ANSWER

KEY
defecation reflex.
FUNDAMENTALS OF NURSING PRACTICE (70
points) Small-volume enema uses hypertonic solution,
thus attracts water into the feces. A and D are for
1. The equivalent of 100.8 degrees Fahrenheit in hypotonic and isotonic enemas, while C for oil
Celsius is A. 38.2 C. 39.4 retention enema.
B. 38.7 D. 40.1
6. According to Orem’s Self-Care Theory, what
FORMULA: F – 32 (5/9) = C type of nursing activity would a G2P1 mother, 7
months pregnant,
2. Dorothy underwent diagnostic test and the
result of the blood examination are back. On
reviewing the result, the nurse notices which of
the following as abnormal finding?
A. Neutrophils - 60%
B. Creatinine – 0.9 mg/dL
C. Erythrocyte sedimentation rate - 25 mm/hr
D. Blood urea nitrogen – 15 mg/dL

NORMAL: 0-20 mm/hr. Any increase in ESR

indicates an inflammatory process.
Neutrophil (60-70%), creatinine (<1 mg/dL) and
BUN (10-20 mg/dl) are all normal. Elevated
neutrophil indicates ACUTE inflammation while
BUN & creatinine indicate renal damage.
Creatinine is more accurate than BUN since BUN
is affected by diet, fluid intake and muscular
activity.

3. When doing physical examination as part of the

nursing process, the nurse should have
sufficient understanding of basic nursing
procedures and skills. While auscultating
Mario's lung fields, the nurse compares the
Lung sounds. The nurse applies a systematic
pattern by:
A. listening from anterior to posterior
B. assessing from top to bottom
C. comparing lung sounds side to side
D. comparing from interspace to interspace.

Chest auscultation involves listening to breath

sounds from side to side, comparing left and right
lung fields as it goes from top to bottom.

4. Who pioneered the idea of the nurse-client

relationship and interactive process?
A. Faye Abdellah
B. Florence Nightingale
C. Hildegard Peplau
D. Virginia Henderson

Abdellah focused on 21 nursing problems,

Nightingale on environmental theory, and
Henderson on 14 basic needs.
5. The physician ordered a small volume enema
to a client with fecal impaction. The client
needed further clarification when she asks the
nurse how the solution will work once it is
administered. The most appropriate explanation
of the nurse is that the solution:
A. Causes distention of the bowel and
stimulates the defecation reflex.
B. Draws water from the colonic mucosa
cause water retention in the lower-colon.
. .
C. Decreases surface tension of stool
allowing water to enter stool more readily.
D. Promotes bowel evacuation that
provides and stimulates the
 who missed the last scheduled visit with her
obstetrician require? This is a test to determine adequacy of
A. Partially compensatory peripheral CIRCULATION.
B. Supportive-educative
C. Universal intervention 11. A client is reported to have orthostatic
D. Wholly compensatory hypotension. Which of the following would
you consider a sign?
(A) is applicable for patients with limited mobility
and can do partial self-care while (D) is for
immobile and unconscious patients who can
needs total care from the nurse. (C) involves
needs that are needed by all individuals or
patients.

7. Guillermo is allergic to non-steroidal drugs

(NSAID). Which of the following would be the
LEAST relevant practice to ensure that the
nurse who is preparing the drugs for the
patient in the medication room becomes aware
of his allergy?
A. The medication administration record has
a note on it that patient is allergic to NSAID
B. Paste a note that patient is allergic to
NSAID on the chart cover
C. Have the patient wear a red
identification bracelet labeled 'With
allergy'
D. Place a note in the patients medication
box that he has an allergy

The question asks what the nurse IN THE

medication room can be made aware of the patient’s
allergy. The patient cannot be with the nurse in the
medication room.

8. Care of patients with intravenous fluids is one

of the major responsibilities of a nurse. A nurse
caring for a client with PICC line (peripherally
inserted central line) knows that the tip of the
IV access is located in the
A. Basilic vein C. Right atrium
B. Cephalic vein D. Antecubital vein

A PICC line is inserted in a peripheral vein with its

tip placed at the right atrium. B, C, and D are the
insertion sites.

9. A frail elderly woman undergoes a timed up

and go test with a result of 18 seconds. This
means that the client
A. moves normally like any other adult
B. is a fall risk
C. is within normal limits for her age
and physical condition
D. needs assistance when moving out of bed

This is a test of mobility which involves measuring

the time a person rises from a chair, walks three
meters, turn around, and walk back to the chair
and sit down. Completion of the test in less than 10
seconds is normal mobility; however, for elderly
adults and those with disability, this may take them
11-20 seconds which is normal for this group.
When a patient takes 21-30 seconds to perform
the test, he needs additional assistance during
ambulation. A 30-second or more result signifies a
patient is a fall risk.

10. Allen’s test is indicated for which of the following clients?

A client
A. who needs an arterial line
B. with ulnar nerve damage
C. with peripheral neuropathy
D. who is about to undergo glucose test
 A. Increase in pulse of 40 beats/minute and
decrease in BP of 30 mm Hg from a sitting 16. Various methods of documentation are
to a standing position practiced by nursing staff, one of which is
B. A drop of 30 mm Hg in BP from a the SOAP method. The SOAP method
supine to a standing position with a rise stands for
in pulse of 40 beats/ minute A. subjective data, objective data, assessment,
C. Decrease in pulse by 20 beats / minute process B. subjective data, objective data,
and increase in BP by 20 mm Hg from assessment, planning
supine to standing position C. subject, objection, assessment, process
D. A sudden drop in BP of 30 mm Hg D. subjective data, objective data, analysis,
systolic and 10 mm Hg diastolic from planning
lying to sitting or sitting to standing
position 17. Somatotropin releasing hormone or the growth
hormone releasing hormone is secreted by the:
Orthostatic hypotension is measured while a
person is lying down, sitting AND standing. A 20-30
drop in systolic BP and 10-15 drop in diastolic BP
when changing position is a positive finding. B and
C are wrong positions for the client.

12. A post-operative client complains of numbness

and tingling around his mouth and shows
prolonged QT interval on the cardiac monitor.
These are associated with which electrolyte
imbalance?
A. Hypocalcemia C. Hyperkalemia
B. Hypokalemia D. Hypercalcemia

The symptom is an early sign of tetany or

hypocalcemia. Prolonged QT interval reflects a low
calcium level.

13. Prevention of infection is one of the essential

measures to reduce negative outcomes in
health care. Catheter care must be performed
frequently to prevent urinary tract infections. How
often should the nurse change a client’s condom
catheter?
A. Every 24 hours C. every 72 hours
B. Every 48 hours D. every 96 hours

Changing the catheter every 24 hours reduces the

risk for UTI.

14. In the physical examination of a patient with

abdominal pain, what is the recommended
sequence of examination techniques?
A. Inspection, auscultation, percussion,
palpation
B. Inspection, percussion, palpation,
auscultation
C. Inspection, percussion, auscultation,
palpation
D. Inspection, palpation, auscultation,
percussion

Inspection is always the first technique of physical

assessment. In abdominal assessment,
auscultation is done first prior to percussion and
palpation to prevent altering the bowel sounds.

15. The patient with an acoustic nerve injury may

have a positive Romberg’s sign. Which of the
following describes a positive Romberg’s sign?
A. Inability to hear a whisper
B. Inability to hear unless the listener is
looking at the speaker
C. Inability to maintain an upright position
with eyes closed
D. Inability to maintain an upright position
with eyes open

Romberg’s test is a test of balance and equilibrium. Inability to

maintain such indicates an abnormality in the
cerebellum.
 A. hypothalamus C. anterior pituitary should the nurse place the stethoscope?
gland A. 5th ICS, left midclavicular
B. posterior pituitary gland D. thyroid B. 4th ICS, left midsternal
gland C. 5th ICS, right midsternal
D. 4the ICS, right midclavicular
18. A suppository is prescribed for the client.
When administering the drug, the nurse must The apical pulse, also known as the point of
place the client in which position? maximum impulse is located in the 5th left
A. Sim’s C. Lithotomy intercostal space, left midclavicular line.
B. Dorsal recumbent D. Prone

Left Sim’s position is the preferred position for any procedure

that involves administration of medication or tube
into the rectum as the sigmoid colon is located in
the left lower quadrant of the abdomen.

19. A client is transferred to the medical unit after

a transurethral resection of the prostate. The
nurse reviews the transfer orders. The
surgeon's order reads: "Maintain traction on
the indwelling triple lumen catheter" Which of
the following is the MOST appropriate action
of the nurse?
A. Tape the catheter to the abdomen and
keep client in supine position.
B. Pull the catheter taut and tape to the thigh
alternately every 6 hours.
C. Instruct the client to keep both legs
together and extended all the time.
D. Pull the catheter taut, tape to one thigh
and keep the leg extended all the time.

This position maintains traction of the catheter.

20. Normal heart sounds originate from the SA

node. How many times per minute does
the SA node emit electric currents in an
adult?
A. 60-100 C. 40-60
B. 50-100 D. 80-120

The sinoatrial node is the pacemaker of the

heart. It normally emits 60-100 electric currents
per minute. The atrioventricular node emits 40-
60, while the Bundles of His, 20-40.

21. When the body responds to stress,

epinephrine is released producing
which physiological response?
A. Decreased oxygenated blood to vital organs
B. Decreased heart rate
C. Peripheral vascular
dilatation D. A more
forceful heart beat

ABC are the opposite effects of epinephrine.

22. The nurse is aware that proper

documentation when taking care of the
client is important. The purposes of client
care documentation include the following:
1. Standardizes plan of care
2. Communicates vital information about
client’s health status to other health
care providers
3. Serves as resource for research and
education
4. Serves as a legal document
A. 2, 3 and 4 C. 1, 2 and 4
B. 1, 3 and 4 D. 1, 2 and 3

According to Kozier, 234 are the purposes of

documentation.

23. When assessing for the apical pulse, where

24. A client has difficulty walking and needs wheel for 4 to 8 hours prior to the test.“
chair to facilitate performance of daily B. "Stool in the bowel may cause a
activities. Anticipating the needs of the client, reporting of inaccurate findings.“
the nurse should have the wheel chair ready by C. "There is no special preparation for this
placing it at procedure. You may eat and drink as
A. 60-degree angle to usual.“
the bed B. 45-degree D. "You will be asked to drink a solution of
angle to the bed radionuclide 2 hours prior to the procedure."
C. 90-degree angle to the bed
D. 30-degree angle to the bed

25. How will a nurse assess the client for pulse

deficits?
A. Ask a colleague to take the apical pulse
together with her.
B. Ask a colleague to take the radial pulse
as she is taking the apical pulse.
C. Take the apical pulse & compare with
the pulse pressure.
D. Take the radial pulse after taking the apical
pulse.

Assessment of pulse deficit can be done by either

the 1-nurse method or 2-nurse method. The question
states “a nurse”.
Option B uses the 2-nurse method.

26. Which of the following best describes

Cheyne-Stokes respiration?
A. Abnormally deep, regular, and increased
rate
B. Abnormally shallow for 2-3 breaths
followed by irregular period of apnea
C. Irregular rate & depth with alternating
periods of apnea & hyperventilation
D. Regular rate & depth with alternating
periods of apnea & hyperventilation

Choice A describes Kussmaul’s respiration.

27. The nurse implement standards of care to

prevent complications related to immobility. A
client on bed rest is rolled to a lateral position
by the nurse. The nurse is negotiating the
move correctly when he:
A. Positions himself at the mid part of the
bed and places both hands at the back
of the client and roll client onto side
B. Places one hand on the client’s far hip and the other
on the client’s far shoulder rock backward and roll
onto side of the body facing him
C. Assumes a broad stance with the foot
nearest the bed placing his arm under the client’s
thighs and shoulder and roll client onto side
D. Supports the back and buttocks of the
client and shifts his own weight from
the forward to the backward foot and
roll the client onto side

Choice B is the most appropriate way to turn a

patient to the lateral position. (Kozier)

28. Which of the following represents ventricular

relaxation?
A. P wave C. Q wave
B. R wave D. T wave

P wave represent atrial depolarization/contraction.

QRS waves reflect ventricular depolarization.

29. The nurse is preparing the client for an

ultrasound of the gallbladder. Which of the
following statements would be the most
important to prepare the client for the test?
A. "You will have food and fluids restricted
NPO must be done prior to ultrasound of the morning.
bladder in order to concentrate the bile in the D. Placing the lid of the culture container
bladder. face down on the bedside table.

30. Cultural sensitivity enables nurses to be Oral care (A) may be done prior to sputum
responsive to the needs of patients with varied specimen collection as long as antiseptic
cultural background. A client practices Islam mouthwash or saline gargles are not done. B
and his diet must consider his religious facilitates sputum expectoration. C is the preferred
practices and beliefs. The nurse is aware that time to collect sputum. D contaminates the lid of
this client would avoid which of the following? the specimen container.
1. Shrimps and crabs
2. Wine and alcohol drinks
3. Fish with scales
4. Pork products like bacon
5. Caffeinated products like
cola drinks A. 2, 4 and 5 C. 3,4, 5
B. 1, 4 and 5 D. 1, 2 and 4

31. What is the formula to obtain cardiac output?

A. Heart rate x Diastolic pressure
B. Heart rate x Pulse pressure
C. Heart rate x Stroke volume
D. Heart rate x Systolic pressure

Cardiac output is the amount of blood ejected by

the heart in one minute. It is determined by the
heart rate and stroke volume or the amount of
blood ejected by the heart PER contraction which is
about 70 mL. If a person’s heart rate is 80, multiply it by
70, then the cardiac output is 5,600 mL.

32. A pulse oximetry measures oxygen saturation

of the blood. The oxygen saturation reading
that is assessed by using a pulse oximeter is
documented as
A. SaO2 c. PO2
B. SpO2 d. PaO2

Oxygen saturation is SaO2. When assessed by a

pulse oximeter, it as reflected as SpO2.

33. The nurse has a sterile field in front of her

and needs to reach something on the other
side of the sterile field. To maintain the sterile
field, the nurse should:
A. Walk around with the back to the sterile field.
B. Reach across the sterile field.
C. Walk around facing the sterile field.
D. Move the sterile field away from her and
reach the object.

ABD all violate the principles of aseptic technique.

34. When obtaining a urine sample from a

patient with an indwelling urinary catheter,
where should the urine be collected?
A. From the balloon port of the catheter using a
needle.
B. From the collection bag.
C. From the collection port using a needle.
D. From the tube near the meatus using a
needle.

Letter A will remove the fluid that anchors the

catheter. Urine is never collected from the collection
bag.
35. A nurse receives an order to obtain sputum
sample for culture from a client with
pneumonia. What action should be avoided
when obtaining the specimen?
A. Having the client brush teeth before
expectoration.
B. Instructing the client to take deep
breaths before coughing.
C. Obtaining the specimen early in the
 external ring clockwise until it clicks into
36. A nurse is preparing to suction a client through place
a tracheostomy tube. Which of the following B. Insert the flange of the tube and lock until it
protective items would the nurse wear to clicks into place
perform this procedure? C. Secure the flange of the inner cannula to
A. Goggles, mask and sterile gloves the outer cannula
B. Mask. gown and cap D. Return the inner cannula, lock by rotating
C. Mask, sterile gloves and cap the external ring counterclockwise until clicks
D. Gown, mask and sterile gloves into place.

Gowns and caps are not required for tracheostomy To lock a tracheostomy cannula = turn clockwise
suctioning. (lock, clock) To unlock a tracheostomy cannula =
turn counterclockwise
37. When performing incentive spirometry after
lobectomy, how should the nurse position
the client?
A. Semi-Fowler’s C. Supine
B. Trendelenburg D. Lithotomy

Incentive spirometry facilitates lung expansion.

Semi-Fowler’s position helps achieve that
purpose.

38. While orienting a new nurse to the unit, the

charge nurse stresses the importance of
accurate documentation, the primary reason
for a nurse to document care accurately is
A. Be in compliance with individual regulatory
agencies B. Demonstrate responsibility and
accountability
C. Facilitate insurance reimbursement
D. Prevent any legal action against the
healthcare facility and its staff

39. A 12-year old girl has a long leg cast applied to

her left leg. She is being instructed in crutch
walking with no weight-bearing on her left leg.
Which of the following observations indicates
that the girl needs further teaching?
A. Her elbows are slightly flexed
B. She is supporting her weight on the
axillary bars and hand pieces of the
crutches
C. She is using the three-point gait
D. She places the crutches approximately
six to eight inches (15-20 cm.) in front of
her with each step

The weight must be borne by the hands on the

hand bars, not by the axillae. This may cause
neurovascular impairment.

40. An infant who weighs 11 lbs. (5 kg.) is to

receive 750 mg of antibiotic in a 24-hour
period. The liquid antibiotic comes in a
concentration of 125 mg per 5 ml. If the
antibiotic is to be given three times each day,
how many milliliters would the nurse
administer with each dose?
A. 10 B. 2 C. 5 D. 6.25

750 mg per day / 3 doses per day = 250

mg/dose 250 mg per dose / 125 mg x 5 ml
= 10 mL

41. The nurse performs tracheostomy care to a

client with acute respiratory distress
syndrome. After thoroughly cleansing the
lumen and the entire inner cannula in
hydrogen peroxide solution the nurse is now
ready to return the cannula to the
tracheostomy site. To ensure that the
cannula is in place the nurse should:
A. Replace the inner cannula following the
curve of the tube, lock by rotating the
42. A patient whose ventilation is inadequate appropriate nursing action would be to
should be observed for early symptoms of A. Remove old dressings with sterile gloves
hypoxia, which include B. Pour antiseptic solution out of the container
A. Restlessness C. Pallor C. Open the sterile dressings with sterile gloves
B. Cyanosis D. Disorientation D. Wear sterile gloves whenever in
contact with the wound area
TIP: Signs of hypoxia
ALWAYS: Early sign of low oxygen is behavioral Sterile dressings are opened by the clean bare
change since the brain is sensitive to changes in hands by holding the edges of the package.
oxygen level. Cyanosis is a LATE sign of hypoxia.
48. A client is positive of neck vein distention if the
43. Urinary tract infections remain to be the most nurse sees a bulging neck vein when the client
common cause of hospital acquired is in what position?
infections. When considering the safety
needs of a client with a urinary catheter,
which of the following should the nurse
observe?
A. Keep a closed sterile drainage system
B. Irrigate the catheter daily
C. Keep the bag lower than the bed
D. Measure intake and output daily

Safety needs = prevention of infection. Maintain a

closed system if a patient is on an indwelling
catheter.

44. Lizbeth is reviewing her notes in preparation

for her upcoming exam. In concepts of health
illness, who postulated that health is the ability
to maintain the internal milieu?
A. Walter Cannon C. Claude Bernard
B. Hans Selye D. Florence
Nightingale

Claude Bernard – first to explain internal

milieu Walter Cannon – first to give the name
“homeostasis” Hans Selye – first to explain
the stress response

45. Nursing practice is governed by different

theoretical framework postulated by
known theorists. The four concepts
common to nursing conceptual models
are: A. Person, environment, health and
nursing
B. Person, environment, psychology and
nursing
C. Person, health, nursing and support system
D. Person, nursing, environment and medicine

These are also called the four metaparadigms in

nursing.

46. Stress is the simple most important

contributing factor to illness. It is related to many
of man’s illnesses and interventions of these are
based on the body’s reaction to stress. Which of
the following body systems is primarily
involved in GAS as a response to stress?
A. Central nervous system and
cardiovascular system B. Neurological and
endocrine system
C. Endocrine system and respiratory system
D. Musculoskeletal and immunological system

GAS = general adaptation syndrome

The nervous system, through the autonomic
nervous system releases epinephrine and the
endocrine system, via the adrenal gland releases
epinephrine and corticosteroids, which are the
stress hormones.

47. Changing the wound dressing of a client

requires utmost care to prevent infection of the
wound. When doing wound care, the most
 A. Supine C. high-Fowler’s Dark amber urine is a sign of dehydration. The
B. Semi-Fowler’s D. Trendelenburg serum sodium is normal (135-145 meq/L). An
elevated level reflects dehydration. Neck vein
The patient is initially placed on supine position for distention suggests fluid overload.
the nurse to check the neck veins. Then the patient
is put on a semi- Fowler’s position. If a patient has a vein 53. Before administering a medication through a
distention, it is visible on that position. nasogastric (NG) tube, the nurse should do
which of the following first?
49. A client with severe flank pain has a A. Inject 10 ml of air into the NG tube and
suspected renal stones and is to undergo aspirate
diagnostic procedures such as intravenous
pyelography. An important nursing
intervention after an intravenous pyelography
is to
A. Determine response to the injected dye
B. Assess for allergy to
iodine C. Push fluids
D. Check the IV site

Intravenous pyelography involves administration of

a dye or contrast medium. Post-procedure, hydrate
the patient to facilitate excretion of the dye.

50. Having finished with you Masters degree in

Nursing, you were hired as a faculty member
and were assigned to teach the topic “History of
Nursing”. Florence Nightingale and her
contemporary nurse learned nursing skills and
techniques as “trainees” during which period in
the nursing history?
A. Apprenticeship period C. Primitive period
B. Intuitive period D. Educative period

TIP: Periods in the history of nursing

1. Intuitive nursing (from pre-historic time to
1700s)– care was based on instincts
2. Apprentice period (1700s-Nightingale era in
1800s) – nursing was based on “on-the job” training, focus
on skills; no formal education for nurses
3. Educated nursing (1800s-1940s) – Florence
Nightingale initiated formal schooling and
training for nurses
4. Contemporary nursing (1940s – present) –
nursing based on scientific principles, research and
influenced by advances in science and technology

51. The nurse correctly performs endotracheal

suctioning when she does which of the
following?
A. Administer 100% oxygen before the
procedure.
B. Apply intermittent suction while gently
inserting the suction catheter.
C. Advance the suction catheter when a
resistance is felt.
D. Suction the client for a minimum of 10-15
seconds.

Always pre-oxygenate the patient before and after

suctioning. Do not apply suction while inserting the
suction catheter (B). Choice C may cause tissue
trauma. TIP: Never force any invasive equipment
past any resistance. Suctioning is done for a
maximum of 15 seconds (D).

52. A client is receiving an IV infusion of dextrose

5% in water and Ringer’s lactate solution at 125
ml/hour to treat a fluid a volume deficit. Which of
these signs indicates a need for additional IV
fluids?
A. Dark amber urine
B. Serum sodium level of 135 mEq/L
C. Temperature of 37.5ºC
D. Neck vein distention
 B. Instruct the client to cough carbonic acid buffer system
C. Give a client a sip of water through a straw 2. Respiratory system – the lungs excrete CO2 if
D. Inject 10 ml of water into the NG tube the blood is acidotic and retains CO2 if it is
alkalotic. CO2 becomes an acid (carbonic acid)
TIP: Methods of checking for the placement of when mixed with water.
NGT 3. Renal system – the last and most effective
 Immersion – dip the end of the NGT in a means to correct imbalances. If the blood is
cup of water. Bubbling indicates placement acidotic, the kidneys retain bicarbonates (base)
of tube in the lungs. and excretes hydrogen ions (acid). If the blood is
 Auscultation – inject 10 ml of air into the alkalotic, they excrete bicarbonates and retain the
tube and listen for gurgling or hydrogen ions.
borborygmi sounds.
 Aspiration – presence of gastric aspirate
confirms placement. It is the most
accurate among the three methods.

Abdominal x-ray, however, is the BEST method to

determine placement of NGT.

54. A female client confesses during admission

assessment that she has a lump in her breast.
Which of the following is the appropriate action
of the nurse?
A. Lift the client hand to palpate the breast
where she noted the lump.
B. Palpate both breasts simultaneously to
compare.
C. Assess the breast with the
lump first. D. Start assessment of
the normal breast.

During admission, the initial action is to start

assessment of the normal breast. The suspected
abnormal breast is done next.

55. Which of the following activities demonstrate

secondary level of prevention?
A. A mother going to her physician for
her annual mammography
B. Nurses attending a seminar of crisis
management strategies
C. Monitoring the blood glucose level of
a diabetic patient
D. A child receives his booster dose of
varicella immunization

TIP: Levels of Prevention

 Primary prevention – health promotion
and disease prevention. Examples are
dietary modification, avoidance of
alcohol and smoking, stress
management, immunization and
exercise.
 Secondary prevention – early diagnosis
and treatment. Examples are screening,
diagnostic tests, medications, surgery.
 Tertiary prevention – recovery and
rehabilitation Examples are prevention of
complications, assistance with ADL,
physical therapy

56. A patient with pneumonia has respiratory

acidosis. In compensating for acid-base
imbalances, the first mechanism that is
usually activated is the
A. Retention of bicarbonates by the kidneys
B. Excretion of carbon dioxide by the lungs
C. Bicarbonate-carbonic acid chemical buffer
system
D. Retention of oxygen by the lungs

TIP: Sequence of compensatory

mechanisms for acid- base imbalances
1. Chemical buffer system – the most
common is the bicarbonate (base/alkaline)-
57. If a blood pressure cuff is too tight for a client,  Low hematocrit = hemodilution; fluid excess
blood pressure readings taken with such a cuff  High USG = urine is concentrated; fluid
may do which of the following? deficit
A. Cause a sciatic nerve damage  Low USG – urine is diluted; fluid excess
B. Fail to show changes in blood pressure
C. Produce a false-high 61. The nurse is taking care of a client, Luisa, 62
measurement D. Produce a years old, who received a diagnosis of uterine
false-low measurement cancer and is in the terminal stage. The focus
on care for the terminally ill client includes:
When the BP cuff is too tight, it needs LESS air to 1. Meeting physiologic needs
inflate the cuff. The reading will be lower. 2. Managing pain
3. Identifying and treating physical
58. A patient with renal failure has elevated symptoms
phosphorus level. Which of the following
interventions is appropriate to restore eliminate
excess phosphorus from the body?
A. Advise patient to drink more milk
B. Tell patient to eat chocolates and nuts
C. Take aluminum- based antacids like
Amphojel
D. Increase fluid intake

Aluminum binds with phosphorous and is

eliminated via the digestive system. Milk (A) and
dairy products (B) have high phosphorus
content. Although increasing fluids may help
eliminate phosphorous, medications are more
effective.

59. The intern-2nd assistant surgeon contaminated

his gown while the surgery is ongoing. He is
expected to change his gown and gloves.
Which of the following is the CORRECT
technique to be followed?
A. The intern removes his gown and gloves
then puts on another sterile gown and
gloves.
B. The intern removes his gloves, then his
gown; does a 3-minute hand scrub and don
another sterile gown and gloves.
C. The intern unties his gown, removes his
gowns and put on another gown and
gloves.
D. The circulating nurse unties the gown. The
intern removes his gown, then removes the
gloves and puts another sterile gown and
gloves.

In ABC, the intern removes the gown on his own.

He is not supposed to do that with contaminated
gloves on. Only choice D has another personnel
removing the gown for him.

60. Mr. Tee is admitted to the hospital with vomiting,

diarrhea, fever and a 5 lb (2.3 kg) weight loss.
The nursing diagnosis reads fluid volume deficit
related to vomiting and diarrhea. Which of the
following laboratory values can the nurse
expect to find on Mr. Tee’s chart?
A. Decreased urine specific gravity (USG)
B. Elevated serum potassium level
C. Increased hematocrit level (Hct)
D. Normal serum chloride level

Hematocrit (37%-47%) is the percentage of blood

cells to plasma, the liquid component of the blood.
When one has fluid volume deficit or dehydrated,
the blood becomes more concentrated, thus giving
a higher hematocrit level.

TIP: Laboratory values

 High hematocrit = hemoconcentration; fluid
deficit
 4. Providing emotional support Medication reconciliation is a process whereby the
A. 2 and 3 C. 1 and 2 nurse endorses the patient’s list of medication, in a written
B. 4 only D. 1, 2 and 4 form, to the next level of care/provider. This practice
aims to promote patient safety and errors in
Hospice care, or care of the terminally ill, focuses medication.
on making the patient feel comfortable by focusing
on pain management and alleviation of symptoms 66. A nurse is reviewing the electrolyte results of
(palliative care). an assigned client and notes that the
potassium level is 6.6 mEq/L. Which of the
62. Control of infection is emphasized in the following would the nurse expect to note on the
care of clients and must not be ECG as a result of this laboratory value?
compromised. An understanding of the
infectious process and appropriate methods
to prevent transmission of infection is
important. The nurse in the health center is
explaining “standard precautions” to the client.
This involves which of the following actions?
A. Use clean gloves when handling items
like blood, body fluids, and non-intact
skin.
B. Recap used needles with both
hands before discarding in
puncture-resistant container.
C. Wash hands thoroughly using
antimicrobial soap and hot water.
D. Wear protective equipment when doing
any nursing procedures.

B is unsafe practice; never recap needles. Use of

antimicrobial soap (C) is only indicated if hands are
contaminated; the guidelines say the for routine
handwashing, regular soap may be used. Not all
routine procedures need PPE (D).

63. Which of the following roles match the work-

related activity of the nurse whereby she
functions as clinician, educator, manager,
consultant and researcher within a specific
practice?
A. Nurse practitioner
B. Nurse anesthetist
C. Clinical nurse specialist
D. Nurse-educator

A clinical nurse specialist performs the roles of a

clinician, educator, manager, consultant and
researcher. A nurse practitioner (A) is a generalist.

64. Maria will be preparing a patient for

thoracentecis. She should assist the patient to
which of the following position for the
procedure?
A. Prone with the head turned to the side and
supported by a pillow
B. Lying in bed on the affected side with the
head of the bed elevated 45 degrees
C. Sim’s position with the head of the bed flat
D. Lying in bed on the unaffected side with
the head of the bed elevated 45 degrees

The preferred position for thoracentesis is an

upright position with arms propped up to exposed
the rib cage or intercostal spaces. If a patient
cannot tolerate this position, the choice D is the
next preferred position.

65. As a nurse, what is one of the best way

to reconcile medications across the
continuum of care?
A. Endorse the routine and “stat” medications every
shift B. Communicate a complete list of the patient’s
medication to the next provider of service
C. Endorse on a case to case basis
D. Endorse in writing
 A. ST depression C. inverted T wave affect of the anesthetic sprayed to suppress the gag
B. prominent U wave D. tall peaked T reflex.
waves
70. Promotion of adequate nutrition is a challenge
The potassium level is increased. NV = 3.5-5.5 to patients with cancer. The nurse caring for a
meq/L client on total parenteral nutrition should
perform which of the following assessments
TIP: Potassium & ECG regularly?
High potassium = high, peak, or tall T wave A. Serum glucose level
Low potassium = low, depressed T wave; presence B. Serum electrolytes
of U wave C. Urine output
D. Level of consciousness
67. A male client with a left lower leg prosthesis
states that he can feel his heart "skipping
beats" when he walks up the stairs. He states
his doctor has ordered an outpatient test that
will take many hours, and he wants to know
what it is. Your response would be:
A. "Your physician has ordered an
echocardiogram, which will utilize sound
waves to project a picture of your heart in
motion.“
B. "Your physician has ordered a Holter
monitor test, which will record your
cardiac rhythm and rate while you go
about your normal activities.“
C. "Your physician has ordered a graded
exercise treadmill test (GXT), which will
record your cardiac activity as you
exercise on a treadmill.“
D. "Your physician has ordered a 12-lead
ECG, which will record your resting heart
rhythm and rate."

Key words: “Skipped beats” refers to cardiac dysrthythmias

which are diagnosed by an ECG. “Out patient test” that takes
“many hours” are characteristics of a Holter monitor (B) . A 12-
lead ECG (D) only takes a few minutes.

68. Which of the following nursing diagnoses

contains the proper components?
A. Risk for caregiver role strain related to
unpredictable illness course
B. Risk for falls related to tendency to
collapse when having difficulty breathing
C. Decreased communication related to stroke
D. Sleep deprivation secondary to fatigue
and a noisy environment

TIP: The components of a nursing diagnosis:

PES
P – patient’s problem
E- etiology or related
factor S – signs and
symptoms

B – the problem (risk for fall) and etiology

(tendency to collapse) are the same
C – the etiology is a medical diagnosis
D – wrongly stated (secondary to); it should be “related to”

69. Following a bronchoscopy, which of the

following complains should be noted as a
possible complication?
A. nausea and vomiting
B. shortness of breath and laryngeal stridor
C. blood tinged sputum and coughing
D. sore throat and hoarseness

Stridor is a narrowing of the upper airway. It may

indicate laryngeal edema as a result of the
bronchoscope irritating the tissues. A blood-tinged
sputum (C), sore throat and hoarseness (D) may
be common and expected after an invasive
procedure. Nausea and vomiting (A) may be an
Total parenteral nutrition delivers a high calorie temperature
glucose, protein and fat-rich solution D. The variable to be measured is the
intravenously. Hyperglycemia is a common side- timing of initial bath
effect that needs to be monitored.
TIP: Independent vs. Dependent Variables
NURSING RESEARCH (20 points)  Independent variable = the presumed
cause, treatment or manipulated
71. Which of the following is NOT a component variable (timing of bath)
of evidence- based practice?  Dependent variable = the presumed
A. Use of the best available research finding effect or measured variable
B. Applying the research evidence (temperature)
using clinical expertise
C. Acceptability of the research finding by the 76. Which of these states the expected
patient relationship between the independent and
D. Generalizability of the research finding to dependent variable?
the general population A. Assumptions C. Hypothesis
B. Research design D. Research purpose
The fourth component of evidence-based practice
(EBP) is the availability of resources to implement
the evidence. The finding is only applicable to a
single patient or a group of patients with similar
problems. Generalizability is not needed in EBP.

72. In most instances, Filipinos do not know their

rights as patients. To be a patient advocate,
nurses must have a good understanding of the
“Patients’ Bill of Rights”. Which of the following is an
emerging role of the nurse in her mission to
provide quality care in any setting regardless
of type of client and meet her goal to
contribute new knowledge and technology in
nursing?
A. Nurse executive D. Nurse manager
B. Nurse researcher C. Nurse educator

The main objective of nursing research is to

contribute new knowledge and technology to
improve patient care.

73. A researcher would like to study two groups

of students, particularly, the freshmen and
the sophomore students regarding their
study habits before every periodical
examination. The survey will be made on a
same time to determine if there is any
difference as regards the two groups. This
type of survey is called:
A. Cross-sectional survey C. Evaluation
survey
B. Longitudinal survey D. Sample survey

74. The researcher would like to determine the

effectiveness of a new system of scheduling
and staffing in a particular tertiary hospital to
prevent sudden shortage in the ratio of
nurses to patients. The type of research
method is called:
A. Manipulative C. Descriptive
B. Quasi-experimental D. Experimental

Although the study determines the

effectiveness of an intervention, the situation
does not specifically mention two groups of
subjects, experimental and control groups,
thus making it a quasi-experimental research.

75. In the research study entitled “Effects of

timing of initial bath on the temperature of
the newborn”, which of the following is
correct?
A. The presumed cause is the timing of initial
bath
B. The presumed effects of the study is
the timing of initial bath
C. The variable to be manipulated is the
Hypothesis = educated guess, a prediction of the C. Communicate the findings
possible result of the study D. Interpret the findings

77. A researcher embarked on an intensive study Research utilization is the last phase of the research
of health problems affecting the residents of process.
Brgy. San Carlos. She decided to study every
third family representing the total population in 82. The type of research design that does not
the said community. Types of sampling suited manipulate independent variable is:
for the study is: A. non-experimental design
A. Cluster sampling C. Incidental sampling B. quantitative design
B. Systematic sampling D. Stratified sampling C. quasi- experimental design
D. experimental design
78. The plan for how a study will be conducted is
called the:
A. Data-collection method C. Research
design
B. Research process D. Hypothesis

79. Which statistical treatment is best used to

answer the research question, “The Level of
Difficulty of the May 2014 Nurse Licensure
Examination as Perceived by the
Examinees”?
A. Chi-square C. ANOVA
B. Mean D. T-test

The study simply requires frequency distribution

and/or mean determination.

TIP: Statistics
 Chi-square – to determine the relationship
between two variables that are on a
nominal or ordinal scale
 ANOVA or analysis of variance – to
determine significant difference between
three or more groups of respondents
 T-test – to determine significant difference
between two groups of respondents and
to determine difference between pre-test
and post-test scores

80. A competency-based assessment tool for

nursing program has been constructed. To
assist the faculty in assessing student
attainment of competencies a measuring
instrument has to be developed. In developing
the research instrument, existing instruments
that measured similar variables were reviewed
by the researcher. After compiling and writing
items, format was decided for each variable to
be assessed. Which of the following should the
researcher do to make sure that the instrument
measures the attainment of competencies?
1.Have colleagues review the items for
logical validity 2.Revise items based on
colleagues' feedback 3.Locate a group with
experience appropriate to the
study
4.Try out the instrument with a group as
similar as possible to the study
respondents.
A. 1,2 and 4 C. 1 and 2
B. 2 and 4 D. 1, 2, 3 and 4

The question refers on how to assess validity

(accuracy) of a research instrument. All of these
items ensure validity.

81. The final step of the research process for the

researcher is to:
A. Analyze the
data B. Utilize the
findings
Experimental and quasi-experimental control group.
researches, which are both quantitative designs,
both involve manipulation of an independent 87. In a research, the hypothesis developed was:
(treatment) variable. Gingko biloba improves memory and retention.
This is an example of what type of hypothesis?
83. In statistics, this expresses the variability of A. Simple, directional hypothesis
the data in reference to the mean. It B. Simple, non-directional
provides us with a numerical estimate of hypothesis C. Complex,
how far, on the average the separate directional hypothesis
observation are from the mean. What is this D. Complex, non-directional hypothesis
called?
A. Mode C. Standard deviation TIP: Types of hypothesis
B. Median D. Frequency

Key word: Variability = measures of variability

includes range, variance, standard deviation

84. The researcher implemented a medication

regimen using a new type of combination
drugs to manic patients while another group of
manic patient receives the routine drugs. The
researcher however handpicked the
experimental group for they are the clients
with multiple episodes of bipolar disorder. The
researcher utilized which research design?
A. Quasi-experimental C Pure experimental
B. Phenomenological D. Longitudinal

TIP: Experimental vs. quasi-experimental

research
If an experimental study DOES NOT involve
random selection of subjects (handpicked) and
include two groups of subjects (experimental and
control groups), it is considered a quasi-
experimental study.

85. In the hypothesis “The utilization of technology in

teaching improves the retention and attention
of the nursing students.” Which is the
manipulated variable in the study?
A. Utilization of technology
B. Improvement in the retention and attention
C. Nursing students
D. Teaching

Manipulated variable is also known as the

independent, treatment variable, or the presumed
cause.

86. Nina, a staff nurse in the Oncology unit was

asked to participate as a member of the
team in the Phase III clinical trial of the
effect of a new drug treatment for cancer
patients. The study has been approved by
the Institutional Review Board of the
hospital where Nina is employed. Nina was
informed that a double blind approach will
be utilized. Which of the following is the
CORRECT description of approach?
A. Subjects who are randomly assigned
to different treatments are different
people
B. Neither the subject nor those who
administer the treatment know who is in the
experimental and control group.
C. Pairing of subjects in one group with those
in another group based on similarities
D. Control group receives the full treatment
and deferred temporarily.

A double blind approach increases the validity of

the study. All subjects receive a treatment but no
one knows, even the one who administers the
treatment, who belongs to the experimental or
Simple – one independent and one dependent
variable Complex – 2 or more independent and 2 or 93. To encourage more health workers to stay in
more dependent variables government service, Republic Act 7305 or
Directional – indicates a positive or Magna Carta of Public Health Workers was
negative effect Non-directional – the passed into law last 1991. “Public health
effect cannot be determined workers” include all persons working in the
government health facilities such as the:
88. A student nurse is curious to find out whether 1. Physicians 4. Cashier, clerical
Safeguard or Dial is more effective in cleaning staff
an infected wound. The first step in locating 2. Midwives 5. Janitor staff
for evidence in evidence-based practice is to
formulate the research question using the
PICO format. PICO stands for
A. Problem, intervention, comparison, outcome
B. Population, interest, control, outcome
C. Presentation, intervention, comparison,
organization
D. Problem, implementation, control, output

89. Which of the following levels of significance

would yield the most accurate research
finding?
A. P = 0.01 C. P = 0.10
B. P = 0.05 D. P = 1.00

TIP: Level of significance

 0.01: 1% margin of error; 99% accuracy rate
 0.05: 5% margin of error; 95% accuracy rate

90. A questionnaire is being used to gather data

on the study sample. Identification numbers on
the corner of the questionnaires correspond to the
researcher’s master list of names and numbers.
Respondents are assured that this information
will not be shared with anyone. The
researcher is trying to provide:
A. Confidentiality C. Informed consent
B. Anonymity D. Data security

Assigning respondents to numbers or codes

ensures anonymity.

COMMUNITY HEALTH NURSING (40 points)

91. The United Nations identified eight Millennium

Development Goals to address the pressing
issues in the entire world. The Philippine
Department of Health adopted the Basic
Emergency Management Obstetric Care in
response to this calling. This reflects
A. Millenium Development Goal #3
B. Millenium Development
Goal #4 C. Millenium
Development Goal #5
D. Millenium Development Goal #6

TIP: Millenium Development Goals

MDG #4 – infants and children
MDG #5 – pregnant mothers and women

92. The community Health Nurse Conduct’s home

visits to families in the community. Planning for
a home visit is an essential tool in achieving
best results in healthcare. The following BUT
ONE are the principles
A. Home visit should have a purpose
B. Planning of continuing care must be
developed by the nurse
C. Planning should be flexible and practical
D. Plans are based on available information
including those from other agencies that
may have rendered services to the family

Planning is collaboratively done by the nurse and

the patient.
 3. Cooks and assistant cooks 6. B. Epidemiologic process
Nurses A. 1,2,3,4,5 and 6 C. Nursing process
B. 1,2,3 and 4 D. Problem-solving process
C. 1,2 and 3
only D. 1,2,3,4 102. The client/patient in community health nursing
and 5 is the
A. Family as a socialization unit and
That is the definition of public health workers as undergoing different stages of development
defined in RA 7305. B. Group of people sharing common
characteristics and interests in a particular
94. PD 825 is law that area
pertains to: A.
environmental
sanitation
B. compulsory immunization of children (PD
996)
C. anti-smoking (RA 9211)
D. registration of child births (PD 651)

95. The purpose of the first home visit is to

A. Assess family situation through initial data
base
B. Develop a health care plan with the family
C. Make a personal account of the family’s
health situation
D. Promote health of the family

First home visit focuses on assessment of the

family.

96. To ensure that the nurse can perform nursing

procedures with ease and deftness, saving
time and effort with the end in view of
rendering effective nursing care, he must
A. Apply the nursing process
B. Develop a family care plan
C. Perform bag technique
D. Prioritize family health nursing problems

97. The primary goal of community health nursing is

A. Enhancing the health capabilities of
the people towards self-reliance in
health
B. Health promotion and disease prevention
C. Upholding the worth and dignity
of man D. Raising the level of health
of the citizenry

98. The philosophy of CHN is

A. Enhancing health capabilities of the
people towards self-reliance in health
B. Health promotion and disease prevention
C. Raising the level of health of the
citizenry D. Upholding the worth and
dignity of man

99. The theoretical bases of Community

Health Nursing practice are theories and
principles of
A. Community Development
B. Nursing
C. Nursing & Public Health
D. Public Health

100. People’s participation in health affairs is optimized

through the establishments of
A. Community-based health program
B. People’s organization
C. NGO
D. Community health centers

101. A dynamic process the nurse employ to

achieve optimum level of functioning of any
level of clientele in CHN is the
A. Community organizing process
 C. Individual that is identified as a bio-psycho- A. It determines the deaths among infants
social and spiritual being within a specific period of time.
D. Population aggregates that require B. It is the best indicator of the community’s health
specialized care status.
C. It shows the number of deaths among
The client in CHN is the community. babies during the first 28 days of life.
D. It reflects the effectiveness of the delivery
103. The focus of care in CHN is the of health services.
A. Family C. Individual
B. Population group D. Community

104. When reviewing the function of the rural

health unit, the community health nurse
concurs that the RHU functions as a:
A. Clinic for the municipality
B. Community resource
C. Health arm of the local government unit
D. Central health resource for the municipality

105. Which of the following herbal medicines

is effective for asthma, cough and
dysentery?
A. Yerba Buena C. Lagundi
B. Sambong D. Tsaang gubat

106. The primary health care (PHC) approach is

implemented to ensure people’s health. Full
participation of the people is made possible
through the application of community
organizing process in health. The ultimate end
is to:
A. Develop community health programs
B. Improve availability and accessibility of
health service
C. Promote people’s health
D. Transfer health into the hands of the people

107. There is the need to phase out the

community once the community-based
health program is functional. The reason for
is to:
A. Indicate termination of community
organizing process B. Provide opportunity for
the role to stand on their own
C. Start a new project in other depressed
communities
D. Test the new health program if already
viable

108. The cornerstones or pillars of PHC are

1-active community
participation 2-multi-
sectoral approach
3- use of appropriate technology
4- support mechanisms made
available
A. All of the above C. 1 and 3
B. 1,2 and 3 D. 1 and 2

109. In prioritizing family health nursing

problems, which of these criteria should not
be used by the nurse?
A. Acceptability of the problem
B. Preventive potential of the problem
C. Modifiability of the problem
D. Nature of the problem

The fourth criterion is salience, how the family

perceives the problem.

110. Vital statistics is one of the epidemiological

tools that the community health nurse uses in
recording the impact of health programs in the
community. What is the most significant
implication of a community’s infant mortality rate?
111. Communicable disease control program is are two of such recent programs. The
one component of CHN services. The nurse EntrepreNurse program is an initiative of the
utilizes her concepts of disease prevention. A. Department of Health
The best strategy in the prevention of B. Department of Labor and Employment
communicable diseases is: C. PRC Board of Nursing
A. Correct diagnosis and treatment D. Philippine Nurses Association
B. Health education
C. Immunization/chemoprophylaxis 120. We are aware that Community Health
D. Screening Nursing (CHN) in the Philippines
encompasses health care provisions affecting
112. Nurses working under the RN Heals are 4 clients: individual, families, population
enrolled in the Philhealth iGroup Insurance. groups and communities. In the course of our
Which of the following are the benefits of community health
the nurses who are under the RN Heals
Project? Select all that apply.
A. Premium of P1,200.00 per person per year
B. GSIS Group Accident Insurance premium
of P 500.00 per person per year covering
the following
C. Accidental Death/Dismemberment of
P500,000.00 per person
D. Medical Reimbursement of P50,000.00
per person E. Bereavement Assistance of
P10,000.00.

113. Primary level of prevention of ascariasis

pertain to the following EXCEPT:
A. Food sanitation
B. Handwashing
C. Mebendazole as prophylaxis
D. Septic tank toilet

Primary level of prevention focuses on disease

prevention and health promotion. Choice C is
secondary prevention.

114. The original objective of the

Expanded Program on Immunization is
A. Correct epidermiological situation in the
country
B. Eradicate communicable diseases among
infants and young children
C. Reduce morbidity and mortality among
infants and children caused six
immunizable diseases
D. Reduce mortality and morbidity of pregnant
women

115. The community health nurse collects data

about 100% of the population in a barangay.
The nurse is conducting:
A. Community assembly C. Community survey
B. Census taking D. Epidemiologic
survey

116. BCG is given to school entrants at

A. 0.1 ml ID C. 0.05 ml ID
B. 0.5 ml ID D. 0.5 ml IM

117. The nurse conducts case findings for

leprosy in the community. She recalls that
for the tuberculoid type of leprosy, the best
treatment is
A. PB 19 blister packs C. MB 18 blister
packs
B. MB 24 blister packs D. PB 6 blister packs

118. The most serious side effect of DPT is

A. convulsion C. fever
B. inflamed site D. infection

119. Various programs have been designed and

implemented by the Philippine government to
assist new nurses in their transition into the
labor market. EntrepreNurse and RN HEALS
 work, traditional, non-traditional, alternative, or TIP: Danger signs
complimentary health care strategies are  Convulsion
stabilized. Legal basis for this action maybe  Lethargy or unconsciousness
derived from the:  Inability to breastfeed or drink
A. PhilHealth Act  Severe vomiting.
B. Traditional and Alternative
Healthcare Law C. Philippine Nursing 126. For purposes of accuracy and completion of
Act documents regarding childbirth in the
D. Philippine Medical Act community, the nurse working at the RHU is
required that registration birth within 30 days
121. The following statements pertain to from must be done. Which law requires this?
Community Organizing EXCEPT A. R.A. 3573 C. R.A. 3375
A. A never-ending process once started B. PD 651 D. EO 119
B. A process for increasing awareness,
facilitating organization and initiating RA 3573 – reporting of communicable diseases
responsible action
C. Can apply to all communities
D. Its goal is community development

Each community is unique. The CO process

depends on the individual community situation.

122. A public health nurse conducts a home visit

and uses the family nursing care plan. During
her assessment, which of the following is
categorized as a health deficit?
A. The father does not want to have a regular
check-up at the rural health unit.
B. The mother has a history of pre-
eclampsia. C. The eldest child is
malnourished.
D. The youngest will enter first grade when the
school starts.

Choices A, B are health threats while D is a

foreseeable crisis.

123. The community health nurse implements

various health programs of the Department of
Health. The Essential Intrapartum and
Newborn Care’s (EINC) Active Management of
Third Stage of Labor (AMTSL) advocates the
implementation of the following practices
EXCEPT?
A. mobility and position of choice in labor
B. partograph use
C. antenatal steroid administration in
preterm labor D. application of fundal
pressure

124. An 8-month-old child is brought to the

health facility for “fast breathing.” Using the
Integrated Management of Childhood Illnesses
(IMCI) guidelines, correct interpretation of “fast
breathing” in this situation MEANS:
A. 40 breaths per minute C. 45 breaths per
minute
B. 38 breaths per minute D. 55 breaths per
minute

TIP: Fast breathing in IMCI

Less than 12 months of age = more than 50
per min More than 12 months of age =
more than 40 per min

125. The nurse utilizes the IMCI chart in

assessing her pediatric clients in the rural
health unit. When checking the general danger
signs in a 4 month old child, the following
questions are asked EXCEPT:
A. Did the child have convulsions?
B. Is the child eating well during illness?
C. Is the child able to
breastfeed? D. Has the child
had diarrhea?
EO 119 – reorganization of the DOH D. ingesting improperly cooked beef

127. A meeting of clients for home care (HC) is Taeniasis is a parasitic infection caused by
essential in order to explain the role of the tapeworms for improperly cooked food. T. saginata
nurse and the advantages of this alternative comes from beef.
health provision. Among important emphasis
to be made is that home care 133. Schistosomiasis is an endemic disease.
A. Encourages a dependent relationship Endemic means that the disease occurs
between the nurse and the client A. at one time during in a specific period of the
B. Provides a holistic view of the client that year
helps nurse to establish appropriate goals B. if there is a sudden increase in infections
and to plan appropriate care
C. Allows the nurse to have primary
control over the environment where the
client will recover
D. Saves the client money because the care
is provided in a one-to-one situation

Home care promotes patient independence (A)

and control (C). It may cost more as care is
provided on 1-on-1 basis (D).

128. In implementing the IMCI guidelines, the

nurse should always make it an assessment
standard in children to check in capillary
refill especially when:
A. The extremities of the child feels cold
B. If there is a fever for more than 7 days
C. The child’s extremities feel warm
D. If the child has petechiae

129. The community health nurse as a

supervisor in the community functions by
doing which of the following?
A. Detects deviations from health
B. Ensures continuity of care to clients/patients
C. Participates in development and
distribution of IEC materials
D. Provides technical and administrative
support to midwives

130. Under Republic Act 9173 of 2002,

AMENDED by Congressional Joint
Resolution of 2009 sets the entry level
position for nurses at what salary grade?
A. Salary Grade 15 C. Salary Grade 24
B. Salary Grade 20 D. Salary Grade 10

COMMUNICABLE DISEASE NURSING (20

points)

131. The nurse observes a patient with typhoid

fever constantly picking the linen while he is
lying supine on the bed. The nurse notes this
as a sign called
A. coma vigil C. asterixis
B. subcultus tendinum D. rhisus sardonicus

Subcultus tendinum – due to the contractions of the

tendons of the wrist
Coma vigil – state of unconsciousness due to
typhoid fever Asterixis – flapping tremors of the
hands seen in hepatic encephalopathy due to
rising ammonia level
Rhisus sardonicus – also called sardonic grin;
seen among patent with tetanus/lockjaw

132. A patient is told he is positive of Taenia

saginata on his stool exam for ova &
parasites. The nurse explains to the patient
that this might have come from
A. drinking contaminated water
B. eating fresh fruits and vegetables
C. swimming in flood water
 C. continuously in a community throughout the animal, its brain tissues can be examined for the
year presence of
D. widespread in the country at a particular A. necrotic tissues C. hematomas
time B. Negri bodies D. antibodies

B refers to epidemic and D pertains to pandemic. The presence of Negri bodies is pathognomomic of
rabies.
134. The nurse evaluates effectiveness of her
health teachings on a group of mothers 140. The nurse notes meningococcemia in a
regarding ascariasis. An accurate statement patient if she observes
made by a mother regarding prevention of A. stiffness of the neck C. petechiae on the
ascariasis is skin
A. “I will tell my kids to wash hands after meals.”
B. “I will discourage my child from playing on the soil.”
C. “I will not let my children eat raw fruits.”
D. “I will make sure not to buy expired canned goods.’

Ascaris lumbricoides thrives in the soil. Playing on

the soil may get the ova into the skin and nails
which may eventually be ingested if proper
handwashing is not observed.

135. Which of the following statements made

by a patient suggests the presence of
enterobiasis?
A. “I feel nauseated every morning.”
B. “I feel itchiness in my anus at night.”
C. “My abdomen is cramping frequently.”
D. “I didn’t’ have a bowel movement in 3 days.”

Pinworm infestation by Enterobius

vermicularis causes nocturnal perianal
pruritus.

136. A patient presents to the emergency room

with meningitis. The patient is most likely to
present with which chief complaints?
A. headache and nuchal rigidity
B. vomiting and blurred vision
C. dilated pupils and seizures
D. loss of consciousness and cyanosis

Early sign of meningeal irritation is stiffness of the

neck. Other signs may include Brudzinsky sign and
Kernig’s sign.

137. Which of the following laboratory results for

CSF suggests the presence of bacterial
meningitis?
A. increased protein level
B. decreased white blood cells
C. reduced glucose level
D. increased red blood cells

Bacteria in the CSF consumes the glucose,

reducing the glucose level in the CSF.

138. The nurse assesses a patient with

meningitis by asking the patient to flex his
knees towards his abdomen and assessing
his response. The nurse is performing an
assessment to elicit the
A. Babinski sign C. Brudzinsky’s sign
B. Kernig’s sign D. Cushing’s sign

Babinski sign – sign of neurological immaturity

seen in infants Brudzinsky sign – sign of meningitis
elicited by flexing the neck and observing for
involuntary flexion of the knees and neck pain
Cushing’s sign – late sign of increased intracranial
pressure characterized by high BP or widened
pulse pressure, bradycardia and bradypnea (slow
RR)

139. To determine the presence of rabies in an

 B. unequal pupils D. diarrhea B. Glycerine oral swabs D. Amphotericin B

Meningococcemia causes disruption in the blood These indicate oral candiasis, a superficial (skin and
vessels, causing hemorrhage. mucous membranes) infection caused by the
fungus, Candida albicans. C and D are both anti-
141. Syphilis is caused by: fungal drugs but Amphotericin B is used for severe
A. Neisseria gonorrhea C. Treponema systemic fungal infections.
pallidum
B. Cytomegalovirus D. Herpes simplex 148. A nurse teaches the public where malaria is
virus endemic about prevention and management of
the infection. Which statement about malaria is
142. A sign of gonorrhea is accurate? Malaria
A. generalized skin rash A. affects the white blood cells
B. yellowish genital discharge
C. clear white genital discharge
D. cheesy substance on the genitalia

Clear white discharge is common in syphilis.

Cheesy white substance is seen in candidiasis.

143. The modes of transmission of the human

immune deficiency virus are categorized as
horizontal and vertical transmission. Which of
these is an example of a vertical mode of
transmission?
A. Sexual intercourse with an infected partner
B. Needlestick injury from an
infected patient C. Placental
transfer from an infected mother
D. Sharing among infected IV drug users

ABD are considered horizontal modes of

transmission.

144. A confirmatory diagnostic test for HIV

infection is
A. the Western blot test
B. enzyme linked immunosorbent assay
(ELISA) test
C. T4 cell count determination
D. differential CBC test

ABC are all used in HIV diagnosis. B is used as

the initial screening test. T4 cell count is used to
monitor progression of the disease.

145. A patient asks the nurse for early signs of

HIV infection. The nurse tells that early HIV
infection is usually manifested by the
presence of
A. enlarged lymph nodes in multiple areas of
the body
B. recurrent oral thrush
C. rapid weight loss and diarrhea
D. multiple infections

Persistent generalized lymphadenopathy or the

enlargement of 1 or more lymph nodes for a long
period of time without the presence of any infection
is an early sign of HIV infection.

146. Multiple drug therapy is given to a

patient with AIDS. Which of these is an
example of an anti-viral drug for AIDS?
A. Amphotericin B C. Zidovudine
B. Amantadine D. Azithromycin

Anti-retroviral therapy is used to inhibit the

replication of the HIV. (A) is an anti-fungal, (B)
anti-flu, and (C) anti-bacterial.

147. A patient with HIV infection has whitish

spots on the mouth and throat. The nurse
will most likely administer
A. Neomycin sulfate C. Nystatin solution
 B. is caused by a protozoan Chloramphenicol (Chloromycetin) is developing
C. is caused by the Anopheles mosquito severe toxic reactions?
D. leads to internal hemorrhage A. Nausea, vomiting,
diarrhea B. Anemia,
Malaria causes hemolysis of RBC (A), not infections, bleeding
hemorrhage (D). It is caused by the protozoa of the C. Jaundice, tinnitus, oliguria
Plasmodium species and is transmitted, NOT D. Photosensitivity, rash, constipation
caused, by a female Anopheles mosquito (C)
Chloramphenicol causes bone marrow
149. Which vital statistics relating to depression, causing reduced production of RBC,
Tuberculosis (TB) in our country is WBC, and platelets, leading to anemia,
INACCURATE? infections, and bleeding, respectively.
A. The Philippine is among the 22 highly
burdened poor countries in the world 154. A patient is in a Respiratory Isolation room
B. TB is the 6th leading cause of illness among and is taking multi-drug therapy for
Filipinos tuberculosis. Which of the following
C. TB is the 6th leading cause of deaths
among Filipinos D. Most TB patients belong to
the 0-15 age groups

150. When a nurse gets a hepatitis vaccine after

exposure to a body fluid of a patient with
hepatitis B, the type of immunity that develops
is
A. a naturally acquired active immunity
B. a naturally acquired passive immunity
C. an artificially acquired passive immunity
D. an artificially acquired active immunity

Hepatitis B immunization involves administration of

immunoglobulins or antibodies for immediate
protection.

TIP: Active vs. passive immunity

Active – the body produces its OWN antibody
Passive – the antibody comes from an OUTSIDE
source

PHARMACOLOGY (30 points)

151. Felicito, 65 years old, post coronary artery

bypass due to acute myocardial infarction,
sought consultation because of worsening
pedal edema. Upon admission, Morphine
sulfate was administered intravenously. Which
of the following is the purpose of administering
the drug?
A. improve efficacy of breathing
B. relieve chest pain
C. reduce venous return
D. reduce anxiety

It is true that Morphine sulfate is an opioid

analgesic and is used to relieve chest pain in
myocardial infarction. The situation presents the
development of pedal edema, which is a sign of
impending heart failure. In heart failure, morphine
is used to promote pulmonary circulation, thus,
improves the breathing of a patient.

152. The physician prescribes

oral penicillin 500 mg every six hours for seven
days. On the fifth day before Cora administer
the first dose for the day she computed the
total amount in milligrams of the oral penicillin
that has been received by the client. Which is
the correct amount? A. 2,500 mg C.
10,000 mg
B. 15,000 mg D. 8,000 mg
The situation is asking the dose given on the
previous four days only (before the nurse gives the
first dose on the 5th day).

153. Which of the following conditions would

alert the nurse that a patient receiving
 statements made by the patient suggests that B. Pilocarpine (Pilocar)
he is exhibiting adverse effect of C. Neostigmine bromide (Prostigmine)
Streptomycin? D. Atenolol (Tenormin)
A. “I am having numbness in my
hands.” B. “I have some trouble TIP: Anti-cholinergic meds to prevent pseudo-
hearing.” parkinsonism or extra-pyramidal symptoms
C. “I noticed my urine turned orange.” (EPS) caused by antipsychotics
D. “My hands seem to be more swollen today.” A – Akineton (Biperiden HCl)
A – Artane (Trihexiphenydyl HCl)
TIP: Side-effects of anti-TB drugs (RIPES) B – Benadryl
Rifampicin – orange discoloration of the (Diphenhydramine HCl) C –
urine Cogentin (Benztropine
Isoniazid – peripheral neuropathy; mesylate)
hepatotoxicity
Pyrazinamide – hyperuricemia
Ethambutol – optic neuritis; hepatotoxicity
Streptomycin – otoxocicity, tinnitus

155. Mr. A is a 56-year old patient admitted at

the ED with an internal hemorrhage. He was
given Epinephrine 1:1000 SQ. Which of the
following sets of physiological responses
reflects the effects of Epinephrine?
A. bradycardia, vasoconstriction, miosis
B. bronchodilation, mydriasis, hyperglycemia
C. tachycardia, hypotension, tachypnea
D. vasodilation, hypoglycemia,
bronchoconstriction

Effects of Epinephrine: tachycardia,

vasoconstriction (hypertension), mydriasis
(pupil dilation), tachypnea,
hyperglycemia, bronchodilation.

156. Low molecular weight Heparin such as

Enoxaparin (Lovenox) was prescribed to be
administered. Which of the following should
the nurse include in her nursing care plan to
ensure absence of injury?
A. Deltoid is the preferred site because it is
less painful
B. Aspirate prior to injecting to ensure no
blood vessel is hit
C. Use gauge 25 and 1/4 inch long needle
D. Massage after the injection to promote fast
absorption

The drug is administered subcutaneously on the

abdomen only (A) using a gauge 25-26, ¼-5/8 inch
needle (C). Aspiration (B) and massage (D) are
not done before and after administering the drug.

157. Mr. C is a 65 y/o patient with myasthenia

gravis. Which of the following medications is
used to treat myasthenia gravis?
A. Pyridostigmine (Mestinon)
B. Trihexyphenidyl HCl (Artane)
C. Bethanechol Cl (Urecholine)
D. Methyldopa (Aldomet)

Myasthenia is caused by low level of

acetylcholine (Ach). Treatment involves use of
antic-cholinesterase medications to prevent the
breakdown of Ach by the enzyme, cholinesterase.
This will eventually increase Ach levels.

158. Mr. S is a 40-year old patient at the

psychiatric unit and is being treated with anti-
psychotic drugs. The nurse observes that Mr. S is
exhibiting symptoms of Parkinson’s disease. Which
of the following anti-cholinergic drugs is often
used to reduce side effects of anti-psychotic
medications such as pseudo-parkinsonism?
A. Benztropine mesylate (Cogentin)
 165. Gingival hyperplasia is a common side-effect
159. A patient is admitted to the ED 12 hours after of
ingesting a half-bottle of Acetaminophen A. Phenytoin (Dilantin)
(Tylenol). To determine organ damage due to B. Valproic acid (Depakote)
the toxic effect of the drug, the nurse should C. Carbamazapine (Tegretol)
evaluate which of these laboratory results? D. Chlordiazepoxide (Librium)
A. Aspartate transaminase (AST) / alanine
transaminase (ALT) levels Gingival hyperplasia or enlargement of the gums is
B. White blood count (WBC) and uric acid a common side-effect of Phenytoin. Oral care helps
levels prevent this condition.
C. Platelet count and urinalysis
D. Blood urea nitrogen (BUN) and creatinine 166. The appropriate information to a COPD
levels patient on action of Acetylcysteine (Mucomyst)
is:
Hepatotoxicity is an effect of Acetaminophen. A. “This medication helps loosen the secretions in your
Elevated ALT/AST levels indicate liver damage. lungs.”
B. “This drug will make you breathe easier by dilating
160. Mr. P is a 76-year old patient with your airways.”
rheumatoid arthritis. He is currently taking C. “You will feel dizzy or sleepy after taking this
Aspirin 325 po q4h prn for joint pains. medication.”
Which of the following nursing interventions is D. “This drug makes your mouth dry because it
appropriate for patients taking Aspirin? decreases oral secretions.”
A. Administer the medication before meals.
B. Monitor the apical pulse prior to giving Acetylcysteine is a mucolytic, used to loosen thick,
the drug. C. Give the medication with tenacious secretions in the trachea-bronchial tree.
meals.
D. Do not give the medication if the patient has 167. A mother is asking questions to her 3-year-old
urinary obstruction. son’s nurse about the newly prescribed
Cromolyn sodium (Intal) for her son’s asthma.
Aspirin, a non-steroidal anti-inflammatory Which of the following nurse’s statements accurately
drug (NSAID), causes gastric irritation. addresses the mother’s concern?
A. “It is the drug of choice for asthma caused by severe
161. A 6-year-old child has a low grade fever acute anaphylaxis.”
due to a viral respiratory infection. The choice B. “It is a potent bronchodilator therefore
of medication to reduce the temperature is easing respirations.”
A. Acetylsalicylic acid C. “It is effective as a preventive measure for future
(Aspirin) B. asthmatic attacks.”
Acetaminophen (Tylenol) D. “It increases the effects of histamine on the lungs.”
C. Ibuprofen (Advil)
D. Mefenamic acid (Ponstan) Cromolyn sodium is a mast cell stabilizer. It
prevents the degranulation of mast cells, which
Acetaminophen is the drug of choice to reduce can release histamine and other chemical
fever in children with viral infection. Salicylates are mediators that triggers the symptoms of asthma.
not given (A) due to the risk of developing Reye’s It is used to prevent asthmatic attacks.
syndrome. C&D are primarily used as analgesics, not
routinely given as anti-pyretic drugs.

162.A patient with cerebral edema is taking 168.A patient is on Digoxin (Lanoxin) 0.25 mg po
Dexamethasone (Decadron) 8 mg po q6h. daily. What is the physiologic action of Digoxin?
Which of the following assessment findings A. Increases the rate of cardiac contraction
suggests a common side-effect of B. Decreases the force of cardiac
corticosteroids? contraction C. Increases the force of
A. Hyperglycemia C. Diarrhea cardiac contraction
B. Hyponatremia D. Dehydration D. Decreases the stroke volume

Hyperglycemia, hypokalemia, sodium and water Digoxin is a cardiac glycoside used in the
retention, and risk for infection due to management of heart failure. It acts by increasing
immunosuppression are side-effects of steroids. the force of cardiac contraction (positive inotropic
effect). It can reduce the heart rate (negative
163.A nurse is conducting an admission interview. per hour. effect)
chronotropic The concentration
so the nurseinneeds
the bag is 25,000
to count
As she is taking the patient’s medication history, the units per 500 ml. How many ml should
the apical pulse for 1 full minute prior to its the nurse
nurse discovers that the patient has a history of document as
administration. Dointake from the infusion
not administer for an
if the apical eight
pulse
using Valproic acid (Depakote) and shift?
is below 60 beats per minute.
Carbamazapine (Tegretol) daily. Which of the A. 300 ml B. 450 ml C. 400 ml D. 240 ml
following conditions from the patient’s medical
history justifies the need to take these Desired dose = 12,000 units (1,500 x 8-hour shift)
medications? x 500 mL Stock dose = 25,000 units
A. Multiple sclerosis C. Seizure disorder = 600,000/25,000 = 240 mL
B. Parkinson’s disease D. Pituitary tumor

These are anti-convulsant medication, used to

treat and prevent seizures.

164. A client with myocardial infarction is receiving

an l.V. infusion of heparin sodium at 1,500 units
169.A patient is newly admitted to the hospital and
tells the nurse during the assessment interview
that she is currently taking a potassium-
wasting diuretic for her cardiac problem. The
nurse reviews her medication orders and finds:
“Digoxin (Lanoxin) 0.125 mg po daily”. The
nurse’s action is appropriate if she
A. Administers the medication as ordered
B. Requests an order to check serum
potassium level
C. Advises the patient to take half of the
diuretic
D. Reviews the patient’s latest CBC result

The patient is taking a potassium-wasting diuretic

which makes him prone to hypokalemia. This can
increase risk for digitalis toxicity. Potassium level
must be monitored.

170. Dilantin 5 mg/kg body weight is ordered to

a client who weighs 50 lbs. The drug is to be
administered in 3 equal doses. The label
reads Dilantin suspension 125 mg/ml. how
much medication should be administered to
the client?
 A.1.8 ml B. 1.5 ml C. 1.0 ml D. 0.5 ml C. bowel sounds is hypoactive
D. does not vomit
50 lbs. / 2.2 kg = 22.73 kg
Desired dose = 5 mg/kg x 22.7 kg x 1 ml = Lactulose helps reduce ammonia level among
0.91 or 1 mL Stock dose = 125 mg patients with hepatic encephalopathy by increasing
its excretion from the digestive system. Diarrhea, 2-
171. A patient asks why insulin is not 3 x a day, is an expected effect. Bowel movement
administered orally. The nurse is correct if she more than 3x per day indicates overmedication.
states:
A. “Insulin is destroyed by the gastric juices. “
B. “Insulin given orally may cause nausea and vomiting.
C. “Insulin may irritate the gastric mucosa.”
D. “Insulin absorption in faster if given orally.”

172. A patient is to take NPH insulin 32 U and

Regular insulin 8 U daily. In preparing the
medication, the nurse would BEST use
A. Two separate syringes
B. An insulin syringe, drawing regular insulin
first
C. An insulin syringe, drawing NPH insulin first
D. A 1-cc syringe, drawing regular insulin first

Two types of insulin can be mixed in one syringe.

However, the question asks for the best way to
administer two types of insulin and gives an option
of using two syringes.

173. For a patient with addisonian crisis, it would

be dangerous to administer
A. Epinephrine hydrochloride
B. Fludrocortisone
C. Potassium chloride
D. Hydrocortisone

Addison’s disease causes reduced level of aldosterone, which

can decrease sodium and water retention. As
sodium decreases, potassium is retained, causing
hyperkalemia.

174. DDAVP is used in the treatment of

A. Pheochromocytoma
B. Syndrome of inappropriate antidiuretic
hormone
C. Diabetes insipidus
D. Addison’s disease

Diabetes insipidus is caused a lack of anti-diuretic

hormone (ADH). Management involves
replacement of synthetic ADH.

TIP: DDAVP
DDA – Desmopressin or Desmopressin
acetate V – Vasopressin
P – Pitressin

175. A patient with reflux disorder is prescribed

Aluminum hydroxide (Amphojel), an antacid. A
common side effect is
A. Nausea and vomiting C. Diarrhea
B. Constipation D. Flatulence
TIP: Side-effects of antacids
Aluminum-based –
constipation Magnesium-
based – diarrhea
Calcium-based –
constipation

176. A patient with liver failure is showing signs

of hepatic encephalopathy. The physician
ordered Lactulose. The nurse knows that
Lactulose is effective if the patient/patient’s
A. ammonia level
remains high B. passes
soft or liquid stools
177. A patient in labor is receiving Pitocin drip.  Novice – no experience; learning skills
Her contractions are becoming more severe  Advanced beginner – 1-2 years of
and intense, and lasting 30 seconds to 2 experience; task- oriented
minutes. What is the nurse’s best initial action?  Competent – 2-3 years of experience;
A. Notify the physician. focuses on organization
B. Check the fetal heart tone.  Proficient – holistic understanding of patient
C. Discontinue the infusion. situation
D. Document the findings.  Expert – uses intuition in patient care

Pitocin (Oxytocin) promotes uterine contraction. 182. Which of the following does not govern
Contractions more than 90 seconds compromise nursing practice?
fetal circulation, due to a reduced utero-placental
circulation. A 2-minute contraction can cause fetal
distress necessitating the drip to be stopped.

The nurse is in charge of a client on a long term 17

Nitroglycerine sublingual tablets for angina 8.
pectoris. What
instruction of the nurse is APPROPRIATE for
the client to maintain the efficacy of the drug?
A. Retain sublinguaI tablets in a plastic
transparent container
B. Maintain a supply for a duration of one year
C. Replace sublingual tablets supply every
three months D. Keep sublingual tablets in
amber glass bottle

Nitroglycerine is heat and light sensitive and must

be stored in a colored/amber bottle, not
transparent (A). An open bottle must be discarded
after 6 months as it loses potency.

179.A patient with significant psychiatric history is

discharged with Haloperidol to take twice a
day by mouth. Which discharge instruction
should the nurse provide?
A. Decrease the dose if symptoms disappear.
B. Double the dose if experiencing
severe stress. C. Apply sunscreen
before exposure to the sun.
D. Wait for two weeks before experiencing the
effects of the drug.

One of the main effects of antipsychotics are

photosensitivity and skin rash. Protection from
exposure to ultraviolet rays of the sun is essential.
Adjusting the dose of any drug is always a wrong
answer (A,B).

180. The physician ordered Epinephrine 1 mg

SQ x 1 dose only. The stock is Epinephrine
1:1000. The nurse should give
A. 0.01 ml C. 0.1 ml
B. 0.05 ml D. 1 ml

1:1000 = 1 g Epinephrine : 1,000

mL solvent
= 1,000 mg : 1,000 mL
= 1 mg : 1 mL
Desired dose = 1 mg x 1 mL
= 1 mL Stock dose = 1 mg

NURSING LEADERSHIP & MANAGEMENT /

NURSING JURISPRUDENCE &
PROFESSIONAL ADJUSTMENT (20
points)

181. According to Benner’s Stages of Clinical

Expertise, how many months of clinical
experience should a nurse possess before
she can be called a competent nurse?
A. 6-12 months C. 24-36 months
B. 12-24 months D. 36-60 months

TIP: Stages of clinical expertise by Benner

(NACPE)
 A. R.A. 7164
B. R.A. 9173 186. Benevolent deception is an ethical concept
C. B.O.N. Resolution for Code of Ethics that describes which of these situations?
D. Board Resolution Scope of Nursing Practice A. A family insists to avail of all possible
alternatives to a terminally ill patient even
RA 7164 is the old nursing law, amended by RA without the possibility of cure.
9173. B. A staff criticizes another staff who
received recognition as an
183. While doing the routine nursing rounds outstanding nurse.
during the night shift, the nurse found a patient C. A doctor tells lies to a patient regarding his
on the floor with blood oozing from the condition in order to benefit the client.
forehead. The nurse called for help and
assisted the patient back to bed. When the
patient's condition stabilized, the nurse
documented the assessment and interventions
in the chart. The nurse also completed an
incident report because:
A. it is a requirement of the head nurse in
case the patient files a legal suit
against the hospital
B. the incident may lead to serious
complications and this may trigger a
malpractice suit.
C. reporting an incident in writing is a hospital
protocol to determine precautionary
measure to avoid similar incidents
D. the incident is critical and therefore
requires documentation for future
reference

Incident reports are made to prevent similar

incidents from happening in the future. It must NOT be
placed in the patient’s chart.

184. To maximize utilization of human resources,

the nurse manager emphasizes to the nurses to
use technology as a means to make work
processes more efficient. She advocates the
use of the nurse call system. When a newly
admitted client is shown to use the nurse call
system, which of the' statements about the
nurse call system below is NOT appropriate?
A. It should be used whenever the client
needs help. B. It should be used during an
emergency only.
C. It must be pushed or pressed several
times to alert the nurse at the station.
D. It must be Within the reach of the client.

The call system can be used by the patient at

anytime, whenever assistance is needed.

185. Quality improvement (QI) requires that client

care activities be constantly evaluated and
improved to meet the needs of the clients. Of
the following situations, which one illustrates
quality improvement?
A. The nurse supervisor plans a ward class for
clients for discharge along with family
members for better home management.
B. The hospital personnel and clients are
constantly reminded about handwashing
especially during the epidemics.
C. The hospital involves the
multidisciplinary team in client
medication by having zero medication
error.
D. A client asks from the nursing aide
assigned to the client to be repositioned in
bed due to post-operative discomfort.

Quality improvement is a process whereby

problem areas are identified and resolved. Only
Choice C presents a problem area that needs to
improve.
 D. A surgeon who performs hysterectomy to a C. It refers to a work ethic involving
client who signed consent for exploratory everyone in the organization.
laparotomy. D. It includes systematic methods of ensuring
conformity to a desired standard or norm.
Benevolent deception is an ethical principle
whereby the truth is withheld from the patient in 192. Which of the following criteria should not
an attempt to protect the patient from potential be used by the charge nurse in delegating
harm. care to her staff?
A. Educational background and training of the
187. The nurse caring for an immobilized client staff
turns the client every 2 hours during her 12- B. Complexity of patient care needed for
hour shift. This action of the nurse the shift C. Adequacy of client’s family support
A. Reflects the standard of care system and
B. Is under the scope of nursing practice resources
C. Is a provision of the Nurse Practice Act
D. Demonstrates respect for the patient’s Bill of Rights

Doing what is supposed to be done reflects

standard of care. Choices B & C are similar
options.

188. Which of the following mandates delineates

the roles and functions as well as
responsibilities of a nurse?
A. Nurse Practice Act
B. Code of Ethics for Nurses
C. Standards of Care
D. Magna Carta for Health Workers

A nurse practice act or nursing law identifies the

scope of nursing practice.

189. A former clinical instructor is preparing his

resume as part of his application portfolio for a
position as clinical educator in a university
medical center. When making his portfolio,
which of the following should be the first major
part of his professional resume?
A. Personal data and address
B. Educational
background C. Work
experience
D. Trainings and professional qualifications

TIP: Resume
New RN – educational attainment comes
first Experienced RN – work experiences
come first

190. A medical-surgical nurse is asked by the

nursing supervisor to float to the understaffed
Neonatal Ward for the entire shift. The
Neonatal Nurse Manager should assign
which patient to the “floater” nurse?
A. A 4-day old neonate with Tetralogy of Fallot
B. A 10-day old neonate with spina bifida
C. A 3-week-old neonate with heart failure
D. A 4-week old neonate with esophageal
atresia

TIP: Floating
 Assign the floater to a patient which
has a case familiar to the RN’s work
experience
 Assign the most stable patient to the floater
191. The nurse reviews several concepts related
to total quality management (TQM). Which of
the following statements refer to quality
improvement?
A. It is concerned with performance
development and is on-going, preventing
future mistakes.
B. It defines performance measurements and
compares actual processes and outcomes
to clinical and satisfaction indicators.
 D. Clinical experience of the nursing staff gave the first dose for having
erroneously transcribed the order
Staffing focuses on analyzing the human resources’ (nurses, C. Only the head nurse under the principle of
aides) education and experience, not the family. command responsibility
D. All nurses involved including the head nurse
193. A nurse who is responsible for the care of
the client from admission to discharge with the It is the responsibility of every nurse to verify doctor’s
primary responsibility of coordinating care is orders prior to preparing and administering a drug.
doing which modality of nursing care?
A. Primary nursing C. Team nursing 197. When a nurse makes a decision based on
B. Functional nursing D. Case management the reasoning that “good consequences will
outweigh bad consequences” she is following
Case management involves coordinating patient which theory?
care from admission to discharge. Primary
nursing (A) provides patient care from admission
to discharge while functional nursing (B) deals
with specific tasks to be performed by the staff.
Team nursing (D) involves a group of staff
working together to provide patient care.

194. The nursing education department of a

hospital is offering a program about evidence-
based practice to prepare nurses before its
implementation in the hospital. Which of the
following refers to this type of program?
A. Seminar workshop in evidence-based
practice
B. Continuing education in evidence-
based practice C. In-service Education
Program
D. Scientific forum in evidence-based practice

When a continuing education program or activity is

required by the employing institution, it is called an
in-service education.
195. A nurse works in a college of nursing as a
faculty and reeds further experience to
possess clinical skills and theoretical
knowledge. Which of the following should this
nurse pursue to qualify for teaching current
nursing practice?
A. Pursue master's degree in other fields
such as business or educational
management
B. Possess a graduate degree in nursing and
pursue doctorate in advanced degrees in
nursing, education and administration
C. Participate in continuing education
program in national and international
conference
D. Keep license valid by updating professional
education with organized groups.

To qualify for teaching current nursing practice, the

nursing law requires not a doctorate degree (B) but a
master’s degree in nursing, not business or education
(A). Continuing education is needed but it does not
have to be national or international acitvities (C).
Keeping the license valid by updating professional
education means that the nurse should complete
the required 20 continuing education hours per
year for three years, through various professional
activities.

196. The doctor’s order is, “Garamycin 1 gm IV

initially after a negative skin test; then 500 mg IV
push every 6 hours for 23 days.“ The order was
countersigned by the head nurse. When the doctor
made his rounds the following day, he found out
that 1 gm Garamycin was given IV push every 6
hours. Who among the following may be held
liable?
A. All the nurses who administered the
drug every 6 hours
B. The head nurse and the nurse who
 A. Formalist theory C. Moralist theory
B. Utilitarian theory D. Deontological
theory

Formalist theory – critical analysis of a situation

Moralist – determines the rightness or wrongness
of an act Deontological theory – based on duty,
rules, laws, obligations

198. During the nurse tour of duty, very often

they are confronted with ethical dilemma. In
their decision making, which of the following
would illustrates medical futility?
A. A young father of three boys with
advanced lung cancer asks that all known
regime be done to prolong his life despite
no improvement
B. A confused 70 year old lady needs
restraints for protection from fall even
if this makes her more agitated
C. A 3rd day post cholecystectomy client
requests narcotic injection every 4
hours
D. A young patient who has asked not to
receive tube feeding due to intense pain

Medical futility refers to interventions that are

unlikely to produce any significant benefit for the
patient.

199. A client is confined in your unit. He says that

he has difficulty sleeping because of the “ambience”
in the unit. When evaluating the effect the
setting has on the quality of care provided to
the client the evaluation being done is called:
A. Quality assurance C. Structure
evaluation
B. Quality improvement D. Outcome
evaluation

TIP: Nursing audit

 Structure evaluation – involves setting,
facilities, equipment, qualifications and
characteristics of personnel
 Process evaluation – refers to the actions or
tasks performed in rendering patient care
 Outcome evaluation – pertains to results of
nursing interventions

200. While taking care of a client, a nurse was

instructed by her head nurse to file an
incident report. The following situations
warrant an incident report EXCEPT:
A. Client and family attitude towards care
B. Medico-legal incident
C. Client’s complaints of illness
D. Medication errors including
administration of intravenous fluids

Incident reports are made when any untoward

incidents happen with the purpose of preventing
same incidents from happening in the future. Patient’s
complaint of illness is never a part of incide
MATERNAL AND NEWBORN NURSING (40 You are caring for this client during the
points) postpartum period. Which of these symptoms, if
present, would be suggestive if disseminated
1. A client, 7 months pregnant, is brought to the intravascular coagulation (DIC)?
emergency department with abdominal pain and A. The woman is nauseated, lethargic, and has
bright red vaginal bleeding. What should the vomited 3 times
nurse do first? B. The woman’s laboratory result are: Hgb 13g/dl, Hct
A. Place the client in left lateral position and 40%, WBC 7,000/mm3
initiate C. There is oozing blood from venipuncture
oxygen therapy as ordered. site and abdominal incision
B. Administer ordered IV oxytocin to
stimulate contractions and prevent
hemorrhage.
C. Ease the client’s anxiety by coaching her to perform
relaxation techniques.
D. Massage the client’s fundus to control
the hemorrhage.

Left lateral position prevents compression of the

inferior vena cava that might compromise utero-
placental circulation.
Oxytocin (B) and uterine massage (D) are
contraindicated as this stimulates contraction of the
uterus. Relaxation techniques
(C) may help but not the priority for a bleeding
patient.

2. At 15 weeks’ gestation, a client is scheduled for an

alpha- fetoprotein (AFP) test. Which maternal
history finding best explains the need for this
test?
A. Family history of Down syndrome on the father’s
side. B. Family history of spina bifida in a sister.
C. History of gestational diabetes during a
previous pregnancy.
D. History of spotting during the first month of
the current pregnancy.

An elevated AFP level may indicate neural tube

defects, such as spina bifida.

3. Ada, a 38-year-old, G1P2, 36 weeks AOG

pregnant mother with a history of precipitous
labor and low birth weight infant informs the
nurse that she has been having on and off
contractions and she feels like “bearing down.”
Upon examination, the obstetrician’s findings show that
the client is “75% effaced and 6 cm dilated”. The
most appropriate disposition for this client
would be to
A. Send her home since she is only 6 cm
dilated and contractions are mild
B. Request the obstetrician for Pitocin drip
to induce stronger contractions
C. Ask the client to return to the hospital
when contractions are 2-3 minutes
apart and strong in intensity
D. Have the client stay in the hospital for
maternal and fetal monitoring

These are signs of true labor and the patient needs

to be monitored in the hospital; this makes A & C
wrong answers. Pitocin drip (B) is inappropriate at
this time since uterine contractions, cervical dilation
and effacement are in progress.

4. Prior to a cesarean section delivery, a 24-year-

old woman is treated for abruption placenta.
 D. The woman’s vital signs are BP 90/50 mm considered pathologic. Physiologic jaundice occurs
hg, temperature 38.3 oC, pulse 24 hours after birth, usually 2nd-3rd day. Enlarged
112/min, respiration 18/min breasts (A) is due to maternal hormones.
Acrocyanosis (C) is common at this time.
DIC is manifested by bleeding tendencies. The Mongolian spots (D) are common during the first
drug of choice is Heparin sulfate. year of life.

5. A mother at 40 weeks’ age of gestation is 10. A client who is 7 months pregnant reports
assessed by the nurse. The nurse finds the severe leg cramps at night. Which nursing
fundic height to be action would be most effective in helping the
A. 35 cm C. 40 cm client cope with these cramps?
B. 38 cm D. 43 cm A. Suggesting that she walk for 1 hour twice
per day.
6. The nurse’s most important assessment on a
client who received epidural anesthesia
during labor is
A. Level of consciousness
B. Urinary
output C.
Blood pressure
D. Return of sensation on the legs

A common side-effect of epidural anesthesia is

hypotension.

7. During the fourth stage of labor, the client

should be assessed for
A. Complete cervical dilation C. Placental
expulsion
B. Umbilical cord prolapse D. Uterine
atony

TIP: Stages of labor

 First stage – true labor to full cervical
dilatation
 Second stage – full cervical dilatation to
expulsion of the fetus
 Third stage – expulsion of the fetus to
expulsion of placenta
 Fourth stage – expulsion of placenta to
uterine contraction

8. A postpartum client is ready for discharge.

During discharge preparation, the nurse
should instruct the client to report which of the
following to a health care provider?
A. A temperature of 99.2 for 24 hours or more
B. Episiotomy discomfort
C. Lochia alba at 2 weeks postpartum
D. Redness, warmth and pain in the breasts

Report a sign that indicates an abnormal

condition. Choice D are signs of mastitis. A low-
grade fever (A) within the first 24 hours is common
due to dehydration. Choices B & C are common
and expected normally during the postpartum
period.

9. Which of the following assessment findings

would the nurse interpret as abnormal in a
full term male neonate born an hour ago?
A. Enlargement of the
mammary glands B. Slight
yellowish hue to the skin
C. Blue hands and feet
D. Black and blue spots on the buttocks

Jaundice that appears within 24 hours after birth is

 B. Advising her to take over-the-counter among babies of mothers who has a history of
calcium supplements twice a day. smoking during pregnancy.
C. Teaching her how to dorsiflex the foot during Vasoconstrictive effects of nicotine reduce
a cramp. uteroplacental circulation.
D. Instructing her to increase her milk
and cheese intake to 5-8 servings per 16. A client at 28 weeks’ gestation complains of
day. uterine contractions. After assessment,
hydration and admission,
Leg cramps are usually caused by depletion of
calcium due to rapid fetal development. This can
be relieved by dorsiflexion of the foot.

11. Which of the following signs of pregnancy

is properly classified?
A. Enlarging uterus: probable sign
B. Elevation of basal body temperature:
Presumptive C. Fetal movements felt by
examiner: positive
D. Chloasma and linea nigra: probable

TIP: Signs of pregnancy

Presumptive signs – subjective; felt by the
mother Probable signs – objective; observed
by the examiner Positive signs – confirms
pregnancy

12. A multigravida is in the second stage of

labor for 30 minutes. This can be
considered as a
A. Precipitous
labor B. Precipitous
delivery
C. Normal labor
D. Normal spontaneous delivery

13. A postpartum mother has a temperature of

99.8 F within the first 24 hours after delivery.
The most common cause of temperature
elevation during this period is
A. Puerperal infection C. Dehydration
B. Chorioamnionitis D. Mastitis

Fever that occurs during the first 24 hours after

delivery is due to dehydration that results from NPO
prior to and fluid loss during delivery.

14. While caring for a full term female neonate,

the nurse notices red stains on the diaper
after the baby voids. Which action should
the nurse take next?
A. Call the physician to report the problem.
B. Encourage the mother to feed the baby
to prevent dehydration.
C. Do nothing because this is normal.
D. Check the baby’s urine for hematuria.

Pseudomenstruation is normal and is caused by

maternal hormones.

15. The nurse is assessing a neonate born a day

ago from a client who smoked during
pregnancy. Which of the following findings is
expected of a neonate from a mother who
smoked during pregnancy?
A. Postterm birth
B. Small for gestational age
C. Large for gestational age
D. Appropriate for gestational age

Small for gestational age (SGA) is common

 the physician orders Beclomethasone 12
mg IM. The purpose of giving this 21. The recommended Essential Intrapartal and
medication is to Newborn Care (EINC) practices during the
A. Slow down uterine intrapartum period include continuous
contractions B. Promote maternal support by having which of the
fetal lung maturity following? Select all that apply.
C. Prevent infection A. a companion of choice during labor
D. Promote fetal growth and delivery B. freedom of movement
during labor
Administration of steroids to premature C. monitoring progress of labor using the
babies facilitates maturation of the lungs, partograph
reducing the risk for respiratory distress. D. pain relief with mild analgesics before
offering labor anesthesia
17. A client is admitted in preterm labor. To halt
labor contractions, the nurse expects the
physician to prescribe
A. Betamethasone
(CElestone) B. Ritodrine
(Yutopar)
C. Dinoprostone (Prepidil)
D. Ergonovine (Ergotrate maleate)

Tocolytics such as Ritodrine and

Terbutaline promote relaxation of the
uterus.

18. The nurse assessing a client with pregnancy-

induced hypertension (PIH) will most
probably expect which signs and symptoms?
A. Proteinuria, headache, vaginal bleeding
B. Headache, double vision, vaginal bleeding
C. Proteinuria, headache, double vision
D. Proteinuria, double vision, uterine
contractions

TIP: Triad symptoms of PIH

 Proteinuria
 Edema
 Hypertension

19. A woman in her 34th week of pregnancy

presents with sudden onset of bright red
vaginal bleeding. Her uterus is soft and
experiences no pain. Fetal heart rate is 120
bpm. Based on the presenting data, the nurse
knows that the client might have developed
A. Threatened abortion C. Abruptio placentae
B. Placenta previa D. Preterm labor

TIP: Bleeding disorders of pregnancy

First trimester: abortion, ectopic
pregnancy Second trimester: H-mole,
incompetent cervix Third trimester:
placenta previa, abruptio placenta
20. The nurse reviews the laboratory results of
a client with hydatidiform mole. Which
finding strongly suggests the presence of
this disorder?
A. An elevated human placental lactogen (hPL)
level
B. A reduced alpha-fetoprotein (AFP) level
C. An increased human chorionic
gonadotropin (hCG) level
D. An increased carcinoembryonic antigen
(CEA) level

An abnormally large abdomen, passage of grape-

like vesicles, absence of positive signs of
pregnancy and elevated HCG level indicate the
presence of an H-mole.
 E. position of choice during labor and delivery C. Pregnancy-induced hypertension
F. spontaneous pushing in a semi-upright D. Infection
position
G. routine episiotomy Bleeding, the most common cause of death during
H. active management of the third stage of the postpartal period, is usually due to uterine atony
labor as a result of multiparity, retained placental
fragments and trauma from severe lacerations.
Based on WHO guidelines, these are the
recommended practices during the intrapartal 27. Which of the following psychological changes
period and during the care of the newborn. during the post-partal period illustrates that
the mother is in the taking-in phase? The
22. At 5 minutes of age, a neonate is pink with blue mother
hands and feet, has his knees flexed and fists A. Looks intently at her newborn
clenched, has a whimpering cry, a heart rate of B. Asks the nurse how to breastfeed the baby
128 per minute and withdraws his foot when C. Restricts visitation because she needs to rest
slapped on his sole. What 5- minute Apgar D. Wants the father of the baby to participate
score should the nurse document for this in bathing the baby
neonate?
A. 6 B. 7 C. 8 D. 9

TIP: APGAR TIP: Psychological responses during post-

Score 0 1 2 partum period
 Taking-in – focuses on the self (mother)
Activity (muscle tone) flaccid poor D. Varicosities
strong Pulse rate
0 <100 >100 Posterior presentation usually causes low back
Grimace (cry) absent weak strong pain. This can be relieved by application of gentle
Appearance (color) all blue acrocyanosis sacral pressure or pelvic rock exercises.
pink Reflex absent weak strong
26. According to the WHO, the most common
23. Based on the Essential Intrapartal and Newborn cause of mortality among women during the
Care’s new protocol, which of the following post-partum period is
traditional beliefs and practices have been A. Cephalo-pelvic
eliminated? Select all that apply. disproportion B.
A. routine Hemorrhage
suctioning B. foot
printing
C. early bathing
D. routine separation
E. continuance of artificial feeding

WHO updated guidelines has eliminated these

practices which were traditionally done for newborn
care.

24. The neonatal nurse is preparing Vitamin K

injection for the newborn. Why does the
neonate need Vitamin K?
A. Due to sterile gastrointestinal tract,
there is no bacteria to produce
vitamin K
B. Vitamin K helps in producing clotting
factors in the liver
C. Platelets need Vitamin K for their
production and maturation
D. Vitamin K is needed by the intestinal
bacteria to produce clotting factors

The absence of bacteria in the intestines makes the

neonate unable to produce Vitamin K, making them
at risk for bleeding. Bacterial growth starts when the
neonate ingests fluid/milk.

25. Which of the following maternal discomfort is

most likely to be expected if the fetus is in a
Right Occiput Posterior position?
A. Urinary
frequency B. Low
back pain
C. Leg cramps
  Taking hold – focuses on the neonate
 Letting go – acceptance of new role as a
parent

28. A mother is in the fourth stage of labor and

the nurses assesses for signs of placental
separation. The earliest sign that can be
observed is
A. Sudden gush of blood from the vagina
B. Lengthening of the umbilical cord
C. Rising of the uterus above the umbilicus
D. Onset of mild dull abdominal pain

TIP: Signs of placental separation

 Sudden gush of blood from the vagina
 Lengthening of the umbilical cord
 Rising of the uterus above the umbilicus

29. A woman had her last menstrual period last

September 8, 2013. The expected date of
delivery is on
A. June 15, 2014 C. November 15,
2013 B. May 1, 2014 D. July 15,
2014

Nagale’s rule: - 3 months, + 7 days of the

30. A mother is pregnant for the fifth time. Her following year
firstborns were twins. Her second child was 9 8 2013
born prematurely and her third pregnancy -3 +7 +1
ended in intrauterine growth retardation. She 6 15 2014
delivered her fourth pregnancy normally. Her
obstetric history is:
A. G5 T2 P1 A0 L4 C. G4 T3 P2 A1 L3
B. G5 T3 P2 A0 L4 D. G4 T2 P1 A0 L4

TIP: Obstetric history

Gravida – pregnancy
Term pregnancy – delivery of a full term
neonate Prematurity – premature births
Abortion
Living – currently surviving children

31. A nurse orientee at the Labor & Delivery Unit

reviews the partogram sheet and identifies the word
“liquor” which refers to
A. The amniotic fluid
B. A meconium-stained amniotic fluid
C. The bloody show
D. An amnioinfusion therapy
32. The appropriate order of steps in active D. “IV fluids help prevent spinal headaches.”
management of the third stage of labor
(AMTSL) include: Epidural anesthesia causes hypotension. This can
A. Cord clamping and cutting, controlled cord be prevented by increasing the circulating blood
traction, ergometrine administration, and volume through infusion of intravenous fluids.
inspection to be sure that the placenta is
intact. 38. A client is scheduled for amniocentesis. When
B. Intravenous oxytocin, cord clamping and preparing her for the procedure, the nurse
cutting, and fundal massage should do which of the following?
C. Intramuscular injection of oxytocin, A. Allowing her to void.
controlled cord traction with counter B. Instruct her to drink 1 liter of fluid.
traction to the uterus, uterine massage C. Prepare to insert an IV access.
D. Controlled cord traction, fundal massage D. Position her on the left side.
and oxytocin
Voiding prior to amniocentesis prevents trauma to
These are the steps in the AMTSL as defined by the bladder.
the WHO.
39. Bonus
33. The nurse explains to the post-partum mother
who is for discharge that the expected 40. Malou is aware that in accordance with R.A.
characteristic of her lochia 6 days after 7600 of 1992, the purpose of the “rooming-in”
delivery is national policy are two- fold:
A. reddish and moderate in
amount B. scant and pinkish
drainage
C. whitish and moderate
D. bright red and scant in amount

TIP: Lochial discharge Ultrasound is used to confirm pregnancy and to

 Lochia rubra – reddish to pink; day 1-3 determine age of gestation.
postpartum
 Lochia serosa – brownish; day 3-6 37. The nurse is preparing a woman for epidural
postpartum anesthesia. The woman asks, “Why is my IV
 Lochia alba – whitish; 1-2 weeks postpartum running so fast? It feels so cold!” What reply by the
nurse is BEST?
34. Which of the following should the nurse tell A. “IV hydration helps prevent the blood pressure from
a mother during the intrapartal period to dropping so low.”
best help relieve pain? B. “Don’t worry, this is a routine procedure in preparation
A. “Find the most comfortable position for you especially for an epidural.”
during the first stage of labor.” C. “I’ll slow the IV down so you won’t feel cold.”
B. “Ambulate as much as you can to relieve the
abdominal discomfort.”
C. “I can administer an opioid analgesic if you cannot
tolerate the pain any longer.”
D. “Do rapid deep breaths every time you feel a
contraction.”

Based on current WHO guidelines, the best

position to relieve pain is whatever the patient
finds most comfortable for her.
35. A post-partum client develops disseminated
intravascular coagulation (DIC). The drug of
choice for this condition is
A. Vitamin K C. Protamine zinc
B. Heparin sulfate D. Aspirin
Heparin is the drug of choice to treat DIC. As an
anticoagulant, Heparin releases the platelets from
clumping, thereby making them available in the
circulation.

36. To confirm pregnancy, the doctor will most

likely perform which of these actions to a
pregnant woman who is on her first prenatal
visit?
A. palpate for fetal parts and
movement B. order an ultrasound
examination
C. instruct the client to do a home type
pregnancy test
D. do an internal examination
 1 Encourage, protect and support the
practice of breastfeeding
2 Save on costs for utilities and
personnel for a newborn nursery
3 Create an environment where basic
physical, emotional, and
psychological needs of mothers and
infants are fulfilled
4 Teach the mother to take
responsibility for caring for her
newborn right after her delivery
A. 2 and 3 are correct C. 1 and 2 are correct
B. 3 and 4 are correct D. 1 and 3 are correct

PEDIATRIC NURSING (40 points)

41. Which of the following findings during

newborn assessment warrants alerting
the pediatrician for a potential problem?
The neonate/neonate’s
A. Arms and feet are
bluish B. Skin color is
yellowish
C. Head is larger than the chest
D. Has red stains on the diaper during voiding

Pathologic jaundice (abnormal) manifests during

the first 24 hours after birth while physiologic
jaundice (normal) appears starting on the second
day after birth. Acrocyanosis is normal at this time
(A). A newborn has a larger head circumference
(C) than the chest circumference until about 1
year of age.
Pseudomenstruation is normal due to effects of
maternal hormones (D).

42. The best indication that the breastfeed baby

is digesting the breast milk properly is when:
A. The baby passes soft, green,
pasty stools B. The baby passes soft,
golden-yellow stools
C. The baby sleeps for several hours after
each feeding
D. The baby does not experience colic

Breast-fed babies pass soft, golden-yellow stools

while bottle- fed babies pass hard, pasty and
smelly stools.

82.The nurse noted the following behaviors in a

6-hour old, full-term newborn: occasional
tremors of extremities, straightens arms and
hands outward and flexes knees when
disturbed, toes fan out when heel is stroked,
and tries to walk when held upright. These
findings indicate A. Expected neurologic
development
B. Signs of drug withdrawal
 C. Abnormal uncoordinated movements
D. Asymmetric muscle tone 45. Bedtime rituals such as tucking to bed and
reading
These are normal characteristics of a newborn,
showing the normal reflexes (moro/startle,
Babinski, walking).

83.While assessing another newborn, you noted

that his areola is flat with less than 0.5 cm of
breast tissue. This finding indicates:
A. Intrauterine growth retardation
B. Maternal hormonal
depletion C. Pre-term
gestational age
D. That the infant is male

Term infants have a raised areola and more than

0.5 mm of breast
tissue.

Norm

al IK

43. The mother is feeding her 20-month-old child.

The child is trying to eat with a spoon and is
muddling the food on the tray. Which of the
following approach of the nurse is the MOST
appropriate?
A. Assist the mother in feeding the child.
B. Instruct the mother to give finger foods
until the child is older.
C. Praise and encourage the child as she eats.
D. Get the spoon and do the feeding.

Toddlers’ main developmental task is autonomy or

independence. Allowing them to explore their
environment and to try out new skills are ways to
establish their independence.

44. When developing plan of care for a child, the

nurse recognizes that which Eriksonian
stage of development corresponds to
Freudian stage of phallic development?
A. Initiative versus guilt
B. Trust versus mistrust
C. Autonomy versus doubt
D. Industry versus inferiority

TIP: Theories of personality development

Freud Erikson
Psychosexual Psychosocial

Infanc Oral Trust vs.

yToddlerho Anal Autonomy vs.
mistrust
Pre-
od Phallic Initiative vs.
shame/doubt
School
school Latency Industry vs.
guilt
age
Adolescen inferiority
Genital Identity vs.
Young
ce diffusionIntimacy vs.
Mid-
adulthood Generativity vs.
isolation
Late adult-
adulthood Integrity vs.
Stagnation
 bedtime stories are particularly important to of their bodies. Having developed their superego
which of the following age groups: from toddlerhood, they associate illness as a
A. Infants C. School-age punishment for misdeeds.
B. Toddler D. Pre-schooler
51. The nurse places a neonate with
46. An 8-year–old child is diagnosed with iron hyperbilirubinemia under a phototherapy lamp,
deficiency anemia (IDA). When assessing the covering the eyes and gonads for
child’s fingernails, the nurse instructed the
mother to look for:
A. spoon nails C. pale nail beds
B. clubbing D. presence of Beau’s lines

Koilonychia or spoon-shaped nails are seen in IDA.

Clubbing
(B) indicates chronic hypoxia and Beau’s lines (D)
suggests trauma. Pale nail beds (C) are not specific
to IDA, but common in all types of anemia.

47. Encouraging fantasy play and participation by

children in their own care is a useful
developmental approach among which
pediatric age group?
A. Preschoolers C. school age
B. Adolescence D. toddlers

Fantasy play and magical thinking are

characteristics of pre- school children. Being in the
phallic stage of development, they become more
aware of their bodies and this enables them to be
more active in participating in their own care.

48. When assessing a neonate born at 30 weeks

gestation, the nurse notes bounding femoral
pulses, a palpable thrill over the suprasternal
notch, tachycardia, tachypnea and crackles.
The nurse suspects for
A. Tetralogy of Fallot
B. Patent ductus arteriosus
C. Ventricular septal defect
D. Coarctation of the aorta

A neonate born at 30 weeks’ gestation is premature. Fetal

cardiac structures are left open, such as the
ductus arteriosus, which may be felt as a
palpable thrill over the suprasternal notch as
blood passes through the pulmonary artery.
Crackles indicate pulmonary edema as blood
flows back into the lungs. Femoral pulses are
absent in coarctation of the aorta (D).

49. The nurse expects an infant to sit without

support at what age?
A. 2 months C. 6 months
B. 4 months D. 8 months

TIP: Gross motor development

 2 months – social smile
 4 months – head control
 6 months – sits with support
 8 months – sits without support

50. When planning care for hospitalized children,

the nurse must consider that which age group
considers illness as a punishment for
misdeeds?
A. Infancy C. Preschoolers
B. Toddlers D. School age

Pre-schoolers are in the phallic stage of

development where they become more aware
 protection. The nurse knows that the goal of intestines.
phototherapy is to
A. Prevent hypothermia 55. The nurse advises a 6-year-old child with
B. Promote respiratory stability celiac disease should not have which of these
C. Reduce conjugated bilirubin dietary choices?
level D. Reduce unconjugated A. Mango shake C. Fruit salad
bilirubin level B. Ice cream D. Spaghetti

Phototherapy is used to manage infants with

jaundice. The aim is to promote conjugation of
bilirubin (unconjugated  conjugated).

52. Which of the following statements, is made by

any parent- client to you indicates
understanding about the causes of the
newborn’s diagnosis cystic fibrosis (CF)?
A. “Both of us carry a recessive treat of a cystic fibrosis”
B. “The gene came from my wife’s side of the family”
C. “The gene came from my husband’s side of the
family”
D. “There is a 50% chance that our next child
will have disease”

Cystic fibrosis is an autosomal recessive trait, not

a sex-linked trait (B,C). When both parents carry
the recessive gene, there is a 25% chance of
developing the disease (D).

TIP: Punnett’s square: to determine

predisposition to genetic diseases
D – abnormal trait DD – has the disease
d – normal trait Dd – has the trait
(carrier) dd – not
affected

Cyctic fibrosis: autosomal recessive (carrier)

transmission from both parents
Mother / D (trait) d
Father ->
D (trait) DD Dd
(25%) (25%)
d Dd Dd
(25%) (25%)

DD – 25% chance to develop the

disease Dd – 50% chance to
become carriers
dd – 25% chance to be unaffected

53. A 2-month old baby is expected to have

completed which immunizations?
A. MMR, DPT, measles, BCG
B. Hepatitis, measles, BCG, OPV
C. OPV, DPT, BCG
D. Hepatitis, OPV, BCG, HIB

Measles is administered at 9 months (A, B).

Hepatitis is not routinely given during infancy
(B,D).

54. A child is brought to the emergency room due

to acute onset of abdominal pain, vomiting and
stools that look like red currant jelly. The nurse
suspects that this may be due to
A. Intussusceptions C. Appendicitis
B. Pyloric stenosis D. inflammatory bowel
disease

Red currant jelly-like stool is a characteristic of

intussusception, or the telescoping of the
 Anything with flour is avoided. Patients with celiac by a sausage- shaped mass on the abdomen,
disease are given gluten-free diet. Foods that abdominal pain and red, currant jelly stools.
come from wheat, barley and rye are Volvulus or twisting of the abdomen is
contraindicated. characterized by severe abdominal pain.

56. A 4-year-old child with a recent history of 60. A 7-year-old child is brought to the ER due to a
nausea, vomiting and diarrhea is admitted to dislocated right shoulder and simple fracture of
the pediatric ward for gastroenteritis. During the right humerus. Which of the following
physical assessment, the nurse observes behaviors of a child would lead the nurse that
tenting. This clinical manifestation supports the the patient is a victim of child abuse? The child
nursing diagnosis of A. Does not answer the nurses’ questions.
A. Activity intolerance related to hypoxia B. Does not maintain eye contact.
B. Deficient fluid volume related to C. Tries to move away from the nurse
dehydration
C. Ineffective peripheral tissue perfusion
related to cyanosis
D. Risk for injury related to capillary fragility

Gastroenteritis causes severe diarrhea and

dehydration which may be manifested by a poor
skin turgor or tenting.

57. The nurse prepares to administer an

intramuscular injection to a 7-month old girl.
The most appropriate site to administer the
drug is:
A. dorso-gluteal region C. ventral forearm
B. vastus lateralis D. gluteal region

The preferred IM injection site for infants is the

vastus lateralis. The dorso-gluteal region is the
least preferred site for all age groups due to the risk
of hitting the sciatic nerve. The ventro- gluteal site
is the preferred site of IM injection among older
children and adults.

58. When developing a post-operative plan of

care to a child who has undergone cleft lip-
repair, which of the following is the nurse’s
priority goal of care?
A. Avoiding disturbing crusts along the suture
line.
B. Comforting the child as quickly as possible.
C. Maintaining the child in a prone position.
D. Restraining the child’s arm at all times, using
soft elbow restraints.

Protecting the integrity of the sutures is the

priority goal of post-cheiloplasty. The nurse
must prevent crying whenever possible to
avoid trauma to the surgical site.

59. A 2-month-old is brought to the clinic by his

mother. His abdomen is distended and he has
been vomiting forcefully for the past 2 weeks.
The nurse notes dehydration and a palpable
mass on the right of the umbilicus. Peristaltic
waves are present, moving from left to right.
Based on these clinical manifestations, the
infant most probably has:
A. Tracheoesophageal fistula C.
Intussusceptions
B. Pyloric stenosis D. Volvulus

An olive-shaped mass on the right side of the

abdomen and non-bilious (without bile) vomiting
are signs suggestive of pyloric stenosis. Tracheo-
esophageal fistula (A) is suspected if the child
chokes after feeding, suggesting the entry of food
into the lungs. Intussusception (C) is manifested
 D. Does not cry when moved B. Ketonuria D. Polyuria

An abused child has a high pain tolerance. Nephrotic syndrome is a protein-wasting disease
Physical injuries may not elicit pain on these manifested by albuminuria/proteinuria,
children. hypoalbuminemia and edema due to decreased
colloid oncotic pressure.
61. A nurse performs cardiopulmonary
resuscitation on an 11- month-old infant. The nurse
should assess for the infant’s pulse on the:
A. carotid area C. temporal area
B. brachial area D. popliteal area

The brachial area is the recommended site for

assessing pulse when doing an infant CPR. The
carotid area is used for adults.

62. Hypospadias is a congenital defect of the

male genitalia where the urethral meatus is
located at the
A. Tip of the penis
B. Ventral surface of the penis
C. Dorsal surface of the penis
D. Side of the penis

TIP: Hypospadias = ventral side or

anterior Epispadias – dorsal
side or posterior
63. The nurse admits a 10-year-old child with
rheumatic fever. Which of the following aspects
in the child’s history the nurse should ask for a
history of:
A. Staphylococcal infection C. Strep throat
B. Influenza D. Chicken pox

The main risk factor of rheumatic fever is a

streptococcal infection, which may commonly
affect the respiratory system.
64. A 10-month-old infant with phenylketonuria
(PKU) is being weaned from breast-feeding. In
providing education to the parents, the nurse
should emphasize the need to restrict
A. Vegetables and meat
B. Grains and fruits
C. Meats and dairy products
D. Sugar and vegetables

Phenylalanine is an essential amino acid (protein),

which is not metabolized in a child with PKU.
Protein foods are restricted.

65. A child is to undergo nephrectomy for a removal

of Wilm’s tumor. Which intervention should
NOT be included in the plan of care?
A. Provide pre-operative teaching to the
child and parents.
B. Palpate the abdomen to assess for
tenderness.
C. Assess vital signs and report hypertension.
D. Monitor urine for hematuria.

Wilm’s tumor affects the kidneys. Abdominal palpation is

contraindicated as this may cause pain and
metastasis.

66. A toddler is diagnosed with nephrotic

syndrome. The nurse monitors the patients
I&O and checks the urine regularly. The nurse
should expect to see which of these findings?
A. Glycosuria C. Albuminuria
67. To prevent discoloration of the teeth of a 6- 73. Which of the following developmental
year-old child with URTI, the physician milestones or behaviors is a characteristic
should not prescribe of a toddler?
A. Tetracycline C. Streptomycin A. Magical thinking
B. Isonicotinic hydrazide D. Chloramphenicol B. Assertion of independence
C. Compliance to parental rules
Tetracycline should not be given to pregnant D. Cooperative play with siblings
women due to its teratogenic effects and to
children below 12 years old due to its destructive
effects on the tooth enamel.

68. Recommended practices under the

Essential Infant and Newborn Care (EINC)
protocol include the following except:
A. skin-to-skin contact
B. properly timed cord clamping
C. initiation of
breastfeeding D.
drying the baby with oil

Current EINC protocol promotes drying the baby

with a warm clean cloth, not oil.

69. After the delivery of the baby, prevention of

hypothermia can be achieved by:
A. drying baby covering with clean dry cloth
B. applying small amounts of oil on the skin
C. covering the baby with warm sterile cloth
D. positioning the baby on the mother’s abdomen

This prevents heat loss after birth of the neonate.

70. A newborn with fetal alcohol syndrome is

NOT expected to manifest which of the
following signs?
A. Low birth weight
B. Facial anomalies
C. Muscular incoordination
D. Cognitive impairment

71. A child with lead poisoning is expected to

manifest signs related to
A. Neurologic deficits
B. Cardiovascular involvement
C. Renal impairment
D. Hepatic damage

Lead can lead to developmental delays and

cognitive impairment due to its neurotoxic effects.

72. Which of the following statements is

not accurate regarding Tanner
staging?
A. It is a rating system for pubertal
development
B. It is a biological marker of maturity
C. It is based on the progressive
development of genitalia, breast and
pubic hair in females
D. It is based on the progressive
development of the genitalia and pubic
hair in males.

Tanner staging is used to determine sexual

maturation among adolescents. Among females,
criteria include assessment of the breast and
pubic hair, NOT the genitals. Among males,
genitalia and pubic hair development are
assessed.
The main developmental task of a toddler is D. “Should Steven have continues hair loss, I
independence or autonomy. Magical thinking, need to call my doctor”
compliance to parents, and cooperative play are
characteristics of a pre-schooler (ACD). hospital following his chemotherapy
TIP: Types of play among children treatments. Which statements of Steven’s mother
Infants Solitary play indicates that she understands when she should
Toddlers Associative play or contact the physician?
parallel play Preschoolers A. “I will call my doctor if Steven has persistent vomiting
Cooperative play and diarrhea”
School age Competitive play B. ”I should contact the physician if Steven has difficulty
in sleeping”
74. A child with hiatal hernia may exhibit which of C. “My physician should be called is Steven is irritable
the following clinical manifestations? and unhappy”
A. Inguinal pain
B. Difficulty of breathing
C. Abdominal pain
D. Intractable pain on the groin area

Hiatal hernia is the protrusion of abdominal organs

into the thoracic cavity though a weakness in the
diaphragm. This causes an increased pressure
within the thoracic cavity. ACD are all
characteristics of inguinal hernia, the protrusion of
abdominal organs into the scrotum via a defect in
the inguinal ring.

75. The nurse is taking nursing history from a

mother. The infant displays discomfort by
crying constantly, fussy behavior and pulling
the left ear. Which of the following
information gathered by the nurse would
support the admitting diagnosis of acute
otitis media?
A. Sudden rise of temperature to 39 degrees C
B. Had colds and low grade fever for a number
of days
C. Irritable and unable to consume scheduled
feedings
D. Pain and itchiness of the ear canal

The question asks about history taking. Acute otitis

media is often preceded by a history of colds and
low grade fever a few days before the onset of the
infection. ACD are all physical assessment
findings, not history, of acute otitis media.

76. Three-year-old Benito has been admitted to the

Pediatric Unit. His blood pressure 100/70
mmHg; pulse rate, 110 beats per minute;
temperature, 38 C, and weight, 18 kg.
Impression: Nephrotic Syndrome. During his
previous check-up at 2 ½ years-old, his blood
pressure was 95/60 mmHg; PR was 100 beats
per minute and weighed 15 kg. Which
assessment finding would support the
impression of nephrotic syndrome?
A. Weight C. Blood pressure
B. Temperature D. Pulse rate

As a protein-wasting disease, nephrotic syndrome

causes hypoalbuminemia which reduces colloid
oncotic pressure. This promotes water to shift from
the intravascular to the interstitial space causing
generalized edema. Fluid retention is best
assessed by daily weight monitoring. Weight is the
best indicator of fluid balance.

77. Steven is diagnosed with acute lymphoid

leukemia (ALL) and is beginning
chemotherapy. Steven is discharged from the
Nausea and vomiting are the most common side- health history, which of the following statements
effects of chemotherapy. However, if they are will alert the nurse to a possible
persistent together with diarrhea, the patient may immunodeficiency disorder?
get dehydrated, which may need medical A. "I love walking several times a week with
attention. friends.'
B. “I had my chest x-ray 6 months ago
78. Wilma and another staff are talking on some when I had pneumonia.”
important reminders on the care of pediatric C. “I had my spleen removed many years ago after a car
patients diagnosed with glomerulonephritis. accident.”
When planning nursing care for a 5- year-old
with acute glomerulonephritis (AGN), the
nurse realizes that the child needs help in
understanding the necessary restrictions, one
of which is:
A. Isolation from other children with infections
B. Daily does of IM penicillin
C. A bland diet high in protein
D. Bed rest for at least 4 weeks

AGN is treated with steroids which may cause

immunosuppression, increasing the risk to
infections.

79. The mother of a nine-month-old infant is

concerned that the head circumference of her
baby is greater than the chest circumference.
The BEST response by the nurse is
A. “ These circumferences normally are the same,
but in some babies this just differs.”
B. “Perhaps your baby was small for
gestational age or premature.“
C. “This is normal until the age of 1 year, when
the chest will be greater”
D. “Let me ask you a few questions, and
perhaps we can figure out the cause of
this difference.”

An infant’s head circumference is normally greater than

the chest circumference until 1 year of age. After
that, the chest circumference slowly becomes
larger than the head.

80. The nurse reads on the chart that a 5-month-

old child has pectus carinatum. She recalls
that this condition is characterized by a chest
that
A. has equal antero-posterior (AP) and
lateral (LAT) diameters
B. has a larger lateral (LAT) diameter than
the antero- posterior (AP) diameter
C. has an antero-posterior diameter (AP)
that is larger than the lateral (LAT)
diameter
D. has a depression in the sternum

TIP: Less than 1 year: AP = LAT

diameter More than 1 year: LAT
> AP diameter
Pectus carinatum (pigeon chest) = AP>LAT
diameter Pectus excavatum (funnel chest) =
LAT>AP diameter

MEDICAL-SURGICAL NURSING (70 points)

81. While you are obtaining an assessment and

 D. “I usually eat eggs or meat for at least 2
meals every day.” TIP: Stages of peritoneal dialysis/per 1 cycle
of dialysate Infusion time 5-10 minutes
The spleen is a lymphoid tissue which produces Dwelling/equilibration time 20-30 minutes
WBC. Removal of the spleen increases risk for Draining time 10-20 minutes
immune disorders.
Dialysis aims to promote excretion of retained
82. The nurse’s action is appropriate if she does fluids, electrolytes and waste products from the
which of the following to nursing interventions body. It is expected that more output should
in a patient with hypothyroidism? come out during the draining time. Turning the
A. Offer a high-calorie diet. patient from side to side can help drain the fluid
B. Increase fluid intake. that might have been trapped in the abdominal
C. Offer extra sheets or blankets to the patient. cavity.
D. Encourage the patient to take a bath twice a
day. 87. A patient received spinal anesthesia 4 hours
ago during surgery. The patient has been on
With decreased level of thyroid hormones, the ward for 2 hours and now reports severe
patients with hypothyroidism have reduced incisional pain. The patient's blood pressure is
basal metabolic rate and reduced heat 170/90 mm Hg, pulse is 108 beats/min,
production. Cold intolerance is therefore temperature is 37.2°C, and respirations are 30
common. Providing warmth helps manage this breaths/min. The patient's skin is pale and the
83. A client recovering from breast surgery asks
symptom. dressing is dry and intact. The most appropriate
you what type of food would fight “free radicals” nursing intervention is to:
to increase protection from cancer. Your best A. call the physician and report the findings
response would be: B. medicate the patient for pain
A. “Do you want reading materials in C. place the patient in a high Fowler
cancer fighting food?” position and administer oxygen
B. “Foods rich in beta – carotene, vitamins A, D. place the patient in a reverse
C, E seem to fight free radicals.” Trendelenburg position and open the IV
C. “Eat foods that are in rich in antioxidants and line
phytochemicals.”
D. “Have you tried the herbal products in the market?” Post-spinal anesthesia, a patient is placed flat on
bed for 6-8 hours (C,D). The vital signs reflect a
Antioxidants and phytochemicals are proven to be patient in severe pain. Since the question asks
effective in fighting free radicals that are known to for a nursing intervention, Choice B would be
cause cancer. wrong since medication required a doctor’s order.
The nurse needs to notify the physician.
84. During hemodialysis, a patient with ESRD
suddenly becomes confused, restless and TIP: In answering medication questions, if the
verbally abusive. The nurse interprets this a question asks for a nursing action, look for the phrase
sign of “as ordered” or “as prescribed”, to qualify that as a nursing
A. helplessness action. Remember giving a medication without an
B. disequilibrium syndrome order is outside the scope of nursing practice.
C. allergic reaction to the dialysate
D. increased cerebral tissue perfusion 88. Bone marrow depression is an adverse effect
of chemotherapy. Which of the following
Rapid removal of fluid from the brain during laboratory values indicate that the patient has
hemodialysis can lead to disequilibrium syndrome bone marrow depression?
that can be manifested by behavioral changes A. hemoglobin - 15.1 mg/dl
during the procedure. B. white blood cell - 4,500 mg/cc
C. red blood cell - 4
85. The nurse should be alert for potential million/ cc D. platelets -
complications during the post-operative 90,000/cc
phase. Which of the following manifestations
possibly suggest a developing complication? Chemotherapy reduces the production of RBC,
A. temperature of 37.9 C, chills and cold WBC and platelets as a result of bone marrow
clammy skin suppression.
B. urine output of 120 cc for the past first
four hours after surgery TIP: CBC normal values
C. tachycardia and decreased blood pressure
D. shallow respirations and pulse oximeter
reading of 95%

A reduced blood pressure and increased pulse decreased output of only 550 ml. The next best
rate may suggest bleeding post-operatively. ABD nursing action is to:
are all normal assessments post-operatively. A. document the output in the flow
sheet B. turn the patient from side to
86. The nurse instilled 2,000 ml of dialysate on a side
patient for peritoneal dialysis. During the C. report the output to the physician
draining time, the nurse observes a D. infuse another bottle of dialysate
 RB 3.5-5.5 million/cu.
WB
C 5,000-
mm.
C
Platele 10,000/cu.mm.
150,000-
89. A staff nurse is called to a client’s room. When the Hemoglo
ts 12-16
450,000/cu.mm
nurse arrived in the room, she noted that the Hematoc
bin 37%-
mg/dL
waste basket is on fire. However, the client rit 47%
has been moved out of the room. Which of
the following is the priority action of the
nurse?
A. Activate the fire alarm C. Evacuate the
unit
B. Extinguish the fire D. Confine the fire

TIP: RACE(E)
R – Rescue the patients
A – Activate the alarm
C – Confine/contain the fire
E – Extinguish the fire
 E – Evacuate the premises causing osmotic diuresis. This may lead to
dehydration.
90. In planning care for a patient with Parkinson’s
disease, the nurse decides that the patient may
need the most help with
A. getting out of bed
B. buttoning his shirt and pants
C. taking his medications
D. communicating with caregivers

Tremors, pill-rolling of the fingers, and rigidity

are characteristics of Parkinson’s disease. Buttoning may
be a difficult task for this patient.

91. Understanding the risks of infection, who

among the clients listed below should
receive immediate attention and care?
A. Adult female with Vitamin B deficiency due
to chronic alcohol intake
B. Adult male with fresh second degree
burns on arms and chest
C. A teenager who is bleeding due to a cut on
the finger
D. An elderly male with diabetes
mellitus and toe infection

An intact skin is the first line of defense against

infection. Altered skin integrity breaks this defense,
increasing the risk for infections.

92. The most important nursing intervention in

caring for a patient with a newly-placed
nephrostomy tube is to
A. clamp the tube every 4 hours
B. disinfect the surgical site every shift
C. flush the tube with normal saline, as ordered
D. monitor the surgical dressing for bleeding

A nephrostomy tube must be kept patient in order to

prevent damage to the kidneys. This can be
accomplished by regularly flushing the tube with 5-10
mL of NSS q4h with a physician’s order.

93. A patient with stroke is put on Mannitol

intravenously. The nurse evaluates the
effectiveness of the drug by noting which
observation?
A. blood pressure increases
B. level of consciousness improves
C. urine output decreases
D. pupils are dilated and sluggishly reacting

Mannitol is an osmotic diuretic that is used to

reduce an increased intracranial pressure. As a
diuretic, it promotes the excretion of fluid from the
kidneys. Reduced fluid volume can decrease
edema in the brain, thereby, improving the level of
consciousness.

94. Extreme hyperglycemia of uncontrolled

diabetes mellitus results in:
A. Metabolic alkalosis C. A state of
dehydration
B. Oliguria D. Weight gain

Hyperglycemia attracts water from various fluid

compartments in an attempt to dilute the
concentrated blood. This temporarily increases the
circulating fluid volume. As the fluid passes through
the kidneys, they are excreted into the urine,
95. Which of these statements made by a sutures post- operatively. ABD refer to wound
mother during an education session in the evisceration, the protrusion of abdominal organs
community tells the nurse that her child is outside the abdominal cavity.
prone to Hepatitis A infection?
A. “I always prepare my child’s lunch for school.” 100. An assessment finding that is consistent
B. “My child shares her lunch with her brother at with pancreatitis is the presence of
recess.” A. severe right upper quadrant pain
C. “My son sometimes buys food from the
street vendor.”
D. “I remember when my daughter had a
blood transfusion.”

Hepatitis A is transmitted via fecal-oral route.

Unsanitary food handling and preparation is a
risk factor.

96. Early signs and/or symptoms of

hepatitis include: A. nausea, vomiting
and abdominal pain
B. fever, yellowish sclera and skin
C. dark colored urine and diarrhea
D. ascites, difficulty breathing and swallowing

While all of these may be seen in hepatic disorders,

early signs of hepatitis are vague and non-specific.

97. For clients with diabetic ketoacidosis (DKA),

their body compensate for the acidosis in
many ways. When caring for these clients,
which of the following manifestations will you
anticipate to observe?
1. Nausea and vomiting 3. Kussmaul
breathing
2. Oliguria 4. Polyuria
A. 1 and 2 C. 3 and 4
B. 1, 3 and 4 D. All of the above

In DKA, the body compensates to reduce the

acidity of the blood by attempting to excrete the
ketone bodies
 from the kidneys by promoting increased
urine output. This can lead to polyuria.
 from the lungs giving the characteristic
deep, rapid breathing (Kussmaul’s) and
acetone odor of the breath
 from the digestive system through vomiting

98. Which of the following laboratory results tell

the nurse that a patient has acute liver failure?
A. increased serum blood urea nitrogen level
B. decreased bilirubin level
C. increased aspartate transaminase level
D. decreased alanine transaminase level

An increased liver enzymes (ALT, AST) indicates

liver damage.

99. The most appropriate nursing action in the

event of a wound dehiscence is to
A. wear sterile gloves then attempt to push
the organs back into the abdominal
cavity
B. cover the intestines with sterile dressing
moistened with normal saline solution
C. apply an abdominal binder to prevent
protrusion of abdominal organs
D. cover the organs with a dry sterile dressing
then notify the physician

Wound dehiscence is the separation of surgical

 B. foul smelling stools
C. palpable abdominal mass 105. The nurse taking care of a patient who
D. blood in the urine underwent gastrectomy with Billroth II
should watch out for complications
The pancreas is located in the left side of the associated with
abdomen (A). in pancreatitis, reduced production of A. electrolyte imbalances C. dumping
lipase reduces fat digestion on the intestines. This syndrome
causes malabsorption of fats causing it to be B. hypoglycemia D. wound dehiscence
excreted to the stools, causing steatorrhea.

101. The nurse assessing for risk factors for

meningitis asks for the presence of which
medical history?
A. diabetes mellitus and
anemia B. tuberculosis and
otitis media
C. renal failure and urinary tract infection
D. hepatitis and pancreatitis

Meningitis is mostly caused by bacteria or virus.

Choice B are caused by bacteria. Diabetes, renal
failure, and pancreatitis not usually caused by
infection.

102. Which of the following observations will

make the nurse suspect of bleeding in a post-
thyroidectomy patient?
A. The patient’s blood pressure increases and
pulse rate decreases.
B. The surgical dressing has a scant
amount of sero- sanguineous drainage.
C. The patient is swallowing frequently.
D. The patient is drowsy and has slow
shallow respirations.

Bleeding can be assessed by monitoring for

frequent swallowing or checking the back of
the neck for blood.
103. During the post-operative period for
thyroidectomy, the nurse observes muscle
twitching on the patient’s arms as the blood
pressure is being taken. This may likely be an
indication of:
A. hypocalcemia caused by accidental
removal of the parathyroid glands
B. hypothermia due to the temperature
inside the recovery room
C. respiratory alkalosis due to inability to
perform deep breathing exercises
D. seizures related to effects of general
anesthesia and narcotics

One of the common complications of thyroidectomy

is tetany or hypocalcemia due to accidental removal
of the parathyroid glands. This can be manifested
by early signs such as numbness and tingling of the
mouth. Characteristics of tetany include Chvostek’s
sign (facial muscle spasms) and Trousseaus’s
(spasms of the hand and feet).

104. A surgical procedure that involves

removing a portion of the stomach and
anastomosing the remaining part with the
duodenum is called
A. total mastectomy C. bougeinage
procedure
B. Billroth I D. Billroth II

TIP: Billroth I –
gastroduodenostomy
Billroth II -
When the stomach is surgically attached to the test. The nurse knows that this is used in the
jejunum, rapid entry of hyperosmolar food into the diagnosis of
small intestines can lead to dumping syndrome. A. diabetes insipidus
B. Cushing’s syndrome
106. A patient undergoing chemotherapy has C. pheochromocytoma
the following as his latest laboratory CBC D. syndrome of inappropriate anti-diuretic
results: RBC - 5 million/cc, hormone
WBC-3,000/cc, and platelets-180,000/cc.
Based on these results, the nurse should Fluid deprivation test is a screening for diabetes
identify which nursing diagnosis? insipidus (DI). If a patient is not given any fluids but
A. Activity still has an increased urine output, it may indicate
intolerance B. DI. This is due to the inability to reabsorb water
Risk for infections from the kidneys caused by lack of anti-diuretic
C. Impaired tissue perfusion hormone.
D. Risk for injury

The CBC shows an abnormal WBC count,

increasing the risk for infections.

107. Which patient statement made prior to

discharge after an appendectomy needs
further teaching?
A. “I need to call the doctor if I develop fever.”
B. “My incision will be painful and sore
for a few days.”
C. “I can resume my activities before surgery
without restrictions.”
D. “I should not see any drainage from the
surgical wound.”

Activity restriction is recommended after

abdominal surgeries. 108.The priority nursing

diagnosis of a patient with Addison’s

disease is
A. Altered nutrition: less than body
requirements
B. Fluid volume deficit
C. Risk of blood glucose imbalance:
hypoglycemia
D. Altered body image

Addison’s disease is characterized by lack of aldosterone

that causes reduced sodium and water retention.
This promotes increased excretion of urine, which
may cause dehydration.

109.A nurse is circulating in an exploratory

laparatomy for a ruptured appendicitis. The
scrub nurse asks for "Normal Saline Solution
(NSS) wash". The circulating nurse
immediately opened one liter of NSS and
began to pour to the sterile basin of the scrub
nurse. Before she can empty the NSS
container, the scrub nurse signals "enough",
what is the appropriate action with the
remaining NSS?
A. Discard the remaining NSS.
B. Pour the remaining NSS to another sterile
basin in the back table.
C. Cover the remaining NSS bottle
aseptically right away.
D. Transfer the remaining NSS to
smaller sterile container.

Any sterile container is considered unsterile once it

is opened.

110.A patient is prepared for a fluid deprivation

111. The nurse encourages a patient with Addison’s 115. The nurse monitoring a patient in the acute
disease to have an adequate intake of which care knows that the intracranial pressure is
types of diet? increased by noting which of these changes in
A. high-sodium, high-calorie, low-potassium vital signs?
diet A. T-40.1 C, BP-165/105 mmHg, RR-10
B. low-sodium, high-calorie, high-potassium cpm, PR-58 B. T-38.2 C, BP-140/90
diet mmHg, RR-14 cpm, PR-95 C. T-37.4 C,
C. high-sodium, low-calorie, high-potassium BP-120/75 mmHg, RR-12 cpm, PR-75 D. T-
diet 36.2 C, BP-90/40 mmHg, RR-22 cpm, PR-
D. low-sodium, low-calorie, low-potassium diet 115

Patients with Addison’s disease have low aldosterone level. TIP: Cushing’s triad – late sign of increased ICP
This reduces sodium reabsorption and potassium  Hypertension or increased/widened pulse
excretion from the kidneys. Patients develop pressure
hyponatremia and hyperkalemia. Diet management  Hyperthermia
should be high in sodium and low in potassium.

112. The nurse’s action is appropriate if she prepares

which of the following pain medications for a
patient complaining of sharp abdominal pain
due to cholelithiasis?
A. Morphine sulfate (MS Contin)
B. Meperidine hydrochloride (Demerol)
C. Mefenamic acid (Ponstan)
D. Butorphanon hydrochloride(Stadol)

The main problem of patients with cholelithiasis is

acute severe pain. The preferred analgesic is
Meperidine HCl. Morphine sulfate is
contraindicated as it may cause contraction of the
sphincter of Oddi.

113. An important nursing intervention for

patients with liver cirrhosis is to
A. provide diet that is low in calories and salt
B. encourage the use of soft-bristled brush
C. massage the skin with alcohol
D. administer Acetaminophen (Tylenol) for
abdominal pain

Patients with liver disorders are prone to bleeding

due to impaired synthesis of clotting factors. Use of
soft-bristled brush prevents gum bleeding. They are
given high-calorie diet (A) due to the high metabolic
rate of the liver. Acetaminophen is hepatotoxic (D).

114. Patients with diabetic ketoacidosis (DKA)

will more likely exhibit the following changes in
their arterial blood gases (ABG):
A. pH - 7.56, pCO2 - 60 mmHg, HCO3 - 15
meq/L
B. pH - 7.40, pCO2 - 44 mmHg, HCO3 - 24
meq/L
C. pH - 7.34, pCO2 - 50 mmHg, HCO3 -
29 meq/L D. pH - 7.25, pCO2 - 30 mmHg,
HCO3 - 19 meq/L

TIP: ABG Interpretation

Normal Increas Decreas

Value ed ed
pH 7.35-7.45 Alkalosis Acidosis
PaCO 35-45 Acidosis Alkalosis
2 mmHg
HCO3 22-26 Alkalosis Acidosis
meq/L
PaO2 80-100 - Hypoxem
mmHg ia
  Bradycar
the upper gastrointestinal system
dia
 Bradypne
116. The nurse should plan the diet of a Upper GI
a series is the other term for barium
patient with liver cirrhosis who has a swallow. Choice A refers to endoscopy; C is
normal ammonia level that is abdominal x-ray; and D is physical assessment.
A. rich in calories C. high in fats
B. low in proteins D. high in sodium 120. A patient with epilepsy is to undergo
electroencephalo- graphy (EEG) after
TIP: Diet in liver disorders breakfast. The nurse enters the patient
 high calorie – liver has a high metabolic rate
 low sodium – reduced albumin
synthesis leads to edema due to
reduced colloid oncotic pressure
 low protein – ONLY if ammonia level is
increased
 balanced diet – if ammonia level is normal

117. The nurse notifies the physician regarding a

patient’s serum potassium of 7.1 meq/l.
The physician orders intravenous glucose
and insulin. This is to
A. enhance renal excretion of
potassium B. promote cellular
entry of potassium
C. cause exchange of potassium with
hydrogen ion in the intestines for
excretion
D. treat hypoglycemia associated with the
potassium imbalance

TIP: Drugs for hyperkalemia

 Glucose with insulin – insulin promotes the
entry of glucose and potassium into the cell
 Kayexalate – ion exchange resin; facilitates
the exchange between potassium and
sodium ions in the intestines

118. The nurse monitors the vital signs of a

patient at risk for internal hemorrhage. Which
set of vital signs reflects that the patient is
having hemorrhage?
A. BP-150/90 mmHg, PR-110, RR-20,
T-37.5 C B. BP-120/75 mmHg, PR-
100, RR-16, T-36.9 C C. BP-90/50
mmHg, PR-55, RR-10, T-38.4
D. BP-90/45 mmHg, PR-120, RR-24, T-36.1 C

TIP: Signs of bleeding

 BP – initially increased due to compensatory
vasoconstriction; eventually decreases as
bleeding progresses
 Pulse – increased as the heart compensates
 Respiratory rate – increased as lungs
attempt to provide more oxygen to tissues
 Temperature – decreased due to reduced
blood flow

119. A patient is anxious about her upcoming

upper gastrointestinal series. The nurse
attempts to allay the patient’s anxiety by explaining
that this procedure involves
A. insertion of a fiber optic tube to visualize
the upper digestive organs
B. getting an x-ray of the upper abdomen
after ingestion of barium
C. visualization of the abdomen through
a CT scan machine
D. thorough physical assessment of
 room, sees the meal tray and tells the patient
not to take the: 125. A client with cancer of the larynx undergoes
A. slice of pineapple C. glassful of water total laryngectomy. Post-laryngectomy, which
B. scrambled eggs D. cup of coffee of the following will the nurse expect?
A. No risk of aspiration during swallowing;
EEG measures electrical activity of the brain and is speech is lost.
used to diagnose seizure and epileptic disorders.
Patients should avoid any stimulants that may
falsely increase brain wave activity.

121. A patient who has been diabetic for 15 years

develops neuropathy. Which of the following
home care instructions will best prevent injury?
A. “Trim your toenails and in-growns every
week to prevent toe infections.”
B. “Take hot shower on your own to promote self-care
and independence.”
C. “Make sure to clean the floor regularly before walking
barefoot.”
D. “Inspect inside your shoes before wearing them.”

Peripheral neuropathy causes numbness that may

increase the risk for injuries since patients have
reduced ability to feel. Foot care and trauma
prevention is therefore essential. Avoid trimming
the in-growns (A), taking hot shower (B) and going
barefoot (C).

122. Which of the following ECG readings

indicate that a patient has a myocardial
infarction?
A. Suppressed ST segment C. Elevated T
waves
B. Absence of P waves D. Pathologic Q
waves

TIP: ECG in myocardial infarction

 Elevated ST segment
 Inverted T wave
 Pathologic or abnormal Q wave

123. The nurse is monitoring the tracheostomy

cuff pressure of a patient of mechanical
ventilation. To minimize the risk of tracheal
tissue necrosis the nurse should maintain the
pressure to
A. 10-15 mmHg C. 30-35 mmHg
B. 20-25 mmHg D. 40-45 mmHg

A pressure of less than 20 mmHg may cause

dislodgement of the tube and increase risk of
aspiration while higher than 25 mmHg can increase
pressure on the tracheal mucosa, causing damage
and necrosis.

124. A patient with fracture of the femur is on

balanced suspension traction. The nurse
considers the following statements when
taking care of a client with traction EXCEPT
A. Steady pull from both directions to keep the
fractured bone in place.
B. Weights should be kept resting on the floor.
C. Clients on traction need adequate skin
care and proper positioning.
D. Traction can be used to correct or
prevent deformities.

ABD are all appropriate when caring for patient

with traction. The weights should be continuous
and not disrupted.
 B. Normal speaking, breathing and B. Acetaminophen D. Fentanyl
swallowing are restored
C. Unable to communicate with difficulty of TIP: WHO Analgesic Ladder – specific pain
swallowing and breathing management depends on level or severity of
D. Permanent tracheostomy created; normal pain
speech is lost  Mild pain – non-opioids
(Acetaminophen, Paracetamol)
TIP: Changes after laryngectomy
 Partial laryngectomy – voice is preserved;
airway normal
 Total laryngectomy – permanent loss of
voice; upper airway is bypassed with a
permanent stoma

126. After appendectomy, the client complained of

abdominal pain, nausea and vomiting with
abdominal distention. The nurse anticipates
which of the following priority management
after referring to the surgeon?
A. Oropharyngeal suctioning
B. Possible surgery
C. Endoscopy
D. Rectal tube insertion

These signs indicate paralytic ileus, which is due

to accumulation of gas due to lack of intestinal
peristalsis. This can be relieved by NGT attached
to intermittent suction and/or rectal tube insertion.

127. Nurse Fely did her admission assessment

on a patient with acute pancreatitis. She
understands that the abdominal pain
associated with this disorder is
characterized as
A. Tenderness that is generalized in the
upper epigastric area
B. Pain in the left upper quadrant radiating
to the left shoulder
C. Tenderness and rigidity at the left
hypogastric area radiating to the back
D. Tenderness and rigidity at the upper
right abdomen radiating to the midsternal
area

Acute pancreatitis is felt as pain the left upper

quadrant since the pancreas is on the left upper
quadrant of the abdomen.

128. The client is scheduled to undergo

appendectomy. Preparation for
appendectomy does not include which of the
following?
1. Intravenous infusion A. 2,3,4
2. Laxative B. 1,3,5
3. Pubic area shaving C. 2,3,5
4. Enema D. 2,4,6
5. Shower
6. Pain medication

Laxatives and enema are contraindicated in

appendicitis as this may cause rupture of the
appendix. Pain medications are generally not
given as this may mask the pain that may falsely
indicate a ruptured appendix.

129. For a client complaining of mild

musculoskeletal pain, the nurse will anticipate that
the treatment for this client’s level of discomfort will
include which of the following?
A. Ibuprofen C. Meperidine HCl
  Moderate pain – NSAIDs (Aspirin,  Radioactive iodine (RAI 131) – to destroy
Ibuprofen, Mefenamic acid) thyroid tissues
 Severe pain – opioids (Morphine,
Meperidine HCl) 134. The nursing student reviews the laboratory
findings of a patient with polycythemia vera
130. Albert came to the hospital with chest pain and finds which blood results are elevated?
and fever. After a thorough assessment by
the doctor he was admitted for pericarditis
management. The nurse positions the client
to reduce pain and discomfort. Describe
this position.
A. Semi-Fowler’s position with one pillow to
support the head.
B. Put two pillows to elevate the head and
one pillow under the knees.
C. Sit the client upright and lean forward
D. Supine lying on either left or right side with
one pillow to elevate the head

Upright position, with the patient leaning

forward, is the position of choice to relieve
chest pain in pericarditis.
131. The nurse is aware that acromegaly is a
condition when growth hormone occurs in
excess. The following are the typical features
of the disorder EXCEPT
A. The soft tissues continue to grow
B. Hands and feet are
enlarged C. The client
grows taller
D. Broad and bulbous nose

TIP: Gigantism (children) – growth in bone length

Acromegaly (adults) – growth in bone width

132. A 30-year-old client had cholesterol blood

test before admission to the hospital. The
nurse in charge would teach the family and
significant others that the client should
exercise to help keep the total cholesterol
to a normal level of
A. 150-200 mg/dl C. 250-300 mg/dl
B. 200-250 mg/dl D. 300-350 mg/dl

Normal cholesterol level is below 200 mg/mL.

133. A 34-year-old female client with Grave’s

disease was admitted for treatment. The
physician prescribed Propylthiouracil to treat
the disorder. The client is to have surgery in
10 days. Lugol’s solution 4 gtts po was
prescribed for 10 days. The client asked the
nurse for the purpose of the drug. Which
response of the nurse is correct?
A. It decreases the risk of bleeding.
B. It eliminates the needs to take hormone
replacement.
C. It stabilizes your immune system to
withstand surgery.
D. It decreases the risk for thyroid crisis.

TIP: Medical management of Grave’s disease

 Iodine solutions – to reduce the size and
vascularity of the thyroid gland to reduce
the risk of bleeding
o Lugol’s solution
o Potassium iodide saturated solution
 Anti-thyroid drugs – to reduce the
production of thyroid hormones
o Propylthiouracil (PTU)
o Methimazole (Tapazole)
 A. RBC, WBC and platelets pulmonary edema. He has a history of
B. WBC, platelet and cholesterol congestive heart failure, type 2 diabetes
C. Bilirubin, RBC, and platelet mellitus and hypertension. Based on the history,
D. BP, WBC, and hematocrit

Polycythemia vera is characterized by abnormal

proliferation of RBC, with accompanying increase
in WBC and platelet.

135. From the following data obtained from the

chart, which is NOT a risk factor which could
have predisposed the patient to breast
cancer?
A. Age – 55 years
B. Height – 5’2”; weight – 160 lbs.
C. Menarche at age 13
D. Mother died of colon cancer

TIP: Risk factors of breast cancer

 Age – increasing age (>40 years old)
 Obesity

Height Male Female

First 5 106 lbs 100 lbs
feet
For 6 lbs 5 lbs
every
inch
Exampl 106+8(6)=1 100+8(5)=1
e: 54 40
5’8”

 Early menstruation (menarche)

 Late menopause
 Use of estrogen
 Family history of cancer

136. The nurse in the intensive care unit is

closely watching a client for signs of
hypovolemic shock. Which of the following
should the nurse report as early signs of
hypovolemic shock?
1. Lethargy A. 2,3,4 and 5
2. Rapid pulse B. 1,2,3 and 5
3. Clammy skin C. 1,2,5 and 6
4. Cyanosis D. 1,3,4 and 6
5. Restlessness
6. Hematemesis

Early signs of decreased oxygenation include

137. The nurse is aware that in acute respiratory changes in the level of consciousness
distress syndrome (ARDS), the basic (restlessness, lethargy) since brain cells are
changes in the lungs result from injury to the sensitive to low oxygen level. The vital signs
alveolar wall and capillary membrane reflect tachycardia and tachypnea. Cold clammy
leading to the following pathological skin is due to reduced peripheral circulation.
changes EXCEPT Cyanosis (4) is a late sign.
A. Fluid and protein leaks into alveoli
and interstitial tissue
B. Elevated blood hydrostatic
pressure C. Reduced colloid
oncotic pressure
D. Increased alveolar capillary permeability

ARDS involves the sudden onset (24-48 hours) of

leakage of fluids into the lungs (pulmonary
edema) as a result to injury to the lung tissues.
Injured tissues release histamine that makes
capillaries more permeable to fluids.

138. The nurse admitted a client because of

 the nurse noted that the patient regularly took D. Metoprolol (Lopressor) 12.5 mg
Losartan. What is the specific action of this
drug? orally daily Hypokalemia increases risk for
A. Improves myocardial contractility,
decreases the heart rate, and reduces digitalis toxicity.
oxygen consumption
B. Causes vasoconstriction, increased 142. The nurse administered 3% saline to a
preload and dilation of the ventricles patient who has a serum sodium level of 124
C. Reduces peripheral vascular resistance and meq/L. Which assessment findings may
afterload, reducing myocardial workload develop as a result of the treatment?
D. Interferes with the production of A. Her blood pressure decreased from 150/90
angiotensin II resulting in improved to 130/80 mmHg
cardiac output and reducing pulmonary B. There is sediment and blood in Wanda’s urine
congestion C. Wanda’s radial pulse is 105 beats per minute
D. There are crackles audible throughout her
Drugs that end in “SARTAN” are angiotensin receptor lung fields
blockers, a type of anti-hypertensive agent.
Angiotensin II causes vasoconstriction and TIP: Concentrations of intravenous fluids
increased sodium and water retention.
Blocking angiotensin II causes vasodilation and
reduced sodium and water retention.

Choice A refers to cardiac glycosides (e.g.

Digoxin) while C describes vasodilators (e.g
Apresoline, Catapress).

139. Due to hypothalamic dysfunction, a

syndrome of inappropriate antidiuretic
hormone (SIADH) develops. Which of the
following manifestations should the nurse
watch closely?
A. Increased urine output, decreased serum
sodium
B. Increased urine output, increased serum
sodium C. Decreased urine output,
decreased serum sodium
D. Decreased urine output, increased serum
sodium

SIADH is due to an increased level of anti-

diuretic hormone. This causes increased water
reabsorption from the kidneys leading to fluid
overload. As water is reabsorbed into the
circulation, it dilutes the sodium causing
dilutional hyponatremia.

140. Neutropenia often results from bone marrow

depression as an adverse effect of
chemotherapy. As a nurse, you should
observe for the following symptoms that
include
A. Headache, dizziness, blurred vision
B. Severe sore throat, bacteremia,
hepatomegaly
C. Petechiae, ecchymosis, epistaxis
D. Weakness, easy fatigability, pallor

Neutropenia is reduced WBC. This increases risk

for infection. A & D are due to anemia while C is
due to thrombocytopenia.

141. Joseph has been receiving diuretic therapy

and is admitted to the hospital with a serum
potassium level of 3.1 meq/L. Of the following
medications that he has been taking at home,
which will you be most concerned about? A.
Oral digoxin (Lanoxin) 0.25 mg daily
B. Lantus insulin 23 U subcutaneously every
evening
C. Ibuprofen (Motrin) 400 mg every 6 hours
 person
 Hypotonic solution0.45% NaCl 4 Open Disoriented, Flexion
 Isotonic solution 0.9% NaCl, D5W, s confused withdrawal
LRS spontaneously
 Hypertonic solution 3% NaCl 3 Opens to Inappropriate Decortica
light sounds te
stimulatio positioni
As a hypertonic solution, 3% NaCl, attracts n ng
water that can increase the circulating blood 2 Opens to Incomprehensi Decerebr
volume. This may lead to fluid excess causing painful ble ate
stimulation sounds positionin
pulmonary edema, which is manifested by
g
crackles upon auscultation. 1 No response No response No response

143. Timothy, 56 years old, was admitted

because of aortic aneurysm, fusiform type.
The nurse recognizes which of the following as
the correct description of the patient’s diagnosis?
A. Tear in the intima of the aorta with
hemorrhage into the tunica media
B. Stretching of both sides of the aorta
C. One-sided protrusion of one distinct area of
the aorta
D. Pulsating hematoma on three layers of the
aorta

TIP: Types of aneurysm

 Saccular – dilation on one side of an artery
 Fusiform – dilation of both sides of an artery
 Dissecting – tear in the layer/s of an artery
 Pseudoaneurysm – false aneurysm

144. Of the following diagnostic tests prescribed

by the physician, which of the following will
the nurse expect to show precise
measurement of a cholelithiasis?
A. Cholecystography
B. Chest x-ray
C. Abdominal ultrasonography
D. Cholangiography

Abdominal ultrasound provides 95% accuracy in

providing information about the location and
measurement of gallstones.

145. A client was rushed to the emergency

department after a vehicular accident where he
had a traumatic head injury (TBI). To determine
the client’s level of consciousness, the Glasgow
Coma Scale (GCS) is used. Which of the
following is a correct interpretation of the nurse
of the GCS score?
A. The higher the score, the higher is the
probability of permanent damage
B. The lower the score is, the lower is the
probability of delayed recovery
C. The higher the score, the greater is the
impairment in the brain
D. The lower the score, the more serious
is the brain injury

TIP: Glasgow Coma Scale

Highest score is GCS of 15
Lowest score is GCS of 3
The GCS is an assessment tool to evaluate level
of consciousness. It assesses eye opening,
verbal response and motor response.

Eye Opening Verbal Response Motor

Response
6 - - Follows
commands
5 - Oriented to Localizes pain
time place &
 an adjuvant (in addition) to chemotherapy.
146. An immediate objective for nursing care of an
overweight mildly hypertensive client with 150. The nurse teaches a group of clients the
ureteral colic and hematuria is to decrease difference between Type I (IDDM) and Type II
A. hypertension C. hematuria (NIDDM) diabetes. Which of the following is
B. pain D. weight true?
A. Both types diabetes mellitus clients are
The pain problem of patients with renal stones is prone to developing ketosis.
pain. Priority goal of care is pain management. B. Type II (NIDDM) is more common and is
Opioid analgesics are the preferred medication. also preventable compared to Type I
(IDDM) diabetes, which is genetic in
147. A client who had a craniotomy has an etiology.
increased intracranial pressure. Which of the C. Type I (IDDM) is characterized by
following interventions can the nurse include in fasting hyperglycemia.
the plan of care to control intracranial pressure
(ICP)?
A. Maintain his head and neck in neutral
alignment
B. Initiate measures to enhance valsalva
maneuver
C. Administer O2 to maintain paCO2 >50
mmHg
D. Elevate head of the bed to 60-90 degrees

The head and neck should be in neutral position

to promote venous outflow from the brain. Flexing
the neck reduces the flow of venous blood from
the brain, increasing ICP. Valvalva maneuver
increases ICP (B). Oxygen below 80 mmHg and
carbon dioxide above 45 mmHg causes dilation of
blood vessels in the brain, increasing blood
volume and eventually increasing ICP (C). The
preferred position to reduce ICP is head of bed
elevated to 30-45 degrees (D).

148. The ER nurse is assessing a client who

had a closed chest injury. Which of the
following will the nurse do to assess
subcutaneous emphysema?
A. Observe for signs of unequal chest
expansion.
B. Auscultate the lungs and observe for
crackles. C. Palpate neck for air bubble-
popping sensation
D. Percuss for a hyperresonant percussion tone

Subcutaneous emphysema or the presence of air

in the subcutaneous tissues causes a
characteristic crackling or popping sound upon
palpation. Unequal chest expansion (A) may be
seen in pneumothorax, flail chest or atelectasis.
Crackles (B) indicate the presence of fluids in the
lungs such as in pulmonary edema.
Hyperresonance (D) is heard on percussion when
excessive air is in the thoracic cavity like in
emphysema or pneumothorax.

149. The nurse recognizes that adjuvant

chemotherapy for cancer management may
include any of the following EXCEPT
A. Monoclonal antibody C. Antitumor
antibiotics
B. Proton inhibitors D. Hormonal
preparations

Chemotherapeutic agents include anti-tumor

antibiotics, hormones, anti-metabolites, alkylating
agents, and plant alkaloids. Immunotherapy, such
as the use of monoclonal antibodies, cytokines,
vaccines, and colony-stimulating factors, is used as
 D. Type II (IDDM) is characterized by illness
abnormal immune response.  Secondary – early diagnosis & treatment
 Tertiary – recovery & rehabilitation
TIP: Types of diabetes mellitus

Type Type 154. The therapeutic approach in the care of an

I II autistic child include the following EXCEPT:
Name Insulin-dependent Non- A. Engage in diversionary activities when acting -
insulin out
depende B. Provide an atmosphere of acceptance
nt C. Provide safety measures
IDDM NIDDM D. Rearrange the environment to activate the
Onset Early; before 40 Late: after 40 y/o child
y/o
Risk Autoimmune – Obesity, genetic Care of autistic children includes maintaining their
virus routine. Disruption of their familiar environment
Ketosis Yes No increases their anxiety.
Treatme Insulin Oral
nt hypoglycemic
drug
More common

MENTAL HEALTH & PSYCHIATRIC NURSING

(50 items)

151. Mental health is defined as:

A. The ability to distinguish what is real from
what is not.
B. A state of well-being where a person can
realize his own abilities, can cope with
normal stresses of life and work
productively.
C. Is the promotion of mental health,
prevention
of mental disorders, nursing care of
patients during illness and rehabilitation
D. Absence of mental illness

Choice A refers to reality-testing. Choice C is

the focus of psychiatric nursing. Choice D is a
very limited definition of mental health.

152. Liza says, “Give me 10 minutes to recall the name of

our college professor who failed many
students in our anatomy class.” She is
operating on her:
A. Subconscious C. Conscious
B. Unconscious D. Ego

TIP: Levels of consciousness

 Consciousness – focuses on the here and
now
 Subconscious – requires effort to recall the
past
 Unconscious – past experiences are
cannot be recalled easily

153. Primary level of prevention in

psychiatric nursing is exemplified by:
A. Helping the client resume self-care
B. Ensuring the safety of a suicidal
client in the institution.
C. Teaching the client stress management
techniques
D. Case finding and surveillance in the
community

TIP: Levels of prevention

 Primary – promotion of health & prevention of
  Presence of support system
155. A 10-year-old child has very limited  Previous use of coping mechanism
vocabulary and interaction skills. She has an
I.Q. of 45. She is diagnosed to have Mental 160. The nurse initiates the nurse-client
retardation of this classification: relationship with Marta. Which of the following is
A. Profound C. Moderate the least appropriate topic during the orientation
B. Mild D. Severe phase?
A. Establishment of regular schedule for
TIP: Levels of mental retardation (diagnosed interaction B. Exploration of the client’s
before 18 y/o) inadequate coping
mechanism
IQ Catego C. Objectives of the nurse-patient interaction
ry D. Perception of the client of the
50-70 Mild Educable, mental age of 6th reason for her hospitalization
grade
35-50 Moderat Trainable ; mental age ACD are activities during the orientation of the
e of 2nd grade therapeutic relationship. B is done during the
20-35 Severe Close supervision working phase.
Below Profoun Custodial; total care
20 d 161. Lalaine, a 29 year-old married woman
believes that the doorknobs are contaminated
156. A client with organic brain disorder is and she touches them only with tissue paper.
exhibiting changes in behavior. What behavior Which of the following is the most appropriate
or action will alert the nurse that the patient may nursing diagnosis that the nurse should
be experiencing delirium? identify?
A. Daytime sleepiness and night time A. Anxiety, moderate
incontinence B. The client becomes B. Impaired adjustment
confused within 24 hours from C. Ineffective coping
admission. D. Self-esteem disturbance
C. Depression alternating with periods of
cheerfulness Obsessive-compulsive behavior or personality
D. Depression and inability to get out of is anxiety- related.
bed to do activities of daily living
162. Which of the following is the rationale for
Delirium is a sudden change in level of allowing a client with obsessive-compulsive
consciousness brought about my acute change in personality to continue her ritualistic behavior?
brain functioning, which may be due to organic A. To prevent increasing her level of anxiety
causes. B. To encourage independence
C. To protect her from physical harm
157. Which of the following situations describes D. To increase her self-esteem and confidence
the cognitive theory as a model of psychiatric
care? Rituals are attempts to displace anxiety. When
A. The nurse enforces limit setting on the rituals are performed, the level of anxiety that the
patient’s inappropriate behavior. patient experiences will decrease. On the other
B. The therapist delves into the past life of hand, the anxiety level increases once they cannot
the client to assess her childhood perform their rituals.
experiences.
C. The psychologist assesses and corrects the client’s 163. Which of the following is the appropriate
distorted and negative thinking. nursing intervention to reduce anxiety and the
D. The psychiatrist prescribes anti-anxiety need for ritualistic behavior?
medications to a client with panic disorder. A. Encourage the client to examine own
perceptions.
TIP: Models of psychiatric care B. Encourage the client to use problem-solving
 Psychodynamic or psychoanalytic model – skills.
focuses on past life experiences C. Focus on the strengths and potential of
 Cognitive model- focuses on thought, the client. D. Provide opportunities to
perceptions or beliefs express feeling.
 Behavioral model – focuses on actions or
characteristics that are learned from the Since ritualistic behaviors arise from anxiety,
environment expression of feelings helps reduce anxiety. A
 Biomedical – focuses on alterations in reduced anxiety level eventually reduces
physiologic processes performance of ritualistic behaviors.
158. Crisis is self-limiting. How many weeks
does it usually last?
A. 4-6 B. 2-4 C. 6-8 D. 8-10

With or without crisis intervention, crisis resolves

usually within 4-6 weeks.
 164. The following statements are true about
159. What is the priority assessment during the anxiety except: A. Anxiety is a response to a
initial phase of crisis intervention? specific negative stimulus.
A. Client’s support system B. Mild anxiety is useful in bringing
B. Individual and the problem about better performance.
C. Plan coping with the crisis C. Persons use defense mechanisms to cope
D. Type of crisis the client is experiencing with their anxiety.
D. Persons who are anxious resort to
TIP: Crisis assessment flight or fight mechanism.
 Perception of the problem – most important
The cause of anxiety is unknown, not specific. The D. “What can you do to alleviate some of your fears
patient feels uneasy without an apparent cause. without being assaulted again?”

165. Four days after admission, Mr. Lee says to the Allowing the patient to verbalize the situation helps
nurse, “I want to go home. I’m alright.” Which of the in discovering emotional components associated
following is the most therapeutic response of the with the event. Therapy is then directed towards
nurse? addressing the identified emotion.
A. “Alright you may go home if you want to.”
B. “I know it must be difficult for you to stay in the
hospital.”
C. “Why do you want to go home?”
D. “You are not yet ready to go home, Mr. Lirio”

Acknowledging patient’s feelings shows a nurse’s acceptance

of the patient. The use of “WHY” is non-therapeutic (C).

166. When should the rehabilitation of a

newly admitted schizophrenic patient
start?
A. Before discharge
B. During the recovery stage
C. In the acute stage of his
illness D. Upon admission

Rehabilitation of patients starts during admission.

167. A client with major depression is to be

discharged. Which of the following areas would
be most important for the nurse to review with
the client?
A. Conflict with another
client B. Medication
management
C. Plans of returning to work
D. Results of psychological testing

Antidepressant medications take an average of

three weeks before therapeutic effects can be felt.
This must be emphasized to patients who are
about to be discharged in order to ensure
compliance to the treatment.

168. Which of the following disorders may be

seen concurrently in a client with generalized
anxiety disorder?
A. Bipolar disorder
B. Gender identity
disorder C. Panic
disorder
D. Schizoaffective disorder

TIP: Levels of anxiety

 Mild – increases perception
 Moderate – presence of physical symptoms
 Severe – difficulty of concentration
 Panic – inability to concentrate; personality
disintegration

169. A female victim of sexual assault went to the

crisis center for her third visit. She was raped 3
months ago and states that she feels as if the
rape just happened yesterday. What would be
the best response of the nurse?
A. “In time, our goal will help you move on from
these strong feelings about your rape.”
B. “It’s been over for 2 months now. Be realistic.”
C. “Tell me more about what happened
during the rape that causes you now to
feel like the rape just occurred.”
 B. Chlordiazepoxide (Librium)
170. Since admission 3 days ago, a female C. Haloperidol (Haldol)
client has refused to take a shower, stating, “There D. Propanolol (Inderal)
are poisonous spiders hidden in the shower
head. I will get bitten by them and get killed if I TIP: Anti-cholinergic meds to prevent pseudo-
take a shower!” How should the nurse respond? parkinsonism or extra-pyramidal symptoms
A. Accept the fear and allow the client to (EPS) caused by antipsychotics
take a sponge bath instead. A – Akineton (Biperiden HCl)
B. Ask a security guard to assist in giving
the client a bath.
C. Dismantle the shower head and show
the client that there is nothing in it.
D. Tell her that the other clients complain
about her body odor, so she must take a
shower.

The nurse should accept that phobia is real for the

client.

171. The characteristic traits of

schizophrenia include the following
except:
A. Blunting of affect
B. Existence of two feeling tones
C. Loose association
D. Rapid change of mood

TIP: 5 As of schizophrenia
 Apathy – lack of affect
 Ambivalence – 2 feelings at the same time
 Associative looseness – jumps into different
topics
 Autism – magical or dereistic thinking
 Auditory hallucination – most common type

172. In taking care of schizophrenic patients,

which of the following nursing interventions
should the nurse consider?
A. Always agree with the patient’s ideas.
B. Make use of short phases and specific
words.
C. Use carefully detailed explanation.
D. Use sign language to be understood clearly.

Schizophrenia is a disorder of thought process.

Use of simple sentences makes it easier for
patient to comprehend.

173. One morning, Paul says, “I hear Jose Rizal’s

voice.” Which of the following statements is the
most therapeutic?
A. “I don’t hear the voice, but I know you hear
what sounds like a voice.”
B. “No need to worry about the voice. It doesn’t
belong to anybody alive.”
C. “That could not be true. Jose Rizal has been
dead for so many years.”
D. “You should ignore that voice. It would not help
you get well.”

Auditory hallucination is real for the client. Present

reality by not acknowledging or focusing on the
hallucination. Do not argue with the patient or
ignore the content of the hallucination.

174. Which of the following drugs should the

nurse expect to be prescribed in order to
reverse Parkinson-type symptoms in a client
receiving anti-psychotic medication?
A. Benztropine mesylate (Cogentin)
 A – Artane (Trihexiphenydyl Although the client is 36-years-old, his behaviors
HCl) reflect an inability to establish relationship and
B – Benadryl patterns of paranoia. These are characteristics of not
(Diphenhydramine HCl) C – being able to establish trust.
175. Which of the
Cogentin following is the most
(Benztropine
appropriate
mesylate) nursing diagnosis for a client 179. During a group therapy session in the
reporting thoughts of being followed by CIA psychiatric unit, a client constantly interrupts
agents? with impulsive behavior and exaggerated
A. Disturbed sensory perception related to stories that cast her as a hero or princess.
increased anxiety
B. Disturbed thought processes related to
increased anxiety
C. Impaired verbal communication related to
disordered thinking
D. Altered thought content related to mistrust

The client is experiencing delusion of persecution.

Delusion is a disorder of though process, not
though content.
 Alteration in thought content - delusion
 Alteration in thought process – hallucination,
illusion

176. A client with paranoid schizophrenia

repeatedly uses profanity during an activity
therapy session. Which response by the
nurse would be most appropriate?
A. “Your behavior won’t be tolerated. Go to your
room immediately.”
B. “You’re just doing this to get back at me for making
you come to therapy.”
C. “Your cursing is interrupting the activity. Take time
out in your room for 10 minutes.”
D. “I’m disappointed in you. You can’t control yourself
even for a few minutes.”

Inappropriate behavior is addressed with a

matter-of-fact approach. Limit setting exerts
external control on the patient.
177. The nurse is assigned to a client with
catatonic schizophrenia. Which
intervention should the nurse include in
the client’s plan of care?
A. Meeting all of the client’s physical needs
B. Giving the client an opportunity to express
concerns
C. Administering lithium carbonate
(Lithonate) as prescribed
D. Providing a quiet environment where the
client can be alone

Catatonic patients remain motionless for a period

of time and may neglect their physical needs (e.g.
nutrition, elimination).

178. A client, age 36, with paranoid schizophrenia

believes the room is bugged by the Central
Intelligence Agency and that his roommate is a
foreign spy. The client has never had a
romantic relationship, has no contact with
family members, and hasn’t been employed in the last
14 years. Based on Erikson’s theories, the nurse
should recognize that this client is in which
stage of psychosocial development?
A. Autonomy versus shame and doubt
B. Generativity versus stagnation
C. Integrity versus
despair D. Trust
versus mistrust
 She also manipulates the group with attention- assessment for suicide risk?
seeking behaviors, such as sexual comments A. “Are you sure you want to kill yourself?”
and angry outbursts. The nurse realizes that B. “I know if my husband left me, I’d want to kill myself.
these behaviors are typical of: Is that what you think?”
A. Narcissistic personality disorder. C. “How do you think you would kill yourself?”
B. Avoidant personality D. “Why don’t you just look at the positives in your life?”
disorder. C. Histrionic
personality disorder.
D. Borderline personality disorder.

Attention-seeking behavior is characteristic of a

histrionic personality. Narcissistic behavior
focuses on the self. Avoidant personality
withdraws from social relationships. Borderline
personality has inability to form relationships and
has self- mutilating tendencies.

180. A client is admitted to a psychiatric facility

with a diagnosis of chronic schizophrenia. The
history indicates that the client has been
taking neuroleptic medication for many years.
Assessment reveals unusual movements of
the tongue, neck, and arms. Which condition
should the nurse suspect?
A. Tardive dyskinesia
B. Dystonia
C. Neuroleptic malignant syndrome
D. Akathisia

Tardive dyskinesia is an irreversible side-effect of

anti- psychotic drugs that involve rhythmic
movement of the tongue. Dystonia involves the
muscles of the neck, arms and face.
Neuroleptic malignant syndrome causes high
fever, tremors. Akathisia involves restlessness
and inability to keep still.

181. The nurse is caring for a client who is

suicidal. When accompanying the client to
the bathroom, the nurse should:
A. Give him privacy in the bathroom.
B. Allow him to shave.
C. Open the window and allow him to get
some fresh air.
D. Observe him.

A patient who is suicidal is placed on suicidal

precautions. Constant 24-hour surveillance must
be done.

182. The nurse is developing a care plan for a

client with anorexia nervosa. Which action
should the nurse include in the plan?
A. Restrict visits with the family until the
client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which
will reduce her anxiety.

Providing external control enables a patient

with anorexia nervosa to eat. The patient
should be observed during meal times to
ensure that she ingests the food that is served.
183. A client whose husband recently left her is
admitted to the hospital with severe
depression. The nurse suspects that the client
is at risk for suicide. Which of the following
questions would be most appropriate and
helpful for the nurse to ask during an
A direct, confrontation approach is A. Sexual dysfunction C. Polyuria
recommended and therapeutic in assessing B. Constipation D. Seizures
suicide risk.
Adverse effects of lithium include polyuria, diarrhea,
184. The nurse is caring for a client tremors.
experiencing an anxiety attack. Appropriate
nursing interventions include: 189. A client is admitted for an overdose of
A. Turning on the lights and opening the amphetamines. When assessing this client,
windows so that the client doesn’t feel the nurse should expect to see:
crowded. A. Tension and irritability. C. Hypotension
B. Leaving the client alone. B. Slow pulse. D. Constipation.
C. Staying with the client and speaking
in short sentences.
D. Turning on stereo music.

During an anxiety attack, the patient should be

kept calm. As cognitive function or perception
may be affected, speaking in short sentences
may be beneficial and therapeutic.

185. The nurse is teaching a new group of mental

health aides.
The nurse should teach the aides that
setting limits is most important for:
A. A depressed client. C. A suicidal client.
B. A manic client. D. An anxious client.

TIP: Attitude therapy

 Active friendliness – withdrawn, isolated
patients
 Passive friendliness – paranoid patients
 Kind firmness – depressed patients
 Matter-of-fact (limit setting) – for any
inappropriate behavior
 No demand – for aggressive and violent
patients

186. The nurse is caring for a client, a Vietnam

veteran, who exhibits signs and symptoms of
posttraumatic stress disorder (PTSD). Signs
and symptoms of posttraumatic stress
disorder include:
A. Hyper alertness and sleep disturbances.
B. Memory loss of traumatic event and somatic
distress.
C. Feelings of hostility and violent behavior.
D. Sudden behavioral changes and anorexia.

Flashback, nightmares, and sleep

disturbances are characteristics of PTSD.

187. A client is admitted for detoxification after a

cocaine overdose. The client tells the nurse that
he frequently uses cocaine but that he can
control his use if he chooses. Which coping
mechanism is he using?
A. Withdrawal C. Repression
B. Logical thinking D. Denial

TIP: Substance abuse

 Defense mechanism – denial
 Nursing diagnosis – Ineffective individual
coping

188. A client with bipolar disorder is being

treated with lithium for the first time. The
nurse should observe the client for which
common adverse effect of lithium?
 D. Teaching eye exercises to strengthen his
Amphetamines are CNS stimulants. BP and pulse eyes
may increase (B,C). Diarrhea is more common.
(D) Conversion disorder is an anxiety disorder
characterized by loss of function of a body part
190. During a shift report, the nurse learns that she’ll without on organic or pathologic cause. It may be a
be providing care for a client who is symbolic representation of an unresolved conflict or
vulnerable to panic attack. Treatment for anxiety. Nurses should not focus on the sign or
panic attacks includes behavioral therapy, symptom so as to prevent reinforcing the anxiety.
supportive psychotherapy, and medication
such as:
A. barbiturates. C. depressants.
B. antianxiety drugs. D. amphetamines.

Panic is the highest level of anxiety. Anti-anxiety

drugs are indicated in this situation. (e.g.
Diazepam (Valium), Lorazepam (Ativan),
Chlordiazepoxide (Librium)).

191. A client has been receiving chlorpromazine

(Thorazine), an antipsychotic, to treat his
psychosis. Which finding should alert the
nurse that the client is experiencing
pseudoparkinsonism?
A. Restlessness, difficulty sitting still, pacing
B. Involuntary rolling of the eyes
C. Tremors, shuffling gait, mask like face
D. Extremity and neck spasms, facial
grimacing, jerky movements

Pseudoparkinsonism or Parkinson’s-like symptoms are

due to a reduction of dopamine level as an effect of
taking anti- psychotic drugs. (A) refers to akathisia;
(B) to oculogyric crisis and (D) dystonia.

192. A 54-year-old female was found

unconscious on the floor of her bathroom with
self-inflicted wrist lacerations. An ambulance
was called and the client was taken to the
emergency department. When she was
stable, the client was transferred to the
inpatient psychiatric unit for observation and
treatment with antidepressants. Now that the
client is feeling better, which nursing
intervention is most appropriate?
A. Observing for extrapyramidal symptoms
B. Beginning a therapeutic relationship
C. Canceling any no-suicide
contracts D. Continuing suicide
precautions

When patients are treated with depression, a

sudden improvement in their mood or a sign of
improvement is a major concern since it may
signal an impending suicide. Suicidal tendencies
are at its highest when the depression starts to lift.

193. A 26-year-old male reports losing his sight

in both eyes. He’s diagnosed as having a
conversion disorder and is admitted to the
psychiatric unit. Which nursing intervention
would be most appropriate for this client?
A. Not focusing on his blindness
B. Providing self-care for him
C. Telling him that his blindness isn’t real
 A & B refer to the roles of the nurse as a clinician
194. A client is being admitted to the substance while C pertains to a patient advocate role.
abuse unit for alcohol detoxification. As part of
the intake interview, the nurse asks him when 199. The objectives and activities that the nurse
he had his last alcoholic drink. He says that plans depend on the various stages of a
he had his last drink 6 hours before therapeutic relationship. Which is the following
admission. Based on this response, the nurse is the most appropriate during the orientation
should expect early withdrawal symptoms to: phase?
A. Not occur at all because the time A. patients perception on the
period for their occurrence has passed. reason of her hospitalization
B. Begin anytime within the next 1 to 2 days. B. identification of more effective ways of coping
C. Begin within 2 to 7 days. C. exploration of inadequate coping skills
D. Begin after 7 days. D. establishment of regular meeting of
schedules
Withdrawal symptoms form alcohol may continue to
be observed up to 3 days or 72 hours after the last ABC are activities during the working phase of a
alcohol intake. therapeutic relationship.

195. The nurse is caring for an adolescent 200. Freud stresses out that the EGO
female who reports amenorrhea, weight loss, A. Distinguishes between things in the mind
and depression. Which additional assessment and things in the reality.
finding would suggest that the woman has an B. Moral arm of the personality that strives for
eating disorder? perfection than pleasure.
A. Wearing tight-fitting clothing C. Reservoir of instincts and drives
B. Increased blood pressure D. Control the physical needs instincts.
C. Oily skin
D. Excessive and ritualized exercise TIP: Components of personality according to
Freud
These are signs of anorexia nervosa. Patients  Id – pleasure principle; seeks satisfaction
with this condition tend to do excessive ritualistic  Ego – reality principle; concerned with here
exercises to promote weight loss. and now; balances the demands of the id
and superego
196. In teaching a client about Alcoholics  Superego – moral principle; censoring
Anonymous, the nurse states that Alcoholics portion of the mind; seeks to delay
Anonymous has helped in the rehabilitation of gratification
many alcoholics, probably because many
people find it easier to change their behavior
when they: A. Have the support of rehabilitated
alcoholics.
B. Know that rehabilitated alcoholics will
sympathize with them.
C. Can depend on rehabilitated alcoholics to
help them identify personal problems
related to alcoholism.
D. Realize that rehabilitated alcoholics will
help them develop defense mechanisms
to cope with their alcoholism.

Alcoholics Anonymous is a self-help group.

Members of the group have similar problems on
alcoholism and they serve to be the support
system for each other.

197.A client walks into the mental health clinic and

states to the nurse, “I guess I can’t make it without my
wife. I can’t even sleep without her.” Which of the
following responses by the nurse would be most
therapeutic?
A. “Things always look worse before they get better.”
B. “I’d say that you’re not giving yourself a fair chance.”
C. “I’ll ask the doctor for some sleeping pills for you.”
D. “Tell me more about what you mean when you say
you can’t make it without your wife.”

Encouraging verbalization of feelings provide a

therapeutic way to assess the patient’s underlying
emotional concern.

198. The psychiatric nurse has a variety or roles

in dealing with patients with maladaptive
disorders. As a manager, the nurse should:
A. Initiates nursing action with co-workers.
B. Plans nursing care with the patient.
C. Speaks in behalf of the
patient. D. Works together
with the team.