Pre-board Exam for July 2011 NLE 1. The nurse should keep in mind that the priority intervention for the client with generalized anxiety disorder who is working to develop his coping skills is: a. Teaching the client on how to use effective communication skill b. Assisting the client to identify his coping mechanisms used in the past c. Determining whether the client has fears or obsessive thinking d. Monitoring the client for overt or covert signs of anxiety 2. The early signs of withdrawal will develop within how much time after cessation or reduction of alcohol intake? a. Within few hours b. After several hours c. In 1 week d. In 2 to 3 weeks 3. The following measures include the spread of HIV apart from: a. Isolating the patient with AIDS b. Labeling blood and specimens from infected person with “AIDS Precaution” c. Disposing used needles into a puncture resistant container d. Cleaning bloody spills with antiseptic solution or chlorox 4. The doctor prescribed an enema for a client who is suspected of appendicitis. The most appropriate action for the nurse to take is? a. Prepare 750 ml of irrigating solution warmed to 100 degree Fahrenheit b. Provide privacy and explain the prescribed procedure to the client c. Assist the client in a lateral Sim’s position d. Question the physician about the order 5. Situation: Mr. Andres receives a large volume of blood transfusion. Coagulation disturbances following massive transfusions for GI bleeding are usually associated with: a. Acidification of blood b. Infected donors c. Poor survival of platelets d. Rapid infusion of cold blood 6. Oxygen therapy is prescribed for a 30-year old patient with a diagnosis of emphysema. To deliver a precise oxygen concentration, which oxygen delivery systems would be used for this client? a. Face tent b. Aerosol mask c. Venturi mask d. Any of these 7. The client is to receive an antibiotic intramuscularly. Which of the following factors might influence the nurse's decision on the route of administration?
a. Condition of muscle tissue b. Diagnosis of a kidney failure c. Skin surface permeability d. Age of the client and the level of consciousness 8. What would be the priority nursing diagnosis for a client with herpes genitalis? a. Ineffective breathing pattern b. Ineffective airway clearance c. Imbalanced Nutrition: Less than body requirements d. Alteration in comfort: Pain 9. The nurse on the morning shift is reviewing the cases of the patients assigned to her. Which of the following clients should the nurse deal with first? a. The client who needs his dressing to be changed b. The client who needs to be medicated c. The client who is incontinent and needs to be cleaned d. The client who needs to be suctioned Question 10 Dissociative amnesia is most likely to occur as a result of which of the following circumstances? Binge eating Close-head injury Hostage situation Fight with family member Question 11 The primary goal of Community Health Nursing is to: To help communities and families to cope with the discontinuities of health and threats by increasing the productivity of the people. To help communities and families to cope with the discontinuities of health and threats by raising the level of health of the citizenry. To help communities and families to cope with the discontinuities of health and threats by enhancing the capacity of individuals, families and communities to cope with their health needs. To help communities and families to cope with the discontinuities of health and threats by supporting and supplementing the efforts of the medical professionals in the promotion of health and prevention of illness. Question 12
Nurse Aya noticed that one of her patients has difficulty breathing when lying down but breaths effectively and comfortably when sitting upright. This condition should be documented by the nurse as: Tachypnea Orthopnea Apnea Dyspnea Question 13 Hetrazan is the drug of choice for: Typhoid fever Cholera Bilhariasis Filiarisis Question 14 In caring for a client with dissociative amnesia, which nursing intervention is significant for the nurse to perform? Encourage the patient to participate in unit activities and meetings Question the client about the events triggering the dissociative disorder Let the client stay in his room whenever he is experiencing feelings of dissociation Encourage the client to form friendships with other clients in his therapy groups to decrease his feelings of isolation Question 15 How many fetal movements per hour are considered normal? Two Three Four Ten to twelve Question 16
Situation: Lily, 11 year old patient, is diagnosed with Rheumatoid Arthritis.
ROM exercises are effective for the patient if: The patient executes the exercise alone without help and performs it in the morning and in the afternoon Leg pain is felt when performing exercises and taking pain medication before executing the exercises Longer nodules under the patient’s skin is no longer felt since she started doing the exercises The patient can now flex and extend the legs and arms fully at anytime without feeling pain Question 17 The pregnant client at her 8th month of gestation had a contraction stress test. The result of the test is negative. The nurse should instruct the client to come back for her next clinic visit at what time? Next month Within 24 hours After a week Every week for two weeks then every month Question 18 A nurse is providing instructions to a pregnant client with genital herpes about measures that need to be implemented to protect the fetus. Which information when given by the nurse is correctly stated? A cesarean section may be necessary if vaginal lesions are present at the time of labor Daily administration of Acyclovir is required during the entire duration of pregnancy Total abstinence from sexual intercourse is important to do the entire pregnancy If vaginal lesions are present, sitz baths need to be taken every 4 hours Question 19 Which is correct regarding dissociative amnesia? It occurs as a result of incest It occur as a result of substance abuse
It occurs in more than 40% of all people It occurs as a result of the brain trying to protect the person from severe stress Question 20 Situation: Maslow’s theory on the Hierarchy of Needs is important for the nurse to know. This provides knowledge and ability to the nurse to identify and immediately intervene to meet especially the physiological needs to save lives.
Nurse Aya is identifying problems of the patient in her shift. Which client has a problem with oxygen transport from the lungs to the tissues? Mr. A with a brain tumor Mr. B with anemia Mr. C with anemia Mr. D with fracture in the femur Question 21 Situation: Lily, 11 year old patient, is diagnosed with Rheumatoid Arthritis.
Which of the following activities is not advisable for Lily? Walking to the school which is two blocks away Watching movies at home Performing isometric exercises Riding bicycle with friends to the park every Saturday Question 22 Situation: Mr. Andres receives a large volume of blood transfusion.
The danger of hypothermia in GI bleeding can be decreased by the nurse is she performs which of the following? Administer blood with normal saline
Administer blood products through a central line Give packed cells only Warm blood to body temperature before transfusion Question 23 The following are the rights of the patient except: Right to visitors, mails and use of telephone Right to generalized treatment plan and to participation in the development of that plan and to an explanation of the treatment Right to confidentiality None of these Question 24 Sources of good problem in nursing research includes the following except: Issues Literature Patient bill of rights Nursing problems Question 25 A rare complication of pinworm is: Appendicitis Hepatitis Stomatitis Pneumonitis Question 26 Which sexually transmitted disease is most detrimental to the baby's safety during pregnancy? Gonorrhea Syphilis
Genital herpes Trichomonas vaginalis Question 27 The nurse stated, “Good morning John. You have combed your hair this morning.” This is an example of which therapeutic communication technique? Making observations Encouraging description Giving recognition Any of these Question 28 The nurse knows that only small doses of medication are usually injected via the subcutaneous route. When instilling insulin to a syringe, the nurse aspirated a correct amount of dose when the instilled dose is: 0.5 ml 5 ml 0.1 ml 0.01 ml Question 29 The nurse is conducting a health teaching on group of mothers regarding pinworm transmission other members of the family and how it can be prevented. Which of the following effectively prevents pinworm transmission? Making sure that the children washes their hands before and after eating Removing all pets in the house Using a Lysol disinfectant spray in the kitchen and bathroom everyday Disinfecting the toilet seat after use Question 30 The presence of chromosome in the same individual of two or more genotypically different cell lines is a chromosomal alteration called:
Mutation Nondisjunction Mosaicism Translocation Question 31 The therapeutic serum level of Lithium is: 0.1-0.3 mEq/ml 0.6-1.2 mEq/ml 0.6-1.2 mEq/L 0.1-0.3 mEq/L Question 32 Situation: Mr. Torres, age 55, has had a significant alcohol problem with alcohol abuse in the past 15 years. He was brought to the ER by his wife due to increasing confusion and coughing with bloody phlegm. His medical diagnosis is liver cirrhosis and esophageal varices.
As a result of liver failure, the nurse expects to find which laboratory value in Mr. Torres’ lab result? Decreased serum creatinine Decreased sodium Increased ammonia Increased calcium Question 33 The nurse can avoid trauma during nasopharyngeal suctioning by: Rotating the catheter as it is inserted with gentle suction Using gloves to prevent introduction of pathogens to the respiratory system Applying suction for at least 20-30 seconds each time to ensure that all secretions are removed in the area Applying no suction while inserting the catheter
Question 34 The primary purpose for regulating nursing practice is to protect: The practicing nurses The public The employing agency The professional standards Question 35 In the initial disease management of gluten-induced enteropathy clients should normalized their nutritional status by following which dietary regimen except? High-calorie Low-protein High-protein Mineral and vitamin supplements Question 36 Within the nurse’s shift, four clients have signaled their bells for the nurse. Which client should the nurse see first? Mrs. Romero in a geri chair with a restrain vest on Mr. Aslan who has just been given morphine Mr. Lorenzo who needs to use the toilet Mrs. Chachi who does not have her glasses or hearing aid Question 37 The best time to perform a cellophane-test for pinworms is: Right after meals Before bathing at bedtime Early morning before arising After a bowel movement
Question 38 Situation: Annie, 15-month old baby, has had a successful cleft lip repair. During a clinic check-up and MMR immunization, the mother told the nurse that her babysitter has just come down with a rubeola.
Annie is scheduled for a cleft palate repair. What is the priority post-op plan of care for Annie? To resume toilet training after she gets well Use a wide-bowl spoon for feeding That Annie will be more prone to respiratory infection now that her airways are smaller That no further treatment is needed until his adult teeth come in at age 6 Question 39 The drug of choice for Bilhariasis is: Heterazan Biltricide Chlorampenicol Tetracycline Question 40 The nurse caring for the patient with emphysema should ensure that the oxygen flow rate should not exceed to: 3 LPM 1 LPM 6 LPM 5 LPM Question 41 The ideal number of members in an inpatient group is: 1 to 4 4 to 7
7 to 10 10 to 15 Question 42 Situation: Mr. Torres, age 55, has had a significant alcohol problem with alcohol abuse in the past 15 years. He was brought to the ER by his wife due to increasing confusion and coughing with bloody phlegm. His medical diagnosis is liver cirrhosis and esophageal varices.
What is the major dietary treatment for ascites? High protein Increased potassium Restricted fluids Restricted sodium Question 43 Milieu therapy can be best described as: A behavioral approach to changing behavior A cognitive approach to changing behavior A behavior modification technique The client is involved in setting goals Question 44 Which position should the nurse place the client before starting a continuous feeding in a client with a percutaneous endoscopic gastrostomy tube inserted for tube feedings? Supine High-fowler’s Semi-fowler’s Reverse trendelenburg Question 45 The legal owner of the chart is the:
Patient Hospital Nurse Physician Question 46 The following are examples of torts except: Assault Battery False imprisonment None of these Question 47 Hypnosis is an appropriate treatment modality if indicative symptoms of post-traumatic stress disorder are present in the client. This symptom most likely includes which of the following? Dissociation Hallucinations Addiction Confabulation Question 48 While checking the patient’s chart, you noted that he has reduced oxygen in the blood as evidenced by the result of the laboratory exam. Reduction of circulating oxygen in the blood is a condition called: Anemia Hypoxemia Hypoxia Cyanosis Question 49 One of the ethical principles that apply to nursing practice is merit. Which of the following correctly describes merit?
It is the appraisal of what is “good”. Practiced when another person makes decisions about what is right or best for the individual. It is a personally held belief, opinion and attitude that guide one’s actions. It is a type distributive justice where allocation of services goes to more deserving. Question 50 If the client consents to his own hospital admission in a psychiatric facility: He may not refuse treatment He must be mentally ill and be a danger to others or oneself He must be released when he chooses to go All of these Question 51 The best activity that the manic client could participate in is: A tetherball Deep breathing and progressive group relaxation Chess A book review and brown-bag luncheon Question 52 A prescription of Mebendazole (Vermox) 100 mg twice daily for 3 days is ordered for a child with pinworms. The nurse knows that it is advisable that the same drug should also be administered to: All family members living with the child with or without noticeable symptoms. The child’s younger brothers only. All members of the family who are positive with the test. All people who are using the same toilet facilities as the child. Question 53 Initially, the nurse is expected to perform which of the following when obtaining a consent for surgery: Evaluate whether the client’s knowledge level is sufficient to give consent
Explain the risks involved in the surgery Explain that obtaining the signature is a routine procedure in any surgery None of these Question 54 A typical eating pattern of a toddler includes: Increase in appetite Food jags Preference to eat alone Consistent table manners Question 55 A physician holds certain information that he/she thinks might put the patient's condition in a critical state. This is an example of: Paternalism Beneficence Nonmaleficence Double effect Question 56 A client in a community health center is asking the nurse about the possible complications of bilhariasis. Which of the following is least likely to be answered by the nurse? Hepatomegaly Meningitis Cor pulmonale Portal hypertension Question 57 Having less than the ideal number of members will most likely result to the following except: Inadequate interaction.
Inadequate material for successful group interaction. Inadequate time for individual participation. All of these Question 58 Sentences that vague connections to each other is referred to as: Loose associations Paranoid ideations Depersonalization Ideas of references Question 59 Situation: Mr. Torres, age 55, has had a significant alcohol problem with alcohol abuse in the past 15 years. He was brought to the ER by his wife due to increasing confusion and coughing with bloody phlegm. His medical diagnosis is liver cirrhosis and esophageal varices.
During physical assessment, the nurse would notice the following changes to the client EXCEPT: Bulging flanks Protruding umbilicus Abdominal distention Bluish discoloration of the umbilicus Question 60 Hypertension during pregnancy is considered when which of the following is observed? Systolic BP increased of 15 mmHg and diastolic BP increased of 30 mmHg anytime during pregnancy Systolic BP increased of 15 mmHg and diastolic BP increased of 30 mmHg during the second trimester Systolic BP increased of 30 mmHg and diastolic BP increased of 15 mmHg anytime during pregnancy
Systolic BP increased of 30 mmHg and diastolic BP increased of 15 mmHg during the second trimester of pregnancy Question 61 The nurse should NOT expect which of the following findings in a pregnant woman’s blood pressure. BP tends to be highest when the pregnant woman is sitting down BP should be taken every visit to the clinic During pregnancy, it is normal for the BP to increase by as much as 33 systolic BP in the third trimester when the pregnant woman is near delivery A pregnant woman’s BP may decrease a little in the second trimester of pregnancy Question 62 Dystocia can be caused least likely by: Cephalic presentation Cephalopelvic disproportion Full bladder Weak contractions Question 63 The client presents with the following clinical manifestations:
Diaphoresis Palpitations Jitters Tachycardia
These clinical manifestations are experienced by the client about 1 and a half hour after taking his regular morning dose of insulin. The most appropriate treatment for this client is: Restrict salt. Administer diuretics and perform a paracentesis. Check the client’s blood glucose level and administer carbohydrates.
Give Nitroglycerin and perform an ECG. Check pulse oximetry and administer oxygen. Question 64 In nursing research, the problem should be originally made to avoid plagiarism. This is emphasized in which characteristic of a good problem? Feasible General applicability Novelty Researchable Question 65 When toddlers are not allowed to develop appropriate independence they will experience a sense of: Mistrust Autonomy Guilt Shame Question 66 Amniocentesis is an examination of amniotic fluid which does NOT screen for: All inborn errors of metabolism Chromosomal abnormalities Some CNS disorders Sex of an infant in sex-related disorders Question 67 If the woman reports only one or two movements per hour, which test is usually conducted? Non-stress test Contraction stress test Biophysical profile
Denver developmental screening test Question 68 A problem becomes an ethical dilemma when: Morals guide a person’s actions. An individual has the right to make his or her own decision regarding treatment and care. The person has to choose an action that violates one principle or value in order to promote another. Allocation of goods and services are inappropriate. Question 69 Prevention of gonorrhea transmission are the following except: Administration of ophthalmic prophylaxis as prescribed by the doctor Case finding Sex education All of these Question 70 Which is not an example of behavioral influences in OLOF on health status? A mother with an adult-onset diabetes Sedentary lifestyle of a clerk Exposure to toxic substances in the workplace Alcohol drinking Question 71 Which of the following is not true regarding the legal concepts related to psychiatric-mental health nursing? In most states, the client who has been involuntarily committed may not refuse treatment There is presently a trend toward finding individuals insane and guilty Individuals who commit crimes and successfully plead insanity defenses may be involuntarily committed to psychiatric hospitals under civil commitment laws
In irresistible impulse insanity defense, the accuse, because of mental health have the will to resist an impulse to commit the act, even though able to differentiate between right and wrong. Question 72 The client has just returned to the unit room from surgery. The nurse transferred him to his bed but did not put up the side rails. The client fell and was injured. What kind of liability does the nurse have? Assault and battery Negligence Intentional tort False imprisonment Question 73 The pregnant woman is tested for a Benedict’s test. The patient is most likely to have which condition? Diabetic Anemic PIH Has urinary tract infection Question 74 MAOI is effective in a client with post-traumatic stress disorder when he states which of the following? “I’m losing my temper all the time.” “I’m no longer afraid of water.” “I can sleep well at nights and my nightmares are gone.” “I stopped craving for alcohol.” Question 75 Treatment and control of dengue hemorrhagic fever least likely includes: Vector eradication Community participation Encourage for vaccination
Treat shock with IVF Question 76 When a client addicted to cocaine becomes pessimistic about treatment which of the following conditions may be present? Depression Impulsiveness Estrangement Fatigue Question 77 The diagnostic tests of a 30-year old female patient reveal gluten-induced enteropathy. Which of the following foods should she eliminate from her diet permanently? Cereal grains except corn and rice Milk and dairy products Carbohydrates Protein-containing foods Question 78 A child who is treated with Mebendazole is expected to manifest the following side effects except: Diarrhea Leukopenia Abdominal pain Dizziness Question 79 Which stage of group development is characterized when group members are discussing and identifying tasks and boundaries? Forming Norming Storming
Performing Question 80 Which of the following is correct when counting fetal movements? Let the woman drink lots of water to make the bladder full Instruct the patient not to talk Have the woman sit or lie down and allow her to relax All of these Question 81 Which of the following is not a legal responsibility of the nurse? Protect the rights and safety of patients. Reveal patient’s confidential information to the church pastor who called and inquired about the health status of the patient. Restrain the patient only in emergencies to prevent injury to self or others. Be responsible for his or her own acts. Question 82 A client with dissociative amnesia says, “You must think I’m really stupid because I have no recollection of the accident.” Which of the following responses would be most appropriate for the nurse to make? “Why would I think you are stupid?” “Have I acted like you are stupid?” “What made you think that way?” “As a protective measure, the brain sometimes doesn’t let us remember traumatic events.” Question 83 The client who is taking Alprazolam (Xanax) reported lightheaded-ness and nausea every morning while getting out of bed. To objectively validate the problem of the client, the nurse should: Obtain a blood chemical profile Teach Valsalva maneuver to the client Monitor the client’s body temperature
Take the client’s BP Question 84 Disulfiram (Antabuse) works on the principle of which therapies to help clients experiencing problems with alcohol? Self-control therapy Aversion therapy Desensitization Milieu therapy Question 85 The context of Community Health Nursing is based on the nurse's evaluation about the: Goals of the DOH Previous and present health status of the people Health devolution Existing health problems and needs of the people Question 86 Situation: Lily, 11 year old patient, is diagnosed with Rheumatoid Arthritis.
The patient’s parent is asking about other possible management for early morning stiffness since the medication offers no effective relief. The most appropriate action for the nurse to take is: Inform the parents that their child needs to increase her dietary intake of calcium Instruct the parents to transfer their child to afternoon classes as there is no remedy for morning stiffness Refer the patient for physical therapy Remind the parents of the importance of waking the child up early at about 3 am to drink the medication and putting the child back to sleep to assure that the medication will take effect Question 87 Which of the following toys is an appropriate toy for an 18-month old toddler?
Miniature cars Comic books Finger paint Playstation Question 88 Situation: Annie, 15-month old baby, has had a successful cleft lip repair. During a clinic check-up and MMR immunization, the mother told the nurse that her babysitter has just come down with a rubeola.
Annie’s mother is asking the nurse when will her child be ready for a cleft palate repair, the nurse’s most appropriate answer would be: Prior to development of speech When the child is completely weaned from the bottle and pacifier When the child is toilet trained When a large-holed nipple is ineffective for his feedings Question 89 Which of the following gauge of the needle is most appropriate for skin testing? 23 26 21 18 Question 90 If the contraction stress test result is equivocal, the test should be repeated within: 1 week 1 day 1 month Any of the above
Question 91 The client’s husband recently died aggravating her depression. One morning the client says, “No one cares about me anymore. All the people I loved are dead.” Which of the following responses by the nurse is most therapeutic? “You are not alone.” “Nah, you are juts upset few hours from now you’ll feel better, trust me.” “You must be feeling all alone at this point.” “What are you feeling right now?” Question 92 The most basic question if a particular health service fails is: Is this what the people need? Who is responsible for this failure? Is this what the people wanted and demanded? What went wrong? Question 93 Nurse Janine, a community health nurse, is very active in contact tracing and epidemiologic treatment of all gonococcal identified contacts to prevent: Asymptomatic infections Reinfection Development of resistant strains Non-venereal transmission Question 94 In an emergency delivery of an infant, which of the following should the nurse consider the least? Maintaining a sterile environment if possible Assessing the affect and ability of the patient to understand directions, as well as other resources available Preventing the membranes to rupture
Staying with the mother at all times Question 95 Which outcome indicates that fluid resuscitation is successful in a client with diarrhea? The client passes formed stools at a regular intervals The client exhibits firm skin turgor The client no longer experiences perianal burning The client reports a decrease in stool frequency and liquidity Question 96 Nurse Ghia is caring for a client with anorexia nervosa. In monitoring the client's behavior, the nurse understands that the client with anorexia nervosa manages anxiety by: Engaging in immoral acts Always reinforcing self-approval Observing rigid rules and regulations Always need to make the right decision Question 97 36 hours after the insertion of the chest tube, the nurse assesses the function of the three-chamber, closed-chest drainage system and notes that the water in the underwater seal tube is not fluctuating. The initial nursing intervention should be to: Turn the patient to the unaffected side Check whether the tube is kinked Inform the physician Take the patient’s vital signs Question 98 The guide in acquiring the appropriate suction tube length to be inserted during nasopharyngeal suctioning in adult patient is: Measuring eight to ten inches Measuring the tube length from the tip of the nose to the base of the neck
Distance: tip of the nose to the middle of the neck Distance: tip of the nose to the tip of the ear lobe Question 99 Situation: Annie, 15-month old baby, has had a successful cleft lip repair. During a clinic check-up and MMR immunization, the mother told the nurse that her babysitter has just come down with a rubeola.
The most appropriate treatment plan for Annie is: Administer immune serum globulin Administer prophylactic penicillin Allow the baby to catch rubeola to develop active immunity Vaccinate the child immediately with MMR Question 100 Ideally rehabilitation services begin during what time in a health care delivery system? During admission in the health care delivery system After the client is treated During discharge from the health care delivery system When the client requests for a rehabilitations service Once you are finished, click the button below. Any items you have not completed will be marked incorrect. Get Results You have completed 1/100 questions .
ANSWERS
Question 1 Explanation:Keyword: Priority intervention; working to develop his coping skills. | Answer: B | Rationale: To help the client develop effective coping skills the nurse must know the client’s baseline functioning. Determining whether the client has fears or obsessive thinking, monitoring for signs of anxiety, and teaching about effective communication skills are later priorities, not initial ones.
Question 2 Explanation:Keyword: Early signs; after cessation or reduction of alcohol intake. | Answer: A | Rationale: Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peaks after 24 to 48 hours.
Question 3 Explanation:Keyword: Except | Answer: A | Rationale: Patients with AIDS are immunocompromised. Reverse isolation is required. But this does no prevent the spread of AIDS. B, C and D are universal preventive measures for AIDS.
Question 4 Explanation:Keyword: Most appropriate. | Answer: D | Rationale: Enemas are contraindicated in an acute abdominal condition of unknown origin such as suspected appendicitis as well as after recent colon or rectal surgery or myocardial infarction.
Question 5 Explanation:Keyword: GI bleeding – Usually associated | Answer: C | Rationale: Hemorrhagic reactions are due to banked blood that is low in platelets and coagulation factors.
Question 6 Explanation:Keyword: Precise oxygen concentration | Answer: C | Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for a client with emphysema, one of the chronic obstructive pulmonary diseases (COPD), because it delivers a precise oxygen concentration.
Question 6 Explanation:Keyword: Precise oxygen concentration | Answer: C | Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for a client with emphysema, one of the chronic obstructive pulmonary diseases (COPD), because it delivers a precise oxygen concentration.
Question 7 Explanation:Keyword: Influence the nurse’s decision. | Answer: A | Rationale: The condition of the muscle tissue is an important factor that can influence the nurse's decision in administering intramuscular medications. Muscles can take a larger volume of fluid without discomfort than subcutaneous tissues can, although the amount varies among individuals, chiefly based on the muscle size and condition and the site used.
Question 8 Explanation:Keyword: priority nursing diagnosis. | Answer: D | Rationale: Genital herpes is characterized by painful vesicles affecting the external genitalia, vagina and cervix.
Question 9 Explanation:Keyword: FIRST | Answer: D | Rationale: Any client with potential compromise of the airway should be dealt with first.
Question 10 Explanation:Keyword: Most Likely | Answer: C | Rationale: Dissociative amnesia typically occurs after the person has experienced a very stressful traumatic situation. Binge eating doesn’t cause dissociative amnesia. Close-head injury could result in physiologic not dissociative amnesia. Fight with a family member wouldn’t be stressful enough to cause dissociative amnesia.
Question 11 Explanation:Keyword: Primary Goal | Answer: C | Rationale: The primary goal of Community Health Nursing is to help communities and families to cope with the discontinuities of health and threats in such a way as to maximize their potential for high level wellness, as well as to promote reciprocally supportive relationship between people and their physical and social environment.
Question 12 Explanation:Keyword: Breaths effectively and comfortable when sitting upright; should be documented. | Answer: B | Rationale: Orthopnea is the inability to breathe except in an upright or standing position. Apnea is the cessation of breathing. Dyspnea is the difficulty or uncomfortable breathing. Tachypnea is an abnormally rapid respiratory rate.
Question 13 Explanation:Keyword: Drug of choice. | Answer: D | Rationale: Hetrazan is the drug of choice for Filiarisis.
Question 14 Explanation:Keyword: Significant | Answer: A | Rationale: Attending unit activities and meetings helps decrease the client’s sense of isolation. Often, the client can’t recall events that triggered the dissociative disorder, so questioning him would not be helpful. The client needs to be isolated from others only if he is unable to interact appropriately. A client with a dissociative disorder has typically had few healthy relationships. Forming friendships with others in therapy could be setting the client to continue in unhealthy relationships.
Question 15 Explanation:Keyword: Fetal movements per HOUR - NORMAL. | Answer: B | Rationale: Generally, at least three movements in one hour are considered normal. Procedure varies with time of
the day, reference to mealtime, maternal position and hydration. Often a baby is more active after a meal.
Question 16 Explanation:Keyword: Effective | Answer: D | Rationale: The purpose of ROM exercises is to keep joint mobility. If the child can move her legs and arms in full range of motion at anytime without experiencing pain, then, exercises are effective.
Question 17 Explanation:Keyword: Contraction stress test – negative; SHOULD INSTRUCT – next clinic visit. | Answer: C | Rationale: A negative contraction stress test (CST) gives an assurance of fetal heath within the following week and the test is repeated after one week. CST is indicated for high risk pregnancies.
Question 18 Explanation:Keyword: Correctly stated. | Answer: A | Rationale: In mothers with genital herpes, the fetus can be contaminated after membranes rupture or with vaginal delivery. Therefore, for women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean to prevent the fetus from coming into contact with the genital herpes.
Question 20 Explanation:Keyword: Oxygen transport from the lungs to the tissues. | Answer: C. | Rationale: A client with anemia (decrease in red blood cells) has problem in transporting oxygen from the lungs to the tissue since hemoglobin, which is responsible in distributing oxygen to the different parts of the body, is located inside an RBC. With decrease number of RBC, a decrease in the number of oxygen-carrying hemoglobin also occurs.
Question 19 Explanation:Keyword: Correct | Answer: D | Rationale: This answer typically describes the cause of a dissociative disorder. As a protective measure, the brain doesn’t let traumatic events to be remembered to protect the person from severe stress.
Question 21 Explanation:Keyword: NOT advisable | Answer: B | Rationale: It is not advisable for children with rheumatoid arthritis to sit or stand for prolonged periods of time, such as when they watch TV, as prolonged immobility results in stiffness and possible contractures.
Question 22 Explanation:Keyword: hypothermia – decreased; performs. | Answer: D | Rationale: Hypothermia with cardiac arrhythmias may occur when infusing the large quantities of blood that are required in GI bleeding. Blood-warming equipment should be used to prevent thus problem.
Question 23 Explanation:Keyword: Except. | Answer: B | Rationale: Patients have the right to INDIVIDUALIZED not generalized treatment plan and to participation in the development of that plan and to an explanation of the treatment.
Question 24 Explanation:Keyword: Except | Answer: C | Rationale: Sources of good problem C – concepts, L – literatures, I – issues, E – essays, N – nursing problems, T – theories
Question 25 Explanation:Keyword: Rare Complication. | Answer: A | Rationale: The worms may lodge and become trapped in the appendix and cause inflammation resulting in appendicitis.
Question 26 Explanation:Keyword: Most detrimental | Answer: B. | Rationale: Syphilis may cross the placenta, causing congenital syphilis. It usually leads to spontaneous abortion, and it increases the incidence of mental abnormality and physical deformities in fetus. In gonorrhea, the fetus is contaminated at the time of delivery. It places the neonate at risk for ophthalmia neonatorum, pneumonia and sepsis, but these can be avoided via cesarean delivery.
Question 27 Explanation:Keyword: Combed your hair this morning. | Answer: C | Rationale: Giving recognition is indicating to the client the nurse’s awareness of him and his behaviors as exemplified by the nurse telling the client that he combed his hair this morning. a.) Making observations – verbalize what you perceive such as the nurse telling the client, “I notice that you can’t sit still.” b.) Encouraging description – asking the client to verbalize his perception. E.g “what is happening to you now?”
Question 28 Explanation:Keyword: Subcutaneous route; correct amount – insulin. | Answer: A | Rationale: Among the many kinds of drugs administered subcutaneously (just beneath the skin) are vaccines, insulin and heparin. Only small doses (0.5 to 1 ml) of medication are usually injected via the subcutaneous route. Question 29 Explanation:Keyword: Effectively prevent pinworm transmission. | Answer: A | Rationale: The best preventive measure is thorough hand washing before and after eating and after defecation because pinworm is transmitted by oral-fecal route.
Question 30 Explanation:Keyword: Same individual – two or more genotypically different cell lines. | Answer: C | Rationale: Mosiacism is the presence of chromosome in the same individual of two or more genotypically different cell lines. Question 31 Explanation:Keyword: Therapeutic. | Answer: C | Rationale: The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. Serum lithium levels above the therapeutic level will produce signs of toxicity. Question 32 Explanation:Keyword: Result of liver failure; EXPECTS. | Answer: C. | Rationale: Increased ammonia levels occur in patients with liver damage as a result of the breakdown of blood protein in intestinal tract. Question 33 Explanation:Keyword: Avoid trauma | Answer: D. | Rationale: While doing nasopharyngeal suctioning, suction should only be applied while removing the catheter, not while inserting it, in order to prevent trauma to the trachea. Question 34 Explanation:Keyword: Primary purpose | Answer: B | Rationale: Each state or province protects the health and welfare of its populace by regulating nursing practice. Question 35 Explanation:Keyword: Except | Answer: B | Rationale: In initial disease management, clients eat a high-calorie, high protein with mineral and vitamin supplements to help normalize the nutritional status. Question 36 Explanation:Keyword: First | Answer: B. | Rationale: An adverse reaction to any drug can be life-threatening and should be dealt with first. Morphine is a respiratory depressant. Question 37 Explanation:Keyword: Best time. | Answer: C | Rationale: Pinworn is enterobiasis and the mode of transmission is fecal-oral route. Because the eggs are deposited to the anus at night, the best time to perform a cellophane test would be in the morning upon awakening of the child. Question 38 Explanation:Keyword: Priority. | Answer: B | Rationale: care should be taken not to put anything in the mouth that should damage the suture line. The mother can feed the baby with a widebowl spoon that cannot enter the mouth. Question 39 Explanation:Keyword: Drug of choice. | Answer: B | Rationale: Praziquantel (Biltricide) is the drug of choice for Schistosomiasis. Question 40 Explanation:Keyword: Emphysema; not exceed. | Answer: A | Rationale: Oxygen is used cautiously in a client with emphysema and should not exceed 3 liters per minute. Because of the longstanding hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, which is the case in a normal respiratory system. Question 41 Explanation:Keyword: Ideal Number of members | Answer: C | Rationale: The ideal number of members in an inpatient group is 7 to 10.
Question 42 Explanation:Keyword: Major dietary treatment. | Answer: D. | Rationale: A major problem in ascites is fluid retention and sodium restriction is the main intervention for controlling it. Question 43 Explanation:Keyword: Best described. | Answer: D | Rationale: Milieu therapy provides a safe environment that is adapted to the individual client's needs and also provides greater comfort and freedom of expression that has been experienced in the past by the client. All members contribute to the planning and functioning of the setting. Question 44 Explanation:Keyword: Before starting a continuous feeding. | Answer: C | Rationale: To prevent aspiration of stomach contents, the nurse should place the client in semi-fowler’s position. The supine and reverse trendelenburg positions may cause aspiration. High-fowler’s position isn’t necessary and may not be tolerated as well as semi-fowler’s. Question 45 Explanation:Keyword: Chart (Legal Owner) | Answer: B | Rationale: The legal owner of the chart is the hospital. On the other hand, the patient is the legal owner of DATA IN THE CHART. Question 46 Explanation:Keyword: Except. | Answer: D | Rationale: Torts are legal wrong committed against a person, his or her property; intentional, willfully committed without a just cause. Examples of torts are: • Assault and battery • False imprisonment • Fraud • Negligence • Malpractice Question 47 Explanation:Keyword: Most likely. | Answer: A | Rationale: Hypnosis is one of the main therapies for clients who dissociate. It is not a treatment of choice for clients with addictive disorders of hallucinations. Confabulation isn’t a symptom of post-traumatic stress disorder. Question 48 Explanation:Keyword: Reduced oxygen in the blood. | Answer: B | Rationale: Hypoxemia refers to reduced oxygen in the blood. Cyanosis is the bluish discoloration of the skin, nail beds and mucous membranes due to reduced hemoglobin-oxygen saturation. Hypoxia is a condition of insufficient oxygen anywhere in the body, from the inspired gas to the tissues. Anemia is a decrease in red blood cells. Question 49 Explanation:Keyword: Correctly. | Answer: D | Rationale: Merit is used as a criterion for transplant recipients and it a form of distributive justice where services go to more deserving individual. Question 50 Explanation:Keyword: Consents to his own hospital admission. | Answer: C | Rationale: Voluntary commitment takes place when a client consents to his own hospital admission in a psychiatric facility. In this case the client has the right to refuse treatment and must be released when he or she no longer chooses to remain in the hospital. Letters A and B are applicable for clients who are hospitalized involuntarily. Question 51 Explanation:Keyword: Best activity | Answer: A | Rationale: A person who is experiencing mania is overactive, full of energy, lacks concentration and has poor impulse control. The client needs an activity that will allow her to use excess energy, yet not endanger others during the process. Tetherball is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy this client is experiencing.
Question 52 Explanation:Keyword: Pinworms – Advisable that the same drug should also be administered. | Answer: A. | Rationale: All members must be treated also because absence of signs and symptoms does not mean they do not have the disease. Some patients are symptomatic. Question 53 Explanation:Keyword: Initially; expected to perform. | Answer: A | Rationale: Informed consent means the client must comprehend the surgery, the alternatives, and the consequences. With Letter B, the explanation of the risks involved with the surgery is not within the nurse’s domain. In Option C, although this is true, it does not determine the client's ability to give informed consent. Question 54 Explanation:Keyword: Typical eating pattern – TODDLER. | Answer: B | Rationale: Toddlers become picky eaters, experiencing food jags and eating large amounts one day and very little the next. A toddler’s food jags express a preference for the ritualism of eating one type of food for several days at a time. Question 55 Explanation:Keyword: Holds certain information – might put patient’s condition in a critical state. | Answer: A | Rationale: Paternalism is a moral principle of deciding what is best for the client and acting without consulting the individual. At times, a physician can intentionally withhold information according too his/her sound judgment when such revelation would do more harm to an emotionally unstable or depressed person. (Benevolent deception). Beneficence refers to doing acts of kindness and mercy that directly benefit the patient. Nonmaleficence means to do no harm. Question 56 Explanation:Keyword: Least likely. | Answer: B | Rationale: Meningitis is not a complication of Bilhariasis. Question 57 Explanation:Keyword: Except | Answer: C | Rationale: Having fewer than 7 patients provides inadequate interaction and material for successful group process. Having more than 10 members doesn’t allow for adequate time for individual participation. Question 58 Explanation:Keyword: Vague connections to each other | Answer: A | Rationale: The term loose associations refer to sentences that have vague connections to each other. Letter B is defined as belief that others intend to harm the client in some way. Depersonalization is a state in which the client feels unreal or believes parts of the body are being distorted. Question 59 Explanation:Keyword: Except. | Answer: D. | Rationale: Bluish discoloration of the umbilicus – Cullen’s sign, results from free blood present in the abdomen. It is not a sign of ascites. Question 60 Explanation:Keyword: Considered. | Answer: C. | Rationale: An increase of more than 30 systolic BP and 15 diastolic BP at anytime during pregnancy is considered hypertension. Question 61 Explanation:Keyword: Should NOT expect. | Answer: C | Rationale: There should be no or only very minimal changes in BP during pregnancy. A decline in the second trimester is expected but it usually returns to baseline at 3rd trimester. BP should be taken at every clinic visit to determine developing PIH. An increase of more than 30 systolic BP and 15 diastolic BP at anytime during pregnancy is considered hypertension.
Question 62 Explanation:Keyword: Least likely. | Answer: A | Rationale: Dystocia can be caused by a disproportion between fetal presentation and maternal pelvis such as in cephalopelvic disproportion (CPD), problems with presentation – breech, shoulder, face, transverse lie, problems with maternal soft tissue – full bladder, myoma uteri, cervical edema, scar tissues and congenital abnormalities and dysfunctional uterine contractions such as too weak, too short or too far apart contractions. Question 63 Explanation:Keyword: Most appropriate. | Answer: B | Rationale: The client is experiencing symptoms of hypoglycemia. Checking the blood glucose level and administering carbohydrates will elevate blood glucose. Question 64 Explanation:Keyword: Originally made to avoid plagiarism | Answer: C | Rationale: Characteristics of good problem in nursing research. G – general applicability – result should be helpful or applicable to all. a.) basic/ Pre – for personal knowledge b.) Applied – focus is solving problems of others; Re – researchable – collectable & abundant data, F – feasible or measurable a.) time, b.) money/ cost, c.) participants, d.) instruments, e.) experience, f.) proper ethics of good researcher; I – important, N – novelty – original to avoid plagiarism, S – significant. Question 65 Explanation:Keyword: Not allowed to develop appropriate independence. | Answer: D | Rationale: According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Question 66 Explanation:Keyword: NOT. | Answer: A | Rationale: Amniocentesis is an examination of amniotic fluid that is used to screen for SOME inborn errors of metabolism. This laboratory or diagnostic test CANNOT detect all inborn errors of metabolism. Question 67 Explanation:Keyword: one or two movements per hour; test usually conducted. | Answer: A | Rationale: A non-stress test (NST) is usually conducted if the woman reports only one or two movements per hour. If the NST result is nonreactive, a biophysical profile or contraction stress test is conducted to further assess the condition of the fetus. Question 68 Explanation:Keyword: Ethical Dilemma. | Answer: C | Rationale: Ethical dilemma is a problem in decision making because there is no clearly correct or right choice. This may result in having to choose an action that violates one principle or value in order to promote another. Question 69 Explanation:Keyword: Except | Answer: A | Rationale: This does not prevent transmission of gonorrhea. It prevents the occurrence of ophthalmia neonatorum. Question 70 Explanation:Keyword: NOT. | Answer: C | Rationale: Behavioral influences refer to the factor in the ecosystem affecting the individual’s health through certain habits that a person has. These may be in the form of smoking, intake of alcoholic drinks, substance abuse or lack of exercise. The people's lifestyle, health care and child rearing practices are shaped, to a large extent, by their culture and ethnic heritage. Option C is not a behavioral influence, it is an environmental influence.
Question 71 Explanation:Keyword: Not true.Answer: CRationale: In irresistible impulse insanity defense, the accuse, because of mental health DID NOT have the will to resist an impulse to commit the act, even though able to differentiate between right and wrong Question 72 Explanation:Keyword: Nurse – did not put up the side rails; liability does the nurse have. | Answer: B | Rationale: The nurse has been negligent. The nurse failed to raise the siderails, which led to the injury of the client. Negligence refers to the commission or omission of an act, pursuant to a duty, that a reasonably prudent person in the same or similar circumstance would or would not do, and acting or non-acting of which is the proximate cause of injury to another person or his property.
Question 73 Explanation:Keyword: Most likely. | Answer: A | Rationale: Benedict’s test is a urine test for sugar. A pregnant woman tested positive for Benedict’s test is most likely to be diabetic. Question 74 Explanation:Keyword: Effective; posttraumatic stress disorder. | Answer: C | Rationale: MAOIs are used to treat sleep problems, nightmares and intrusive daytime thought in individuals with posttraumatic disorder. Question 75 Explanation:Keyword: Treatment and control; least likely. | Answer: C | Rationale: There is no known vaccination for Dengue fever. Question 77 Explanation:Keyword: Gluten-induced enteropathy – Eliminate from her diet PERMANENTLY. | Answer: A | Rationale: To manage gluten-induced enteropathy, the client must eliminate gluten, which means avoiding all cereal grains except rice and corn
Question 78 Explanation:Keyword: Except | Answer: D | Rationale: Mebendazole (Vermox): 100 mg 2x/day x 3 days. • Side effects: diarrhea, abdominal pain, leukopenia Question 79 Explanation:Keyword: discussing and identifying tasks and boundaries. | Answer: A | Rationale: In the forming or initial stage, the members are identifying tasks and boundaries. Question 80 Explanation:Keyword: Correct | Answer: C | Rationale: When counting fetal movements, the woman should empty her bladder first. Then assist her to lie down or sit, be relaxed and quiet and instruct her to place her hands over her abdomen. She then observes and counts the number of times the baby moves. The patient is instructed to report fewer than normal fetal movements. Question 81 Explanation:Keyword: NOT a legal responsibility. | Answer: B | Rationale: The nurse can only reveal confidential information about the patient to appropriate persons such as the physician or health staff or the next nurse who will care for the same patient. Revealing information to the church minister should never be practiced by nurses. Question 82 Explanation:Keyword: Most Appropriate | Answer: D | Rationale: This provides a simple explanation for the client. The use of “why” can put someone on the defensive. The second choice takes focus off the client.
Question 83 Explanation:Keyword: while getting out of bed – nausea and lightheaded-ness; nurse SHOULD. | Answer: D. | Rationale: the nurse should take the BP of the client to validate orthostatic hypotension. A body temperature reading or chemistry profile will not yield useful information about hypotension. The Valsalva maneuver is performed to lower the heart rate and isn’t an appropriate intervention. Question 84 Explanation:Keyword: Principle of which therapy – Disulfiram (antabuse) . | Answer: B | Rationale: Aversion therapy, also known as aversion conditioning or negative reinforcement, is a technique used to change behavior. In this therapy, a stimulus (alcohol) attractive to the client is paired with an unpleasant event in hopes of instituting the stimulus with negative properties. Question 86 Explanation:Keyword: Most Appropriate | Answer: C | Rationale: The management for early morning stiffness is physical therapy to keep the joint mobile as possible and the help lessen the severity of morning stiffness. Question 87 Explanation:Keyword: Appropriate toy - TODDLER. | Answer: C | Rationale: Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Thus, finger paints would be an appropriate toy choice. Question 88 Explanation:Keyword: Most appropriate. | Answer: A | Rationale: Correcting a cleft palate prior to development of speech allows for formation of more normal speech pattern. Question 89 Explanation:Keyword: Most appropriate – Needle gauge. | Answer: B | Rationale: A 25- to 27-gauge needle measuring a half-inch in length is commonly used when administering an intradermal injection. Question 90 Explanation:Answer: B. | Rationale: If result of CST is equivocal or unsatisfactory, the test is repeated within 24 hours or 1 day. Question 91 Explanation:Keyword: Most therapeutic. | Answer: C | Rationale: The client is experiencing loss and is feeling hopeless. The most therapeutic response by the nurse is the one that attempts to translate words into feelings. Question 92 Explanation:Keyword: most basic question – health service fails. | Answer: A | Rationale: If a particular health service fails, it is important to reassess the felt needs of the people not their demands. Question 93 Explanation:Keyword: Prevent | Answer: A | Rationale: 80% of gonoccocal infection particularly in females has no symptoms. Question 94 Explanation:Keyword: Least. | Answer: C | Rationale: If the nurse has to deliver the baby herself membranes should be ruptured manually (if necessary) for birth or delivery to take place. Question 95 Explanation:Keyword: Successful FLUID RESUSCITATION in a client with diarrhea. | Answer: B | Rationale: Because of the criteria in the question, FLUID RESUSCITATION, the diagnosis for diarrhea
in this case is narrowed to Deficient Fluid Volume related to excessive fluid loss in stool. Thus, fluid resuscitation is needed and expected outcomes of successful intervention include: • Firm skin turgor, • Moist mucous membranes, • Urine output of at least 30 ml/hr. The client also has a nursing diagnosis of diarrhea with the following expected outcomes: • Passage of formed stools at regular intervals, • Decrease in stool frequency and liquidity. However, since the question is focused on the expected outcome of fluid resuscitation, thus the correct answer is a firm skin turgor. Question 96 Explanation:Keyword: Manages anxiety – anorexia nervosa | Answer: C | Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety. Question 97 Explanation:Keyword: Initial | Answer: B | Rationale: Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung re-expansion is unlikely 36 hours after a traumatic open chest injury. Informing the physician is unnecessary at this time; the chest tube is occluded and nursing intervention should be attempted first. Question 98 Explanation:Keyword: Appropriate suction tube length; adult patient. | Answer: D | Rationale: In performing nasopharyngeal suctioning, the length of insertion of the tubing for an adult would be the distance from the tip of the nose to the tip of the ear lobe. Question 99 Explanation:Keyword: Most appropriate. | Answer: A. | Rationale: Administration of immune serum globulin will provide the child with passive immunity to prevent a full-blown case of measles or reduce the severity of symptoms. Active immunization with MMR can be given at a later time. Question 100 Explanation:Keyword: Begin. | Answer: A | Rationale: In the Health Care Delivery System, ideally, rehabilitation services begin upon admission of the client in the health care system.
