than 45mmHg
Situation: Mr. Sigarilyo, a chronic smoker and smokes at least 1pack of cigarette per day, was brought to the emergency room with complaints of dyspnea and productive cough. He was diagnosed having COPD and was admitted in the hospital for further observations.
121. Which one of the following delivery systems provides the most precise oxygen concentrations?
A. non-rebreather mask
B. Venturi mask
C. Partial rebreather mask
D. Simple face mask
122. When Mr. Sigarilyo questions you about the phrase “dead space”, your best answer is to describe it as:
A. An area in your lung that does not exchange air
B. A small area of dead tissue that causes infection
C. The part of the lower airway that brings in fresh air
D. Any part of your lungs that traps mucous
123. Mr. Sigarilyo has COPD. His nurse has taught him pursed lip breathing, which helps him in which one of the following ways?
A. Increases carbon dioxide concentration, which stimulates breathing in a patient with COPD
B. Teaches him to lengthen inspiration and shorten expiration
C. Enables him to lengthen expiration, which increases CO2 retention in a patient with COPD
D. Decreases the amount of air that is trapped in the alveoli after expiration
124. Which one of the following is an initial finding at assessment of a patient with atelectasis?
A. Wheezes at lung bases
B. Decreased or absent breath sounds in some areas
C. Stridor on inspiration
D. Crackles and rhonchi at lung bases
125. In which order should the following medications be given to an asthmatic patient?
A. Intranasal steroid, inhalation bronchodilator
B. Inhalation bronchodilator, intranasal steroid
C. It depends on whether the asthma is new onset or chronic
D. The steroids should be given according to the client’s circadian rhythm; the bronchodilator may be given any time
Situation: A newly registered nurse was hired in EENT clinic. In order for her to be competent in her practice he started reviewing important topics about EYE, EAR, NOSE, and THROAT disorders.
126. Meliton is having a chief complaint of dizziness. His medical history indicates that his father has a Meniere’s disease. This disease presents with a triad of symptoms that includes all of the following:
A. vertigo, tinnitus, hearing loss
B. pain, vertigo, blindness
C. tinnitus, pain, hearing loss
D. fever, inflammation, pain
127. The new nurse know that the early symptoms of retinal detachment may include:
A. pain
B. Reddened eye
C. floaters
D. Purulent discharge
128. The nurse had an encounter with a patient having glaucoma. The patient wants to know what differs the open-angle glaucoma from its other types. The nurse’s correct response is that the open-angle glaucoma is usually:
A. congenital
B. asymptomatic
C. Easily reversible
D. A medical emergency
129. John comes to the hospital with a complaint of recurrent throat pain. The staff nurse assigned to the client knows that untreated tonsillitis can lead to:
A. pharyngitis
B. laryngitis
C. abscess
D. cancer
130. Nurse Winslow is caring for a patient with epistaxis. The bleeding is profuse. The nurse can expect to:
A. Place tissue and cotton gauze In the nares to stop bleeding
B. Spray the nose with 0.50% phenylephrine hydrochloride
C. Have the patient lay flat with nose pointing upward
D. Instruct patient to sit up and point nose forward
Situation: Edward, newly registered nurse was assigned in the orthopedic ward of St. Peter hospital. He is caring for 5 patients and his monitoring them all for possible complications.
131. Jacob will be discharged from the hospital 4 days after closed reduction of a fractured tibia. His right leg is in a long leg cast. Which of the following assessment findings should be of greatest concern to the nurse?
A. temperature 97 degrees
B. Respiratory rate of 16
C. Ecchymosis of several toes
D. discrete, small, red spots on the skin
132. Alice, a 24 year old dancer told the nurse she has a comminuted fracture of the right radius. The nurse should explain to him that this means there is:
A. Splintering on one side of the bone
B. A palpable bone protrusion under the skin
C. A break of the bone in two parts under intact skin
D. Fragmentation of the bone under the intact skin
133. A patient has multiple traumas. She is out of the in a chair 8 days after fracture of the femur. She is in a long leg cast. When assessing the patient, the nurse suspects fat embolism. Which of the following actions should the nurse undertake initially?
A. Administer oxygen
B. Call the physician immediately
C. Bivalve the cast to release pressure
D. Return the patient to bed with the assistance of ancillary personnel
134. The patient is to be placed a cast in the leg. Which of the following danger the nurse must be alert for?
A. Loss of distal pulses
B. Increased muscle movement
C. A cold tingling sensation in the extremity
D. Muscle ischemia
135. The nurse is caring for a patient with compartment syndrome. He is planning to get the patient out of the bed and is sure to avoid:
A. Assessing the patient’s pain
B. Elevating the extremity
C. Removing constricting garments
D. Assessing circulation
136. Venus is diagnosed having Grave’s disease. When assessing the patient for symptoms of Grave’s disease. The nurse would expect to see:
A. dehydration
B. cyanosis
C. Cold intolerance
D. Palmar erythema
137. A nursing class is having a case presentation about thyroid disorders. Pathophysiologic processes found in hyperthyroidism include:
A. Decreased cardiac output
B. Decreased heart rate
C. Decreased bowel sounds
D. Increased vitamin metabolism
138. One case presented in the nursing class is about hypothyroidism disease. Which of the following is not an etiology of primary hypothyroidism?
A. Thyroid cancer
B. thyroiditis
C. Hashimoto’s disease
D. Congenital defects
139. Nurses must be aware that while caring for a patient with secondary hypothyroidism, they would monitor for the life-threatening complication of:
A. Thyroid storm
B. Myxedema coma
C. Cushing’s syndrome
D. Grave’s disease
140. Nurse Donita must know that the body’s normal pathophysiologic response to elevated serum calcium is:
A. decreased PTH secretions by the parathyroid
B. increased PTH secretion by the parathyroid
C. Calcium retention in the bone
D. Decreased release of calcium to the kidneys
Situation: Mr. Sandler has had an exploratory laparatomy. The physician has ordered a dressing change to the abdominal wound every shift.
141. Nurse Jhong can best prevent the spread of infection by placing Mr. Sandler’s soiled dressing in?
A. The garbage receptacle in the patient’s room
B. The garbage receptacle in the utility room marked “soiled”
C. A paper bag
D. A plastic bag
142. After cleaning Mr. Sandler’s wound with the prescribed antiseptic solution, the nurse should apply a:
A. Dry, sterile dressing
B. Thick, heavy dressing
C. Single-layered gauze pad soaked in normal saline solution
D. Singe-layered gauze pad soaked in povidone-iodine solution
143. Nurse Jhong’s main priority when changing Mr. Sandler’s dressing is to:
A. Wash her hands before and after the dressing change
B. Wash her hands before the dressing change
C. Wear disposable gloves to remove the dressing
D. Wear sterile gloves during the entire dressing change
144. Documentation of Mr. Sandler’s dressing change should include all of the following except:
A. Approximation of the wound edges
B. Amount, odor, and appearance of any drainage
C. Appearance of erythema and edema
D. Amount of time needed to change the dressing
145. The nurse documents the following in Mr. Sandler’s chart: “Abdominal dressing changed; small amount of serous drainage noted. Wound edges well approximated with no inflammation or exudates.” This indicates that Mr. Sandler’s wound:
A. Is healing by first intention
B. Is healing by second intention
C. Has eviscerated
D. Is infected
146. Which of the following nursing history findings might impede Mr. Sandler’s wound healing?
A. 35-year-old Caucasian computer operator
B. 5’9”, 150 lbs, well-nourished male with good skin turgor
C. Hematocrit 43%, hemoglobin 16
D. Smoker (has smoked one pack of cigarettes per day for 15 years)
147. Which of the following nursing orders is most important during the patient’s immediate postoperative phase?
A. Encourage the patient to perform deep-breathing exercises and to use an incentive spirometer hourly while awake
B. Assess the patient’s bowel sounds, and check for abdominal distension every 4 hours
C. Assess for Homans’ sign, and have the patient perform leg exercises hourly
D. Assess the patient’s pain tolerance every 4 hours, and administer analgesics as ordered
148. While coughing, Mr. Sandler complains of a sudden, sharp abdominal pain. The nurse observes that Mr. Sandler’s wound edges have separated and the viscera are exposed. The nurse should:
A. Notify the physician immediately
B. Apply Steri strips to the wound edges
C. Encourage the patient to cough harder
D. Apply sterile wet saline compresses
149. Which of the following is the correct procedure for emptying a closed drainage system, such as a Hemovacc:
A. Irrigate the wound catheter with sterile saline solution
B. Test the drainage for occult blood before emptying the drainage system
C. Rinse the Hemovac with tap water after discarding the drainage
D. Reestablish the closed drainage system after emptying the drainage
150. After emptying the Hemovac, the nurse cleans the plug with an alcohol sponge before reinserting it into the evacuator. This is done to:
A. Provide lubrication
B. Decrease the risk of transmitting microorganisms into the drainage system
C. Maintain surgical asepsis
D. Prevent the emergence of resistant strains of bacteria
Situation: Communicable diseases must be given a great consideration by nurses whether in the hospital or community setting. These diseases greatly contribute to poverty, lost productivity, and high cost of health care.
151. Nurse Pheomela is admitting a client with possible Haemophilus influenzae—meningitis. It is MOST important for the nurse to take which of the following actions?
A. Place the client on airborne precautions for twenty-four hours.
B. Perform neurological checks every four to six hours.
C. Dim the lights in the room and minimize environmental stimuli.
D. Encourage PO fluids during the day to decrease fever.
152. Mrs. Magdalene, a 45-year-old woman with hepatitis B is scheduled for an abdominal hysterectomy. It is MOST important for the nurse to check which of the following lab results before the patient goes to surgery?
A. Potassium.
B. Sodium.
C. Prothrombin time.
D. Hemoglobin.
153. As a community health nurse, a parent ask you which home remedy is suitable to relieve the itching associated with varicella?
A. Dusting the lesions with baby powder
B. Applying gauze saturated in hydrogen peroxide
C. Using cool compresses of normal saline
D. Applying a paste of baking soda and water
154. Mr. Torrecampo, a 54-year-old client with tertiary syphilis is admitted to a nursing unit. He is exhibiting signs of marked dementia and disorientation. Which of these actions should the nurse do INITIALLY?
a. Place the nurse call bell within reach.
B. Frequently observe the client’s behavior.
C. Apply a vest-type restraint.
D. Provide an around-the-clock sitter.
155. When doing an admission assessment on a client who has herpes zoster (shingles), it would be important for the nurse to determine which of the following?
A. When the client developed this allergic reaction and how long it has lasted.
B. If the client has eaten any new foods within the past 24 hours.
C. If the client has a history of fever blisters or chancre sores.
D. If the client comes in contact with anyone with chicken pox.
156. Katie, a six-year-old girl is admitted to the pediatric unit with a diagnosis of bacterial meningitis. As the nurse explains care to the parents, they ask how long their daughter will need to be in a room by herself. Which response by the nurse would be MOST appropriate?
A. “It depends on the results of her blood counts.”
B. “Patients like her are usually in isolation a couple of days or so.”
C. “Isolation can usually be stopped 24 hours after the start of antibiotic therapy.”
D. “When she has been afebrile for 48 hours, we will move her.”
157. Which nursing action is MOST appropriate when an infant is admitted for fever, poor feeding, irritability, and a bulging fontanel?
A. Perform neurological checks every four hours.
B. Place the client on droplet precautions.
C. Monitor the client’s urine output closely.
D. Encourage fluid intake.
158. A mother tells the nurse that one of her children has chicken pox and asks what she should do to care for that child. When teaching the mother, which of the following would be most important to prevent?
A. Acid-base imbalance
B. Malnutrition
C. Skin infection
D. Respiratory infection
159. When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn?
A. The head and chest circumference are the same.
B. The head is 2cm larger than the chest.
C. The head is 3cm smaller than the chest.
D. The head is 4cm larger than the chest.
160. Prior to discharging an infant home with his parents, which of the following statements, if made by the mother to the nurse, indicates a need for further teaching about newborn care?
A. “I will notify my physician about absence of breathing for 10 seconds.”
B. “I will notify my physician about more than one episode of projectile vomiting.”
C. “I will notify my physician if my baby’s temperature is greater than 101°F.”
D. “I will rock and cuddle my infant frequently to promote a sense of trust.”
161. Theodoro, a client recovering from streptococcal pneumonia has a chest x-ray that reveals a higher degree of atelectasis in the right lower lobe. Which of the following nursing interventions would be MOST appropriate?
A. Instruct the client to take deep breaths more frequently.
B. Reposition the client every hour to the right side.
C. Increase the frequency of incentive spirometry.
D. Change respiratory treatment to every 2 hours.
Situation: Because there is great demand for including assessment and care for children, the IMCI chart booklet is used for the improvement of the health care delivery.
162. Baby Chiara, a 13-month old infant was brought by her mother to the health center because of cough. Her respiratory rate is 40/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, her breathing is considered
A. Fast
B. Slow
C. Normal
D. Insignificant
163. Which of the following signs will indicate that a young child is suffering from severe pneumonia?
A. Cough
B. Wheezing
C. Fast breathing
D. Chest indrawing
164. Using IMCI guidelines, you classify a child as having severe pneumonia. What is the best management for the child?
A. Administer an antibiotic.
B. Refer urgently to the hospital.
C. Instruct the mother to increase fluid intake.
D. Instruct the mother to continue breastfeeding
165. Baby Japoy, a 9-month old infant was brought by his mother to the health center because of diarrhea occurring 4 to 5 times a day. His skin goes back slowly after a skin pinch and his eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category?
A. No signs of dehydration
B. Some dehydration
C. Severe dehydration
D. The data is insufficient
166. Based on the assessment made to Baby Japoy in QUESTION NO. 14, using the IMCI guidelines, which of the following management will you do?
A. Bring the infant to the nearest facility where IV fluids can be given
B. Supervise the mother in giving 200 to 400 ml. of Oresol in 4 hours
C. Give the infant’s mother instructions on home management
D. Keep the infant in your health center for close observation
167. To minimize the side effects of a DPT immunization for a six-month-old, the nurse should instruct the parents to:
A. Give the child an alcohol bath for an elevated temperature.
B. Administer antipyretics for discomfort, irritability, and fever.
C. Place an ice bag on the child’s leg for one hour.
D. Check the child’s temperature every four hours for three days.
168. A parent asks why it is recommended that the second dose of the measles, mumps, rubella (MMR) vaccine be given at 4 to 6 years of age. The nurse responds based on which of the following as the most important reason?
A. The risks to a fetus are high if a girl receiving the vaccine becomes pregnant
B. The chance of contracting the disease is much lower at this age
C. The dangers associated with a strong reaction to the vaccine are increased at this age
D. A serious complication from the vaccine is swelling of the joints.
169. The public health nurse is the supervisor of rural health midwives. Which of the following is a supervisory function of the public health nurse?
A. Referring cases or patients to the midwife
B. Providing technical guidance to the midwife
C. Providing nursing care to cases referred by the midwife
D. Formulating and implementing training programs for midwives
170. You are the public health nurse in a municipality with a total population of about 20,000. There are 2 rural health midwives in the Rural Health Unit. How many midwives will the RHU still need?
A. 1
B. 2
C. 3
D. 0
171. Nurse Alyssa wants to monitor health service delivery nationwide. She went to the Department of Health and search for the FHSIS. All but one is the objective of FHSIS:
A. To complete the clinical picture of chronic disease and describe their natural history
B. To provide standardized, facility level data base which can be accessed for more in depth studies
C. To minimize recording and reporting burden allowing more time for patient care and promotive activities
D. To provide summary data on health service delivery and selected program accomplishment indicators at the barangay, municipality, district, provincial, regional and national levels.
172. The Barangay health station is considered the lowest level of reporting unit in the field health services and information system or FHSIS only if:
A. It delivers health services to defined catchment area composed of one or more barangays
B. A midwife renders regular services to the area
C. Health services are provided in a physical structure constructed for this purpose
D. All of the above
173. What is the fundamental block or foundation of the field health service information system?
A. Individual treatment record
B. Target Client list
C. Reporting forms
D. Output record
174. Which of the following is used to monitor particular groups that are qualified as eligible to a certain program of the DOH?
A. Family treatment record
B. Target Client list
C. Reporting forms
D. Output record
175. This is an indispensable tool that provides the summary of data on service delivery and program accomplishment done when monitoring and evaluating the services rendered by the RHU:
A. Target client list
B. Reporting forms
C. FHSIS
D. Barangay health plan
176. This refers to the systematic study of events such as births, illness, marriages, divorces and deaths:
A. Epidemiology
B. Demographics
C. Vital Statistics
D. Health Statistics
177. The Micronutrient supplementation program of the DOH includes:
Select all that apply.
1. Fats
2. Carbohydrates
3. Vitamins
4. Minerals
A. All of the above
B. None of the above
C. 2, 3, and 4
D. 3 and 4
Situation: Aling Petra rushed her daughter in the rural health unit because of suspected dengue case. The rural health nurse reports that the incidence of dengue fever is doubling up their community.
178. What is the latest program campaign of DOH?
A. Iwas Sakit, Iwas Dengue
B. Aksyon Barangay Kontra Dengue
C. Iwas Lamok, Iwas Dengue
D. Knock-out Dengue
179. Which of the following is a function of the DOH?
A. Provide technical assistance and capability-building services
B. Provide technically sound advice to the Secretary of Health and other stakeholders
C. Ensure adequate provision of strategic resource requirements of programs
D. Reduce morbidity and mortality from certain diseases
180. The Millenium Development Goals adopted by the global community as represented by the UN General Assembly has the following purposes, except:
A. Reduce poverty
B. Achieve sustainable development
C. Prioritize the participation of developed countries only
D. Implement only the priority health program to achieve these goals
181. The following Millennium Development Goals are all health related except:
- Achieve universal primary education
- Combat HIV/AIDS, malaria and other diseases
- Eradicate extreme poverty and hunger
- Promote gender equality empower women
- reduce child mortality
- improve maternal health
A. 1, 2, and 3
B. 1 and 4
C. 1, 3, and 4
D. 4 only
Situation: Mr. Ramzey, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital.
182. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when Mr. Ramzey:
A. Verbalizes the role of sexual activity in spread of the disorder.
B. States he will make arrangements to drop his college classes.
C. Acknowledges the need to avoid all contact sports.
D. Says he will avoid close contact with his three-year-old niece.
183. Which question is least useful in the assessment of a client with AIDS?
A. Are you a drug user?
B. Do you have many sex partners?
C. What is your method of birth control?
D. How old were you when you became sexually active?
184. An infected person who unknowingly serve as a potential source of infection to man or animal:
A. Contact
B. Suspect
C. Susceptible
D. Carrier
185. The most important principle during a home visit is which of the following?
A. Inquiry about health and welfare
B. Performance of health assessment
C. Use of available information about the client
D. Evaluation of past service
Situation: Aling Aguida asks the nurse about head lice infestation during a visit to the health center.
186. Which of the following symptoms would the nurse tell the parent is most common in a child infected with head lice?
A. Itching of the scalp
B. Scaling of the scalp
C. Serous weeping on the scalp surface
D. Pinpoint hemorrhagic spots on the scalp surface
187. Aling Aguida then ask, “can I get head lice too?” The nurse indicates that adults can also be infested with head lice but that pediculosis is more common among school children, primarily for which of the following reasons?
A. An immunity to pediculosis usually established by adulthood
B. School-age children tend to be more neglectful of frequent hand washing
C. Pediculosis usually is spread by close contact with infested children
D. The skin of adults is more capable of resisting the invasion of lice.
188. After teaching the parents about the cause of ringworm of the scalp, which of the following, if stated by the father, indicates successful teaching?
A. Overexposure to the sun
B. Infestation with a mite
C. Fungal infection of the scalp
D. An allergic reaction
189. Another mother asks the nurse, “How did my children get pinworms?” the nurse explains that pinworms are most commonly spread by hands and with which of the following when contaminated?
A. Food
B. Bed linens
C. Animals
D. Toilet seats
Situation: Community organizing aims to motivate, enhance, and seek wider community participation in decision-making in activities that affect community health.
190. Which of the following activities is part of the collaboration phase of community organizing?
A. Integration into the community
B. Community diagnosis
C. Core group formation
D. Sourcing out of external sources
191. Which step in community organizing involves training of potential leaders in the community?
A. Integration
B. Community organization
C. Community study
D. Core group formation
192. In which step are plans formulated for solving community problems?
A. Mobilization
B. Community organization
C. Follow-up/extension
D. Core group formation
193. The public health nurse takes an active role in community participation. What is the primary goal of community organizing?
A. To educate the people regarding community health problems
B. To mobilize the people to resolve community health problems
C. To maximize the community’s resources in dealing with health problems
D. To curtail the resources in dealing with health problems
194. An indicator of success in community organizing is when people are able to
A. Participate in community activities for the solution of a community problem
B. Implement activities for the solution of the community problem
C. Plan activities for the solution of the community problem
D. Identify the health problem as a common concern
Situation: Nurse Jessica wanted to know how breastfeeding mothers manage nursing problems while in the workplace.
195. Nurse Jessica decided to conduct an interview to know about the breastfeeding mothers’ experiences. All of the following are true statements about interview as a method of data gathering EXCEPT:
A. Good interviewers do not rush the participant for answers.
B. Good interviewers realize that the participant is learning from the interviewer.
C. Good interviewers immediately correct the participant’s misinformation.
D. Good interviewers do not lead the participant and play a passive role.
196. This type of quantitative research is designed to obtain information from populations regarding the prevalence, distribution and interrelations of variables within those populations:
A. Field studies
B. Methodological research
C. Evaluation Research
D. Survey Research
197. What is the most appropriate design to use in answering the research question, “What are the informational needs of patients undergoing surgical procedure on an outpatient basis?”
A. Quantitative research
B. Qualitative research
C. Experimental research
D. Non-experimental research
198. A clinical instructor is teaching a class about community diagnosis. She tells them to use a sampling method where each member of the study population has an equal chance to be selected. This is known as:
A. Convenience Sampling
B. Purposive sampling
C. Simple random sampling
D. Systematic random sampling
Situation: Malaria continues to be a major health problem in the country. The nature of malaria as a public health problem requires sustained and systemic efforts towards reduction of morbidity and prevention of mortality.
199. Which of the following require pink row classification? Select all that apply.
1. Malaria in high malaria risk area
2. Severe complicated measles
3. Severe dengue hemorrhagic fever
4. Very sever febrile disease
5. Measles with eye or mouth complications
A. 1 and 5
B. 2, 3, and 4
C. 1, 2, 3, and 4
D. All of these
200. Chinee, the community health nurse has the following functions in communicable disease control. Select all that apply.
1. Assist the family in recognizing and solving health problems
2. Guides the family in recognizing need for medical supervision and care
3. Instructs on isolation and quarantine procedures
4. Confidentiality in care for cases of sexually transmitted diseases
A. 1 only
B. 1 and 2
C. 1, 2, and 3
D. 1, 2, 3, and 4
Situation: In a health care setting, clients are often faced with stressful situations. As nurses, it is essential that we know how to apply the nursing process to these clients.
201. Mr. Bieber, 18-years old, is admitted to the psych unit. The family decided to bring him for treatment due to his addiction to methamphetamine. Which of the following assessment findings would indicate intoxication from the drug?
A. Hypertension and dilated pupils
B. Hypotension and constricted pupils
C. Hypertension and constricted pupils
D. Hypotension and dilated pupils
102. Mrs. Casao is brought to the emergency department with complaints of severe headache, nausea and vomiting, tachycardia, and chest pain. The attending physician rules out any physiological causes and endorses her to the in-house psychiatrist. The client is experiencing severe anxiety. Which of the following interventions would best help Mrs. Casao?
A. Bring the client to a small room, and let her have privacy.
B. Encourage the client to talk to other patients for her to be distracted.
C. Remain with the client, be calm, confident, and supportive
D. Help the client remember how she felt anxious in the first place.
203. Mr. Go has an incapacitating obsessive-compulsive behavior. The statement that best describes how a client with obsessive-compulsive behavior view this disorder would be:
A. “The devil makes me do this things, it’s not my fault.”
B. “I know these are irrational but I cannot help it.”
C. “The things I do take a little time, but they make me a productive person.”
D. “There is nothing wrong with what I do, I don’t why people are telling me otherwise.”
204. Melanie B, a 19 year-old ballet dancer was diagnosed with anorexia nervosa. The nurse is aware signs and symptoms that would be most specific for diagnosing anorexia nervosa are:
A. Slow pulse, 15% weight loss, and alopecia
B. Impulsive behaviors, excessive fears and nausea
C. Excessive activity, memory lapses, and an increase pulse
D. Excessive weight loss, amenorrhea, and abdominal distention
205. Daniel was admitted to the Psych ward with a diagnosis of bipolar disorder with social aggressive behavior. Which of the following activities would be most appropriate for Daniel?
A. Ping-pong
B. Writing
C. Chess
D. Basketball
206. Fedor, a male adolescent with the diagnosis of antisocial personality disorder spends a great deal of time with Geneva, a female adolescent client on the unit. One day the nursing assistant enters Geneva’s room and finds them in her bed. Later the nursing assistant reports the incident to the nurse. The nurse should:
A. Arrange a discussion with both adolescents
B. Assign a staff member to observe both clients every 15 minutes
C. Lock the bedroom doors to keep the clients within view of the staff
D. Call a ward meeting to talk about sexual activity among all of the clients
207. Harold is assigned as the nurse counselor in a community mental health clinic and is working with a couple and their two kids. One son has been in trouble in school because of fighting and poor grades. The other daughter appears quiet and withdrawn. But the parents report no problems. The father has been in and out of jobs in the last 3 years and the mother works as a waitress. They have severe marital problems for the past 10 years. The priority nursing diagnosis for this family at this time would be:
A. Impaired adjustment related to children growing older
B. Impaired parenting related to marital problems
C. Disabled family coping related to the son’s school problems
D. Impaired social interaction related to an inability to form relationships
208. Nurse Ingrid is caring for a client diagnosed with Alzheimer’s-type dementia. She is correct when she says that this medication is indicated for treatment of this condition:
A. Donapezil
B. Benazepril
C. Fosinopril
D. Tofranill
209. A psychiatric nurse saw an autistic toddler sitting in a corner rocking and spinning a toy. How can the nurse be most therapeutic in this situation?
A. Gently stroking the toddler’s arm to gain the child’s attention
B. Sitting down and staring at the spinning top with the toddler
C. Holding the toddler to provide a sense of support and security
D. Waiting for the toddler to make the initial contact before moving close
210. Community Health Nurse Janette makes a routine home visit to an 80-year old Mrs. Kardashian who is living with her son and daughter-in-law. Mrs. Kardashian’s daughter -in-law stays at home to take care of her and the children. Which action or statement should make Nurse Janette suspect elder abuse?
A. The client speaks with Nurse Janette in private
B. The client’s hair and clothes are kempt
C. The client talks in a hesitant manner
D. The client helps out around the house
211. Mr. and Mrs. Lambert are concerned about their 3-year old child who is admitted to children’s mental health unit with a diagnosis of infantile autism. The couple asks the nurse what would be the major goal of therapy for a child with this pervasive developmental disorder?
A. Develop language skills
B. Limit the use of regressive behavior
C. Be mainstreamed into a regular preschool group
D. Recognize the self as an independent person of worth
Situation: Nurse Nelly is working in a hospital at the chemical dependency unit. She is caring for clients with substance abuse disorders.
212. Mr. Ortigas reportedly consumes 3 bottles of strong liquor every day. He will be brought to the hospital at 8:00 am for alcohol detoxification. His last bottle was at 6:00 am this morning. Nurse Pamela would anticipate that Mr. Ortigas will start to show symptoms of withdrawal between:
A. 10:00 am to 6:00 pm at the same day
B. 8:00 pm to 6:00 am the next day
C. 9:00 am to 9:00 pm the same day
D. 7:00 pm to 10:00 am the next day
213. To help deter Mr. Querol from drinking, the physician prescribes DIsulfiram (Antabuse). Nurse Rosano teaches Mr. Querol about avoiding products that could cause severe adverse reactions from the drug. Mr. Querol understood the instruction when he states to the nurse:
A. “I will refrain from drinking carbonated beverages starting today.”
B. “I will read the deodorant’s product label first before I buy it.”
C. “I will have to eat my spaghetti without cheese.”
D. “I will use water instead of shaving cream when I shave.”
214. Mr. Santa Maria has been admitted to the hospital due to substance abuse. As the care provider, how can the nurse best help the client to develop healthier coping mechanisms?
A. Promoting interpersonal relationships with peers
B. Providing a stress-free environment for the client
C. Allowing the client to assume responsibility for decisions
D. Setting realistic limits on the client’s maladaptive behavior
215. A community health nurse is educating adolescents about substance and drug abuse. A factor might place a young person in a high-risk category for substance abuse would be:
A. Curiosity and a daring attitude
B. Occasional periods of depression
C. Family Violence
D. Typical stresses associated with adolescence
216. Trevor, a chronic alcoholic has decided to stop drinking. He was brought to the emergency because of coarse hand tremors, elevated vital signs, nausea and vomiting. He is now experiencing alcohol withdrawal. When planning care for him, the nurse must be aware that the most serious, life threatening symptoms from alcohol withdrawal usually occur:
A. 8 to 10 hours after the last drink
B. 12 to 24 hours after the last drink
C. 24 to 72 hours after the last drink
D. 72 to 96 hours after the last drink
217. Ms. Ursula reportedly consumes 5 bottles of gin every night and is brought to the hospital in the morning for alcohol detoxification. The physician prescribes Disulfiram (Antabuse). She was also prescribed Vitamin B1 (Thiamine). Ms. Ursula asks the nurse, “Why do I need to take this particular vitamin?” The nurse’s most appropriate response would be:
A. “It prevents severe adverse reactions of disulfiram (Antabuse).”
B. “It prevents or treats Wernicke’s and Korsakoff’s syndrome.”
C. “It corrects your nutritional deficiencies.”
D. “It helps get rid of the effects of alcohol in your system.”
218. Nurse Patrick, a psychiatric nurse knows that the distinguishing features of anorexia nervosa from bulimia are:
A. Earlier age of onset and below normal body weight
B. Later age of onset and near normal body weight
C. Earlier age of onset and near normal body weight
D. Later age of onset and below normal body weight
219. Nurse Arvin learned that a scale is a device used to assign a numerical score to subjects to place them on a continuum with respect to attributes being measured. With regards to confidentiality of information in research, the nurse knows that information gathered through research may be revealed when:
A. The patient permits such revelation as in the case of claim for hospitalization, or insurance benefit among others
B. The case is medico-legal such as attempted suicide, gunshot wounds which have to be reported to the local police or NBI
C. The patient is ill of communicable disease and public safety may be jeopardized.
D. All of the above
220. Nurse Shamcey is going through various concepts that would help enhance her research design. Internal validity refers to the extent to which it is possible to make an inference that the independent variable is truly causing the dependent variable and that the relationship between the two is not spurious. Which among the following type of research possess a high degree of internal validity?
A. Pre-experimental design
B. Correlational design
C. Experimental design
D. Quasi-experimental design
221. Mr. Geraldito, a 37-year old patient was admitted because of manic disorder. When he has pressured speech and mumbles incoherently, the most appropriate intervention would be for the nurse to:
A. Set limits on the client’s behavior by refusing to talk with him unless he speaks clearly
B. Ignore the client’s mumbling since he is using this pathologic manner of speech to get attention
C. Consistently ask the client to repeat what he said, so he will learn to recognize that he is mumbling
D. Indicate to the client that he needs to slow down because what he says is important and cannot be understood
222. A 45-year old client was diagnosed with amyotropic lateral sclerosis and has progressed rapidly. The client commented “I have been good all my life and still I got this disease, there are so many bad and rotten people around and they are the ones who should be infected with this illness.” The nurse best respond by saying:
A. “I can understand you are afraid of death.”
B. “It’s really unfair that you have the disease.”
C. “Do not say that because other people might be mad at you.”
D. “Have you thought of selling all your possessions?”
223. Sushmita is admitted to the female psych ward because of a diagnosis of Anorexia Nervosa. A nurse is caring for her when she found out that Susan is not eating her food. Which nursing action is most appropriate?
A. Allowing the client to hide her food
B. Telling the client that she is not allowed to hide her food
C. Interrupting the client and offering to take her for a walk
D. Setting limits with the client about eating habits
224. The primary medical treatment for schizophrenia is psychopharmacology; neuroleptics: conventional antipsychotic agents and atypical antipsychotic agents are used. Which of the following statements is true about atypical antipsychotic drugs?
A. They target positive signs of schizophrenia like alogia, blunted affect, and catatonia, but have no observable effect on the negative signs.
B. They target negative signs of schizophrenia like ambivalence, delusions, and echopraxia, but have no observable effect on the positive signs.
C. They not only diminish negative symptoms, they also lessen positive signs of lack volition and motivation, social withdrawal, and anhedonia.
D. They do not only diminish positive symptoms, they also lessen negative signs of lack volition and motivation, social withdrawal, and anhedonia.
Situation: Nurse Pawie encountered various research articles during her review of literature. Through this process, she realized that knowledge of various research designs is important in developing accurate and interpretable evidence.
225. Nurse Pawie read about a study in alcohol consumption among the Chinese over a 10-year period using data from 1984, 1990 and the 1995 International Alcohol Survey. This study revealed that the rate of heavy drinking fell between 1984 and 1990, but remained unchanged between 1990 and 1995. This study utilized which among the following research designs?
A. Cross-sectional design
B. Trend study
C. Cohort design
D. Experimental research
226. Nurse Leriza understands that there are myths and facts about suicide. The following are facts about suicide except:
A. Suicidal people have already thought of the idea of suicide
B. Suicidal people have mixed feelings about their wish to die
C. Once a client has a suicide risk, he always is a suicide risk
D. Suicidal gestures are a potentially lethal way to act out
227. After suffering from the lost of his job and fortune, a 40-year old businessman was diagnosed with major depression. The nurse assesses the client and identifies the client’s altered nutrition related to poor nutritional depression. The nurse assesses the client and identifies the client’s altered nutrition related to poor nutritional intake as a major concern. Based on your knowledge regarding clients with mood disorders what is the most appropriate nursing intervention related to this diagnosis?
A. Explaining to the client the importance of a good nutritional intake
B. Weighing the client three times a week before breakfast
C. Reporting the nutritional concern to the psychiatrist and obtaining a nutritional consultation as soon as possible
D. Consulting with the nutritionist, offering the client several small, frequent meals per day, and scheduling brief nursing interactions with the client during these times.
228. Nurse Tamara notes that Mr. Delgado, diagnosed with major depressive disorder, hasn’t taken a shower and hasn’t changed his clothes for two days. Which of the following statements by Nurse Tamara would be most appropriate?
A. “Mr. Delgado, it is time for you to take a shower.”
B. “Mr. Delgado, ask your family to give you a shower.”
C. “Mr. Delgado, are you ready to take a bath?”
D. “Mr. Delgado, it is important that you take a bath.”
229. Henry, a 24 year-old disturbed client, unprovoked and agitated, attacks another client. A short-term goal for this client would be:
A. Get the client to apologize for the attack to other client
B. Have a staff member whom the client trust stay with the client
C. Protect the others from the client’s impulsive acts by secluding the client
D. Keep the client actively participating in activities and in contact with reality
230. Mr. Edd has been living alone with mild dementia. A home health nurse visits him and determines that he is dependent on drugs. Which of the following assessment questions would assist the nurse to provide appropriate nursing care?
A. “Why did you get started on these drugs?”
B. “How long do you think this would take before someone finds out?”
C. “How much do you use and what effect does it have on you?”
D. The nurse does not ask any questions in fear that the client is in denial and will throw the nurse out of the home.
231. Sarah G., a popular pop singer was admitted to the hospital due to excessive weight loss. The singer was diagnosed with anorexia nervosa. After the patient stabilized from her condition, the parents, the client and the psychiatrist decided to initiate a behavior modification program to assist her in her recovery. The nurse knows that a major component of behavior modification program is that:
A. Punishes negative reactions
B. Reconditions the patient to fear of gaining weight
C. Rewards positive behavior
D. Control the behavior of the patient
232. Josemari, a 35 year old married client was being discharged. After having paranoid delusions and unjustifiably accusing his wife of having extramarital affairs, the nurse understands that a long term goal that a client can develop is:
A. Faith in his wife
B. Better Self control
a. Faith in his wife b. Better Self control c. Feelings of self-worth
D. Insight to his behavior
233. Jonathan, a newly diagnosed psychiatric patient suddenly lies on the floor on a side-lying knee chest position. The most appropriate intervention for the nurse to take after finding an acting-out, disturbed client in the fetal position would be to:
A. Tap the client gently on the back and say, “Ok I say understand you want to lie down.”
B. Sit down beside the client on the floor and say, “I will stay with you till you get up.”
C. Go to the client and say, “I’ll be waiting for you at the dining table and chairs, so please get up and join me.”
D. Leave the client alone because the behavior demonstrates the client is too regressed to benefit from talking with the nurse.
234. Dexan, a nursing graduate, has been unable to sleep for 2 days and has a splurged on her credit card, was admitted to the hospital for depression. The symptoms that the nurse should expect the client to exhibit in the hospital would include:
A. Depressed mood and crying
B. Increased insight into behavior
C. Decreased psychomotor activities
D. Increased interest in the environment
235. Christian, a 22 year old college drop-out has been caught stealing in a community grocery store for the third time. He is being observed for anti-social personality disorder. Christian tells the nurse about his terrible childhood. Based on these findings, the most appropriate nursing assessment would be that the client is using:
A. Escape ideation
B. Evoking sympathy
C. Impaired judgment
D. Distorted reality testing
236. Yuri, an 8-year old was diagnosed with Leukemia and has only about 7 months to live. As the depressed family heard of the news, the nurse would like to include family therapy for their child. What is the rationale and advantage of family therapy in this scenario?
A. It will be more time-efficient to manage this family.
B. The nurse can control and manage the outcome using this mode of intervention.
C. It will prevent denial from the parents about their child’s condition.
D. The entire family is involved, since what happens to one member impacts all.
Situation: Majority of abusive and violent behavior is seen in the domestic setting (elder abuse, spouse abuse, child abuse/neglect and rape). It is part of the nurse’s role to identify these types of abuse in different settings to provide proper care and support.
237. Mrs. Margaux is rushed to the emergency room after being beaten by her husband, a well-known surgeon. You are the nurse is attending to Mrs. Margaux, and you understand that?
A. Spouse or partner abuse is all about physical abuse of one person by another
B. Abused women often internalize the criticisms that they receive from the abuser
C. It is typical for an abuser to have high self-esteem and good problem solving skills
D. The most common trait found in abused wives is independence
238. Nurse Hildegard believes a coworker is diverting narcotics. The nurse approaches the nurse manager to report the suspicions. Which of the following statements by the nurse is BEST?
A. “After my coworker has been on duty, the patients often need repeated doses of pain medication. I have seen him sleeping on duty three times.”
B. “I saw my co-worker downtown after work. She was acting really strange, like he didn’t even recognize me.”
C. “I think my coworker is stealing narcotics because he is always acting euphoric and seems high.”
D. “My coworker is hanging around with drug dealers, and I think I saw tracks on his arms.”
239. Rodrigo, a 36 year old medical student has exhibited an inappropriate affect and apathy. A diagnosis of acute schizophrenia reaction is made. Considering the diagnosis, a symptom the nurse would expect to observe in the client’s communication or behavior is:
A. Suicidal preoccupation
B. Absence of self-criticism
C. Autistic magical thinking
D. Abstract and deduction
240. The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed?
A. Redness or inflammation of the tissue.
B. Mottling or graying of the tissue.
C. The client states that she feels a cold sensation in the area
D. The client state that she feels numbness.
241. The nurse is caring for a client in a manic phase of bipolar affective disorder. It is MOST important for the nurse to offer which of the following meals?
A. Tuna salad sandwich and orange slices.
B. Bologna sandwich and french fries
C. Milkshake and banana.
D. Fried chicken and tossed salad.
242. Mang Tiboy, an involuntary psychiatric patient asks the nurse to mail his letter to the President. He states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which of the following responses by the nurse is BEST?
A. Accept the letter and place it in the patient’s medical record.
B. Read the patient’s letter and decide if it is appropriate to mail.
C. Call the patient’s psychiatrist and inform him of the letter.
D. Discourage the patient from sending the letter, but mail it if patient insists.
243. During administration of oral medications to an elderly, confused client, the client states, “These pills look funny. They belong to the lady down the hall.” Which of the following is the BEST response by the nurse?
A. “Your physician has ordered new medications for you. They will help you get well.”
B. “Remember yesterday when I brought your medications? They look the same.”
C. “I’ll explain why you are receiving these medications.”
D. “I’ll be back after I check your medications again.”
244. Krissy, on suicide precautions asks for a razor to shave her legs. The nurse tells her to go back in her room. She responds, “Don’t you trust me?” Which of the following responses by the nurse is BEST?
A. “It is against hospital policy to allow patients on suicide precautions to have razors unsupervised.”
B. “I trust you, but your doctor said someone has to watch you if you want to shave your legs.”
C. “Wouldn’t you rather wait until you are feeling better before you try and shave your legs?”
D. “You have been having thoughts about wanting to hurt yourself recently, so I’ll stay with you.”
245. Which of the following indicates that a client is beginning to develop a trusting relationship with the nurse?
A. The client describes delusions to the nurse.
B. The client can describe his/her feelings to the nurse.
C. The nurse feels more comfortable with the client.
D. The client reports feeling less anxious.
246. Nurse Tremaine encounters Mr. Jones, a psychotic client coming out of his room nude. Which of the following responses by the nurse is BEST?
A. “Come with me, Mr. Jones. You need to get dressed.”
B. “Why are you coming into the hallway undressed, Mr. Jones?
C. “Being naked in the hallway is inappropriate, Mr. Jones. Return to your room to get dressed.”
D. “Do I need to get a male nurse to help you get dressed, Mr. Jones?”
Situation: Althea brought her 74-year-old father to the emergency room. When asked his name he is unable to remember it, and appears to be disheveled, restless, and confused. His daughter says she has been caring for him at home for the last year, but he “ran away” after they had an argument about his deteriorating personal hygiene. She found him several hours later sitting in the street.
247. Althea confides to the nurse that she feels horrible about yelling at her father. Which of the following is the BEST response by the nurse?
A.“We all do things that we are sorry for later.”
B. “Don’t feel guilty because he is confused.”
C. “Your father’s illness must be difficult for both of you.”
D. “The social worker will be able to help you with this problem.”
Situation: Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual during any stage of a normal sexual activity, including desire, arousal or orgasm. The following questions pertain to sexual disorders.
248. Andre is reviewing content for a test on the phases of sexual response cycle. He demonstrates understanding of the material by identifying which phase as the one involving fantasy and expectation?
A. Desire phase
B. Excitement phase
C. Orgasm phase
D. Resolution phase
249. Which behavior or disorder would the nurse identify as a possible cause of or contributing factor to sexual dysfunction?
A. Drug use
B. Dissociative disorder
C. Supplemental vitamin use
D. Exercise
250. The history of the patient reveals a persistent urge to show his genitalia to a stranger. The nurse identifies this as:
A. Fetishism
B. Pedophilia
C. Exhibitionism
D. Transsexualism
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