Comprehensive Exam II (with Answer and Rationale)

1. In a child with suspected coarctation of the aorta, the nurse would expect to find

The correct answer is D: Bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased flow to the upper extremities (increased pressure and pulses)

2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by

The correct answer is C: Confine the percussion to the rib cage area
Percussion (clapping) should be only done in the area of the rib cage.

3. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for

The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido.

4. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?

The correct answer is D: "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s behavior will not cause the abuser to become nonviolent.

5. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the

The correct answer is B: Yin, the negative force that represents darkness, cold, and emptiness. Chinese folk medicine proposes that health is regulated by the opposing forces of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness. Excessive yin predisposes one to nervousness.

6. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be

The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is important for clients to acknowledge that relapse is a possibility and to identify early signs of relapse.

7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates

The correct answer is B: Social isolation related to altered thought processes
Hostility and absence of involvement are data supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of medication suggests altered thinking processes.

8. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client?

The correct answer is B: Flexion of the hip and knees with passive flexion of the neck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of the neck; a positive Kernig’s sign—inability to extend the knee to more than 135 degrees, without pain behind the knee, while the hip is flexed usually establishes the diagnosis of meningitis.

9. Post-procedure nursing interventions for electroconvulsive therapy include

The correct answer is C: Remaining with client until oriented
Client awakens post-procedure 20-30 minutes after treatment and appears groggy and confused. The nurse remains with the client until the client is oriented and able to engage in self care.

10. The nurse is talking to parents about nutrition in school aged children. Which of the following is the

The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These include heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.

11. The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
A) Stressors in the home

The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the symptoms of Schizophrenia. Compliance with daily doses is a critical assessment.

12. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?

The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, causing a false high in that arm.

13. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?

The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood cannot flow into the heart. As a result, venous pressure rises and the neck veins become distended.

14. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should

The correct answer is C: Give the client simple information about what she will be doing. The distressed disoriented client should be gently oriented to reduce fear and increase the sense of safety and security. Environmental changes provoke stress and fear.

15. When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection?

The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this country. Prevention is similar to safe sex practices taught to prevent any STD: use of a condom and spermicide for protection during intercourse.

16. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?

The correct answer is C: Lung remodeling and permanent changes in lung function
While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help you to reinforce the need for daily management of the disease whether or not the patient "feels better".

17. The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is

The correct answer is B: "Your child has less red blood cells that carry oxygen." The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell levels, low hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is appropriate.

18. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
The correct answer is B: When the client threatens self-harm and harm to others. Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the public.

19. At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?

The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without support is 8 months.

20. First-time parents bring their 5 day-old infant to the pediatrician's office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings?

The correct answer is C: This breathing pattern is normal
Respiratory rate in a newborn is 30-60 breaths/minute and periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is normal to allay their anxiety.

21. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?

The correct answer is B: Large wooden puzzle
Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding board, toy telephone, puppets, wooden puzzles, finger paint, and thick crayons.

22. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?

The correct answer is C: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern in these clients. Other information of interest is that cystic fibrosis is an autosomal recessive disease. There is a 25% chance that each of these parent''s pregnancies will result in a child with systic fibrosis.

23. A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent?

The correct answer is A: Age of the child
During the preschool period children are using their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child''s age is most important in determining if any true dysfunction might be occurring.

24. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?

The correct answer is C: Clothing has become tight around the waist
Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.

25. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?

The correct answer is D: Occlusive moist dressing
This wound has granulation tissue present and must be protected. The use of a moisture retentive dressing is the best choice because moisture supports wound healing.

26. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to

The correct answer is A: Ask the client about the refusal of certain pain medications. Beliefs regarding pain are one of the oldest culturally related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.

27. The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?

The correct answer is B: Place client on a pressure reducing support surface
This client is at greatest risk for skin breakdown because of immobility and decreased sensation. The first action should be to choose and then place the client on the best support surface to relieve pressure, shear and friction forces.

28. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client??"

The correct answer is C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety.

29. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?

The correct answer is C: Reminiscence groups
According to Erikson''s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss.

30. Which type of accidental poisoning would the nurse expect to occur in children under age 6?

The correct answer is A: Oral ingestion
The greatest risk for young children is from oral ingestion. While children under age 6 may come in contact with other poisons or inhale toxic fumes, these are not common.

31. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?

The correct answer is C: Continue with the present formula
The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.

32. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?

The correct answer is B: Twenty month-old who has just learned to climb stairs. Toddlers are at most risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior.

33. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?

The correct answer is A: Stand on 1 foot
At this age, gross motor development allows a child to balance on 1 foot.

34. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?

The correct answer is A: Activity intolerance caused by fatigue related to chronic tissue hypoxia. Activity intolerance describes a condition in which the client''s physiological capacity for activities is compromised.

35. A nurse is caring for a client with multiple myeloma. Which of the following should be included in the plan of care?

The correct answer is C: Precautions with position changes
Because multiple myeloma is a condition in which neoplastic plasma cells infiltrate the bone marrow resulting in osteoporosis, client’s are at high risk for pathological fractures.

36. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?
A) Reading

The correct answer is D: Ping-pong
This provides an outlet for physical energy and requires limited attention.

37. What is the most important aspect to include when developing a home care plan for a client with severe arthritis?

The correct answer is A: Maintaining and preserving function
To maintain quality of life, the plan for care must emphasize preserving function. Proper body positioning and posture and active and passive range of motion exercises important interventions for maintaining function of affected joints.

38. A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants?

The correct answer is C: Provides antibodies
Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest, therefore less residual is left in the infant''s stomach.

39. Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects?

The correct answer is A: Red reflex test
A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.

40. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?
The correct answer is D: Note patterns of increased blood pressure
Hypertension is a key assessment in the course of the disease.

41. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?


The correct answer is B: Withdrawal
The early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alchohol intake.

42. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child?
The correct answer is B: Explain the surgery 1 week prior to the procedure
A 5 year-old can understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.

43. During the evaluation phase for a client, the nurse should focus on

The correct answer is B: The client''s status, progress toward goal achievement, and ongoing re-evaluation. Evaluation process of the nursing process focuses on the client''s status, progress toward goal achievement and ongoing re-evaluation of the plan of care.

44. The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
The correct answer is A: Review the medications the client is receiving
Antibiotics and medications containing sorbitol may induce diarrhea.

45. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication?

The correct answer is D: Thiocyanate
Thiocyanate levels rise with the metabolism if nitroprusside and can cause cyanide toxicity.

46. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client’s behavior most likely indicates

The correct answer is C: Flight of ideas
Flight of ideas - defines nearly continuous flow of speech, jumping from 1 topic to another.

47. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings?

The correct answer is B: Tissue hypoxia
When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the blood.

48. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to

The correct answer is B: Ask the client what foods are acceptable
Many Hispanic women subscribe to the balance of hot and cold foods in the post partum period. What defines "cold" can best be explained by the client or family.

49. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and

The correct answer is B: Decreased colloidal osmotic pressure in the capillaries. The increased glomerular permeability to protein causes a decrease in serum albumin which results in decreased colloidal osmotic pressure.

50. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?

The correct answer is C: Bilirubin
In the laboratory data provided, the only elevated level expected is bilirubin. Additional liver function tests will confirm the diagnosis.

51. The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?

The correct answer is C: 15 minutes
Frequency is the time from the beginning of one contraction to the beginning of the next contraction.

52. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best?

The correct answer is D: "The recovering person cannot return to drinking without starting the addiction process over." Recovery is total abstinence from all drugs.

53. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?

The correct answer is A: Measure head circumference
In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to bed on admission to the unit.

54. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
The correct answer is B: With fear of rejection causing increased rage toward the victim. The fear of rejection and loss only serve to increase the batterer’s rage at his partner.

55. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated?

The correct answer is B: "I find the mood swings and the change from a calm person to being angry all the time hard to deal with."
The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in this area results in findings such as emotional lability, changes in personality, inattentiveness, flat affect and inappropriate behavior.

56. A client who has been drinking for five years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with

The correct answer is C: Life’s stressors
Alcohol is used by some people to manage anxiety and stress. The overall intent is to decrease negative feelings and increase positive feelings.

57. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

The correct answer is A: High in carbohydrates and proteins
Provide a high-energy diet by increasing carbohydrates, protein and fat (possibly as high as 40%). A favorable response to the supplemental pancreatic enzymes is based on tolerance of fatty foods, decreased stool frequency, absence of steatorrhea, improved appetite and lack of abdominal pain.

58. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?


The correct answer is D: Should be limited to three to four cups of milk daily
More than 32 ounces of milk a day considerably limits the intake of solid foods, resulting in a deficiency of dietary iron, as well as other nutrients.

59. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus?

The correct answer is B: Set time aside to get the mother to express her feelings and concerns.
Non-judgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be revealed.

60. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client
The correct answer is B: Use oxygen during meals improves gas exchange
Clients with emphysema breathe easier when using oxygen while eating.

61. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?

The correct answer is B: Place the client in a sitting position with legs dangling
Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema. The result will enhance the client’s ability to breathe. The next actions would be to contact the heath care provider, then take the vital signs and then the administration of the antianxiety agent.

62. Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?

The correct answer is C: Assessing the client''s learning style
As with any anticipatory teaching, assess the client''s level of knowledge and learning style first.

63. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of

The correct answer is B: Dehydration
Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.

64. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

The correct answer is C: "If I drink, my baby may be harmed before I know I am pregnant."
Alcohol has the greatest teratogenic effect during organogenesis, in the first weeks of pregnancy. Therefore women considering a pregnancy should not drink.

65. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding?

The correct answer is A: Retractions in the soft tissues of the thorax
Slight intercostal retractions are normal. However in disease states, especially in severe airway obstruction, retractions become extreme.

66. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age?

The correct answer is B: Imitation of Sounds
Imitation of sounds such as "da-da" is expected at this time.

67. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?

The correct answer is D: "Would you like to take your medicine from a spoon or a cup?"
At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine will allow the child to express an opinion and have some control.

68. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction?

The correct answer is D: I can switch to a bottle if I need to take a break from breast feeding.
Babies adapt more quickly to the breast when they aren''t confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do. The use of an artificial nipple weakens the baby''s suck as the baby decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the learning stage of breast feeding.

69. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?

The correct answer is C: Mild emesis progressing to projectile vomiting
Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis as an initial finding. The other findings are present, though not initial findings.

70. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver?

The correct answer is B: It assesses a child''s development.
The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.

71. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should

The correct answer is C: Compile a history of behavior patterns and developmental accomplishments
A complete behavioral, and developmental history plays an important role in determining the diagnosis.

72. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by

The correct answer is B: Minimizing the episode and underestimating the victim’s injuries
Many abusers lack an understanding of the effect of their behavior on the victim and use excessive minimization and denial.

73. The nurse, assisting in applying a cast to a client with a broken arm, knows that

The correct answer is C: The wet cast should be handled with the palms of hands
Handle cast with palms of the hands and lift at 2 points of the extremity. This will prevent stress at the injury site and pressure areas on the cast.

74. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to

The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching
A toddler with atopic dermatitis need to have fingernails cut short and covered so the child will not be able to scratch the skin lesions, thereby causing new lesions and possible a secondary infection.

75. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?

The correct answer is C: Tripled the birth weight
The infant usually triples his birth weight by the end of the first year of life. Height usually increases by 50% from birth length. A 12 month- old child should have approximately 6 teeth. ( estimate number of teeth by subtracting 6 from age in months, ie 12 – 6 = 6). By 12 months of age, head and chest circumferences are approximately equal.

76. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
A) Age 40 years

The correct answer is D: Uses cocaine on weekends
Binge use of cocaine can be just as harmful to the breast fed newborn as regular use.

77. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?

The correct answer is A: Leave the room and return five minutes later and give the medicine
Since the nurse gave the child a choice about taking the medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not have an accurate sense of time, leaving the room and coming back later is another episode to the toddler.

78. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?

The correct answer is C: Riding a tricycle
Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.

79. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?

The correct answer is A: All lesions crusted
The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then crusts over. When all lesions are crusted, the child is no longer in a communicable stage.

80. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

The correct answer is D: Moist saline dressing
This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement. The wound must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more rapidly.

81. A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:

The correct answer is D: Reflects an average blood sugar for several months Glycosolated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 3-4 months and is used to monitor client adherence to the therapeutic regimen.

82. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should

The correct answer is C: Assist the client with pursed lip breathing Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.

83. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have


The correct answer is D: Heaviness in the affected testicle
The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and related issues are not affected at this time.

84. After successful alcohol detoxification, a client remarked to a friend, "I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink." The client’s belief that he needs alcohol indicates his dependence is primarily

The correct answer is A: Psychological
With psychological dependence, it is the client ‘s thoughts and attitude toward alcohol that produces craving and compulsive use.

85. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?

The correct answer is A: Separation anxiety
While a toddler will experience all of the stresses, separation from parents is the major stressor.

86. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?

The correct answer is C: Perceived loss of control
For school age children, major fears are loss of control and separation from friends/peers.

87. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?

The correct answer is A: Cardizem SR tablet (diltiazem)
Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The health care provider must substitute another medication.

88. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?

The correct answer is B: Drug tolerance
Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.

89. What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
The correct answer is A: Acceptance of the pregnancy
During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.

90. The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?

The correct answer is B: Prescribed use of an MAO inhibitor
SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.

91. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

The correct answer is C: Apply bulky, loose dressing to nose and ears.
Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.

92. A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

The correct answer is A: "Touching the abdomen could cause cancer cells to spread."
Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.

93. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?

The correct answer is C: Respiratory rate of 32
Clients with deep vein thrombosis are at risk for the development of pulmonary embolism. The most common symptoms are tachypnea, dyspnea, and chest pain.

94. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is

The correct answer is A: Avoid alcohol use during this time
Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the health care provider''s direction. During this time, alcohol must be avoided

95. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?

The correct answer is B: Administer the medication with a syringe next to the tongue
Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.

96. A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

The correct answer is B: Talk with the client to find out about the preferred herbal preparation
Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health-care provider is to understand the client''s perspective. "Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death".

97. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating

The correct answer is A: "I will increase sodium and fluids and restrict potassium."
The manifestation of Addison''s disease due to mineralocorticoid deficiency resulting from renal sodium wasting and potassium retention include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.

98. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to

The correct answer is A: Promote verbal and nonverbal communication with both the client and the interpreter
The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues

99. The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?

The correct answer is D: Color
Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.

100. The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
The correct answer is B: Frequent turning
Frequent turning will prevent skin breakdown.

NLE Practice Test D

Situation: Intrapartal Nursing Care

1. In the delivery room, Mrs. Oro Is 10 cm. Dilated- and the head is fast emerging. Her attending physician has not yet arrived. The initial action the nurse must take after the head emerges is:

a. Support the head while the rest of the body is spontaneously delivered.
b. Push down on the fundus to help expel the infant.
c. Call the doctor STAT
d. Deliver the shoulder by turning the presenting part to internal rotation.

2. As labor progresses satisfactorily, it would be appropriate to administer pain medication with cervical dilatation of:

a. 4 cm.
b. 3 cm.
c. 5 cm.
d. 7 cm.

3. Mrs. Oro is kept informed of the, progress of her delivery, the nurse anticipates the placenta to be delivered within what period of time following delivery

a. 10-15 minutes
b. 3-10 minutes
c. 15-20 minutes
d. 1-3 minutes

4. Several minutes after the delivery, the placenta is still intact. The nurse will do which of these actions?

a. Push gently, but firmly on the fundus
b. Call the nursing supervisor for help
c. Allow the infant to suck on the breast
b. Initiate separation by gently pulling on the cord.

5. The placenta has been delivered and the nurse now adds the medication ordered to the i.V. solution which is:

a. Methergin
b. Oxytocin
c. Penicellin
d. Atropine

6. The nurse is giving health education to Felicity about discomfort of pregnancy. Which of the following conditions is brought about by increased absorption of phosphorus?

a. Back pain
b. Leg cramps
c. Constipation
d. Heartburn

7. The nurse was Instructed to watch out for the occurrence of norma! physiologic changes of pregnancy. Which of the following is usually observed during pregnancy?

a. Increased BP
b. Palpitation
c. Anemia
d. Blurred vision

8. Which of the following is TRUE about latent stage of tabor?

a. self-focused
b. effacemant 100%
c. dilatation for 2 hours
d. 3 cm cervical dilatation

9. What is the term that refers to menopausal stage of women?

a. cessation of menstruation
b. onset of'menstruation
c. excessive menstruation
d. intermittent menstruation

10 What structure of the body is responsible for the production of follicle-stimutattng hormone (FSH)?

a. hypothalamus
b. thymus
c. kidney
d. anterior pituitary gland

11. A primigravida asks the nurse, "When will I fee! the baby move?" The correct response of the nurse is:

a. 3 mos
b. 5 mos.
c. 4 mos
d. 6rnos.

Situation: Rico. 1 month deliverd via NSVD

12. Mrs. Cadacia observed on Rico's buttocks, a gray color, What do you call this pigmentation in the skin?

a. milia
b. telangiectatic nevi
c. erythema toxicum
d. mongolian spots

13. How would you define a word, "acrocyanosis?

a. cyanosis of hands and feet.
b. transient mottling when infant is exposed to the temperature.
c. fine, downy hair
d. thin, white mucus

14. How can you assess a child who is mentally retarded?

a. let .the child make story
b. observe for the developmental milestone
c. ask the mother what food the child is eating
d. ask the child to sing

15. What serves as sperm producers?

a. epididymis
b. Vas deferens
c. prostate gland
d. testes

Situation: Pediatric nursing.

16. In what psychosexuai development according to Freud is temper tantrum observed?

a. phallic
b. oral
c. anal
d. latency

17. The baby cries and the mother notices tiny, shiny and white specks on the mouth and hard palate- The mother understood If she states:

a. "it is caused by milk curd
b. I'll use sterile gauzed in removing the crusts."
c. "I'll notify the dentist
d. "prevent infection"

18. The nurse is giving Instruction about neonatal care. Which of the following instruction is most critical?

a. proper feeding
b. provide bathing
c. provide warm clothing
d. prevent infection

19. The mother notices a cheese-like substances in a neonate forehead. She asked the nurse if it can be removed. The appropriate response is:

a. a soft towel and a baby oil can be used to remove the subslance
b. an alcohol and gauzed can removed it
c. it is a protected substance, leave It alone there
d. baby lotion can be used to remove it .

20. A 12-month old boy weighs 9 kgs. His birth weight was 3 kgms. "The mother asks if her baby's weight Is appropriate to his age. The nurse's therapeutic response is:

a. He needs to take more milk for supplement
b. Weight must be doubled during this time
c. Weight is right because weight is tripled at this age
d. He is underweight for this age.

21. At the age of 2 years, which of the following teeth have not been erupted?
a. canine
b. pre-molar
c. molar
d. incisor

22. The mother asks the nurse when will the soft bone at the head be closed? The nurse response would be:

a. 12-18wks
b. 2-3 mos.
c. 12-18 mos.
d. 14-18 wks

23. What is the most appropriate factor in toilet training?

a. age of child
b. developmental readiness of the child
c. available time
d. maternal flexibility

Situation: Medical - Surgical Nursing

24. In what area of the body will be affected by bed sore if the patient maintains supine position?

a. heels
b. ilium
c. sacrum
d. malleolus

25. Which of the following can you visualize in intravenous pyelogram (IVP )?

a. bladder
b. bladder and kidney
c. bladder, kidney , ureter
d. bladder and ureter

26. An anesthetic agent which has side effects of confusion and suicidal tendencies;

a. ether
b. ketalar
c. halothane
d. sodium pentothal

27. What instrument is not included in Mayo table?

a. retractor
b. tissue forcep
c. smooth forcep
d. towel forcep

Situation: The adolescent years have the potential to be very exciting as well as a different time for both the child and his parents.

28. As stated by Erikson, the major concern of the adolescent years is the:

a. formation of romantic association
b. attainment of independence '
c. gratification of his needs
d. resolution of the crisis of personal identity

29. Parental actions which can help achieve the goal of adolescent years are all of the following, EXCEPT;

a. permits increasing independence
b. discusses future plans with the adolescent
c. intolerance of .adolescent's need to be liked by peers
d. permits and encourages peer relationships

30. Here are teenagers today who engage In sex without realizing the repercussions of their actions. Witch of the parental response would be appropriate for this problem?

a. Providing regular and open communication
b. Limiting the number of teenager's social activities
c. Inforcing stricter rules and punishment
d. Screening the teenager's company of friends

31. Some of the task of adolescent years include the following, except:

a. developing a personal Identity
b. advicing independence from patients
c. developing relationship with peers
d. unlimited expression of sexual drives

32. Which of the following statements best describe the nutritional profiie of the adolescent?

a. Rapid growth, desires company with meals
b. Rapid growth, eat meals alone
c. Slow but steady growth, poor eating habits
d. Stunted growth, voracious appetite

Situation: You are assigned a Rural Health Unit which is a training area for student nurse, in a conference with the students, questions on the DOH programs such as:

33. The most effective measure of controlling schistosomlasis is;

a. casefinding and prompt treatment of cases
b. provision of sanitary toilets
c. environmental sanitation and environmental control
d. practice of hygiene

34. Rabies virus can be transmitted through:

a. Penetration of broken skin
b. contact with a pre-existing wound or scratch
c. penetration of intact mucosa
d. any of these modes of transmission

35. Which of the followimg statements about- diphtheria is false?

a. Immunity is often acquired through a complete immunization series of Diphtheria
b. infants born to immune mothers maybe protected up to 5 months
c. Diphtheria transmission Is Increased in hospital households, schools and other
crowded areas.
d. Recovery from clinical attack is always followed by a lasting Immunity to the
disease

Situation: The following questions pertain to concepts on Community Health Nursing:

36. A logical approach used by the nurse in providing community health and communicable nursing is:

a. problem solving
b. nursing process
c. logical nursing intervention
d. nursing assessment

37. Which of the following statement is wrong:

a. A nursing diagnosis is stated in terms of a problem and not a need
b. A nursing diagnosis describes a patient's health problem
c. A nursing process to the method of data gathering and diagnosing diseases
d. A component of the nursing process that pertains to the organization of data and describes the nursing problem is the assessment

38. Debbie is experiencing dystocia, a painful, difficult and prolonged delivery. The nurse is aware that the primary cause related to problems with all of these Except the.

a. Power
b. Prognosis
c. Passenger
d. Passageway

39. In dystocia, the nurse assessess:

1. contractions dropping intensity and frequency
2. progress of labor
3. vagina! exam
4. abdominal palpation and fetal position

a. 1,2 and 3
b. 1,2,3 and 4
c. 2,3 and 4
d. 1,3, and 4

40. The nursing intervention that Is most important in a patient on IV Morphine?

a. Monitor for hypertension
b. Monitor for decreased respiratlons
c. Monitor for cardiac rates
d. Monitor for hyperglycemia

Situation: A clinical instructor, Mrs. Romero is giving a pre-test on Psychiatric Nursing to third year nursing students.

41. The fundamental concepts in Psychiatric nursing is seeing the patient as a whole organism with distinct personality. The nurse should:

a. Respect the patient's moral values
b. Avoid labeling the patient as psychiatric entity
c. Understand the patient's family background
d. Uphold the patients right to make decisions

42. On crisis intervention, one of the important personal qualities . that can enhance the nurse's effectiveness is:a. Friendliness

b. Flexibility
c. Patience
d. Consistency

43. A technique In crisis intervention which 'involves using the clients emotion and values to his own benefit in the therapeutic regmen Is known as:

a. clarification
b. reinforcement of behavior
c manipulation
d. Support defense

44. Family therapy is the treatment of choice in one of the following situatlons:

a. There is a need to uncover repressed feelings and concerns of the clients
b. There is a need to promote an environment adaptive to the individual client's needs
c. The primary problem Is related to marital conflict or sibling rivalry
d. The client requested for this type of therapy

Situation - This pertains to Intrapartum Care.

45. True labor contraction Is best described by this discomfort that:

a. starts over the fundus, radiating downward to the cervix
b. radiates upward and downward from the umbilicus
c. Is localized over the fundus of the uterus
d. begins In the lower back and the abdomen radiating over entire abdomen

46. The nurse performs vaginal exams on a laboring woman and records this data is correctiy Interpreted as:

a. fetal presenting part is 1 cm. above the ischlal spines
b. cervical dilatation is 25% completed
c. progress of effacement is 5 cm. completed
d. fetal presenting part is 1 cm below the ischial spines

47.Monitoring the progress of labor in'the delivery room is a standard activity. The. nurse prioritizes her work load by recognizing that a nulliparous mother in the first stage of labor would expect these;

a. Latent phase is completed less than 20 hours
b. Maximum slope averages 4 to 5 hrs
c. Acceleration phase is 6 to 8 hours
d. Transition phase lasting no longer than 4 hours.

Situation - Growth and development is a human cycle with milestone to achieve. 48- Based on Erikson's theory, the primary developmental task of the middle years is:

a. to attain independence
b. to achieve generativity
c. to establish heterosexual relationship
d. to develop a sense of personal identity

49. Early adult age Is partlcular!y focused on achieving

a. independence from parental control
b. greater stability and life style
c. greater stability and life style
d. self-direction and self-appraisal

50. These are characteristics of a mature person, except;

a. practical and ambitious
b. accountable and responsible for his actions
c. feels comfortable with himself
d. acknowledges strengths and weaknesses .

51. The group at greatest risk for unmet needs is:

a. the very young and the very old
b. all age groups
c. the poor and the very rich
d. the adult and the aged

Situation -At the health center, the nurse conducts a, nutrition class, very lively question and answer prevailed in this group meeting-

52.Amy, a pregnant mother from a sectarian group strictly adheres to a. vegetarian diet. The vitamin supplement the nurse recommend Is

a. Vit.C
b. Vit B12
c. Vit D
d. Vit. A

53. For point of clarification a patient asks for the importance of Folic Acid in pregnancy. The nurse explains that vitamin is especially needed during pregnancy as it:

a. assists in growth of heart and lungs
b. helps in coagulation of red blood cells
c. is essential for cell and RBC formation
d. helps in maternal circulation

54. In this mother's class, the nurse discusses about: specific needs during pregnancy and lactation, She states that the daily servings required for the carbohydrates group are:

a. 4 servings
b. 6 servings
c. 2 servings
d. 3 servings

Situation - Charito de Lapaz, a PHN, is discussing with the mothers the different herbal medicines used In the community.

55. It is effective for asthma, cough, and dysentery:

a. Yerba Buena
b. Lagundi
c. Sambong
d. Tsaang-gubat

56. lt is an anti-edema, diuretic and anti-urolithiasis.

a. Sambong
b. Tsaang-gubat
c. Niyug-niyogan
d. Akapulko

57. Its seeds are taken 2 hours after supper to expel round worms, which can cause ascariasis;

a. Akapulko
b. Bayabas
c. Niyug-niyogan
d. Bawang

58. It is effectively used for mild non-insulin dependent diabetes mellitus.

a. bawang
b. Bayabas
c. Ulasimang Bato
d. ampalaya

59. The following are true in the preparation of herbal medicines, EXCEPT:

a. Avoid the use of Insecticides as may poison on plants
b. Stop giving the medication in case reaction such as allergy occurs
c. Use only the part of the plant being advocated
d. Use a day pot and cover while boiling at low heat.

Situation - Leo Leon, a carpenter has been complaining of headache for 2 days. his wife, a trained BHW used the acupressure technique on Leo to relieve Mm of his discomfort.

60. Acupressure was started same 5.000 years ago by:

a. Germans
b. Filipinos
c. Chinese
d. Americans

Situation - In a mother class, several topics are discussed. Questions 15 to 20 pertain to these

61. According to the goals of Reproductive health, all are true, EXCEPT:

a. Every pregnancy should be Intended
b. Every birth be healthy
c. Every woman should be g|ven a condom to protect herself from pregnancy and other STDs
d. Every sex should be free or coercion and infection

62. It is record used when rendering prenatal care in the community,

a. Prenatal record
b. Home Based mother's record
c. Pink Card
d. Mother's book

63. Which of the following is given to the pregnant woman?

a. Chloroquine
b. Iron
c. iodized oil capsule
d. All of the above

64 All of the following should be observed in home deliveries, EXCEPT:

a. Clean hands
b. Clean sheets
c. Clean cord
d. Clean surface

65. What is the major cause of maternal death?

a. Infection
b. Hemorrhage
c. Prolonged labor
d. Retained placenta

66. The first postparturn should be done when:

a. After 48 hours
b. After 24 hours
c. After 3 days
d. Within 24 hours .

Situation: The following questions are Included In the review of EPI

67. It provides for compulsory basic immunization for infants and children below 8 years of age;

a. Presidential proclamation N.773
b. Republic Act 7846
c Presidertial Decree No, 996
d. Presidential Proclamation No.147

68. The vaccine should be given on:

a. 1 month
b. 6 months
c. 3 months
d. 9 months

69. How much Vit A should be given to 6-11 months old Infants who is experiencing Vit. A deficiency?

a. 200,000 IU
b. 400.000 IU
c. 100,000 IU
d. 50,000 IU

70. Micronutrient supplementation is included In what program of the DOH?

a. Expanded program on Immunization
b. Reproductive Health
c. Araw ng Sangkap Pinoy
d. Sentrong sigla

Situation - Communicabie Diseases are most prevalent in Brgy, Problemado, a group of PHN went to the area to disseminate necessary information regarding early detection, control and cure of the different communicable diseases.

71. It is the name for a comprehensive strategy which primary health services around the world is using to detect and cure TB patients.

a. National TB program
b. Direct Observe Treatment Short Course (DOTS)
c. center for Communicable diseases
d. international TB control Organization

72. All but one is the early sign of leprosy:

a. Madarosis
b. Nasal obstruction or bleeding
c. Change In skin color
d. Ulcers that do not heal

73. Leprosy can be transmitted through

a. Blood
b. Sex
c. Semen
d. Prolonged skin to skin contact

74. The best method of prevention of TB and leprosy esp. among children is:

a. Taking INH for prophylaxis
b. Healthy environment
c. Good nutrition
d. BCG immunization

75. What is the host of schistosoma japonlcum?

a. Mosquitoes
b. Rats
c. Snails
d. Dogs

76.The drug cf choice for schistosomiasis:

a. Metrifonate
b. Praziquante
c. Hetrazan
d. Quinidine Suifale

Situation - Ella Caidic Is pregnant with her first baby. She went to the clinic for check-up

77. According to Mrs. Caidic, her LMP is November 15, 2002. Using the Naegele's rule what is her EDC

a. August 22, 2003
b. July 22, 2003
c. August 18, 2003
d. February 22, 2003

78. She Is so concerd about the development of varicose veins, which of the statement below indicates a need for further education?

a. "I should wear support hose"
b. '"I should be wearing flat, non-slip shoes that have an arch support
c. "I should wear a pantyhose"
d. I can wear knee-high as long as I don't leave them on longer than 8 hours

79. She complained of leg cramps, winch usually occurs at night. To provide relief, the nurse must telI Mrs. Caidic to:

a. dorsiftex the foot white extending the knee when the cramps occur
b. dorsiflex the foot whiie flexing the knee when the cramps occur.
c. Plantar flex the foot while flexing the knee when cramps occur
d. plantar flex the foot while extending the knee when the cramps occur.

NLE Practice Test C

1. A client is admitted with Wernicke's encephaiopathy. The nurse anticipates that the first physician's order will include:

a. Ordering an MRI
b. Administering a steroid medication, such as Decadron
c. Giving thiamine 100 mg IM STAT
d. Ordering an EEG

2. Which of the following statements, if made by a four year old child whose brother just died of cancer, would be age-appropriate?

a. "I know i will never see my mother again."
b. "I'm glad my mother isn't crying anymore."
c. "I can't wait to go get pizza with my brother."
d. "i know where my brother is buried."

3. A patient who has AIzheimer's disease is told by the nurse to brush his teeth. He shouts angrily, "Tomato soup!" Which of the following actions by the nurse would be correct?

a. Focusing on the emotional reaction
b. Clarifying the meaning of his statement
c. Giving him step-by-step directions
d. Doing the procedure for him

4. A nurse should teach a patient who is taking chlorpromazine (Thorazine) to avoid:

a. Exposure to the sun
b. Swimming in a chlorinated pool
c. Drinking fluids high in sodium
d. Eating foods such as chocolate and aged cheese

5. in caring for a psychotic patient who is experiencing hallucinations, which of the following interventions is considered critical?

a. Setting fewer limits in order to allow for more expressions of feeling
b. Maintaining constant observation.
c. Providing more frequent opportunities for interaction with others.
d. Constantly negating the patient's hallucinatory Ideations.

6. A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. Two weeks ago, his girlfriend broke off their engagement and cancelled the wedding. Given the Diagnosis and Statistical Manual of Mental Disorders, edition, text' revised (DSM-IV-TR) criteria for this disorder the nurse expects to find which of the following data during the interview with the client?

a. Current treatment for pneumonia
b. Regular use of alcohol and marijuana
c. Evidence of delusions and hallucinations
d. A history of chronic depression

7. A set of monozygotic twins who are 23 years old have begun attending groups at mental health center. One twin is diagnosed with schizophrenia. Her twin has no diagnoses but has been experiencing significant anxiety since becoming engaged. In counseling the engaged twin, it would be crucial to include which of the following tacts?

a. Her future children will be at risk for developing schizophrenia
b. She may have a predisposition for schizophrenia
c. One of her parents may develop schizophrenia later in life
d. It is unlikely that she wil! develop schizophrenia, at her age

8. A client tells the nurse that her co-workers are sabotaging the computer. When the nurse asks questions, the client becomes argumentative. This behavior shows personality traits associated with which of the following personality disorders?

a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal

9. Which of the following types of behavior is expected from a client diagnosed with paranoid personality disorder?

a. Eccentric
b. Exploitative
c. Hypersensitive
d. Seductive

10. A nurse is reviewing the serum laboratory test results for a client with sickle cell anemia. The nurse finding that which of the following values is elevated?

a. Hemoglobin F
b. Hemoglobin S
c. Hemoglobin C
d. Hemoglobin a

11. A parent with a daughter with bulimia nervosa asks a nurse, "How can my child have an eating disorder when she isn't underweight?" Which of the following responses is best?

a. "A person with bulimia nervosa can maintain a normal weight."
b. It's hard to face this type of problem in a person you love."
c. "At first there is no weight loss; it comes later In the disease."
d. "This is a serious problem even though there is no weight loss."

12. A nurse is assessing an adolescent girl recently diagnosed with an eating disorder and symptoms of bulimia nervosa. Which of the following findings is expected based on laboratory test results?

a. Hypocalcemia
b. Hypoglycemia
c. Hypokalemia
d. Hypophosphatemia

13. Which of the following complications of bulimia nervosa Is life threatening?

a. Amenorrhea
b. Bradycardia
c. Electrolyte Imbalance
d. Yellow skin

14. A nurse is talking to a client with bulimia nervosa about the complications of Laxative abuse. Which of the foilowing complications should be included?

a. Loss of taste
b. Swollen glands
c. Dental problems
d. Malabsorption of nutrients

15. A nurse is assessing a client to determine the distress experienced after binge eating. Which of the following symptoms are typical after bingeing?

a. Ageusia
b. Headache
c. Pain
d. Sore throat

16. Which of the following difficulties are frequently found in families with a member who has bulimia nervosa?

a. Mental Illness
b. Multiple losses
c. Chronic anxiety
d. Substance abuse

17. A client with anorexia nervosa tells a nurse, "My parents never hug me or say I've done anything right." Which of the following Interventions is the best to use with this family?

a. Teach the family principles of assertive behavior.
b. Discuss the difficulties the family has in social situations.
c. Help the family convey a positive attitude toward the client.
d. Explore the family's ability to express affection appropriately.

18. A client with anorexia nervosa tells a nurse she always feels fat. Which of the following interventions is the best for this client?

a. Talk about how important the client is.
b. Encourage her to look at herself in a mirror.
c. Address the dynamics of the disorder.
d. Talk about how she's different from her peers.

Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days following a hypophysectomy for a pituitary tumor. She is alert, oriented, and eager to return to her job as an executive to the hospital director. She is alert, oriented and eager to return to her job as an executive assistant to the hospital director. She calls the nurse to her room to express her concern about the frequency of urination she is experiencing, as well as the feeling of weakness that began this morning.

19. The most likely cause of her chief complaint this morning is

a. A decrease in postoperative stress causing poiyuria
b. The onset of diabetes mellitus, an unusual complication
c. An expected result of the removal of the pituitary gland
d. A frequent complication of the hypophysectomy

20. Following hypophysectomy, patients require extensive teaching regarding this major alteration in their lifestyle

a. Abnormal distribution of body hair
b. Lifetime dependency on hormone replacement
c. The need to drink many fluids to replace those lost
d. The need to undergo repeat surgical procedures

21. The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:

a. pupil size, response to pain, motor responses
b. Pupil size, verbal response, motor response
c. Eye opening, verbal response, motor response
d. Eye opening, response to pain, motor response

J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.

22. The nurse will monitor J.E. for the following signs and symptoms:

a. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
b. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
c. Loss of consciousness, bradycardia, petechiae, and severe leg pain
d. Change in leve! of consciousness, bradycardia, chest pain and oliguria

23. Appropriate nursing interventions for J.E. would be

a. Skin care and position q2h and prn; maintain alignment of extremities; respiratory exercises
b. Skin care/bathe daily; passive leg exercises daily; respiratory therapy for intermittent positive pressure breathing therapy
c. Skin care and position q2h; teach use of overhead trapeze; respiratory exercises, and intermittent positive pressure breathing q2h
d. Skin care q2h; teach use of overhead trapeze; respiratory exercises; use pressure relief devices

Ms. J., a 34-year old white female, is admitted via the emergency room complaining of abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who been managed at 30 U NPH insulin every AM and a 1200-calorie ADA diet. Her glucose in ER 700 mg/dL. Regular insulin 30 U was given and a repeat glucose were drawn. Results were not avaiIable upon transfer to the unit.

24. Given the above Information, which nursing activities should be highest priority?

a. Monitoring vita i signs
b. Obtaining blood glucose results
c. Assessing neurological status
d. Assessing pedai pulses and feet

25. The nurse received the lab results from the biood sample drawn in ER. Her glucose is now-100. However, her WBC count is 25,000 mm3. What conclusion can the nurse draw basing on this information?

a. Lab results are within normal limits, no action Is necessary
b. Her diabetes is out of control
c. insulin administration increase WBC count
d. Infection has increased her insulin needs

26. Later that evening, Ms. J's abdominal pain increased in intensity. A diagnosis of appendicitis is made and Ms. J is scheduled for surgery in the morning. The physician has written the following orders:

-NPO after midnight
-At 6 AM start-ari iV of D5W to be'infused at 250 ml/hr
-15 U NPH insulin at 6AM
-Draw FBS prior to initiating iV fluids

The statement that best describe the rationale for these orders Is:

a. To provide calories to offset the patient being NPO
b. To prevent a hypoglycemic reaction
c. To prevent a fluid volume deficit
d. To assist with the body's response to stress

27. When ambulating a client following surgical removal of a protruded intervertebral lurnbar disc, the nurse would do which of the following?

a. Maintain proper body alignment
b. Administer anaigesia after walking
c. Provide a cane for support
d. Immobilize the head and neck

28. Which of the following point scores on the post anesthesia chart, indicates that the client has fulfilled minimal criteria for discharge from the PACU?

a. One point In each of the five areas .for a total score of 5.
b. One point in at least three areas" respiratory, circulatory, and consciousness - for a total of 3
c. A total score for the five areas of 7 or.above.
d. Two points each in each of the five areas for a total score of 10.

29. Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?

a. "I think you should ask the doctor. Would you like me to cail him for you?"
b. " The blood supply to the brain has decreased causing permanent brain damage."
c. "It Is a temporary interruption in the blood flow to the brain."
d. "TIA means a transient ischemic attack."

30. While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?

a. Wash the radiation site vigorously with soap and water to remove dead cells.
b. Eat a diet high in protein and calories to optimize tissue repair.
c. Apply coo! compresses to the radiation site to reduce edema,
d. Drink warm fluids throughout the day to relieve discomfort in swallowing.

31. A client using an over-the counter nasal decongestant spray reports unrelieved and worsening nasal congestion. The nurse should instruct the client to do which of the following?

a. Switch to a stronger dosage of the medication.
b. Discontinue the medication for a few weeks
c. Use the spray more frequently
d. Combine the spray with an oral decongestant.

32. Following a thyroidectomy, the client experiences.hemorrhage. The nurse would prepare for which of the following emergency Interventions?

a. intravenous administration of calcium
b. insertion of an oral airway
c. Creation of a tracheostomy
d. Intravenous administration of thyroid hormone

33. After a client signs the form, giving informed consent for surgery and the physician !eaves the room, the client asks the nurse, "When will this hotel bring me some food?" After confirming that the client is confused, which of the following would be the nurse's priority action?

a. Reporting that the consent has been obtained from a confused client.
b. Teaching preoperative moving, coughing, and deep-breathing,exercises.
c. Inserting a bladder catheter to urine output.
d. Administering preoperative medication immediately ,

34. At 16 weeks gestation, no fetal heart rate was detected during assessment of a pregnant patient. An ultrasound confirmed a hydatidiform molar pregnancy. Which of the following actions should the nurse tell the patient to expect during her one-year follow-up?

a. Multiple serum chorionic gonadotropin levels will be drawn
b. An Intrauterine device will be used to decrease vaginal bleeding
c. Pregnancy will be restricted for another year
d. Oral contraceptives will not be prescribed because they will increase the risk' of cancer

35. Thirty minutes after the nurse removes a nasogastric tube that has been In piace for seven days, the patient experiences epistaxis (nosebleed). Which of the following nursing actions is most appropriate to control the bleeding?

a. Apply pressure by pinching the anterior portion of the for five to ten minutes
b. Place the patient in a sitting position with the neck hyperextended
c. Pack the nostrils with gauze and keep the gauze in piace for four to five days
d. Apply ice compresses to the patient's forehead and back of the neck

36. The staff nurse calls a physician regarding an order to administer digoxin (Lanoxin) to a patient with a pulse of 55 and a serum potassium levei of 2.9 mEq/L The physician says to give the medication, as ordered .The staff nurse's best response would be

a. "I'll give the medication but you wiil still be responsbIe if anything happens to the patient."
b. "I will not give this medication."
c. '"I think we should discuss this with the nursing supervisor."
d. "I'm sorry, but if you want the medication given, you will have to give it yourself."

37. During the night, shift report, the charge nurse learns that an elderly patient has become very confused and is shouting obscenities and undressing himseif. Which of the following actions is the most appropriate Initial nursing response?

a. Restrain the patient with a Posey jacket
b. Medicate the patient with haloperidol (Haldol) as ordered.
c. Notify the physician
d. Complete a nursing assessment of the patient

38. When a woman is 10weeks pregnant which of the following hematology test results would need further Investigation?

a. Hemoglobin level of 9 mg/dL
b. white blood cell count of 15,000/cu mm
c. platelet count of 200,000/cu mm
d. red blood cell count of 4,200,000/ cu mm

39. Which of the foitowing techniques would a nurse use when interviewing a 94-year-old patient?

a. Using a low-pitched voice
b. Enunciating each word .slowly
c. Varying voice intonations
d. Reinforcing the words with pictures .

40. A patient who is receiving total parenteral nutrition has an elevated blood glucose eve! and is to be administered intravenous insulin. Which of the following types of insulin should a nurse has available?

a. Isophane insulin (NPH)
b. Regular insulin (Humulin R)
c. Insulin zinc suspension (Lente)
d. Semi-Lente Insulin (Semiterd)

41. A nurse is taking history from a patient who has just been admitted to the hospital withl an acute myocardia! infarction. Which of the following questions would be most important for the nurse to ask?

a. "At what time did the pain start?"
b. "When did you eat your last meal?"
c. "Have you experienced a pounding headache?"
d. "Did you feel fluttering in your chest"

42. An infant who weighs 11 lbs. is to receive 750 mg of an antibiotic in a 24-hour period. The liquid antibiotic comes in a concentration of 125 mg/5ml. If the antibiotic were to be given three times each day. how many ml would the nurse administer with each dose?

a. 2
b. 5
c. 6.25
d. 10

43. Spasm of the neck muscles developed in a patient who is taking phenothiazine (Nemazine). Which of the following medications should the nurse administer?

a. Vistaril)
b. Acetaminophen (Tyienol)
c. Acetylsalicylic acid (Aspirin)
d. Benztropine mesyiate (Cogentin)

Mr. Anthony Malailinelii is a 54-year old truck driver. He is admitted for possible gastric ulcer, He is a heavy smoker.

44. When discussing his smoking habits with Mr. Martinelli. the nurse should advise him to:

a. Smoke low-tar, filter cigarettes
b. Smoke cigars instead
c. Smoke only right after meals
d. Chew gum Instead

45. As the nurse preparing Ivlr. Martinelii for gastric analysis. You should know which of the following Is not.correct concerning this test

a. The patient Is fasting 12 hours prior to test
b. Gastric contents are aspirated via a tube
c. Smoking for 8 hours prior to test is not allowed
d. Various position changes are necessary during the test

46. Mr. Martinelli had an Hgb of 9.8. You would not find which of the following assessments in a patient with severe anemia?

a. Pallor
b. Cold sensitivity
c. Fatigue
d. Dyspnea only on exertion

47. When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?

a. moist gurgling respirations
b. Weak, slow pulse
c. Distended neck veins
d. Dyspnea and coughing

48. A new staff nurse is on an orientation tour with the head nurse. A client approaches her and says, "I don't belong here. Please try to get me out." The staff nurse's best response would be:

a. "What would you do if you were out of the hospital?"
b. "I am a. new staff member, and I'm on a tour. I'll come back and talk with you
later."
c. "I think you should talk to the head nurse about that.'
d. "I can't do anything about that."

49. A 50 year-old male client has a history of many hospitalizations for schizophrenic disorder. He has been on long-term phenothiazines (Thorazine), 400 mg/day. The nurse assessing this client observes that he demonstrates a shuffling gait, drooling and exhibits generaj dystonic symptoms.. From these symptoms and his history, the nurse concludes that the client has developed:

a. Tardive dyskinesia
b. Parkinsonism
c. Dystonia
d. Akathisia

50. A client with antisocial personality disorder tells a nurse "Life has been full of problems since childhood." Which of the following situations or conditions would the nurse explore in the assessment?

a. Birth defects
b. Distracted easily
c. Hypoactive behavior
d. Substance abuse

51. A client with antisocial personality disorder is trying to manipulate the healthcare team. Which of the following strategies is important for the staff to use?

a. Focus on how to teach the client more effective behaviors for meeting basic needs.
b. Help the client verbalize underlying feelings of hopelessness and learn coping skills.
c. Remain calm and don't emotionally respond to the client's manipulative actions.
d. Help the client eliminate the intense desire to have everything in life turn out perfectly.

52. A client with antisocial personality disorder is beginning to practice several socially acceptable behaviors in the group setting. Which of the following
outcomes will result from this change?

a. Fewer panic attacks
b. Acceptance of reality
c. Improved self-esteem
d. decreased physical symptoms

53. Which of the following discharge instructions would be most accurate to provide to a female client who has suffered a spinal cord injury at the C4 level?

a. After a spinal cord injury, women usually remain fertile; therefore, you may consider contraception if you don't want to become pregnant.
b. After a spinal cord injury, women usually are unable to conceive a child.
c. Sexual intercourse shouldn't be different for you.
d. After a spinal cord injury, menstruation usually stops.

54.A client with chronic obstructive pulmonary disease (COPD) tells the nurse, "I no longer have enough energy to make love to my husband." Which of the following nursing interventions would be most appropriate?

a. Refer the couple to a sex therapist.
b. Advise the woman to seek a gynecologic consult
c. Suggest methods and measures that facilitate sexual activity.
d. Tell the client, "if you talk this over with your husband, he will understand.

55. A cllent tells the nurse she is having her menstrual period every 2 weeks and it lasts for 1 week. Which of the following conditions is best defined by this menstrual pattern?

a. Amenorrhea
b. Dyspareunia
d. menororrhagia
d. metrorrhagia

56. A nurse has just been toSd by a. physician that an order has been written to administer an iron injection to an adult client. The nurse plans to administer the medication In which of the following locations?

a. In the gluteal muscle using Z-track technique
b. In the deltoid muscle using an air lock
c. In the subcutaneous fesue of the abdomen
d. in the anterior lateral thigh using a 5/8 inch needle '

57. A 59-year-old patient with a diagnosis of delirium is admitted to the hospital. To evaluate the cause of a patient's delirium, blood is sent to the laboratory for analysis. The results are as follows: M,a+ 1.56, Cr 100. K4' 4.0, C0221, BUN 86, glucose 100. Based on these laboratory result, the nurse should record which of the following nursing diagnoses on the patient's care. plan?

a. Alteration in patterns of urinary elimination.
b. Fluid volume deficit
c. Nutritional deficit: less than body requirements
d. Self-care deficit: feeding

58. The nurse knows that gender Is part of one's identity. Which of the following events signifies when gender is first ascribed?

a. A baby is born
b. A child attends school
c. A child receives sex-specific toys
d. A child receives sex-specific clothing

NLE Practice Test B

Situation 1 A client is brought into the emergency department with brain stem contusion

1. Two days after the admission, the client has a large amount of urine and a serum sodium level of 155 mEq/dl. Which, of the following conditions may be developing?

a. Myxedema coma
b. Diabetic insipidus
c. Type 1 diabetes mellitus
d. Syndrome of inappropriate ant-diuretic Hormone secretion

2. After a thorough assessment and laboratory works shall shows serum ketones and serum glucose level above 300mg/dl, what condition would be diagnosed to patient?

a. Diabetes insipidus
b. Diabetes ketoacidosis
c. Hypoglycemia
d. Somogyi phenomena

3. Which of the following combinations of adverse effects must be carefully monitored when administering I.V. insulin to a client diagnosed with diabetic ketoacidosis?

a. Hypokalemia and hypoglycemia
b. Hypocalcemia and Hyperkalemia
c. Hyperkalemia and hyperglycemia
d. Hypernatremia and hypercaleemia

4. Which of the following method of insulin administration would be used in the initial treatment of hyperglycemia in a client with diabetic ketoacidosis.

a. Subcutaneous
b. Intramuscular
c. I.V bolus only
d. I.V. bolus followed by continuous infusion

5. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can be differentiated from diabetic ketoacidosis by which of the following conditions?

a. Hyperglycemia
b. Serum osmolarity
c. Absence of ketosis
d. Hypokalemia

Situation 2: Mr. Reynaldo Layag executive officer, was brought to the hospital because of chest pain-Diagnosis of angina was established.

6. Mr. Layag state that his anginal pain increases after activity. The nurse should realize that the angina pectoris is a sign of:

a. Mitral insufficiency
b. Myocardial infraction
c. Myocardial ischemia
d. Coronary thrombosis

7. Nitroglycerine S.L. is prescribed for Mr. Layag'a anginal pain. When teaching how to use nitroglycerine, the nurse tells him to place 1 tablet under the tongue when pain occurs and to repeat the dose in 5 minutes if pain persist. The nurse should tell Mr. Layag to:

a. Place two tablets under the tongue when the intense pain occurs
b. Swallow 1 tablet and place 1 tablet under the tongue when pain is intense
c. Place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes if pain occurs
d. Place 1 tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent reoccurrence

8. The nurse realizes that the pain associated with coronary occlusion is caused primarily by:

a. Arterial Spasm
b. Ischemia of the heart muscle
c. Blocking of the coronary veins
d. Irritation of the nerve endings in the cardiac plexus

9. When cardiovascular disease is concern, reduction of the saturated fat in the diet may be desired and substance made of polyunsaturated fat When teaching about this diet the nurse should instruct Mr. Layag to avoid :

a. Fish
b. Corn Oil
c. Whole milk
d. soft margarine

10. When teaching Mr. Layag, who has been placed on a high-unsaturated fatty acid diet, the nurse should stress the importance of increasing the intake of:

a. Enriched whole milk
b. Red meats, such as beef
c. Vegetables and Whole Grains
d. Liver and other glandular organ meals

Situation 3: A group of nursing students were discussing the normal growth and development concepts when assigned to observe the school children.

11. During the oedipal stage of growth and development, the child:

a. Loves and hates ( ambivalence) both parents
b. Loves the parent of the same sex and the parent of the opposite sex
c. Loves the parent of the opposite sex and hates the parent of the same sex
d. Love the parent of the same sex and hates the parent of the opposite sex.

12. The stage of growth and development basically concerned with the role identification is the:

a. Oral Stage
b. Genital-Stage
c. Oedipal Stage
d. Latency stage

13. Play for the preschool-age child is necessary for the emotional development of:

a. Projection
b. Introjection
c. Competition
d. Independence

14. Resolution of the oedipal complex takes place when the child overcomes the castration complex and:

a. Rejects the parent of the same sex
b. Introjects behavior of both parents
c. Identities with me parent of the same sex
d. Identifies with the parent of the opposite sex

15. Any surgery should be delayed, if possible, because of me effects on personality development during the

a. Oral Stage.
b. Anal Stage
c. Oedipal Stage
d. Latency Stage

Situation 4 - Transurethral resection prostatectomy, (TURP) is performed to Mr. Recto, 60 years old, due to prostate enlargement. Post operatively he has continuous irrigation (Cystoclysis).

16. Which of these statements explain the reason for continuous bladder irrigation?

a. To remove clot from the bladder
b. To maintain the patency of the catheter
c. To maintain the patency of me bladder
d. To dilute urine

17. Nursing assessment is vital to prevent and detect indications of postoperative complications. The following are the possible complications after prostatectomy except:

a. Residual urine
b. Urethral structure
c. Erectile dysfunction
d. The drainage has stopped

18. When should the nurse increase, the flow rate of cystoclysis of Mr.Recto?

a. The drainage appear cloudy
b. The drainage is continuous but slow
c. The drainage is bright red
d. The drainage has stopped

19. After the removal of the three way catheter, the nurse should inform Mr. Recto that he can normally experience:

a. Dribbling incontinence
b. Polyuria
c. Dysuria
d. The drainage has stopped

20. Which of the following measures should you encourage Mr. Recto to do, in order to regain urinary control?

a. Wear scrotal support
b. Take warm bath 2 times daily
c. Ambulate frequently
d. Alternately tense and relax the perineal muscles

Situation 5 - Nurses are generalist, in order to cope up with the works demand you must have broad knowledge on anything. Nurse Joan was assigned in the medical ward. During the endorsement she found out that she was assigned to several patients of different case

21. When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress

a. Glaucoma is easily corrected with eye glasses
b. White and Asian individuals are the highest risk of glaucoma
c. Yearly screening for people ages 20 to 40 years is recommended
d. Glaucoma can be painless and visions may be lost before the person is aware of the problem.

22. Which of the conditions is an early symptoms cgmmonly seen in Myasthenia Gravis?

a. Dysphagia
b. Fatigue improving at the end of the day
c. Ptosis
d. Respiratory Distress

23. Which of the following statements best describes the Parkinson's Disease?

a. Loss of myelin sheath surrounding peripheral nerves
b. Degeneration of the substantia nigra; depleting dopamine
c. Bleeding into the brain stem, resulting in meter dysfunction
d. An autoimmune disorder that destroys acetlycholine receptors

24. Which of the following pathophysiological processes are involved in multiple sclerosis (MS)?

a. Destruction of the brain stem and basal ganglia in the brain
b. Degeneration of the nucleus pulposus, causing pressure on the spinal cord
c. Chronic inflammation of rhizomes just outside the central nervous system
d. Development of demyelinization of the myelin sheath, interfering with the nerve transmission

25. When teaching the client, with Meniere's disease, which of the following instructions would a nurse give about vertigo.

a. Report dizziness at once
b. Drive in daylight hours only
c. Get up slowly, turning the entire body
d. Change your position using the logroll technique

Situatitm 6 - Mr. Punsalan is 36 years old, was admitted to the hospital with complaints of a burning sensation in the epigastric area after eating and inability to sleep at night. He was placed on bed rest and schedule for diagnostic studies. A diagnosis of Peptic Ulcer was made.

26. Mr. Punsalan with gastric pain is advised to take any one of the following antacids, except:

a. Aluminum hydroxide
b. Calcium bicarbonate
c. Magnesium carbonate
d. Sodium bicarbonate

27. An occult blood examination was ordered. The specific specimen needed from Mr. Punsalan is;

a. Stool
b. Blood
c. Sputum
d. Gastric juice

28. Preparation of Mr. Punsalan for occult blood examination is :

a. Fluid intake is limited only 1 liter/day
b. NPO for 12 hours prior to obtaining of specimen
c. Fluid intake is increased
d. Meatless diet for 48 hours prior to obtaining of specimen

29. X -ray examination for Mr. Punsalan to detect tumors or ulcerations of the stomach and duodenum is:

a. Gastroscopy
b. GIT series
c. Cold G.I. series
d. Ba enema

30. Diet that prevents gastric irritation in case of Mr. Punsalan is:
a. Bland Diet
b. Liquid Diet
c. Full Diet
d. High Protein low fat diet

Situation 7 - Mr. Reyes suffered head injuries in a motor vehicle accident

31. When caring for Mr. Reyes, the nurse should assess for

a. Decreased carotid pulses
b. Bleeding from oral cavity
c. Altered level of consciousness
d. Absence of deep tendon-reflexes

32. Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;

a. Confusion or delirium can be a defense against further stress
b. Destruction of brain cells has occurred, interrupting mental activity
c. Teaching based on information progressing from the simple to the complex
d. A minimum of information should be given, since he is unaware of surroundings

33. Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the

a. Frontal lobe
b. Occipital lobe
c. Six cranial nerve (abducent)
d. Eight Cranial Nerve (Vestibulocochlear)

34. Mr. Reyes has a possible skull fracture. The nurse should:

a. Observe him for signs of Brain injury
b. Check for hemorrhaging from the oral cavity
c. Elevate the foot of the bed if he develops symptoms of shock
d. Observe for symptoms of decreased intracranial pressure and temperature

35. Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;

a. Provide positive feedback when he uses the word correctly
b. Wait for him to verbally state needs regardless of how long it may take c. Suggest that he get help at home because the disability is permanent
d. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication

Situation 8 - Patricia Zeno is a client with history myasthenia gravis.

36. Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:

a. Progressive deterioration until death
b. Increased risk of respiratory complications
c. Deficiencies of essential neurotransmitter
d. Involuntary twitching of small muscle groups

37. Myasthenia gravis most frequently affect:

a. Males ages 15 to 3 5 years
b. Children ages 5 to 15 years
c. Female ages 10 to 30 years old
d. Both sexes ages 20 to 40 years

38. Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

a. A genetic defect in the production of acetylcholine
b. A reduced amount of neurotransmitter acetylcholine
c. A decreased number of functioning acetyl-choline receptor sites
d. An inhibition of the enzyme Ache leaving the end plates folded.

39. To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:

a. A tracheostomy set
b. An intravenous set-up
c. A hypothermia blanket
d. A syringe and edrophonium HCl(Tensilon)

40. Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:

a. For its synergestic effect
b. To rule out cholinergic crisis
c. To confirm the diagnosis of myasthenia
d. Because of the client's resistance to Neostigmine

Situation 9 - Hariet, a 38 year-old school teacher with rheumatoid arthritis, is admitted to the hospital with severe and swelling of the joints of both hands.

41. A regimen of rest, exercises and physical therapy is ordered for Hariet This regimen will;

a. Prevent arthritic pain
b. Halt me inflammatory process
c. Help prevent the drippling effects of the disease
d. Provide for the return of joint motion after prolonged loss

42. Hariet ask the nurse why the physician is going to inject hydrocortisone into her affected joint. The nurse explains that the most important reason for doing this is to:

a. Relieve pain
b. Reduce inflammation
c. Provide Psychotherapy
d. Prevent ankylosis of the joint

43. When planning nursing care for Hariet, the nurse should take into consideration the fact that:

a. Inflammation of the synovial membrane will rarely occur
b. Bony ankylosis of the joint is irreversible and causes immobility
c. Complete immobility is desired during the acute phase of inflammation
d. If the redness and swelling of a joint occur, they signify irreversible damage

44. The diet the nurse would expect the physician to order for Hariet would be:

a. Salt free and low fiber
b. High calorie with low cholesterol
c. High protein with minimal calcium
d. Regular diet with vitamins and minerals

45. The medication the nurse would expect to prescribed to relieve Hariet's pain;

a. Xanax 0.5 mg, TID
b. Aspirin, 0.6 g_q4
c. Codeine , 30 mg, q4
d. Meperidine 30 mg q4 pm

Situation 10 - Lizbeth 20 year-old college student is brought to the hospital by her mother who states that for the past week her behavior has become very strange. She has become more and more withdrawn - Diagnosis: Schizophrenia Catatosis. ' •

46. During the physical assessment Lizbeth's arms remains outstretched after her pulse and blood pressure were taken and the nurse has to reposition it for her. Lizbeth is showing;

a. Distractability
b. Muscle rigidity
c. Waxy flexibility
d. Echopraxia

47. Lizbeth keeps her eyes closed and does not answer the questions asked by the nurse or physician. The nurse know that;

a. The patient can cannot hear nor understand what is being asked
b. The patient is aware of what is happening around her even though she does not respond
c. The patient is in regressed state and should be treated like a frightened child
d. The patient is aware of what is going on around her and could respond if she wants to.

48. While Lizbeth remains in an unreasonable state, does not eat or drink, the nurse first priority id to assess her:

a. Fluid intake and output
b. Skin turgor
c. Bowel elimination
d. Vital signs such as T.P.R. and blood pressure

49. One evening, Lizbeth suddenly begins running up and down the hall. She strips her clothing and strikes out widely at anyone she sees. All of the following interventions would be appropriate except:

a. Restrain me patient and call for help
b. Call for the assistance of at least three staff members
c. Clear the area of other patients
d. Obtain me order and prepare chlorpromazine (thorazine)

50. When Lizbeth become agitated, the therapeutic approach of the nurse is one that is:

a. Authoritarian and directive
b. Related casual and friendly
c. Permissive and comforting
d. Calm and firm but not threatening

Situation 11- Michelle, 36 weeks gestation visits the hospital because the suspects that her bag of water was ruptured. -

51. While the nurse is assessing Michelle, she states that her bag of water ruptured few minutes ago. Which of the following should the nurse do first?

a. Check the status of the fetal heart rate
b. Turn the client to her right side
c. Test the leaking fluid with nitrazine paper
d. Perform a sterile vaginal examination

52. To confirm Michelle's statement, the nurse uses nitrazine paper; if the membrane has ruptured the paper which of the following color?

a. Yellow
b. Green
c. Blue
d. Blue

53. After being confirmed that membranes has been ruptured and there was no evidence of labor, which of me following would the nurse expect the physician to order?

a. Frequent assessment of cervical dilation
b. Intravenous oxytocin adminitration
c. Vaginal culture for Neisseria Gonorrhoeae
d. Sonogram for amniotic fluid volume index

54. Few hours after, the nurse noted that her cervix is 2 cm dilated and 50% effaced. Which of the following would the priority assessment for this client?

a. Red blood cell count
b. Degree of Discomfort
c. Urinary Output
d. Temperature

55. Michelle is to be discharged home on bed rest with follow -tip by the community health nurse. After instruction about care while at home, which of the following client's statements indicates effective teaching?

a. "It is permissible to douche if the fluid irritates my vaginal area."
b. " I can take either a tub Bath or a shower when I feel it"
c. "I shouldn't limit my fluid intake to less than 1 quart daily."
d. " I should contact the doctor if my temperature is 100.4 F or higher."

Situation 12 - Jerome, a 37 years old man, was admitted to the hospital with periodic episode of manic behavior alternating with me depression. Diagnosis: Bipolar I disorder.

56. Which of the following statements is true and manic reaction? It is;

a. An expression of destructive impulse
b. A means of coping with frustrations and disappointments
c. A Means of Ignoring reality
d. An attempt toward off feeling of underlying depression.

57. Nursing care plan for a hyperactive patient like Jerome, should give priority to:

a. Discourage him from manipulating the staff
b. Prevent him from assaulting other patients
c. Protect him against suicidal attempts
d. Provide adequate food and fluid intake

58. During a nurse patient interaction, Jerome jumps rapidly from one topic to another. This is known as:

a. Flight of Ideas
b. Idea of Reference
c. Clang association
d. Neologism

59. A priority nursing diagnosis would be

a. Ineffective individual coping
b. Altered family process
c. Potential for violence, self directed
d. Sensory perceptual disturbance

60. Initially one of the following activities would be appropriate for Jerome;

a. Playing basketball
b. Playing chess
c. Gardening
d. Writing

Situation 13 - .Mr,. Baldo , 36 years old patient complaints of fatigue, weight loss, and low-grade fever. He also has pa in his fingers, elbows, and ankles.

61. Which of the following conditions is suspected?

a. Anemia
b. Leukemia
c. Rheumatic arthritis
d. Systematic Lupus Erythematosus (SLE)

62. Systematic lupus erymematosus (SLE) primarily attacks which of the following tissues?

a. Connective
b. B. Heart
c. Lung
d. Nerve

63. Which of the following elements shows that the client does not understand the cause of exacerbation of system lupus erythematosus (SLE)?

a. " I need to stay away from sunlight"
b. "I don't have to worry if I get a strep. throat
c. I need to work on managing stress in life."
d. "I don't have to worry about changing my diet."

64. Which of the following symptoms is a classic sign of systemic lupus erythematosus (SLE)?

a. Vomiting
b. Weight loss
c. Difficulty urinating
d. Superficial lesions over the cheek and nose

65. Mr Balao asks the nurse as to the source of this disease. The nurse is aware that this is a disease of:

a. Joints
b. Bones
c. connective tissue
d. purine metabolism

Situation 14 - Mr Gil age 86 years, has been diagnosed with Alzheimer's disease.

66. Which characteristics could the nurse expect when observing Mr. Gil?

a. Transient ischemic attacks
b. Remissions & exacerbations
c. Rapid deterioration of mental functioning because of arteriosclerosis
d. Slowly progressive deficits in intellect, which may be noted for a long time

67. Mr. Gil frequently switches from being pleasant and happy to being hostile and sad without apparent external cause. How can the nurse best care for Mr. Gil?

a. Try to point out reality to him
b. Avoid Mr. Gilwhen he is angry and sad
c. Encourage him to talk about his feelings
d. Attempt to give nursing care when he is in a pleasant mood

68. What type of environment should be provided by the health care team for Mr. Gil?

a. Familiar
b. Variable
c. Challenging
d. Non-stimulating

69. Mr. Gil will need assistance in maintaining contact with society for as long as possible. Which therapy might help him achieve this goal?

a. Psychodrama
b. Recreation therapy
c. Occupational therapy
d. Remotivation therapy

70. What is the nurse's primary objective for Mr. Gil when he is experiencing dementia and delirium?

a. Diminished psychologic faculties
b. Interaction with the environment
c. Participation with the environment
d. Face to face contact with the other clients

Situation I5: Baby Philip, a full term male child, is delivered by his mother who is RH negative.

71. At the time of delivery, baby Philip's blood is typed to determine the ABO group and the presence of the RH factor. The nurse is aware that:

a. The RH factor is not genetically determined
b. Not all infants of RH-positive fathers are RH positive
c. The RH factor of the fetus is determined by the father
d. During gestation, the RH factor of the fetus may change

72. Baby Philip is RH positive and his mother is RH negative. Baby Philip is to receive an exchange transfusion. The nurse know that he will receive RH-negative blood because:

a. It is me same as die mother's blood
b. It is neutral and will not react with his blood
c. It eliminates the possibility of a transfusion reaction occurring
d. His RBC's will not be destroyed by the maternal anti-RH antibodies

73. Hyperbilirubinemia is anticipated to baby Philip because of RH incompatibility. Hyperbilirubinemia occurs with incompatibility between mother and fetus because

a. The mother's blood does not contain the RH factor, so she produces anti-RH antibodies that cross the placental barrier and cause hemolysis of red blood cells in infants
b. The mother's blood contains the RH factor and the infant's does not, and antibodies are formed in the fetus that destroy red blood cells.
c. The mother has the history of previous yellow jaundice caused by a blood transfusion, which was passed the fetus through the placenta.
d. The infant develops a congenital defect shortly after birth that causes the destruction of red blood cells.

74. If RhoGAm is given to Baby Philip's mother after delivering Baby Philip, the condition that must be present rbr the globulin to be effective is that:

a. Philip's mother is Rh positive
b. Baby Philip is Rh negative
c. Philip's mother has no titer in her blood
d. Philip's mother has some titer in her blood

75. When the nurse brings Philip to his mother, she comments about the milia on the baby's face. The nurse should:

a. Tell her that all babies have them and they clear up in 2 to 3 days
b. Explain that these are birthmarks that will disappear within a few months
c. Instruct her about proper handwashing since the milia can be infectious
d. Instruct her to avoid squeezing them or attempting to wash them off

Situation 16: Ronald 23 years old was voluntarily admitted to the in-patient unit with a diagnosis of paranoid schizophrenia.

76. As the nurse approaches Ronald he says, "If come any closer. I'll die." This is an example of:

a. Hallucination
b. Delusion
c. Illusion
d. Idea of reference

77. The best response for the nurse to make to this behavior is:

a. "How can I hurt you?"
b. "I'm the nurse."
c. "Tell me more about this."
d. "That's a silly thing to say."

78. When communicating with the paranoid client, the main principle is to:

a. Use logic and be persistent
b. Provide an anxiety-free environment
c. Express doubt and do not argue
d. Encourage ventilation of anger

79. Ronald is pacing the hall and is agitated. The nurse hears him saying, "Those doctors are faying to commit me to the state hospital. The nurse's continued assessment should include:

a. Clarifying information with the doctor
b. Observing Ronald for rising anxiety
c. Reviewing history of involuntary commitment
d. Checking dosage of prescribed medication

80. An appropriate activity for the nurse is to recommend for a client who is extremely agitated is:

a. Competitive sports
b. Bingo
c. Trivial Pursuit
d. Daily walks

Situation 17: Mrs. Lim has had confirmation of her pregnancy. She presents the emergency room with abdominal pain not yet. diagnosed.

81. The nurse would suspect an ectopic pregnancy if Mrs Lim complained of:

a. An adherent painful ovarian mass
b. Lower abdommal cramping for a long period of time
c. Leukonhea and dysuria a few days after the first missed period
d. Sharp lower right or left abdominal pain radiating to the shoulder

82. The most common type of ectopic pregnancy is tubal. Within a few weeks after conception the tube may rupture suddenly, causing:

a. Painless vaginal bleeding
b. Intermittent abdominal contractions
c. Continues dull, upper-quadrant abdominal pain
d. Sudden knife-like, lower-quadrant abdominal pain

83. Mrs. Lim has been complaining of vaginal bleeding and one sided lower quadrant pain. The nurse suspects mat she has:

a. Abruptio placenta
b. An incomplete abortion
c. An ectopic pregnancy
d. A rupture of graafian follicle

84. A few hours after being admitted with a diagnosis of inevitable abortion, a client begins to experience bearing down sensations and suddenly expels the products of conception in bed. To give safe nursing care, the nurse should first

a. Check the fundus for firmness
b. Give her the sedation
c. Immediately notify the physician
d. take her immediately to the delivery home

85. After a spontaneous abortion the nurse should observe the client for:

a. Hemorrhage and infection
b. Dehydration and hemorrhage
c. Subiiivolution and dehydration
d. Signs of pregnancy-induced hypertension

Situation 18: Arnold, age 67, has had successfully treated depressive disease for more than 10 years. Lately he has been developing a plan of action. Arnold is admitted to hospital for reassessment.

86. Which assessment would best aid the nurse in evaluating Arnold's potential for suicide?

a. Ask him about plans for the future
b. Ask other clients about suicide while in a group
c. Ask the family if he had ever attempted suicide
d. Ask him if suicide was ever or is now being considered

87. Which factor is most important in evaluating Arnold's risk for suicide?

a. Presence of multiple personal problems
b. Length of time the depression has existed
c. Impending of the loss of a loved one
c. development plans for discharge from hospital or program

88. Arnold confides to the nurse that he has been thinking of suicide. Which of the following motivations should the nurse recognize in Arnold?

a. Wishes to frighten the nurse
b. Wants attention from the staff
c. Feels safe and can share his feelings with the nurse
d. Shows fearful of his own impulses and is seeking protection from them

89. Arnold is placed on suicide precautions. Which would be the most therapeutic way to provide his safety measures?

a. Not allow him to leave his room
b. Remove all sharp and cutting objects
c. Give him the opportunity to ventilate feelings
d. Assign staff member to be with him at all times

90. The psychiatrist prescribes Electro convulsive therapy for Arnold. The nurse when discussing ECT with Arnold, should tell him which of the following information?

a. Sleep will be induced and treatment will not cause pain
b. There will be a memory loss aa a result of the treatment
c. It is better not to talk about it, but he can asks any question

Situation 19: Josh is a 2-year old child who was bom with a unilateral cleft lip and palate. He is being readmitted for a palate repair.

91. When a toddler is hospitalized, age appropriate toys would include:

a. Wind-up toys, music boxes, and electric trains
b. Toys requiring pushing, pulling and to big to be swallowed
c. Marble tracks and small blocks encouraging fine-motor coordination
d. Colorful mobiles, wind-up toys, and marble tracks

92. Which of the following would be the most important factor in preparing Josh for his hospitalization?

a. Gratification of Josh wishes
b. Josh's previous hospitalization
c. Never leaving Josh with strangers
d. Assurance of affection and security

93. Prior to a repair of a unilateral cleft lip and palate, feeding will probably be:

a. Limited to IV fluids
b. Wish a soft, large altered nipple
c. Accomplished per gastrostomy tube
d. Facilitated by the use of spoon or medicine dropper

94. Which of the following nursing actions would have been included for Josh following his cleft lip repair?

a. Using a spoon to administer oral feedings
b. Cleansing the suture line to prevent infection
c. Allowing Josh to suck on a pacifier to prevent crying
d. Positioning Josh on the abdomen to avoid aspiration

95. Why will Josh be unable to use toothbrush postoperatively?

a. The suture line might be injured
b. Josh would probably have no teeth
c. The toothbrush might be frightening to Josh
d. Josh would not be accustomed to a brush at home

Situation 20: Vincent, age 26, who is caught in me raging conflict between his mother and his wife, complains of pains in his right leg that has progressed to the point of paralysis. After orthopedic consultation has shown no pathology, he is referred for a psychiatric consultation and is found to have a conversion disorder.

96. The nurse understands which of the following concepts about Vincent's conversion disorder?

a. It is an unconscious method for him to cope with the present situation
b. It is usually necessary for him to cope with the present situation
c. It is reversible and will subside if he is helped to focus on other things
d. It will probably be solved when he learns to deal with ongoing family conflicts

97. Vincent's conflict may be caused by which of the following stimuli?

a. Hostile feelings towards his home
b. Ambivalent feelings toward his wife
c. Needs to be a dependent child and an independent adult
d. Inadequate feelings in regard to assuming the role of husband

98. Which behavior is Vincent most likely to manifest?

a. Demonstrate a spread of paralysis to other body parts
b. Require continuous psychiatric treatment to maintain individual functioning
c. Recover the use of the affected leg but under stress, again develop similar symptoms
d. Follow a rather unpredictable emotional course I the future, depending on exposure to stress

99. How would the nurse expect Vincent to behave?

a. Appear gently depressed
b. Exhibit free floating anxiety
c. Appear calm and composed
d. Demonstrate anxiety when discussing symptoms

100. Which intervention would be most therapeutic for the nurse to make?

a. Encourage him to try to walk
b. Tell him there is nothing wrong
c. Avoid focusing on his physical symptoms
d. Help him follow through with the physical therapy plan