Medical-Surgical Nursing Exam- Rationale Click to edit Master subtitle style

LYCEUM ST. CABRINI

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1. D

The old woman is in the middle of a train railway. It is very unsafe to immobilize here legs and remain still at the middle of a railway considering that a train might come anytime while waiting for an ambulance. Safety is the utmost importance at this point. If letter D is not among the choices and the situation is a little less dangerous, the answer will be A. Remember that in all cases
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2. D

SADDER should be your keyword. A hip fracture will produce a SHORTENED, ADDUCTED AND EXTERNALLY ROTATED extremity. Treatment will evolve in casting the leg and putting it in a EXTENSION, NEUTRALLY POSITIONED and SLIGHT INTERNAL ROTATION. In Hip prosthesis, The nurse should maintain the clients leg in FLEXION, EXTERNAL ROTATION and ABDUCTION to prevent the dislocation of the prosthesis from the acetabulum. Take note of the difference because I mistakenly answered the LATTER in casting a hip fracture thinking that it is similar to a the leg 4/27/12

3. C

After a trauma, Inflammation will start almost instantly. Infection occurs 24-48 hours after bone fracture and not immediately. Thrombophlebitis occurs within 4 to 7 days of hospitalization after prolonged immobilization. There is no evidence that the client has a degenerative 4/27/12 disease and degenerative

4. A

* B,C,D all contributes to bone demineralization except HYPOTHYROIDISM. Hyperthyroidism will contribute to bone demineralization as well as Hyperparathyroidism due to the increase in PTH, It will cause the movement of calcium from the bone to the blood causing HYPERCALCEMIA. ESRD will cause increase in PHOPHSATE due to its poor excretion. The amount of phosphate is inversely proportional to the amount of calcium. Cushing
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5. A

Hemorrhage results in severing of the vascular supply of the bone of the femur and the pelvis due to the fracture leading to bleeding causing the s/s of tachycardia and hypotension.

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6. B

Reciprocal motion is a very important aspect of rehabilitation. Mr. Rojas has a weakness on his right leg. If a human moves his right leg, the left arm will accompany the movement of the right leg. That is what you call RECIPROCAL MOTION which is innate, natural and required to maintain balance. Mr. Rojas has weakness in his RIGHT LEG. If we put the cane on his right arm, The client will then be left UNSUPPORTED when he use his stronger leg [LEFT LEG] and stand with his weaker leg [RIGHT LEG] due to the fact that the opposite arm must accompany the movement of the opposite leg [RIGHT ARM]. In an easier term, Always put the cane on the opposite of the weaker side. A is not
4/27/12 correct because the client is NOT hemiplegic and will never be

7. C

Remove option A, the client will kick off the cane if it was in the front of the foot. Remove option D because that is too far and will cause the cane to poorly support the client because the side, not the tip, is touching the ground. At 3 inches, imagine how short it is and will cause a very poor supporting base. The correct answer is 4/27/12

8. A

If the right side of the brain is affected, weakness will always be CONTRALATERAL and therefore, Mr. Rojas will have weakness on his left side. Earlier I told you that cane is held on the opposite side of the weaker side, which in this situation, will be on the RIGHT. Imagine if the client moves his RIGHT LEG together with the RIGHT CANE, it already violated the LAW OF
4/27/12 RECIPROCAL MOTION. Moving the right leg will

9. A

PPD stands for purified protein derivative. It is used to check for TB exposure. All clients who had BCG need not perform this test because they will always be + .
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10. C

A Wheal is created intradermally and then it is marked and timed. reading will be done within 2 to 3 days.

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11. D

10 mm Induration [ redness ] is considered positive for individuals with competitive immune response. Wheals are not measured, they will not anymore enlarge. A 5 mm induration is considered positive for
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patients with AIDS or immuno-

12. B

Clients are asked to comeback within 2 to 3 days for the reading.

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13. A

The nurse has no authority order the radiology department for a chest x ray evaluation nor order for a sputum exam. The client need not be isolated because Mantoux test do not determine the activeness of the
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disease.

14. D

Almost all filipinos tests positive for mantoux test due to the fact that BCG are required and TB exposure in the country is fullminant. All individuals vaccinated with BCG will test POSITIVE for mantoux test all their lives.
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15. A

Category I patients are those with a newly diagnosed TB whose sputum culture are positive. II are for those who have relapses while III are those with negative sputum culture but positive chest x ray, or PTB Minimal.
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16. C

Clients in category I will have 2

months INTENSIVE and 4 months maintenance treatment.

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17. C

Drugs given in the maintenance phase includes Rifampicin and Isoniazid. Ethambutol is given on the intensive phase along with rifampicin and isoniazid. Pyridoxine is given during Isoniazid treatment to prevent peripheral neuritis in contrast in
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18. A

According to the department of health, the most hazardous period for development of clinical disease is during the first 6 to 12 months.

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19. B

National tuberculosis control program is the name of the program of the DOH to control and eradicate TB in the country. DOTS refers to the STRATEGY used by the department in treating TB patients. EPI is not a
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program for TB control although BCG

20. A

Nutrition, Long term immunosupression and drug abuse are all factors that affects the resistance of an individual in acquiring communicable diseases. Other factors includes extremes of ages, poor environmental sanitation, poverty and
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21. B

National board exam loves asking about level of prevention. Mastery with the primary, secondary and tertiary levels of prevention is a must. All diagnostic, case finding and treatment belongs to the
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secondary level of prevention.

22. B

Actual participation conveys positive acceptance and adjustment to the altered body image. Although looking at the ostomy site also conveys acceptance and adjustment, Participating with the nurse to his daily ostomy care is the BEST
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23. A

The colon is not sterile, nor the stomach. Tap water is used in enema irrigation and not NSS. Although some clients would prefer a distilled, mineral or filtered water, NSS is not always necessary. KY Jelly is used as the lubricant for the irrigation tube and is inserted 3-4 inches into the colostomy pointing towards the RIGHT. Irrigation sleeve
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24. B

Remember 3-4 inches. They are both used in the rectal tube and colostomy irrigation tube insertion. 1 to 2 inches is too short and may spill out the irrigant out of the stoma. Starting from 6 inches, it would be too long
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already and may perforate the bowel.

25. B*

If you will answer in the CGFNS and NCLEX, C will be the correct answer. According to BRUNNER AND SUDDARTHS and Saunders, The height of the colostomy irrigation bag should be hanging above the clients shoulder at around 18 inches. According to MOSBY, 12 inches should be the maximum height. According to Lippincott's, 18 inches is the maximum height. According the board of examiners, 12 inches should be the maximum height and an 18 inches irrigant height 4/27/12 would cause rapid flow of the irrigant towards the

26. C

The client made the best initial step in learning to care for his colostomy once he looks at the site. This is the start of the client's acceptance on his altered body image. A,B and D delays learning and shows the client's
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disintrest regarding colostomy care.

27. A

Stopping the irrigation will also stop the cramping and pain. During the first few days of irrigation, The client will feel pain and cramping as soon as the irirgant touches the bowel. This will start to lessen once the client got accustomed to colostomy irrigation. Slowing down the irrigation will not stop the pain. Telling the client that it is normal and will subside eventually is not acceptable when a client experiences pain. Pain is
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28. D

A refers to a retracted stoma, B refers to a stoma that is getting a very poor blood supply. C is a description of stenosis of the stoma.
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29. C

Kinchay and Pechay helps lessen the odor of the colostomy. Spinach, broccoli, Cabbage, Cucumbers, Patola or bottle gourd also help lessen the odor BUT are gas formers. Eggs are not recommended because they are known to cause unpleasant odors in
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30. B

1 inch is equal to 2.54 cm. Convert the cm if you are not familiar. 45 cm is around 17 inches which is ideal for colostomy irrigation. Any value from 12 to 18 is accepted as the colostomy irrigant height. Tap water is used as an irrigant and is infused at room temperature. 4 cm is a little bit short for 4/27/12

31. A

The stoma should be RED in color. Pale pink are common with anemic or dehydrated patients who lost a lot of blood after an operation. Blue stoma indicated cyanosis or alteration in perfusion. Stomas are
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not expected to be Gray.

32. D

This is unnecessary. Suctioning is done on PRN basis and not every hour. A,B and C are all correct processes of suctioning a tracheostomy.
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33. D

The height is given and it looks like James is a very tall individual. The maximum height of suction tube is used. Fr 12-18 are used for adults while 6-8 are used in
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children.

34. C

A is used in pediatric clients. B is for children and C is for adults. 2025 mmHg is too much for a portable suction unit and is not recommended.
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35. C

A is used in pediatric clients. B is for children and C is for adults. 155-175 mmHg is too much for a wall suction unit and is not recommended.
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36. C

In an emergency like this, The first thing the nurse should do is maintaining the airway patency. With the cannulas dislodged, The stoma will stenosed and narrows giving james an obstructed airway. The nurse would insert the kelly clamp to open the stoma and lock the clamp in place to maintain it open while she uses an obturator as to prevent further stenosis of the stoma. An obturator is a part of the NGT package included by most 4/27/12

37. A

Wilma should place 2 fingers underneath the tie to ensure that it is not too tight nor too loose. Letter D is the measurement for NGT insertion and is unrelated to tracheostomy.
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38. A

An RR of 18 means that James is not tachypneic and has an adequate air exchange. Oxygen saturation should be more than 95%. Frank blood is not expected in the suction tube. A slight tinged of blood in the tube is acceptable and expected. Amount of secretion are not in any way related in assessing the 4/27/12

39. A

According to our reviewers and lecturers, 10 to 15 seconds is the maximum suction time. But according to almost all foreign books I read, it should only be 10 seconds at max. I prefer following Saunders, Mosby and
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Lippincott when they are all united.

40. D

There is NO PAIN in open angle glaucoma. A,B,C are all present in both glaucomas including the low pressure glaucoma. Pain is absent because the increase in intra ocular pressure is not initiated abruptly. It is gradual and progressive and will lead to unoticed loss of peripheral vision. Pain is present in acute close angle glaucoma because there is a sudden closure or narrowing of the canal of schlemm. Therefore
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41. A

Sudden blockage of the angle will cause s/s of acute angle closure glaucoma. B and C are all related to open angle glaucoma. D is insignificant, If the client bends or cough, IOP can increase from 8 to as much as 30 mmHg but then return
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42. B

Tonometry measures the IOP. Normal range is 8 to 21 mmHg.

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43. D

CONES Are responsible for COLOR VISION and DAY VISION, they are very sensitive to RED LIGHT that is why red lights are use to guide the elderly towards the bathroom when they wake up to urinate. Rods are responsible for night vision. They are
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44. D

AH is produced in the CILIARY BODY. It is filtered by the trabecular meshwork into the canal of schlemm.

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45. A

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46. B

CN II is the optic nerve. To assess its acuity, Snellen's chart is used. Slit lamp is the one you see in the usual Eye glasses shop where in, you need to look into its binocular-like holes and the optometrist is on the other side to magnify the structures of the eye to assess gross damage and structure. Woods light is a BLUE LIGHT used in dermatology. It is use to mark lesions usually caused skin
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47. A

When the ciliary muscles contract, pupils constrict and the angle widens causing an increase AH outflow and decrease IOP. Relaxing the ciliary muscle will cause mydriasis or dilation, it is used as a pre op meds for cataract surgery and eye examination to better visualize the structures behind the iris. A and C are the
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48. B

All the eye drops that ends in OLOL decreases AH production. They are BETA BLOCKERS. Watch out for the S/S of congestive heart failure, bradycardia, hypotension and arrythmias.
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49. B

Bending at the waist increase IOP and should be avoided by patients with glaucoma. Treatment for glaucoma is usually for life. Patients are given laxatives to avoid straining at the stool. They should avoid all activities that will lead to sudden IOP increase
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50. A

The client had an eye angiography. Eye angiography requires the use MYDRIATICS preprocedure. It is done by injecting an Intravenous dye and visualizes the flow of the dye through the fluoroscopy along the vessels of the eye. This is to assess macular degeneration or neovascularizations [ proliferation of new vessels to compensate for continuous rupture and aneurysms of the existing vessels ] Mydriatics usually takes 6 hours to a day to wear off. If client uses a mydriatic, his pupil will dilate making it 4/27/12

51. A

Atropine sulfate is used to reverse the effects of systemic toxicity of Pilocarpine. Narcan is the antidote for respiratory depression caused by narcotics like morphine and demerol. Serentil is an
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antipsychotic.

52. C

Rotary nystagmus towards the ear [ if warm ] or away from it [ if cool ] is a normal response. It indicates that the CN VIII Vestibular branch is still intact.
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53. B

Instillation for children under age 3 is CHILD : DOWN AND BACK. Directing the solution towards the eardrum might perforate or damage the infants fragile tympanic membrane.
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54. D

Although A is priority according to Maslow, it is not specific in clients with Menieres disease. The client has an attack of incapacitating vertigo and client is high risk for injury due to falls. The client will perceive the environment moving due to disruption
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55. C

The facial nerve branches from the back of the ear and spread towards the mouth, cheeks, eyelids and almost all over the face. In mastoidectomy, Incision is made at the back of the ears to clear the mastoid air cells of the mastoid bone that is infected. Clients are at very high risk for CN VII injury because of this. Observation during the post
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56. C

Clients with acute attack of Menieres are required to have bed rest with side rails up to prevent injury. During periods of incapacitating vertigo, patient's eyes will have rotary nystagmus because of the perception that the environment is moving. Patients are also observed to hold the side rails so hard because they
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thought they are going to fall. Benadryl is

57. A

Clients are advised to limite fluid and sodium intake as not to further cause accumulation of fluids in the endolymph. C is the diabetic diet. D are the foods not eaten when clients are about to
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have a guaiac test.

58. A

Lights can coax the insect out of the child's ear. This is the first measure employed in removing a live insect from the childs ear. Insects are not removed ALIVE, therefore, C and D are both wrong. Antibiotics has no effects since the child do not have any infection. If the insect did not come out after coaxing it with light, 2nd measure
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59. D

After ear surgery, Air travel is halted for a while. There is no need to restrict activities. The client is not allowed to shower for 7 days, Patient can clean himself using a sponge bath but avoids to shampoo or wet the face and hair. Straws are not used after
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60. D

* Refer to #52

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61. B

Patient do not have signs of anxiety, knowledge deficit or body image disturbance. The safest answer is B because before cataract surgery, client has a blurry vision that alters his sensory perception. After surgery client will be APHAKIC and again, will have an
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62. C

Webers test assesses both air and bone conduction but is not decisive enough to judge which is which. When the tuning fork is tapped on the examiners knee, it is placed in the forehead or above the clients top lip. If the sound lateralizes towards the left ear, 4/27/12 its either, the client has conductive

63. D

* Refer to # 57

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64. B

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65. C

* 1L = 1kg

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66. B

Postural hypotension is exhibited by a drop of systolic BP when client changes position from lying to sitting or standing.

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67. A

The patient will not tolerate large amount of oral fluid due to incessant vomiting.

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68. D

Client need not maintain a temperature of 36.5 C. As long as the client will exhibit absence of fever or hypothermia, Nursing interventions are successfully carried out.
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69. C

Parkinson's disease does not affect the cognitive ability of a person. It is a disorder due to the depletion of the neurotransmitter dopamine which is needed for inhibitory control of muscular contractions. Client will exhibit mask like facial expression, Cog wheel rigidity,
4/27/12 Bradykinesia, Shuffling gait etc. Muscle

70. D

Dopamine producing cells in the basal ganglia mysteriously deteriorates due to unknown cause.

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71. A

Levodopa is an altered form of dopamine. It is metabolized by the body and then converted into dopamine for brain's use thus increasing dopamine availability. Dopamine is not given directly because of its inability to cross the
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72. D

Vitamin b6 or pyridoxine is avoided in patients taking levodopa because levodopa increases vitamin b6 availability leading to toxicity.
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73. A

Telling the client to walk erect neglects the clients complain of difficulty walking. Wheelchair is as much as possible not used to still enhance the client's motor function using a cane. Telling the client not to force himself walk is non therapeutic. The client wants 4/27/12 to talk and we should help her

74. D

A,B and C are all affected by dementia except ENDURANCE, which is normally lost as a person ages. There will be alteration in balance because coordination and spatial ability gradually deteriorates. Judgement is also impaired as the client exhibits poor memory and concentration. Speech is severely altered. Client
4/27/12 develops aphasia, agnosia and in at end,

75. D

This question was RECYCLED during the last 2006 NLE. Aphasia is the INABILITY to speak or understand. Aphraxia is the inability to carry out purposeful tasks. Agnosia is the inability to recognize familiar objects.
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Insomnia is the inability to fall asleep.

76. D

Talk as normally as possible. The client has dementia and is not deaf, although hearing might be impaired progressively as the client ages, the nurse should not alter his voice, shout or over enunciate the words. Client
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will preceive this things as belittling

77. B

Hallucinations and delusions are part of DEMENTIA and is termed as ORGANIC PSYCHOSES. The daughter needs further teaching when she try to bargain, explain, dissprove or advice a client with dementia. the client has an impaired judgement, concentration, thinking, reasoning and memory and has inability to learn that is
4/27/12 why institutional care for clients with

78. B

Drug compliance is the most important teaching for Mr. Dela Isla to prevent the symptoms of psychoses and to control behavioral symptoms.
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79. C

Probanthine reduces glandular secretion of the different organs of the body. It is an anti-cholinergic / anti spasmodic drug and still, not approved by the FDA for treatment with various disorders. Probanthine exerts benifits for treatment of severe diaphoresis, Ulcers due to over
4/27/12 secretion of HCl, Spasms, PANCREATITS

80. A

Like other anti cholinergics/ anti spasmodics, Probanthine causes dizziness, blurred vision and drowsiness. Patients are advised not to drive, operate heavy machineries etc. Probanthine should be taken with a full glass of water but is contraindicated with inflammatory bowel diseases like ulcerative colitis and chrons disease. Drug is taken with meals to prevent
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81. D

Probanthine on its own already cause severe dizziness and drowsiness. Addition of alcohol will further depress the CNS and might lead to potentiation of the side effects of probanthine. A,B,C are not contraindicated when taking probanthine EXCEPT when the disease entity itself do not permit intake of such drugs like in
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82. A

Probanthine alters the ability of the body to secrete sweat. Telling the client to avoid hot weathers to prevent heat stroke is appropriate. Chlorinated pool is discouraged for patients undergoing skin radiation for skin cancer to prevent breakdown. Limiting
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fluid intake and avoiding cold weather

83. B

Probanthine is use in PUD to decrease gastric acid secretion. It is also used in Pancreatitis to rest the pancreas from over secretion of pancreatic enzyme and to prevent pain and spasm. Probanthine is contraindicated in clients with UC, Glaucoma. Since this
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is an anti spasmodic drug, Urinary

84. D

Airway is always a priority in an unconscious client. Refer to maslows hierarchy of needs for prioritization. Although this is not absolute, knowledge with pathophysiology will best lead you
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to the correct option.

85. D

CVA patients has impaired swallowing ability and if not absent, depressed gag reflex. Client is at the highest risk for aspiration when eating or drinking that is why NGT is initiated early in the hospitalization. B prevent EXTERNAL ROTATION in hip or leg fracture. Footboards and splint prevents FOOTDROP seen in clients that has a severed peroneal nerve or prolonged immobilization 4/27/12

86. D

Client will be on NGT once comatose, A is removed first. Client with CVA MAY have seizures, but it is RARE enough that it must require a frequent mouth care, B is eliminated next. Knowing that tactile stimulation is done by touching the patient and not by peforming mouth care will lead you to letter D. Comatose patient uses the 4/27/12

87. B

Frequent turning and positioning is the single most important nursing intervention to prevent ulcer formation. Skins are massaged but once the areas are reddened already [ CLASS I Ulcer ], It is not anymore massaged as not to prevent further breakdown. Lotions and Oils are not use in clients skin because it will further enhance skin breakdown. Water matress are used in BURN patients to limit the pressure on the skin by his own body weight. An alternating-inflatable air matress is much more compatible in periodic
4/27/12 distribution of pressure in clients with prolong

88. A

If the client's right side is weak, the affected lobe is the LEFT LOBE which is where the broca's area is located. Client will exhibit expressive aphasia, careful and slow movements and right sided weakness. Judging distance and proprioception is usually impaired in clients with RIGHT sided stroke. Telling that the clients orientation to time and space will be much affected is a blind shot analysis. This is seen on clients with severe and massive hemorrhagic stroke with recovery failure related to
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89. D

WBC increases with inflammation and infection.

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90. B

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91. A

Pain is not reduced in appendicitis. Clients are not given pain medication as to assess whether the appendix ruptured. A sudden relief of pain indicates the the appendix has ruptured and client will have an emergency appendectomy and
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92. A

Spinal anesthesia is the most common method used in appendectomy. Using this method, Only the area affected is anesthetized preventing systemic side effects of anesthetics like dizziness, hypotension and RR
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depression.

93. B

Client's peristalsis will return in 48 to 72 hours post-op therefore, Fluid and food are witheld until the bowel sounds returns. Remember that ALL PROCUDURES requiring GENERAL and SPINAL anesthesia above the nerves that supply the intestines will cause temporary paralysis of the bowel. Specially when the bowels are traumatized during the
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94. D

Peritonitis will cause all of the above symptoms. The peritoneum has a natural tendency to GUARD and become RIGID as to limit the infective exudate exchange inside the abdominal cavity. Hypovolemia and F&E imbalance are caused by severe nausea and vomiting in patients with peritonitis because of acute pain. As inflammation and infection spreads, fever and chills will become more apparent causing elevation in temperature,
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95. B

Paralytic Ileus is a mechanical bowel obstruction where in, the patients intestine fails to regain its motility. It is usually caused by surgery and anesthesia. Intusussusception, Appendicitis and Peritonitis also
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causes paralytic ileus.

96. A

NGT after appendectomy is used not to deliver nutrients but to decompress the GI tract because of the absence of peristalsis after appendectomy. The stomach and intestines are not sterile, Clean technique is sufficient during irrigation. NGT is placed and not anymore advanced as long as it already reach the stomach. Naso enteric tubes are the one that are advanced periodically until obstruction is reached in the intestine. The client still needs 4/27/12

97. C

When flatus is expelled, it means that peristalsis has returned and theres is no need for continuing the NGT.
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98. D

Organic psychoses is a broad and collective term used for psychoses and schizophrenia that has an organic cause. [ Due to Creutzfeldt jakob disease, huntington, hydrocephalus, increase ICP, dementia, stroke etc. ] Manifesting signs and symptoms like hallucination, delustions, illusion, ideas of reference etc. that is 4/27/12

99. C

Chronic brain syndrome tends to be progressive and irreversible. Organic brain syndrome is acute and irreversible or reversible depending on the causative factor.

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100. A

B, C and D are all behaviors that results from organic psychoses. Organic psychosis is the same as the usual psychoses except that the causative factor of organic psychoses is evidently caused by a disease process of the brain or affecting the brain. Example are patients who suffer stroke suddenly experience hallucinations and delusions. Organic psychoses is simply a psychoses that
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has an IDENTIFIED CAUSE. Knowing this will