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Instruction: Write the letter of the best answer on the space provided before each number.

FUNDAMENTALS OF NURSING PRACTICE (70 points) 8. Care of patients with intravenous fluids is one of the major
responsibilities of a nurse. A nurse caring for a client with
1. The equivalent of 100.8 degrees Fahrenheit in Celsius is PICC line (peripherally inserted central line) knows that
A. 38.2 C. 39.4 the tip of the IV access is located in the
B. 38.7 D. 40.1 A. Basilic vein C. Right atrium
2. Dorothy underwent diagnostic test and the result of the B. Cephalic vein D. Antecubital vein
blood examination are back. On reviewing the result the 9. While interviewing Geline, she starts to moan and doubles
nurse notices which of the following as abnormal finding? up in pain. She tells the nurse that this pain occurs about
A. Neutrophils - 60% an hour after taking black coffee without breakfast for a
B. Creatinine – 0.9 mg/dL few weeks now. The nurse will record this as follows:
C. Erythrocyte sedimentation rate - 25 mm/hr A. Client complained of intermittent abdominal pain an
D. Blood urea nitrogen – 15 mg/dL hour after drinking coffee.
3. When doing physical examination as part of the nursing B. Claims to have abdominal pains after intake of coffee
process, the nurse should have sufficient understanding of unrelieved by analgesics
basic nursing procedures and skills. While auscultating C. After drinking coffee, the client experienced severe
Mario's lung fields, the nurse compares the Lung sounds. abdominal pain
The nurse applies a systematic pattern by: D. Client reported abdominal pain an hour after drinking
A. listening from anterior to posterior black coffee for three weeks now.
B. assessing from top to bottom 10. Allen’s test is indicated for which of the following clients? A
C. comparing lung sounds side to side client
D. comparing from interspace to interspace. A. who needs an arterial line
4. Who pioneered the idea of the nurse-client relationship B. with ulnar nerve damage
and interactive process? C. with peripheral neuropathy
A. Faye Abdellah D. who is about to undergo glucose test
B. Florence Nightingale 11. A client is reported to have orthostatic hypotension.
C. Hildegard Peplau Which of the following would you consider a sign?
D. Virginia Henderson A. Increase in pulse of 40 beats/minute and decrease in
5. The physician ordered a small volume enema to a client BP of 30 mm Hg from a sitting to a standing position
with fecal impaction. The client needed further clarification B. A drop of 30 mm Hg in BP from a supine to a
when she asks the nurse how the solution will work once it standing position with a rise in pulse of 40 beats/
is administered. The most appropriate explanation of the minute
nurse is that the solution: C. Decrease in pulse by 20 beats / minute and increase
A. Causes distention of the-bowel and stimulates the in BP by 20 mm Hg from supine to standing position
defecation reflex. D. A sudden drop in BP of 30 mm Hg systolic and 10
B. Draws water from the colonic mucosa cause water mm Hg diastolic from lying to sitting or sitting to
retention in the lower-colon. . . standing position
C. Decreases surface tension of stool allowing water to 12. Trousseau’s sign is associated with which electrolyte
enter stool more readily. imbalance?
D. promotes bowel evacuation that provides and A. Hypocalcemia C. Hyperkalemia
stimulates the defecation reflex. B. Hypokalemia D. Hypercalcemia
6. According to Orem’s Self-Care Theory, what type of 13. Prevention of infection is one of the essential measures to
nursing activity would a G2P1 mother, 7 months pregnant, reduce negative outcomes in health care. Catheter care
who missed the last scheduled visit with her obstetrician must be performed frequently to prevent urinary tract
require? infections. How often should the nurse change a client’s
A. Partially compensatory condom catheter?
B. Supportive-educative A. Every 24 hours C. every 72 hours
C. Universal intervention B. Every 48 hours D. every 96 hours
D. Wholly compensatory 14. In the physical examination of a patient with abdominal
7. Guillermo is allergic to non-steroidal drugs (NSAID). Which pain, what is the recommended sequence of examination
of the following would be the LEAST relevant practice to techniques?
ensure that the nurse who is preparing the drugs for the A. Inspection, auscultation, percussion, palpation
patient in the medication room becomes aware of his B. Inspection, percussion, palpation, auscultation
allergy? C. Inspection, percussion, auscultation, palpation
A. The medication administration record has a note on it D. Inspection, palpation, auscultation, percussion
that patient is allergic to NSAID 15. The patient with an acoustic nerve injury may have a
B. Paste a note that patient is allergic to NSAID on the positive Romberg’s sign. Which of the following describes
chart cover a positive Romberg’s sign?
C. Have the patient wear a red identification bracelet A. Inability to hear a whisper
labeled 'With allergy' B. Inability to hear unless the listener is looking at the
D. Place a note in the patients medication box that he speaker
has an allergy C. Inability to maintain an upright position with eyes
closed
D. Inability to maintain an upright position with eyes D. 30-degree angle to the bed
open 25. How will a nurse assess the client for pulse deficits?
16. Various methods of documentation are practiced by A. Ask a colleague to take the apical pulse together with
nursing staff, one of which is the SOAP method. The her.
SOAP method stands for B. Ask a colleague to take the radial pulse as she is
A. subjective data, objective data, assessment, process taking the apical pulse.
B. subjective data, objective data, assessment, planning C. Take the apical pulse & compare with the pulse
C. subject, objection, assessment, process pressure.
D. subjective data, objective data, analysis, planning D. Take the radial pulse after taking the apical pulse.
17. Somatotropin releasing hormone or the growth hormone 26. Which of the following best describes Cheyne-Stokes
releasing hormone is secreted by the: respiration?
A. hypothalamus C. anterior pituitary gland A. Abnormally deep, regular, and increased rate
B. posterior pituitary gland D. thyroid gland B. Abnormally shallow for 2-3 breaths followed by
18. A suppository is prescribed for the client. When irregular period of apnea
administering the drug, the nurse must place the client in C. Irregular rate & depth with alternating periods of
which position? apnea & hyperventilation
A. Sim’s C. Lithotomy D. Regular rate & depth with alternating periods of
B. Dorsal recumbent D. Prone apnea & hyperventilation
19. A client is transferred to the medical unit after a 27. The nurse implement standards of care to prevent
transurethral resection of the prostate. The nurse reviews complications related to immobility. A client on bed rest is
the transfer orders. The surgeon's order reads: "Maintain rolled to a lateral position by the nurse. The nurse is
traction on the indwelling triple lumen catheter" Which of negotiating the move correctly when he:
the following is the MOST appropriate action of the nurse? A. Positions himself at the mid part of the bed and
A. Tape the catheter to the abdomen and keep client in places both hands at the back of the client and roll
supine position. client onto side
B. Pull the catheter taut and tape to the thigh alternately B. Places one hand on the client’s far hip and the other
every 6 hours. on the client’s far shoulder rock backward and roll
C. Instruct the client to keep both legs together and onto side of the body facing him
extended all the time. C. Assumes a broad stance with the foot nearest the bed
D. Pull the catheter taut, tape to one thigh and keep the placing his arm under the client’s thighs and shoulder
leg extended all the time. and roll client onto side
20. Normal heart sounds originate from the SA node. How D. Supports the back and buttocks of the client and
many times per minute does the SA node emit electric shifts his own weight from the forward to the
currents in an adult? backward foot and roll the client onto side
A. 60-100 C. 40-60 28. Which of the following represents ventricular relaxation?
B. C. 50-100 D. 80-120 A. P wave C. Q wave
21. When the body responds to stress, epinephrine is B. R wave D. T wave
released producing which physiological response? 29. The nurse is preparing the client for an ultrasound of the
A. Decreased oxygenated blood to vital organs gallbladder. Which of the following statements would be
B. Decreased heart rate the most important to prepare the client for the test?
C. Peripheral vascular dilatation A. "You will have food and fluids restricted for 4 to 8
D. A more forceful heart beat hours prior to the test.“
22. The nurse is aware that proper documentation when B. "Stool in the bowel may cause a reporting of
taking care of the client is important. The purposes of inaccurate findings.“
client care documentation include the following: C. "There is no special preparation for this procedure.
1. Standardizes plan of care You may eat and drink as usual.“
2. Communicates vital information about client’s D. "You will be asked to drink a solution of radionuclide 2
health status to other health care providers hours prior to the procedure."
3. Serves as resource for research and education 30. Cultural sensitivity enables nurses to be responsive to the
4. Serves as a legal document needs of patients with varied cultural background. A client
A. 2, 3 and 4 C. 1, 2 and 4 practices Islam and his diet must consider his religious
B. 1, 3 and 4 D. 1, 2 and 3 practices and beliefs. You are aware that this client would
23. When assessing for the apical pulse, where should the avoid which of the following?
nurse place the stethoscope? 1. Shrimps and crabs
A. 5th ICS, left midclavicular 2. Wine and alcohol drinks
B. 4th ICS, left midsternal 3. Fish with scales
C. 5th ICS, right midsternal 4. Pork products like bacon
D. 4the ICS, right midclavicular 5. Caffeinated products like cola drinks
24. A client has difficulty walking and needs wheel chair to A. 2, 4 and 5 C. 3,4, 5
facilitate performance of daily activities. Anticipating the B. 1, 4 and 5 D. 1, 2 and 4
needs of the client, the nurse should have the wheel chair 31. What is the formula to obtain cardiac output?
ready by placing it at A. Heart rate x Diastolic pressure
A. 60-degree angle to the bed B. Heart rate x Pulse pressure
B. 45-degree angle to the bed C. Heart rate x Stroke volume
C. 90-degree angle to the bed D. Heart rate x Systolic pressure
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 A. Replace the inner cannula following the curve of the
B. SpO2 d. PaO2 tube, lock by rotating the external ring clockwise until
33. The nurse has a sterile field in front of her and needs to it clicks into place
reach something on the other side of the sterile field. To B. Insert the flange of the tube and lock until it clicks into
maintain the sterile field, the nurse should: place
A. Walk around with the back to the sterile field. C. Secure the flange of the inner cannula to the outer
B. Reach across the sterile field. cannula
C. Walk around facing the sterile field. D. Return the inner cannula, lock by rotating the external
D. Move the sterile field away from her and reach the ring counterclockwise until clicks into place.
object. 42. A patient whose ventilation is inadequate should be
34. When obtaining a urine sample from a patient with an observed for early symptoms of hypoxia, which include
indwelling urinary catheter, where should the urine be A. Restlessness C. Pallor
collected? B. Cyanosis D. Disorientation
A. From the balloon port of the catheter using a needle. 43. Urinary tract infections remain to be the most common
B. From the collection bag. cause of hospital acquired infections. When considering
C. From the collection port using a needle. the safety needs of a client with a urinary catheter, which
D. From the tube near the meatus using a needle. of the following should the nurse observe?
35. A nurse receives an order to obtain sputum sample for A. Keep a closed sterile drainage system
culture from a client with pneumonia. What action should B. Irrigate the catheter daily
be avoided when obtaining the specimen? C. Keep the bag lower than the bed
A. Having the client brush teeth before expectoration. D. Measure intake and output daily
B. Instructing the client to take deep breaths before 44. Lizbeth is reviewing her notes in preparation for her
coughing. upcoming exam. In concepts of health illness, who
C. Obtaining the specimen early in the morning. postulated that health is the ability to maintain the internal
D. Placing the lid of the culture container face down on milieu?
the bedside table. A. Walter Cannon C. Claude Bernard
36. A nurse is preparing to suction a client through a B. Hans Selye D. Florence Nightingale
tracheostomy tube. Which of the following protective items 45. Nursing practice is governed by different theoretical
would the nurse wear to perform this procedure? framework postulated by known theorists. The four
A. Goggles, mask and sterile gloves concepts common to nursing conceptual models are:
B. Mask. gown and cap A. Person, environment, health and nursing
C. Mask, sterile gloves and cap B. Person, environment, psychology and nursing
D. Gown, mask and sterile gloves C. Person, health, nursing and support system
37. When performing incentive spirometry after lobectomy, D. Person, nursing, environment and medicine
how should the nurse position the client? 46. Stress is the simple most important contributing factor to
A. Semi-Fowler’s C. Supine illness. It is related to many of man’s illnesses and
B. Trendelenburg D. Lithotomy interventions of these are based on the body’s reaction to
38. While orienting a new nurse to the unit, the charge nurse stress. Which of the following body systems is primarily
stresses the importance of accurate documentation, the involved in GAS as a response to stress?
primary reason for a nurse to document care accurately is A. Central nervous system and cardiovascular system
A. Be in compliance with individual regulatory agencies B. Neurological and endocrine system
B. Demonstrate responsibility and accountability C. Endocrine system and respiratory system
C. Facilitate insurance reimbursement D. Musculoskeletal and immunological system
D. Prevent any legal action against the healthcare facility 47. Changing the wound dressing of a client requires utmost
and its staff care to prevent infection of the wound. When doing wound
39. A 12-year old girl has a long leg cast applied to her left care, the most appropriate nursing action would be to
leg. She is being instructed in crutch walking with no A. Remove old dressings with sterile gloves
weight-bearing on her left leg. Which of the following B. Pour antiseptic solution out of the container
observations indicates that the girl needs further teaching? C. Open the sterile dressings with sterile gloves
A. Her elbows are slightly flexed D. Wear sterile gloves whenever in contact with the
B. She is supporting her weight on the axillary bars and wound area
hand pieces of the crutches 48. A client is positive of neck vein distention if the nurse sees
C. She is using the three-point gait a bulging neck vein when the client is in what position?
D. She places the crutches approximately six to eight A. Supine C. high-Fowler’s
inches (15-20 cm.) in front of her with each step B. Semi-Fowler’s D. Trendelenburg
40. An infant who weighs 11 lbs. (5kgs) is to receive 750mg of 49. A client with severe flank pain has a suspected renal
antibiotic in a 24-hour period. The liquid antibiotic comes stones and is to undergo diagnostic procedures such as
in a concentration of 125mg per 5 ml. If the antibiotic is to intravenous pyelography. An important nursing
be given three times each day, how many milliliters would intervention after an intravenous pyelography is to
the nurse administer with each dose? A. Determine response to the injected dye
A. 10 B. 2 C. 5 D. 6.25 B. Assess for allergy to iodine
41. The nurse performs tracheostomy care to a client with C. Push fluids
acute respiratory distress syndrome. After thoroughly D. Check the IV site
cleansing the lumen and the entire inner cannula in 50. Having finished with you Masters degree in Nursing, you
hydrogen peroxide solution the nurse is now ready to were hired as a faculty member and were assigned to
return the cannula to the tracheostomy site. To ensure teach the topic “History of Nursing”. Florence Nightingale
that the cannula is in place the nurse should: and her contemporary nurse learned nursing skills and
techniques as “trainees” during which period in the nursing gown and gloves. Which of the following is the CORRECT
history? technique to be followed?
A. Apprenticeship period C. Primitive period A. The intern removes his gown and gloves then puts on
B. Intuitive period D. Educative period another sterile gown and gloves.
51. The nurse correctly performs endotracheal suctioning B. The intern removes his gloves, then his gown; does a
when she does which of the following? 3-minute hand scrub and don another sterile gown
A. Administer 100% oxygen before the procedure. and gloves.
B. Apply intermittent suction while gently inserting the C. The intern unties his gown, removes his gowns and
suction catheter. put on another gown and gloves.
C. Advance the suction catheter when a resistance is D. The circulating nurse unties the gown. The intern
felt. removes his gown, then removes the gloves and puts
D. Suction the client for a minimum of 10-15 seconds. another sterile gown and gloves.
52. A client is receiving an IV infusion of dextrose 5% in water 60. Mr. Tee is admitted to the hospital with vomiting, diarrhea,
and Ringer’s lactate solution at 125 ml/hour to treat a fluid fever and a 5 lb (2.3 kg) weight loss. The nursing
a volume deficit. Which of these signs indicates a need for diagnosis reads fluid volume deficit related to vomiting and
additional IV fluids? diarrhea. Which of the following laboratory values can the
A. Dark amber urine nurse expect to find on Mr. Tee’s chart:
B. Serum sodium level of 135 mEq/L A. Decreased urine specific gravity
C. Temperature of 37.5ºC B. Elevated serum potassium level
D. Neck vein distention C. Increased hematocrit level
53. Before administering a medication through a nasogastric D. Normal serum chloride level
(NG) tube, the nurse should do which of the following 61. The nurse is taking care of a client, Luisa, 62 years old,
first? who received a diagnosis of uterine cancer and is in the
A. Inject 10 ml of air into the NG tube and aspirate terminal stage. The focus on care for the terminally ill
B. Instruct the client to cough client includes:
C. Give a client a sip of water through a straw 1. Meeting physiologic needs
D. Inject 10 ml of water into the NG tube 2. Managing pain
54. A female client confesses during admission assessment 3. Identifying and treating physical symptoms
that she has a lump in her breast. Which of the following is 4. Providing emotional support
the appropriate action of the nurse? A. 2 and 3 C. 1 and 2
A. Lift the client hand to palpate the breast where she B. 4 only D. 1, 2 and 4
noted the lump. 62. Control of infection is emphasized in the care of clients
B. Palpate both breasts simultaneously to compare. and must not be compromised. An understanding of the
C. Assess the breast with the lump first. infectious process and appropriate methods to prevent
D. Start assessment of the normal breast. transmission of infection is important. The nurse in the
55. Which of the following activities demonstrate secondary health center is explaining “standard precautions” to the
level of prevention? client. This involves which of the following actions?
A. A mother going to her physician for her annual A. Use clean gloves when handling items like blood,
mammography body fluids, and non-intact skin.
B. Nurses attending a seminar of crisis management B. Recap used needles with both hands before
strategies discarding in puncture-resistant container.
C. Monitoring the blood glucose level of a diabetic C. Wash hands thoroughly using antimicrobial soap and
patient hot water.
D. A child receives his booster dose of varicella D. Wear protective equipment when doing any nursing
immunization procedures.
56. A patient with pneumonia has respiratory acidosis. In 63. Which of the following roles match the work-related
compensating for acid-base imbalances, the first activity of the nurse whereby she functions as clinician,
mechanism that is usually activated is the educator, manager, consultant and researcher within a
A. Retention of bicarbonates by the kidneys specific practice?
B. Excretion of carbon dioxide by the lungs A. Nurse practitioner
C. Bicarbonate-carbonic acid chemical buffer system B. Nurse anesthetist
D. Retention of oxygen by the lungs C. Clinical nurse specialist
57. If a blood pressure cuff is too narrow for a client, blood D. Nurse-educator
pressure readings taken with such a cuff may do which of 64. Maria will be preparing a patient for thoracentecis. She
the following? should assist the patient to which of the following position
A. Cause a sciatic nerve damage for the procedure?
B. Fail to show changes in blood pressure A. Prone with the head turned to the side and supported
C. Produce a false-high measurement by a pillow
D. Produce a false-low measurement B. Lying in bed on the affected side with the head of the
58. A patient with renal failure have elevated phosphorus bed elevated 45 degrees
level. Which of the following interventions is appropriate to C. Sim’s position with the head of the bed flat
restore eliminate excess phosphorus from the body? D. Lying in bed on the unaffected side with the head of
A. Advise patient to drink more milk the bed elevated 45 degrees
B. Tell patient to eat chocolates and nuts 65. As a nurse, what is one of the best way to reconcile
C. Take aluminum- based antacids like Amphojel medications across the continuum of care?
D. Increase fluid intake A. Endorse the routine and “stat” medications every shift
59. The intern-2nd assistant surgeon contaminated his gown B. Communicate a complete list of the patient’s
while the surgery is ongoing. He is expected to change his medication to the next provider of service
C. Endorse on a case to case basis 73. A researcher would like to study two groups of students,
D. Endorse in writing particularly, the freshmen and the sophomore students
66. A nurse is reviewing the electrolyte results of an assigned regarding their study habits before every periodical
client and notes that the potassium level is 5.6 mEq/L. examination. The survey will be made on a same time to
Which of the following would the nurse expect to note on determine if there is any difference as regards the two
the ECG as a result of this laboratory value? groups. This type of survey is called:
A. ST depression C. inverted T wave A. Cross-sectional survey C. Evaluation survey
B. prominent U wave D. tall peaked T waves B. Longitudinal survey D. Sample survey
67. A male client with a left lower leg prosthesis states that he 74. The researcher would like to determine the effectiveness
can feel his heart "skipping beats" when he walks up the of a new system of scheduling and staffing in a particular
stairs. He states his doctor has ordered an outpatient test tertiary hospital to prevent sudden shortage in the ratio of
that will take many hours, and he wants to know what it is. nurses to patients. The type of research method is called:
Your response would be: A. Manipulative C. Descriptive
A. "Your physician has ordered an echocardiogram, B. Quasi-experimental D. Experimental
which will utilize sound waves to project a picture of 75. In the research study entitled “Effects of timing of initial
your heart in motion.“ bath on the temperature of the newborn”, which of the
B. "Your physician has ordered a Holter monitor test, following is correct?
which will record your cardiac rhythm and rate while A. The presumed cause is the timing of initial bath
you go about your normal activities.“ B. The presumed effects of the study is the timing of
C. "Your physician has ordered a graded exercise initial bath
treadmill test (GXT), which will record your cardiac C. The variable to be manipulated is the temperature
activity as you exercise on a treadmill.“ D. The variable to be measured is the timing of initial
D. "Your physician has ordered a 12-lead ECG, which bath
will record your resting heart rhythm and rate." 76. Which of these states the expected relationship between
68. Which of the following nursing diagnoses contains the the independent and dependent variable?
proper components? A. Assumptions C. Hypothesis
A. Risk for caregiver role strain related to unpredictable B. Research design D. Research purpose
illness course 77. A researcher embarked on an intensive study of health
B. Risk for falls related to tendency to collapse when problems affecting the residents of Brgy. San Carlos. She
having difficulty breathing decided to study ever third family representing the total
C. Decreased communication related to stroke population in the said community. Types of sampling
D. Sleep deprivation secondary to fatigue and a noisy suited for the study is:
environment A. Cluster sampling C. Incidental sampling
69. Following a bronchoscopy, which of the following B. Systematic sampling D. Stratified sampling
complains should be noted as a possible complication? 78. The plan for how a study will be conducted is called the:
A. nausea and vomiting A. Data-collection method C. Design
B. shortness of breath and laryngeal stridor B. Research process D. Hypothesis
C. blood tinged sputum and coughing 79. Which statistical treatment is best used to answer the
D. sore throat and hoarseness research question, “The Level of Difficulty of the May
70. Promotion of adequate nutrition is a challenge to patients 2014 Nurse Licensure Examination as Perceived by
with cancer. The nurse caring for a client on total the Examinees”?
parenteral nutrition should perform which of the following A. Chi-square C. ANOVA
assessments regularly? B. Mean D. T-test
A. Serum glucose level 80. A competency-based assessment tool for nursing program
B. Serum electrolytes has been constructed. To assist the faculty in assessing
C. Urine output student attainment of competencies a measuring
D. Level of consciousness instrument has to be developed. In developing the
research instrument, existing instruments that measured
NURSING RESEARCH (20 points) similar variables were reviewed by the researcher. After
compiling and writing items, format was decided for each
71. Which of the following is NOT a component of evidence- variable to be assessed. Which of the following should the
based practice? researcher do to make sure that the instrument measures
A. Use of the best available research finding the attainment of competencies?
B. Applying the research evidence using clinical 1.Have colleagues review the items for logical validity
expertise 2.Revise items based on colleagues' feedback
C. Acceptability of the research finding by the patient 3.Locate a group with experience appropriate to the
D. Generalizability of the research finding to the general
study
population
72. In most instances, Filipinos do not know their rights as 4.Try out the instrument with a group as similar as
patients. To be a patient advocate, nurses must have a possible to the study respondents.
good understanding of the “Patients’ Bill of Rights”. Which A. 1,2 and 4 C. 1 and 2
of the following is an emerging role of the nurse in her B. 2 and 4 D. 1, 2, 3 and 4
mission to provide quality care in any setting regardless of 81. The final step of the research process for the researcher is
type of client and meet her goal to contribute new to:
knowledge and technology in nursing? A. Analyze the data
A. Nurse executive D. Nurse manager B. Utilize the findings
B. Nurse researcher C. Nurse educator C. Communicate the findings
D. Interpret the findings
82. The type of research design that does not manipulate B. Anonymity D. Data security
independent variable is:
A. non-experimental design COMMUNITY HEALTH NURSING (40 points)
B. quantitative design
C. quasi- experimental design 91. The United Nations identified eight Millennium
D. experimental design Development Goals to address the pressing issues in the
83. In statistics, this expresses the variability of the data in entire world. The Philippine Department of Health adopted
reference to the mean. It provides us with a numerical the Basic Emergency Management Obstetric Care in
estimate of how far, on the average the separate response to this calling. This reflects
observation are from the mean. What is this called/ A. Millenium Development Goal #3
A. Mode C. Standard deviation B. Millenium Development Goal #4
B. Median D. Frequency C. Millenium Development Goal #5
84. The researcher implemented a medication regimen using D. Millenium Development Goal #6
a new type of combination drugs to manic patients while 92. The community Health Nurse Conduct’s home visits to
another group of manic patient receives the routine drugs. families in the community. Planning for a home visit is an
The researcher however handpicked the experimental essential tool in achieving best results in healthcare. The
group for they are the clients with multiple episodes of following BUT ONE are the principles
bipolar disorder. The researcher utilized which research A. Home visit should have a purpose
design? B. Planning of continuing care must be developed by the
A. Quasi-experimental C Pure experimental nurse
B. Phenomenological D. Longitudinal C. Planning should be flexible and practical
85. In the hypothesis “The utilization of technology in teaching D. Plans are based on available information including
improves the retention and attention of the nursing those from other agencies that may have rendered
students.” Which is the manipulated variable in the study? services to the family
A. Utilization of technology 93. To encourage more health workers to stay in government
B. Improvement in the retention and attention service, Republic Act 7305 or Magna Carta of Public
C. Nursing students Health workers was passed into law last 1991. “Public
D. Teaching Health workers” include all persons working in the
86. Nina, a staff nurse in the Oncology unit was asked to government health facilities such as the:
participate as a member of the team in the Phase III 1. Physicians 4. Cashier, clerical staff
clinical trial of the effect of a new drug treatment for 2. Midwives 5. Janitor staff
cancer patients. The study has been approved by the 3. Cooks and assistant cooks 6. Nurses
Institutional Review Board of the hospital where Nina is A. 1,2,3,4,5 and 6
employed. Nina was informed that a double blind B. 1,2,3 and 4
approach will be utilized. Which of the following is the C. 1,2 and 3 only
CORRECT description of approach? D. 1,2,3,4 and 5
A. Subjects who are randomly assigned to different 94. PD 825 is law that pertains to:
treatments are different people A. environmental sanitation
B. Neither the subject nor those who administer the B. compulsory immunization of children
treatment know who is in the experimental and control C. anti-smoking
group. D. registration of child births
C. Pairing of subjects in one group with those in another 95. The purpose of the first home visit is to
group based on similarities A. Assess family situation through initial data base
D. Control group receives the full treatment and deferred B. Develop a health care plan with the family
temporarily. C. Make a personal account of the family’s health
87. situation
88. The hypothesis developed was: Gingko biloba improves D. Promote health of the family
memory and retention. This is an example of: 96. To ensure that the nurse can perform nursing procedures
A. Simple, Directional hypothesis with ease and deftness, saving time and effort with the
B. Simple, non-directional hypothesis end in view of rendering effective nursing care, he must
C. Complex, Directional hypothesis A. Apply the nursing process
D. Complex, Non- Directional hypothesis B. Develop a family care plan
89. A student nurse is curious to find out whether Safeguard C. Perform bag technique
or Dial is more effective in cleaning an infected wound. D. Prioritize family health nursing problems
The first step in locating for evidence in evidence-based 97. The primary goal of CHN is
practice is to formulate the research question using the A. Enhancing the health capabilities of the people
PICO format. PICO stands for towards self-reliance in health
A. Problem, intervention, comparison, outcome B. Health promotion and disease prevention
B. Population, interest, control, outcome C. Upholding the worth and dignity of man
C. Presentation, intervention, comparison, organization D. Raising the level of health of the citizenry
D. Problem, implementation, control, output 98. The philosophy of CHN is
90. A questionnaire is being used to gather data on the study A. Enhancing health capabilities of the people towards
sample. Identification numbers on the corner of the self-reliance in health
questionnaires correspond to the researcher’s master list B. Health promotion and disease prevention
of names and numbers. Respondents are assured that C. Raising the level of health of the citizenry
this information will not be shared with anyone. The D. Upholding the worth and dignity of man
researcher is trying to provide:
A. Confidentiality C. Informed consent
99. The theoretical bases of Community Health Nursing 110. Vital statistics is one of the epidemiological tools that the
practice are theories and principles of community health nurse uses in recording the impact of
A. Community Development health programs in the community. What is the most
B. Nursing significant implication of a community’s infant mortality
C. Nursing & Public Health rate?
D. Public Health A. It determines the deaths among infants within a
100. People’s participation in health affairs is optimized through specific period of time.
the establishments of B. It is the best indicator of the community’s health
A. Community-based health program status.
B. People’s organization C. It shows the number of deaths among babies during
C. NGO the first 28 days of life.
D. Community health centers D. It reflects the effectiveness of the delivery of health
101. A dynamic process the nurse employ to achieve optimum services.
level of functioning of any level of clientele in CHN is the 111. Communicable disease control program is one component
A. Community organizing process of CHN services. The nurse utilizes her concepts of
B. Epidemiologic process diseases prevention. The best strategy in the prevention
C. Nursing process of communicable diseases is:
D. Problem-solving process A. Correct diagnosis and treatment
102. The client/patient in community health nursing is the B. Health education
A. Family as a socialization unit and undergoing different C. Immunization/chemoprophylaxis
stages of development D. Screening
B. Group of people sharing common characteristics and 112. Nurses working under the RN Heals are enrolled in the
interests in a particular area Philhealth iGroup Insurance. Which of the following are
C. Individual that is identified as a bio-psycho-social and the benefits of the nurses who are under the RN Heals
spiritual being Project? Select all that apply.
D. Population aggregates that require specialized care A. Premium of P1,200.00 per person per year
103. The focus of care in CHN is the B. GSIS Group Accident Insurance premium of P 500.00
A. Family C. Individual per person per year covering the following
B. Population group D. Community C. Accidental Death/Dismemberment of P500,000.00
104. When reviewing the function of the rural health unit, the per person
community health nurse concurs that the RHU functions D. Medical Reimbursement of P50,000.00 per person
as a: E. Bereavement Assistance of P10,000.00.
A. Clinic for the municipality 113. Primary level of prevention of ascariasis pertain to the
B. Community resource following EXCEPT:
C. Health arm if the LGU A. Food sanitation
D. Central health resource for the municipality B. Handwashing
105. Which of the following herbal medicines is effective for C. Mebendazole as prophylaxis
asthma, cough and dysentery? D. Septic tank toilet
A. Yerba Buena C. Lagundi 114. The original objective of the Expanded Program on
B. Sambong D. Tsaang gubat Immunization is
106. The primary health care (PHC) approach is implemented A. Correct epidermiological situation in the country
to ensure people’s health. Full participation of the people B. Eradicate communicable diseases among infants and
is made possible through the application of community young children
organizing process in health. The ultimate end is to: C. Reduce morbidity and mortality among infants and
A. Develop community health programs children caused six immunizable diseases
B. Improve availability and accessibility of health service D. Reduce mortality and morbidity of pregnant women
C. Promote people’s health 115. The community health nurse collects data about 100% of
D. Transfer health into the hands of the people the population in a barangay. The nurse is conducting:
107. There is the need to phase out the community once the A. Community assembly C. Community survey
community-based health program is functional. The B. Census taking D. Epidemiologic survey
reason for is to: 116. BCG is given to school entrants at
A. Indicate termination of community organizing process A. 0.1 ml ID C. 0.05 ml ID
B. Provide opportunity for the role to stand on their own B. 0.5 ml ID D. 0.5 ml IM
C. Start a new project in other depressed communities 117. The nurse conducts case findings for leprosy in the
D. Test the new health program if already viable community. She recalls that for the tuberculoid type of
108. The cornerstones of pillars of PHC are leprosy, the best treatment is
1-active community participation A. PB 19 blister packs
2-multi-sectoral approach B. MB 18 blister packs
3-use of appropriate technology C. MB 24 blister packs
4-support mechanisms made available D. PB 6 blister packs
A. All of the above C. 1 and 3 118. The most serious side effect of DPT is
B. 1,2 and 3 D. 1 and 2 A. Convulsions C. Fever
109. In prioritizing family health nursing problems, which of B. inflamed site D. Infection
these criteria should not be used by the nurse? 119. Various programs have been designed and implemented
A. Acceptability of the problem by the Philippine government to assist new nurses in their
B. Preventive potential of the problem transition into the labor market. EntrepreNurse and RN
C. Modifiability of the problem HEALS are two of such recent programs. The
D. Nature of the problem EntrepreNurse program is an initiative of the
A. Department of Health B. Provides a holistic view of the client that helps nurse
B. Department of Labor and Employment to establish appropriate goals and to plan appropriate
C. PRC Board of Nursing care
D. Philippine Nurses Association C. Allows the nurse to have primary control over the
120. We are aware that Community Health Nursing (CHN) in environment where the client will recover
the Philippines encompasses health care provisions D. Saves the client money because the care is provided
affecting 4 clients: individual, families, population groups in a one-to-one situation
and communities. In the course of our community health 128. In implementing the IMCI guidelines, he nurse should
work, traditional, non-traditional, alternative, or always make it an assessment standard in children to
complimentary health care strategies are stabilized. Legal check in capillary refill especially when:
basis for this action maybe derived from the: A. The extremities of the child feels cold
A. PhilHealth Act B. If there is a fever for more than 7 days
B. Traditional and Alternative Healthcare Law C. The child’s extremities feel warm
C. Philippine Nursing Act D. If the child has petechiae
D. Philippine Medical Act 129. The CH nurse as a supervisor in the community functions
121. The following statements pertain to Community by doing which of the following?
Organizing EXCEPT A. Detects deviations from health
A. A never-ending process once started B. Ensures continuity of care to clients/patients
B. A process for increasing awareness, facilitating C. Participates in development and distribution of IEC
organization and initiating responsible action materials
C. Can apply to all communities D. Provides technical and administrative support to
D. Its goal is community development midwives
122. A public health nurse conducts a home visit and uses the 130. Under Republic Act 9173 of 2002, AMENDED by
family nursing care plan. During her assessment, which of Congressional Joint Resolution of 2009 sets the entry
the following is categorized as a health deficit? level position for nurses at what salary grade?
A. The father does not want to have a regular check-up A. Salary Grade 15 C. Salary Grade 24
at the rural health unit. B. Salary Grade 20 D. Salary Grade 10
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 COMMUNICABLE DISEASE NURSING (20 points)
starts.
123. The community health nurse implements various health 131. The nurse observes a patient with typhoid fever constantly
programs of the Department of Health. The Essential picking the linen while he is lying supine on the bed. The
Intrapartum and Newborn Care’s (EINC) Active nurse notes this as a sign called
Management of Third Stage of Labor (AMTSL) advocates A. coma vigil C. asterixis
the implementation of the following practices EXCEPT? B. subcultus tendinum D. rhisus sardonicus
A. mobility and position of choice in labor 132. A patient is told he is positive of Taenia saginata on his
B. partograph use stool exam for ova & parasites. The nurse explains to the
C. antenatal steroid administration in preterm labor patient that this might have come from
D. application of fundal pressure A. drinking contaminated water
124. An 8-month-old child is brought to the health facility for B. eating fresh fruits and vegetables
“fast breathing.” Using the Integrated Management of C. swimming in flood water
Childhood Illnesses (IMCI) guidelines, correct D. ingesting improperly cooked beef
interpretation of “fast breathing” in this situation MEANS: 133. Schistosomiasis is an endemic disease. Endemic means
A. 40 breaths per minute C. 45 breaths per minute that the disease occurs
B. 38 breaths per minute D. 55 breaths per minute A. at one time during in a specific period of the year
125. The nurse utilizes the IMCI chart in assessing her B. IF there is a sudden increase in infections
pediatric clients in the rural health unit. When checking the C. continuously in a community throughout the year
general danger signs in a 4 month old child, the following D. widespread in the country at a particular time
questions are asked EXCEPT: 134. The nurse evaluates effectiveness of her health teachings
A. Did the child have convulsions? on a group of mothers regarding ascariasis. An accurate
B. Is the child eating well during illness? statement made by a mother regarding prevention of
C. Is the child able to breastfeed? ascariasis is
D. Has the child had diarrhea? A. “I will tell my kids to wash hands after meals.”
126. For purposes of accuracy and completion of documents B. “I will discourage my child from playing on the soil.”
regarding childbirth in the community, the nurse working at C. “I will not let my children eat raw fruits.”
the RHU is required that registration birth within 30 days D. “I will make sure not to buy expired canned goods.’
from its occurrence must be done. Which law requires 135. Which of the following statements made by a patient
this? suggests the presence of enterobiasis?
A. R.A. 3573 C. R.A. 3375 A. “I feel nauseated every morning.”
B. PD 651 D. EO 119 B. “I feel itchiness in my anus at night.”
127. A meeting of clients for home care (HC) is essential in C. “My abdomen is cramping frequently.”
order to explain the role of the nurse and the advantages D. “I didn’t’ have a bowel movement in 3 days.”
of this alternative health provision. Among important 136. A patient presents to the emergency room with meningitis.
emphasis to be made is that home care The patient is most likely to present with which chief
A. Encourages a dependent relationship between the complaints?
nurse and the client A. headache and nuchal rigidity
B. vomiting and blurred vision
C. dilated pupils and seizures A. The Philippine is among the 22 highly burdened poor
D. loss of consciousness and cyanosis countries in the world
137. Which of the following laboratory results for CSF suggests B. TB is the 6th leading cause of illness among Filipinos
the presence of bacterial meningitis? C. TB is the 6th leading cause of deaths among Filipinos
A. increased protein level D. Most TB patients belong to the 0-15 age groups
B. decreased white blood cells 150. When a nurse gets a hepatitis vaccine after exposure to a
C. reduced glucose level body fluid of a patient with hepatitis B, the type of
D. increased red blood cells immunity that develops is
138. The nurse assesses a patient with meningitis by asking A. a naturally acquired active immunity
the patient to flex his knees towards his abdomen and B. a naturally acquired passive immunity
assessing his response. The nurse is performing an C. an artificially acquired passive immunity
assessment to elicit the D. an artificially acquired active immunity
A. Babinski sign C. Brudzinsky’s sign
B. Kernig’s sign D. Cushing’s sign PHARMACOLOGY (30 points)
139. To determine the presence of rabies in an animal, its brain
tissues can be examined for the presence of 151. Felicito, 65 years old, post coronary artery bypass due to
A. necrotic tissues C. hematomas acute myocardial infarction, sought consultation because
B. Negri bodies D. antibodies of worsening pedal edema. Upon admission, Morphine
140. The nurse notes meningococcemia in a patient if she sulfate was administered intravenously. Which of the
observes following is the purpose of administering the drug to the
A. stiffness of the neck C. petechiae on the skin patient?
B. unequal pupils D. diarrhea A. improve efficacy of breathing
141. Syphilis is caused by: B. relieve chest pain
A. Neisseria gonorrhea C. Treponema pallidum C. reduce venous return
B. Cytomegalovirus D. Herpes simplex virus D. reduce anxiety
142. A sign of gonorrhea is 152. The physicians prescribes oral penicillin 500 mg every six
A. generalized skin rash hours for seven days. On the fifth day before Cora
B. yellowish genital discharge administer the first dose for the day she computed the
C. clear white genital discharge total amount in milligrams of the oral penicillin that has
D. cheesy substance on the genitalia been received by the client. Which of the following is the
143. The modes of transmission of the human immune correct amount?
deficiency virus are categorized as horizontal and vertical A. 2,500 mg C. 10,000 mg
transmission. Which of these is an example of a vertical B. 15,000 mg D. 8,000 mg
mode of transmission? 153. Which of the following conditions would alert the nurse
A. Sexual intercourse with an infected partner that a patient receiving Chloramphenicol (Chloromycetin)
B. Needlestick injury from an infected patient is developing severe toxic reactions?
C. Placental transfer from an infected mother A. Nausea, vomiting, diarrhea
D. Sharing among infected IV drug users B. Anemia, infections, bleeding
144. A confirmatory diagnostic test for HIV infection is C. Jaundice, tinnitus, oliguria
A. the Western blot test D. Photosensitivity, rash, constipation
B. enzyme linked immunosorbent assay (ELISA) test 154. A patient is in a Respiratory Isolation room and is taking
C. T4 cell count determination multi-drug therapy for tuberculosis. Which of the following
D. differential CBC test statements made by the patient suggests that he is
145. A patient asks the nurse for early signs of HIV infection. exhibiting adverse effect of Streptomycin?
The nurse tells that early HIV infection is usually A. “I am having numbness in my hands.”
manifested by the presence of B. “I have some trouble hearing.”
A. enlarged lymph nodes in multiple areas of the body C. “I noticed my urine turned orange.”
B. recurrent oral thrush D. “My hands seem to be more swollen today.”
C. rapid weight loss and diarrhea 155. Mr. A is a 56-year old patient admitted at the ED with an
D. multiple infections internal hemorrhage. He was given Epinephrine 1:1000
146. Multiple drug therapy is given to a patient with AIDS. SQ. Which of the following sets of physiological responses
Which of these is an example of an anti-viral drug for reflects the effects of Epinephrine?
AIDS? A. bradycardia, vasoconstriction, miosis
A. Amphotericin B C. Zidovudine B. bronchodilation, mydriasis, hyperglycemia
B. Amantadine D. Azithromycin C. tachycardia, hypotension, tachypnea
147. A patient with HIV infection has whitish spots on the D. vasodilation, hypoglycemia, bronchoconstriction
mouth and throat. The nurse will most likely administer 156. Low molecular weight Heparin such as Enoxaparin
A. Neomycin sulfate C. Nystatin oral solution (Lovenox) was prescribed to be administered. Which of
B. Glycerine oral swabs D. Amphotericin B the following should the nurse include in her nursing care
148. A nurse teaches the public where malaria is endemic plan to ensure absence of injury?
about prevention and management of the infection. Which A. Deltoid is the preferred site because it is less painful
statement about malaria is accurate? Malaria B. Aspirate prior to injecting to ensure no blood vessel is
A. affects the white blood cells hit
B. is caused by a protozoan C. Use gauge 25 and 1/4 inch long needle
C. is caused by the Anopheles mosquito D. Massage after the injection to promote fast absorption
D. leads to internal hemorrhage 157. Mr. C is a 65 y/o patient with myasthenia gravis. Which of
149. Which vital statistics relating to Tuberculosis(TB) in our the following medications is used to treat myasthenia
country is INACCURATE? gravis?
A. Edrophonium Cl (Tensilon) B. “This drug will make you breathe easier by dilating
B. Trihexyphenidyl HCl (Artane) your airways.”
C. Bethanechol Cl (Urecholine) C. “You will feel dizzy or sleepy after taking this
D. Methyldopa (Aldomet) medication.”
158. Mr. S is a 40-year old patient at the psychiatric unit and is D. “This drug makes your mouth dry because it
being treated with anti-psychotic drugs. The nurse decreases oral secretions.”
observes that Mr. S is exhibiting symptoms of Parkinson’s 167. A mother is asking questions to her 3-year-old son’s nurse
disease. Which of the following anti-cholinergic drugs is about the newly prescribed Cromolyn sodium (Intal) for
often used to reduce side effects of anti-psychotic her son’s asthma. Which of the following nurse’s
medications such as pseudo-parkinsonism? statements accurately addresses the mother’s concern?
A. Benztropine mesylate (Cogentin) A. “It is the drug of choice for asthma caused by severe
B. Pilocarpine (Pilocar) acute anaphylaxis.”
C. Neostigmine bromide (Prostigmine) B. “It is a potent bronchodilator therefore easing
D. Atenolol (Tenormin) respirations.”
159. A patient is admitted to the ED 12 hours after ingesting a C. “It is effective as a preventive measure for future
half-bottle of Acetaminophen (Tylenol). To determine asthmatic attacks.”
organ damage due to the toxic effect of the drug, the D. “It increases the effects of histamine on the lungs.”
nurse should evaluate which of these laboratory results? 168. A patient is on Digoxin (Lanoxin) 0.25 mg po daily. What is
A. Aspartate transaminase (AST) / alanine transaminase the physiologic action of Digoxin?
(ALT) levels A. Increases the rate of cardiac contraction
B. White blood count (WBC) and uric acid levels B. Decreases the force of cardiac contraction
C. Platelet count and urinalysis C. Increases the force of cardiac contraction
D. Blood urea nitrogen (BUN) and creatinine levels D. Decreases the stroke volume
160. Mr. P is a 76-year old patient with rheumatoid arthritis. He 169. A patient is newly admitted to the hospital and tells the
is currently taking Aspirin 325 po q4h prn for joint pains. nurse during the assessment interview that she is
Which of the following nursing interventions is appropriate currently taking a potassium-wasting diuretic for her
for patients taking Aspirin? cardiac problem. The nurse reviews her medication orders
A. Administer the medication before meals. and finds: “Digoxin (Lanoxin) 0.125 mg po daily”. The
B. Monitor the apical pulse prior to giving the drug. nurse’s action is appropriate if she
C. Give the medication with meals. A. Administers the medication as ordered
D. Do not give the medication if the patient has urinary B. Requests an order to check serum potassium level
obstruction. C. Advises the patient to take half of the diuretic
161. A 6-year-old child has a low grade fever due to a viral D. Reviews the patient’s latest CBC result
respiratory infection. The choice of medication to reduce 170. Dilantin 5 mg/kg body weight is ordered to a client who
the temperature is weighs 50 lbs. The drug is to be administered in 3 equal
A. Acetylsalicylic acid (Aspirin) doses. The label reads Dilantin suspension 125 mg/ml.
B. Acetaminophen (Tylenol) how much medication should be administered to the
C. Ibuprofen (Advil) client?
D. Mefenamic acid (Ponstan) A.1.8 ml B. 1.5 ml C. 1.0 ml D. 0.5 ml
162. A patient with cerebral edema is taking Dexamethasone 171. A patient asks why insulin is not administered orally. The
(Decadron) 8 mg po q6h. Which of the following nurse is correct if she states:
assessment findings suggests a common side-effect of A. “Insulin is destroyed by the gastric juices. “
corticosteroids? B. “Insulin given orally may cause nausea and vomiting.
A. Hyperglycemia C. Diarrhea C. “Insulin may irritate the gastric mucosa.”
B. Hyponatremia D. Dehydration D. “Insulin absorption in faster if given orally.”
163. A nurse is conducting an admission interview. As she is 172. A patient is to take NPH insulin 32 U and Regular insulin 8
taking the patient’s medication history, the nurse discovers U daily. In preparing the medication , the nurse would
that the patient is taking Valproic acid (Depakote) and BEST use
Carbamazapine (Tegretol) daily. Which of the following A. Two separate syringes
medical diagnoses from the patient’s medical history B. An insulin syringe, drawing regular insulin first
justifies the need to take these medications? C. An insulin syringe, drawing NPH insulin first
A. Sleeping disorder C. Seizure disorder D. A 1-cc syringe, drawing regular insulin first
B. Anxiety disorder D. Chronic pain disorder 173. Saturated solution of potassium iodide is administered to a
164. A client with myocardial infarction is receiving an l.V. patient who is to undergo thyroidectomy in order to
infusion of heparin sodium at 1,500 units per hour. The A. Reduce the size and vascularity of the thyroid
concentration in the bag is 25,000 units per 500 ml. How B. Inhibit the production of thyroid hormones
many ml should the nurse document as intake from the C. Facilitate the release of thyroxine from the thyroid
infusion for an eight shift? D. Provide supplemental iodine prior to surgery
A. 300 ml B. 450 ml C. 400 ml D. 240 ml 174. For a patient with addisonian crisis, it would be dangerous
165. Gingival hyperplasia is a common side-effect of to administer
A. Phenytoin (Dilantin) A. Epinephrine hydrochloride
B. Valproic acid (Depakote) B. Fludrocortisone
C. Carbamazapine (Tegretol) C. Potassium chloride
D. Chlordiazepoxide (Librium) D. Hydrocortisone
166. The appropriate information to a COPD patient on action 175. DDAVP is used in the treatment of
of Acetylcysteine (Mucomyst) is: A. Pheochromocytoma
A. “This medication helps loosen the secretions in your B. Syndrome of inappropriate antidiuretic hormone
lungs.” C. Diabetes insipidus
D. Addison’s disease D. the incident is critical and therefore requires
176. A patient with reflux disorder is prescribed Aluminum documentation for future reference
hydroxide (Amphojel), an antacid. A common side effect of 184. To maximize utilization of human resources, the nurse
this medication is: manager emphasizes to the nurses to use technology as a
A. Nausea and vomiting C. Diarrhea means to make work processes more efficient. She
B. Constipation D. Flatulence advocates the use of the nurse call system. When a newly
177. A patient with liver failure is showing signs of altered admitted client is shown to use the nurse call system,
mental status due to an increasing ammonia level in the which of the' statements about the nurse call system
blood. The physician ordered Lactulose. The nurse knows below is NOT appropriate?
that Lactulose is effective if the patient/patient’s A. It should be used whenever the client needs help.
A. ammonia level remains high B. It should be used during an emergency only.
B. passes soft or liquid stools C. It must be pushed or pressed several times to alert
C. bowel sounds is hypoactive the nurse at the station.
D. does not vomit D. It must be Within the reach of the client.
178. A patient in labor is receiving Pitocin drip. Her contractions 185. Quality improvement (QI) requires that client care
are becoming more severe and intense, and lasting 30 activities be constantly evaluated and improved to meet
seconds to 2 minutes. What is the nurse’s best action? the needs of the clients. Of the following situations, which
A. Notify the physician. one illustrates quality improvement?
B. Check the fetal heart tone. A. The nurse supervisor plans a ward class for clients for
C. Discontinue the infusion. discharge along with family members for better home
D. Document the findings. management.
179. The nurse is in charge of a client on a long term B. The hospital personnel and clients are constantly
Nitroglycerine sublingual tablets for angina pectoris. What reminded about handwashing especially during the
instruction of the nurse is APPROPRIATE for the client to epidemics.
maintain the efficacy of the drug? C. The hospital involves the multidisciplinary team in
A. Retain sublinguaI tablets in a plastic transparent client medication by having zero medication error.
container D. A client asks from the nursing aide assigned to the
B. Maintain a supply for a duration of one year client to be repositioned in bed due to post-operative
C. Replace sublingual tablets supply every three months discomfort.
D. Keep sublingual tablets in amber glass bottle 186. Benevolent deception is an ethical concept that describes
180. A patient with significant psychiatric history is discharged which of these situations?
with haloperidol to take twice a day by mouth. Which A. A family insists to avail of all possible alternatives to a
discharge instruction should the nurse provide? terminally ill patient even without the possibility of
A. Decrease the dose if symptoms disappear. cure.
B. Double the dose if experiencing severe stress. B. A staff criticizes another staff who received
C. Apply sunscreen before exposure to the sun. recognition as an outstanding nurse.
D. Wait for two weeks before experiencing the effects of C. A doctor tells lies to a patient regarding his condition
the drug. in order to benefit the client.
D. A surgeon who performs hysterectomy to a client who
NURSING LEADERSHIP & MANAGEMENT / NURSING signed consent for exploratory laparotomy.
JURISPRUDENCE & PROFESSIONAL ADJUSTMENT (20 187. The nurse caring for an immobilized client turns the client
points) every 2 hours during her 12-hour shift. This action of the
nurse
181. According to Benner’s Stages of Clinical Expertise, how A. Reflects the standard of care
many years of clinical experience should a nurse possess B. Is under the scope of nursing practice
before she can be called a competent nurse? C. Is a provision of the Nurse Practice Act
A. 6-12 months C. 24-36 months D. Demonstrates respect for the patient’s Bill of Rights
B. 12-24 months D. 36-60 months 188. Which of the following mandates delineates the roles and
182. Which of the following does not govern nursing practice? functions as well as responsibilities of a nurse?
A. R.A. 7164 A. Nurse Practice Act
B. R.A. 9173 B. Code of Ethics for Nurses
C. Standards of Care
C. B.O.N. Resolution for Code of Ethics
D. Magna Carta for Health Workers
D. Board Resolution Scope of Nursing Practice 189. A former clinical instructor is preparing his resume as part
183. While doing the routine nursing rounds during the night of his application portfolio for a position as clinical
shift, the nurse found a patient on the floor with blood educator in a university medical center. When making his
oozing from the forehead. The nurse called for help and portfolio, which of the following should be the first major
assisted the patient back to bed. When the patient's part of his professional resume?
condition stabilized, the nurse documented the A. Personal data and address
assessment and interventions in the chart. The nurse also B. Educational background
completed an incident report because: C. Work experience
A. it is a requirement of the head nurse in case the D. Trainings and professional qualifications
patient files a legal suit against the hospital 190. A medical-surgical nurse is asked by the nursing
B. the incident may lead to serious complications and supervisor to float to the understaffed Neonatal Ward for
this may trigger a malpractice suit. the entire shift. The Neonatal Nurse Manager should
C. reporting an incident in writing is a hospital protocol to assign which patient to the “floater” nurse?
determine precautionary measure to avoid similar A. A 4-day old neonate with Tetralogy of Fallot
incidents B. A 10-day old neonate with spina bifida
C. A 3-week-old neonate with heart failure 196. The doctor’s order is, “Garamycin 1 gm IV initially after a
D. A 4-week old neonate with esophageal atresia negative skin test; then 500 mg IV push every 6 hours for
191. The nurse reviews several concepts related to total quality 23 days.“ The order was countersigned by the head nurse.
management (TQM). Which of the following statements When the doctor made his rounds the following day, he
refer quality improvement? found out that 1 gm Garamycin was given IV push every 6
A. It is concerned with performance development and is hours. Who among the following may be held liable?
on-going, preventing future mistakes. A. All the nurses who administered the drug every 6
B. It defines performance measurements and compares hours
actual processes and outcomes to clinical and B. The head nurse and the nurse who gave the first
satisfaction indicators. dose for having erroneously transcribed the order
C. It refers to a work ethic involving everyone in the C. Only the head nurse under the principle of command
organization. responsibility
D. It includes systematic methods of ensuring conformity D. All nurses involved including the head nurse
to a desired standard or norm. 197. When a nurse makes a decision based on the reasoning
192. Which of the following criteria should not be used by the that “good consequences will outweigh bad
charge nurse in delegating care to her staff? consequences” she is following which theory?
A. Educational background and training of the staff A. Formalist theory C. Moralist theory
B. Complexity of patient care needed for the shift B. Utilitarian theory D. Deontological theory
C. Adequacy of client’s family support system and 198. During the nurse tour of duty, very often they are
resources confronted with ethical dilemma. In their decision making,
D. Clinical experience of the nursing staff which of the following would require application of the
193. A nurse who is responsible for the care of the client from Principle of Beneficence?
admission to discharge with the primary responsibility of A. A young father of three boys with advanced lung
coordinating care is doing which modality of nursing care? cancer asks that all known regime be done to prolong
A. Primary nursing C. Team nursing his life despite no improvement
B. Functional nursing D. Case management B. A confused 70 year old lady needs restraints for
194. The nursing education department of a hospital is offering protection from fall even if this makes her more
a program about evidence-based practice to prepare agitated
nurses before its implementation ii the hospital. Which of C. A 3rd day post cholecystectomy client requests
the following refers to this type of program? narcotic injection every 4 hours
A. Seminar workshop in evidence-based practice D. A young patient who has asked not to receive tube
B. Continuing education in evidence-based practice feeding due to intense pain
C. In-service Education Program 199. A client is confined in your unit. He says that he has
D. Scientific forum in evidence-based practice difficulty sleeping because of the “ambience” in the unit.
195. A nurse works in a college of nursing as a faculty and When evaluating the effect the setting has on the quality
reeds further experience to possess clinical skills and of care provided to the client the evaluation being done is
Theoretical knowledge. Which of the following should this called:
nurse pursue to qualify for teaching current nursing A. Quality assurance C. Structure evaluation
practice? B. Quality improvement D. Outcome evaluation
A. Pursue master's degree in other folds such as 200. While taking care of a client, a nurse was instructed by
business or educational management her head nurse to file an incident report. The following
B. Possess a graduate degree in nursing and pursue situations warrant an incident report, EXCEPT:
doctorate in advanced degrees in nursing, education A. Client and family attitude towards care
and administration B. Medico-legal incident
C. Participate in continuing education program in C. Client’s complaints of illness
national and international conference D. Medication errors including administration of
D. Keep license valid by updating professional education intravenous fluiids
with organized groups.
A. Level of consciousness
MATERNAL AND NEWBORN NURSING (40 points) B. Urinary output
C. Blood pressure
1. A client, 7 months pregnant, is brought to the emergency D. Return of sensation on the legs
department with abdominal pain and bright red vaginal 7. During the fourth stage of labor, the client should be
bleeding. What should the nurse do first? assessed for
A. Place the client in left lateral position and initiate A. Complete cervical dilation
oxygen therapy as ordered. B. Placental expulsion
B. Administer ordered IV oxytocin to stimulate C. Umbilical cord prolapse
contractions and prevent hemorrhage. D. Uterine atony
C. Ease the client’s anxiety by coaching her to perform 8. A postpartum client is ready for discharge. During
relaxation techniques. discharge preparation, the nurse should instruct the
D. Massage the client’s fundus to control the client to report which of the following to a health care
hemorrhage. provider?
2. At 15 weeks’ gestation, a client is scheduled for an A. A temperature of 99.2 for 24 hours or more
alpha-fetoprotein (AFP) test. Which maternal history B. Episiotomy discomfort
finding best explains the need for this test? C. Lochia alba at 2 weeks postpartum
A. Family history of Down syndrome on the father’s D. Redness, warmth and pain in the breasts
side. 9. Which of the following assessment findings would the
B. Family history of spina bifida in a sister. nurse interpret as abnormal in a full term male neonate
C. History of gestational diabetes during a previous born an hour ago?
pregnancy. A. Enlargement of the mammary glands
D. History of spotting during the first month of the B. Slight yellowish hue to the skin
current pregnancy. C. Blue hands and feet
3. Ada, a 38-year-old, G1P2, 36 weeks AOG pregnant D. Black and blue spots on the buttocks
mother with a history of precipitous labor and low birth 10. A client who’s 7 months pregnant reports severe leg
weight infant informs the nurse that she has been cramps at night. Which nursing action would be most
having on and off contractions and she feels like effective in helping the client cope with these cramps?
“bearing down.” Upon examination, the obstetrician’s A. Suggesting that she walk for 1 hour twice per day.
findings show that the client is “75% effaced and 6 cm B. Advising her to take over-the-counter calcium
dilated”. The most appropriate disposition for this client supplements twice a day.
would be to C. Teaching her how to dorsiflex the foot during a
A. Send her home since she s only 6 cm dilated and cramp.
contractions are mild D. Instructing her to increase her milk and cheese
B. Request the obstetrician for Pitocin drip to induce intake to 5-8 servings per day.
stronger contractions 11. Which of the following signs of pregnancy is properly
C. Ask the client to return to the hospital when classified?
contractions are 2-3 minutes apart and strong in A. Enlarging uterus: probable sign
intensity B. Elevation of basal body temperature: Presumptive
D. Have the client stay in the hospital for maternal and C. Fetal movements felt by examiner: positive
fetal monitoring D. Chloasma and linea nigra: probable
4. Prior to a cesarean section delivery, a 24 year old 12. A multigravida is in the second stage of labor for 30
woman is treated for abruption placenta. You are caring minutes. This can be considered as a
for this client during the postpartum period. Which of A. Precipitous labor
these symptoms, if present, would be suggestive if B. Precipitous delivery
disseminated intravascular coagulation (DIC)? C. Normal labor
A. The woman is nauseated, lethargic, and has D. Normal spontaneous delivery
vomited 3 times 13. A postpartum mother has a temperature of 99.8 F within
B. The woman’s laboratory result are: Hgb 13g/dl, Hct the first 24 hours after delivery. The most common
40%, WBC 7,000/mm3 cause of temperature elevation during this period is
C. There is oozing blood from venipuncture site and A. Puerperal infection C. Dehydration
abdominal incision B. Chorioamnionitis D. Mastitis
D. The woman’s vital signs are BP 90/50 mm hg, 14. While caring for a full term female neonate, the nurse
temperature 38.3 oC, pulse 112/min, respiration notices red stains on the diaper after the baby voids.
18/min Which action should the nurse take next?
5. A mother at 40 weeks’ age of gestation is assessed by A. Call the physician to report the problem.
the nurse. The nurse finds the fundic height to be B. Encourage the mother to feed the baby to prevent
A. 35 cm C. 40 cm dehydration.
B. 38 cm D. 43 cm C. Do nothing because this is normal.
6. The nurse’s most important assessment on a client who D. Check the baby’s urine for hematuria.
received epidural anesthesia during labor is
15. The nurse knows that the client has probable signs of C. pain relief with mild analgesics before offering labor
pregnancy by noting for the presence of anesthesia
A. Amenorrhea D. position of choice during labor and delivery
B. Tender breasts E. spontaneous pushing in a semi-upright position
C. Softening of the cervix F. routine episiotomy
D. Nausea and vomiting G. active management of the third stage of labor
16. The nurse is assessing a neonate born a day ago from 23. At 5 minutes of age, a neonate is pink with blue hands
a client who smoked during pregnancy. Which of the and feet, has his knees flexed and fists clenched, has a
following findings is expected of a neonate from a whimpering cry, a heart rate of 128 per minute and
mother who smoked during pregnancy? withdraws his foot when slapped on his sole. What 5-
A. Postterm birth minute Apgar score should the nurse document for this
B. Small for gestational age neonate?
C. Large for gestational age A. 6 B. 7 C. 8 D. 9
D. Appropriate for gestational age 24. Based on the Essential Intrapartal and Newborn Care’s
17. A client at 28 weeks’ gestation complains of uterine new protocol, which of the following traditional beliefs
contractions. After assessment, hydration and and practices have been eliminated? Select all that
admission, the physician orders Beclomethasone 12 mg apply.
IM. The purpose of giving this medication is to A. routine suctioning
A. Slow down uterine contractions B. foot printing
B. Promote fetal lung maturity C. early bathing
C. Prevent infection D. routine separation
D. Promote fetal growth E. continuance of artificial feeding
18. A client is admitted in preterm labor. To halt labor 25. The neonatal nurse is preparing Vitamin K injection for
contractions, the nurse expects the physician to the newborn. Why does the neonate need Vitamin K?
prescribe A. Due to sterile gastrointestinal tract, there is no
A. Betamethasone (CElestone) bacteria to produce vitamin K
B. Ritodrine (Yutopar) B. Vitamin K helps in producing clotting factors in the
C. Dinoprostone (Prepidil) liver
D. Ergonovine (Ergotrate maleate) C. Platelets need Vitamin K for their production and
19. The nurse assessing a client with pregnancy-induced maturation
hypertension (PIH) will most probably expect which D. Vitamin K is needed by the intestinal bacteria to
signs and symptoms? produce clotting factors
A. Proteinuria, headache, vaginal bleeding 26. Which of the following maternal discomfort is most likely
B. Headache, double vision, vaginal bleeding to be expected if the fetus is in a Right Occiput Posterior
C. Proteinuria, headache, double vision position?
D. Proteinuria, double vision, uterine contractions A. Urinary frequency
20. A woman in her 34th week of pregnancy presents with B. Low back pain
sudden onset of bright red vaginal bleeding. Her uterus C. Leg cramps
is soft and experiences no pain. Fetal heart rate is 120 D. Varicosities
bpm. Based on the presenting data, the nurse knows 27. According to the WHO, the most common cause of
that the client might have developed mortality among women during the post-partum period is
A. Threatened abortion A. Cephalo-pelvic disproportion
B. Placenta previa B. Hemorrhage
C. Abruptio placentae C. Pregnancy-induced hypertension
D. Preterm labor D. Infection
21. The nurse reviews the laboratory results of a client with 28. Which of the following psychological changes during the
hydatidiform mole. Which finding strongly suggests the post-partal period illustrates that the mother is in the
presence of this disorder? taking-in phase? The mother
A. An elevated human placental lactogen (hPL) level A. Looks intently at her newborn
B. A reduced alpha-fetoprotein (AFP) level B. Asks the nurse how to breastfeed the baby
C. An increased human chorionic gonadotropin (hCG) C. Restricts visitation because she needs to rest
level D. Wants the father of the baby to participate in
D. A n increased carcinoembryonic antigen (CEA) bathing the baby
level 29. A mother is in the fourth stage of labor and the nurses
22. The recommended Essential Intrapartal and Newborn assesses for signs of placental separation. The earliest
Care (EINC) practices during the intrapartum period sign that can be observed is
include continuous maternal support by having which of A. Sudden gush of blood from the vagina
the following? Select all that apply. B. Lengthening of the umbilical cord
A. a companion of choice during labor and delivery C. Rising of the uterus above the umbilicus
freedom of movement during labor D. Onset of mild dull abdominal pain
B. monitoring progress of labor using the partograph
30. A woman had her last menstrual period last September 38. The nurse is preparing a woman for epidural
8, 2013. The expected date of delivery is on anesthesia. The woman asks, “Why is my IV running so
A. June 15, 2014 C. November 15, 2013 fast? It feels so cold!” What reply by the nurse is BEST?
B. May 1, 2014 D. July 15, 2014 A. “IV hydration helps prevent the blood pressure from
31. A mother is pregnant for the fifth time. Her firstborns dropping so low.”
were twins. Her second child was born prematurely and B. “Don’t worry, this is a routine procedure in
her third pregnancy ended in intrauterine growth preparation for an epidural”
retardation. She delivered her fourth pregnancy C. “I’ll slow the IV down so you won’t feel cold”
normally. Her obstetric history is: D. “ IV fluids help prevent spinal headaches.”
A. G5 T2 P1 A0 L4 C. G4 T3 P2 A1 L3 39. A client is scheduled for amniocentesis. When preparing
B. G5 T3 P2 A0 L4 D. G4 T2 P1 A0 L4 her for the procedure, the nurse should do which of the
32. A nurse orientee at the Labor & Delivery Unit reviews following?
the partogram sheet and identifies the word “liquor” A. Allowing her to void.
which refers to B. Instruct her to drink 1 liter of fluid.
A. The amniotic fluid C. Prepare to insert an IV access.
B. A meconium-stained amniotic fluid D. Position her on the left side.
C. The bloody show 40. Malou is aware that in accordance with R.A. 7600 of
D. An amnioinfusion therapy 1992, the purpose of the “rooming-in” national policy are
33. The appropriate order of steps in active management of two-fold:
the third stage of labor include: 1 Encourage, protect and support the practice
A. Cord clumping and cutting, controlled cord traction, of breastfeeding
ergometrine administration, and inspection to be 2 Save on costs for utilities and personnel for a
sure that the placenta is intact. newborn nursery
B. Intravenous oxytocin, cord clumping and cutting, 3 create an environment where basic physical,
and fundal massage emotional, and psychological needs of
C. Intramuscular injection of oxytocin, controlled cord mothers and infants are fulfilled
traction with counter traction to the uterus, uterine 4 Teach the mother to take responsibility for
massage caring for her newborn right after her delivery
D. Controlled cord traction, fundal massage and A. 2 and 3 are correct C. 1 and 2 are correct
oxytocin B. 3 and 4 are correct D. 1 and 3 are correct
34. The nurse explains to the post-partum mother who is for
discharge that the expected characteristic of her lochia PEDIATRIC NURSING (40 points)
6 days after delivery is
A. reddish and moderate in amount 41. Which of the following findings during newborn
B. scant and pinkish drainage assessment warrants alerting the pediatrician for a
C. whitish and moderate potential problem? The neonate/neonate’s
D. bright red and scant in amount A. Arms and feet are bluish
35. Which of the following should the nurse tell a mother B. Skin color is yellowish
during the intrapartal period to best help relieve pain? C. Head is larger than the chest
A. “Find the most comfortable position for you D. Has red stains on the diaper during voiding
especially during the first stage of labor.” 42. The best indication that the breastfeed baby is digesting
B. “Ambulate as much as you can to relieve the the breast milk properly is when:
abdominal discomfort.” A. The baby passes soft, green, pasty stools
C. “I can administer an opioid analgesic if you cannot B. The baby passes soft, golden-yellow stools
tolerate the pain any longer.” C. The baby sleeps for several hours after each
D. “Do rapid deep breaths every time you feel a feeding
contraction.” D. The baby does not experience colic
36. A post-partum client develops disseminated 82. The nurse noted the following behaviors in a 6-hour old,
intravascular coagulation. The drug of choice for this full-term newborn: occasional tremors of extremities,
condition is straightens arms and hands outward and flexes knees
A. Vitamin K C. Protamine zinc when disturbed, toes fan out when heel is stroked, and
B. Heparin sulfate D. Aspirin tries to walk when held upright. These findings indicate
37. To confirm pregnancy, the doctor will most likely perform A. Expected neurologic development
which of these actions to a pregnant woman who is on B. Signs of drug withdrawal
her first prenatal visit? C. Abnormal uncoordinated movements
A. palpate for fetal parts and movement D. Asymmetric muscle tone
B. order an ultrasound examination 83. While assessing another newborn, you noted that his
C. instruct the client to do a home type pregnancy test areola is flat with less than 0.5 cm of breast tissue. This
D. do an internal examination finding indicates:
A. Intrauterine growth retardation
B. Maternal hormonal depletion
C. Pre-term gestational age A. “Both of us carry a recessive treat of a cystic
D. That the infant is male fibrosis”
43. The mother is feeding her 20-month-old child. The child B. “The gene came from my wife’s side of the family”
is trying to eat with a spoon and is muddling the food on C. “The gene came from my husband’s side of the
the tray. Which of the following approach of the nurse is family”
the MOST appropriate? D. “There is a 50% chance that our next child will have
A. Assist the mother in feeding the child. disease”
B. Instruct the mother to give finger foods until the 53. A 2-month old baby is expected to have completed
child is older. which immunizations?
C. Praise and encourage the child as she eats. A. MMR, DPT, measles, BCG
D. Get the spoon and do the feeding. B. Hepatitis, measles, BCG, OPV
44. When developing plan of care for a child, the nurse C. OPV, DPT, BCG
recognizes that which Eriksonian stage of development D. Hepatitis, OPV, BCG, HIB
corresponds to Freudian stage of phallic development? 54. A child is brought to the emergency room due to acute
A. Initiative versus guilt onset of abdominal pain, vomiting and stools that look
B. Trust versus mistrust like red currant jelly. The nurse suspects that this may
C. Autonomy versus doubt be due to
D. Industry versus inferiority A. Intussusceptions C. Appendicitis
45. Bedtime rituals such as tucking to bed and reading B. Pyloric stenosis D. inflammatory bowel disease
bedtime stories are particularly important to which of the 55. The nurse advises a 6-year-old child with celiac disease
following age groups: should not have which of these dietary choices?
A. Infants C. School-age A. Mango shake C. Fruit salad
B. Toddler D. Pre-schooler B. Ice cream D. Spaghetti
46. An 8- year – old child is diagnosed with iron deficiency 56. A 4-year-old child with a recent history of nausea,
anemia. When assessing the child’s fingernails. The vomiting and diarrhea is admitted to the pediatric ward
nurse instructed the mother to look for: for gastroenteritis. During physical assessment, the
A. spoon nail C. pale nail beds nurse observes tenting. This clinical manifestation
B. clubbing D. presence of Beau’s lines supports the nursing diagnosis of
47. Encouraging fantasy play and participation by children A. Activity intolerance related to hypoxia
in their own care is a useful developmental approach B. Deficient fluid volume related to dehydration
among which pediatric age group? C. Ineffective peripheral tissue perfusion related to
A. Preschoolers C. school age cyanosis
B. Adolescence D. toddlers D. Risk for injury related to capillary fragility
48. When assessing a neonate born at 30 weeks gestation, 57. The nurse prepares to administer an intramuscular
the nurse notes bounding femoral pulses, a palpable injection to a 7-month old girl. The most appropriate site
thrill over the suprasternal notch, tachycardia, to administer the drug is:
tachypnea and crackles. The nurse suspects for A. dorso-gluteal region C. ventral forearm
A. Tetralogy of Fallot
B. Patent ductus arteriosus B. vastus lateralis D. gluteal region
C. Ventricular septal defect 58. When developing a post-operative plan of care to a child
D. Coarctation of the aorta who has undergone cleft lip-repair, which of the
49. The nurse expects an infant to sit without support at following is the nurse’s priority goal of care?
what age? A. Avoiding disturbing crusts along the suture line.
A. 2 months C. 6 months B. Comforting the child as quickly as possible.
B. 4 months D. 8 months C. Maintaining the child in a prone position.
50. When planning care for hospitalized children, the nurse D. Restraining the child’s arm at all times, using soft
must consider that which age group considers illness as elbow restraints.
a punishment for misdeeds? 59. A 2-month-old is brought to the clinic by his mother. His
A. Infancy C. Preschoolers abdomen is distended and he has been vomiting
B. Toddlers D. school age forcefully for the past 2 weeks. The nurse notes
51. The nurse places a neonate with hyperbilirubinemia dehydration and a palpable mass on the right of the
under a phototherapy lamp, covering the eyes and umbilicus. Peristaltic waves are present, moving from
gonads for protection. The nurse knows that the goal of left to right. Based on these clinical manifestations, the
phototherapy is to infant most probably has:
A. Prevent hypothermia A. Tracheoesophageal fistula C. Intussusceptions
B. Promote respiratory stability B. Pyloric stenosis D. Volvulus
C. Reduce conjugated bilirubin level 60. A 7-year-old child is brought to the ER due to a
D. Reduce unconjugated bilirubin level dislocated right shoulder and simple fracture of the right
52. Which of the following statements, is made by any humerus. Which of the following behaviors of a child
parent-client to you indicates understanding about the would lead the nurse that the patient is a victim of child
causes of the newborn’s diagnosis cystic fibrosis (CF)? abuse? The child
A. Does not answer the nurses’ questions. B. Facial anomalies
B. Does not maintain eye contact. C. Muscular incoordination
C. Tries to move away from the nurse D. Cognitive impairment
D. Does not cry when moved 71. A child with lead poisoning is expected to manifest signs
61. A nurse performs cardiopulmonary resuscitation on an related to
11-month-old infant. The nurse should assess for the A. Neurologic deficits
infant’s pulse on the: B. Cardiovascular involvement
A. carotid area C. temporal area C. Renal impairment
B. brachial area D. popliteal area D. Hepatic damage
62. Hypospadias is a congenital defect of the male genitalia 72. Which of the following statements is not accurate
where the urethral meatus is located at the regarding Tanner staging?
A. Tip of the penis A. It is a rating system for pubertal development
B. Ventral surface of the penis B. It is a biological marker of maturity
C. Dorsal surface of the penis C. It is based on the progressive development of
D. Side of the penis genitalia, breast and pubic hair in females
63. The nurse admits a 10-year-old child with rheumatic D. It is based on the progressive development of the
fever. Which of the following aspects in the child’s genitalia and pubic hair in males.
history the nurse should ask for a history of: 73. Which of the following developmental milestones or
A. Staphylococcal infection C. Strep throat behaviors is a characteristic of a toddler?
B. Influenza D. Chicken pox A. Magical thinking
64. A 10-month-old infant with phenylketonuria is being B. Assertion of independence
weaned from breast-feeding. In providing education to C. Compliance to parental rules
the parents, the nurse should emphasize the need to D. Cooperative play with siblings
restrict 74. A child with hiatal hernia may exhibit which of the
A. Vegetables and meat following clinical manifestations?
B. Grains and fruits A. Inguinal pain
C. Meats and dairy products B. Difficulty of breathing
D. Sugar and vegetables C. Abdominal pain
65. A child is to undergo nephrectomy for a removal of D. Intractable pain on the groin area
Wilm’s tumor. Which intervention should NOT be 75. The nurse is taking nursing history from a mother. The
included in the plan of care? infant displays discomfort by crying constantly, fussy
A. Provide pre-operative teaching to the child and behavior and pulling the left ear. Which of the following
parents. information gathered by the nurse would support the
B. Palpate the abdomen to assess for tenderness. admitting diagnosis of acute otitis media?
C. Assess vital signs and report hypertension. A. Sudden rise of temperature to 39 degrees C
D. Monitor urine for hematuria. B. Had colds and low grade fever for a number of days
66. A toddler is diagnosed with nephrotic syndrome. The C. Irritable and unable to consume scheduled feedings
nurse monitors the patients I&O and checks the urine D. Pain and itchiness of the ear canal
regularly. The nurse should expect to which of these 76. Three-year-old Benito has been admitted to the
findings? Pediatric Unit. His blood pressure 100/70 mmHg; pulse
A. Glycosuria C. Albuminuria rate, 110 beats per minute; temperature, 38C and
B. Ketonuria D. Polyuria weight, 18 kg. Impression: Nephrotic Syndrome. During
67. To prevent discoloration of the teeth of a 6-year-old his previous check-up at 2 ½ years-old, his blood
child with URTI, the physician should not prescribe pressure was 95/60 mmHg; PR was 100 beats per
A. Tetracycline C. Streptomycin minute and weighed 15 kg. Which assessment finding
B. Isonicotinic hydrazide D. Chloramphenicol would support the impression of nephrotic syndrome?
68. Recommended practices under the EINC protocol A. Weight C. Blood pressure
includes the following except: B. Temperature D. Pulse rate
A. skin-to-skin contact 77. Steven is diagnosed with acute lymphoid leukemia
B. properly timed cord clamping (ALL) and is beginning chemotherapy. Steven is
C. initiation of breastfeeding discharged from the hospital following his chemotherapy
D. drying the baby with oil treatments. Which statements of Steven’s mother
69. After the delivery of the baby, prevention of hypothermia indicates that she understands when she should contact
can be achieved by: the physician?
A. drying baby covering with clean dry cloth A. “I will call my doctor if Steven has persistent
B. applying small amounts of oil on the skin vomiting and diarrhea”
C. covering the baby with warm sterile cloth B. ”I should contact the physician if Steven has
D. positioning the baby on the mother’s abdomen difficulty in sleeping”
70. A newborn with fetal alcohol syndrome is NOT expected C. “My physician should be called is Steven is irritable
to manifest which of the following signs? and unhappy”
A. Low birth weight
D. “Should Steven have continues hair loss, I need to C. “Eat foods that are in rich in antioxidants and
call my doctor” phytochemicals.”
78. Wilma and another staff are talking on some important D. “Have you tried the herbal products in the market?”
reminders on the care of pediatric patients diagnosed 84. During hemodialysis, a patient with end-stage renal
with glomerulonephritis.When planning nursing care for disease (ESRD) suddenly becomes confused, restless
a 5-year-ld with acute glomerulonephritis, the nurse and verbally abusive. The nurse interprets this a sign of
realizes that the child needs help in understanding the A. helplessness
necessary restrictions, one of which is: B. disequilibrium syndrome
A. Isolation from other children with infections C. allergic reaction to the dialysate
B. Daily does of IM penicillin D. increased cerebral tissue perfusion
C. A bland diet high in protein 85. The nurse should be alert for potential complications
D. Bed rest for at least 4 weeks during the post-operative phase. Which of the following
79. The mother of a nine-month-old infant is concerned that manifestations possibly suggest a developing
the head circumference of her baby is greater than the complication?
chest circumference. The BEST response by the nurse A. temperature of 37.9 C, chills and cold clammy skin
is ; B. urine output of 120 cc for the past first four hours
A. “ These circumferences normally are the same, after surgery
but in some babies this just differs.” C. tachycardia and decreased blood pressure
B. “Perhaps your baby was small for gestational age D. shallow respirations and pulse oximeter reading of
or 95%
premature.“ 86. The nurse instilled 2,000 ml of dialysate on a patient for
C. “This is normal until the age of 1 year, when the peritoneal dialysis. During the draining time, the nurse
chest will be greater” observes a decreased output of only 550 ml. The next
D. “Let me ask you a few questions, and perhaps we best nursing action is to:
can figure out the cause of this difference.” A. document the output in the flow sheet
80. The nurse reads on the chart that a 5-month-old child B. turn the patient from side to side
has pectus carinatum. She recalls that this condition is C. report the output to the physician
characterized by a chest that D. infuse another bottle of dialysate
A. has equal antero-posterior and lateral diameters 87. A patient received spinal anesthesia 4 hours ago during
B. has a larger lateral diameter than the antero- surgery. The patient has been on the ward for 2 hours
posterior diameter and now reports severe incisional pain. The patient's
C. has an antero-posterior diameter that is larger than blood pressure is 170/90 mm Hg, pulse is 108
the lateral diameter beats/min, temperature is 37.2°C, and respirations are
D. has a depression in the sternum 30 breaths/min. The patient's skin is pale and the
dressing is dry and intact. The most appropriate nursing
MEDICAL-SURGICAL NURSING (70 points) intervention is to:
A. call the physician and report the findings
81. While you are obtaining an assessment and health B. medicate the patient for pain
history, which of the following statements will alert the C. place the patient in a high Fowler position and
nurse to a possible immunodeficiency disorder? administer oxygen
A. "I love walking several times a week with friends.' D. place the patient in a reverse Trendelenburg
B. “I had my chest x-ray 6 months ago when I had position and open the IV line
pneumonia.” 88. Bone marrow depression is an adverse effect of
C. “I had my spleen removed many years ago after a chemotherapy. Which of the following laboratory values
car accident.” indicate that the patient has bone marrow depression?
D. “I usually eat eggs or meat for at least 2 meals A. hemoglobin - 15.1 mg/dl
every day.” B. white blood cell - 4,500 mg/cc
82. The nurse’s action is appropriate if she does which of C. red blood cell - 4 million/ cc
the following nursing interventions in a patient with D. platelets - 90,000/cc
hypothyroidism? 89. A staff nurse is called to a client’s room. When the
A. Offer a high calorie diet. nurse arrived in the room, she noted that the waste
B. Increase fluid intake. basket is on fire. However, the client has been moved
C. Offer extra sheets or blankets to the patient. out of the room. Which of the following is the priority
D. Encourage the patient to take a bath twice a day. action of the nurse?
83. A client recovering from breast surgery asks you what A. Activate the fire alarm C. Evacuate the unit
type of food would fight “free radicals” to increase B. Extinguish the fire D. Confine the fire
protection from cancer. Your best response would be: 90. In planning care for a patient with Parkinson’s disease,
A. “Do you want reading materials in cancer fighting the nurse decides that the patient may need the most
food?” help with
B. “Foods rich in beta – carotene, vitamins A, C, E A. getting out of bed
seem to fight free radicals.” B. buttoning his shirt and pants
C. taking his medications 99. The most appropriate nursing action in the event of a
D. communicating with caregivers wound dehiscence is to
91. Understanding the risks of infection, who among the A. wear sterile gloves then attempt to push the organs
clients listed below should receive immediate attention back into the abdominal cavity
and care? B. cover the intestines with sterile dressing moistened
A. Adult female with Vitamin B deficiency due to with normal saline solution
chronic alcohol intake C. apply an abdominal binder to prevent protrusion of
B. Adult male with fresh second degree burns on arms abdominal organs
and chest D. cover the organs with a dry sterile dressing then
C. A teenager who is bleeding due to a cut on the notify the physician
finger 100. An assessment finding that is consistent with
D. An elderly male with diabetes mellitus and toe pancreatitis is the presence of
infection A. severe right upper quadrant pain
92. The most important nursing intervention in caring for a B. foul smelling stools
patient with a newly-placed nephrostomy tube is to C. palpable abdominal mass
A. clamp the tube every 4 hours D. blood in the urine
B. disinfect the surgical site every shift 101. The nurse assessing for risk factors for meningitis asks
C. flush the tube with normal saline, as ordered for the presence of which medical history?
D. monitor the surgical dressing for bleeding A. diabetes mellitus and anemia
93. A patient with stroke is put on Mannitol intravenously. B. tuberculosis and otitis media
The nurse evaluates the effectiveness of the drug by C. renal failure and urinary tract infection
noting which observation? D. hepatitis and pancreatitis
A. blood pressure increases 102. Which of the following observations will make the nurse
B. level of consciousness improves suspect of bleeding in a post-thyroidectomy patient?
C. urine output decreases A. The patient’s blood pressure increases and pulse
D. pupils are dilated and sluggishly reacting rate decreases.
94. Extreme hyperglycemia of uncontrolled diabetes mellitus B. The surgical dressing has a scant amount of sero-
results in: sanguineous drainage
A. Metabolic alkalosis C. A state of C. The patient is swallowing frequently.
dehydration D. The patient is drowsy and has slow shallow
B. Oliguria D. Weight gain respirations.
95. Which of these statements made by a mother during an 103. During the post-operative period for thyroidectomy, the
education session in the community tells the nurse that nurse observes muscle twitching on the patient’s arms
her child is prone to Hepatitis A infection? as the blood pressure is being taken. This may likely be
A. “I always prepare my child’s lunch for school.” an indication of:
B. “My child shares her lunch with her brother at A. hypocalcemia caused by accidental removal of the
recess.” parathyroid glands
C. “My son sometimes buys food from the street B. hypothermia due to the temperature inside the
vendor.” recovery room
D. “I remember when my daughter had a blood C. respiratory alkalosis due to inability to perform deep
transfusion.” breathing exercises
96. Early signs and/or symptoms of hepatitis include: D. seizures related to effects of general anesthesia
A. nausea, vomiting and abdominal pain and narcotics
B. fever, yellowish sclera and skin 104. A surgical procedure that involves removing a portion of
C. dark colored urine and diarrhea the stomach and anastomosing the remaining part with
D. ascites, difficulty breathing and swallowing the duodenum is called
97. For clients with diabetic ketoacidosis, their body A. total mastectomy C. bougeinage
compensate for the acidosis in many ways. When caring procedure
for these clients, which of the following manifestations B. Billroth I D. Billroth II
will you anticipate to observe? 105. The nurse taking care of a patient who underwent
1. Nausea and vomiting 3. Kussmaul gastrectomy with Billroth II should watch out for
brething complications associated with
2. Oliguria 4. Polyuria A. electrolyte imbalances C. dumping syndrome
A. 1 and 2 C. 3 and 4 B. hypoglycemia D. wound dehiscence
B. 1, 3 and 4 D. All of the above 106. A patient undergoing chemotherapy has the following as
98. Which of the following laboratory results tell the nurse his latest laboratory CBC results: RBC - 5 million/cc,
that a patient has acute liver failure? WBC-3,000/cc and platelets-180,000/cc. Based on
A. increased serum blood urea nitrogen level these results, the nurse should identify which nursing
B. decreased bilirubin level diagnosis?
C. increased aspartate transaminase level A. Activity intolerance
D. decreased alanine transaminase level B. Risk for infections
C. Impaired tissue perfusion 114. Patients with diabetic ketoacidosis (DKA) will more likely
D. Risk for injury exhibit the following changes in their arterial blood
107. Which patient statement made prior to discharge after gases (ABG):
an appendectomy needs further teaching? A. pH - 7.56, pCO2 - 60 mmHg, HCO3 - 15 meq/L
A. “I need to call the doctor if I develop fever.” B. pH - 7.40, pCO2 - 44 mmHg, HCO3 - 24 meq/L
B. “My incision will be painful and sore for a few C. pH - 7.34, pCO2 - 50 mmHg, HCO3 - 29 meq/L
days.” D. pH - 7.25, pCO2 - 30 mmHg, HCO3 - 19 meq/L
C. “I can resume my activities before surgery without 115. The nurse monitoring a patient in the acute care knows
restrictions.” that the intracranial pressure is increased by noting
D. “I should not see any drainage from the surgical which of these changes in vital signs?
wound.” A. T-40.1 C, BP-165/105 mmHg, RR-10 cpm, PR-58
108. The priority nursing diagnosis of a patient with Addison’s B. T-38.2 C, BP-140/90 mmHg, RR-14 cpm, PR-95
disease is C. T-37.4 C, BP-120/75 mmHg, RR-12 cpm, PR-75
A. Altered nutrition: less than body requirements D. T-36.2 C, BP-90/40 mmHg, RR-22 cpm, PR-115
B. Fluid volume deficit 116. The nurse should plan the diet of a patient with liver
C. Risk of blood glucose imbalance: hypoglycemia cirrhosis who has a normal ammonia level that is

D. Altered body image A. rich in calories C. high in fats


109. A nurse is circulating in an Exploratory Laparatomy for a B. low in proteins D. high in
Ruptured Appendicitis. The scrub nurse asks for sodium
"Normal Saline Solution(NSS) wash". The circulating 117. The nurse notifies the physician regarding a patient’s
nurse immediately opened one liter of NSS and began serum potassium of 7.1 meq/l. The physician orders
to pour to the sterile basin of the scrub nurse. Before intravenous glucose and insulin. This is to
she can empty the NSS container, the scrub nurse A. enhance renal excretion of potassium
signals "enough", What is the APPROPRIATE action B. promote cellular entry of potassium
with the remaining NSS? C. cause exchange of potassium with hydrogen ion in
A. Discard the remaining NSS. the intestines for excretion
B. Pour the remaining NSS to another sterile basin in D. treat hypoglycemia associated with the potassium
the back table imbalance
C. Cover the remaining NSS bottle aseptically right 118. The nurse monitors the vital signs of a patient at risk for
away. internal hemorrhage. Which set of vital signs reflects
D. Transfer the remaining NSS to smaller sterile that the patient is having hemorrhage?
container A. BP-150/90 mmHg, PR-110, RR-20, T-37.5 C
110. A patient is prepared for a fluid deprivation test. The B. BP-120/75 mmHg, PR-100, RR-16, T-36.9 C
nurse knows that this is used in the diagnosis of C. BP-90/50 mmHg, PR-55, RR-10, T-38.4
A. diabetes insipidus D. BP-90/45 mmHg, PR-120, RR-24, T-36.1 C
B. Cushing’s syndrome 119. A patient is anxious about her upcoming upper
C. Pheochromocytoma gastrointestinal series. The nurse attempts to allay the
D. syndrome of inappropriate anti-diuretic hormone patient’s anxiety by explaining that this procedure
111. The nurse encourages a patient with Addison’s disease involves
to have an adequate intake of which types of diet? A. insertion of a fiber optic tube to visualize the upper
A. high-sodium, high-calorie, low-potassium diet digestive organs
B. low-sodium, high-calorie, high-potassium diet B. getting an x-ray of the upper abdomen after
C. high-sodium, low-calorie, high-potassium diet ingestion of barium
C. visualization of the abdomen through a CT scan
D. low-sodium, low-calorie, low-potassium diet machine
112. The nurse’s action is appropriate if she prepares which D. thorough physical assessment of the upper
of the following pain medications for a patient gastrointestinal system
complaining of sharp abdominal pain due to 120. A patient with epilepsy is to undergo electroencephalo-
cholelithiasis? graphy (EEG) after breakfast. The nurse enters the
A. Morphine sulfate (MS Contin) patient room, sees the meal tray and tells the patient not
B. Meperidine hydrochloride (Demerol) to take the:
C. Mefenamic acid (Ponstan) A. slice of pineapple C. glassful of water
D. Butorphanon hydrochloride(Stadol) B. scrambled eggs D. cup of coffee
113. An important nursing intervention for patients with liver 121. A patient who has been diabetic for 15 years develops
cirrhosis is to neuropathy. Which of the following home care
A. provide diet that is low in calories and salt instructions will best prevent injury?
B. encourage the use of soft-bristled brush A. “Trim your toenails and in-growns every week to
C. massage the skin with alcohol prevent toe infections.”
D. administer Acetaminophen (Tylenol) for pain B. “Take hot shower on your own to promote self-care
and independence.”
C. “Make sure to clean the floor regularly before 4. Enema D. 2,4,6
walking barefoot.” 5. Shower
D. “Inspect inside your shoes before wearing them.” 6. Pain medication
122. Which of the following ECG readings indicate that a 129. For a client complaining of mild musculoskeletal pain,
patient has a myocardial infarction? the nurse will anticipate that the treatment for this
A. Suppressed ST segment C. Elevated T waves client’s level of discomfort will include which of the
B. Absence of P waves D. Pathologic Q waves following?
123. The nurse is monitoring the tracheostomy cuff pressure A. Ibuprofen C. Meperidine HCl
of a patient of mechanical ventilation. To minimize the B. Acetaminophen D. Fentanyl
risk of tracheal tissue necrosis the nurse should 130. Albert came to the hospital with chest pain and fever.
maintain the pressure to After a thorough assessment by the doctor he was
A. 10-15 mmHg C. 30-35 mmHg admitted for pericarditis management. The nurse
B. 20-25 mmHg D. 40-45 mmHg positions the client to reduce pain and discomfort.
124. A patient with fracture of the femur is on balanced Describe this position.
suspension traction. The nurse considers the following A. Semi-Fowelr’s position with one pillow to support
statements when taking care of a client with traction the head.
EXCEPT B. Put two pillows to elevate the head and one pillow
A. Steady pull from both directions keep the fractured under the knees.
bone in place. C. Sit the client upright and lean forward
B. Weights should be kept resting on the floor. D. Supine lying on either left or right side with one
C. Clients on traction need adequate skin care and pillow to elevate the head
proper positioning. 131. The nurse is aware that acromegaly is a condition when
D. Traction can be used to correct or prevent growth hormone occurs in excess. The following are the
deformities. typical features of the disorder EXCEPT
125. A client with cancer of the larynx undergoes total A. The soft tissues continue to grow
laryngectomy. Post-laryngectomy, which of the following B. Hands and feet are enlarged
will the nurse expect? C. The client grows taller
A. No risk of aspiration during swallowing; speech is D. Broad and bulbous nose
lost. 132. A 30-year-old client had cholesterol blood test before
B. Normal speaking, breathing and swallowing are admission to the hospital. The nurse in charge would
restored teach the family and significant others that the client
C. Unable to communicate with difficulty of swallowing should exercise to help keep the total cholesterol to a
and breathing normal level of
D. Permanent tracheostomy created; normal speech is A. 150-200 mg/dl C. 250-300 mg/dl
lost B. 200-250 mg/dl D. 300-350 mg/dl
126. After appendectomy, the client complained of 133. A 34-year-old female client with Grave’s disease was
abdominal pain, nausea and vomiting with abdominal admitted for treatment. The physician prescribed
distention. The nurse anticipates which of the following Propylthiouracil to treat the disorder. The client is to
priority management after referring to the surgeon? have surgery in 10 days. Lugol’s solution 4 gtts po was
A. Oropharyngeal suctioning prescribed for 10 days. The client asked the nurse for
B. Possible surgery the purpose of the drug. Which response of the nurse is
C. Endoscopy correct?
D. Rectal tube insertion A. It decreases the risk of bleeding.
127. Nurse Fely did her admission assessment on a patient B. It eliminates the needs to take hormone
with acute pancreatitis. She understands that the replacement.
abdominal pain associated with this disorder is C. It stabilizes your immune system to withstand
characterized as surgery.
A. Tenderness that is generalized in the upper D. It decreases the risk for thyroid crisis.
epigastric area 134. The nursing student reviews the laboratory findings of a
B. Pain in the left upper quadrant radiating to the left patient with polycythemia vera and finds which blood
shoulder results are elevated?
C. Tenderness and rigidity at the left hypogastric area A. RBC, WBC and platelets
radiating to the back B. WBC, platelet and cholesterol
D. Tenderness and rigidity at the upper right abdomen C. Bilirubin, RBC, and platelet
radiating to the midsternal area D. BP, WBC, and hematocrit
128. The client is scheduled to undergo appendectomy. 135. From the following data obtained from the chart, which
Preparation for appendectomy does not include which of is NOT a risk factor which could have predisposed the
the following? patient to breast cancer?
1. Intravenous infusion A. 2,3,4 A. Age – 55 years
2. Laxative B. 1,3,5 B. Height – 5’2”; weight – 160 lbs.
3. Pubic area shaving C. 2,3,5 C. Menarche at age 13
D. Mother died of colon cancer A. Her blood pressure decreased from 150/90 to
136. The nurse in the intensive care unit is closely watching a 130/80 mmHg
client for signs of hypovolemic shock. Which of the B. There is sediment and blood in Wanda’s urine
following should the nurse report as early signs of C. Wanda’s radial pulse is 105 beats per minute
hypovolemic shock? D. There are crackles audible throughout her lung
1. Lethargy A. 2,3,4 and 5 fields
2. Rapid pulse B. 1,2,3 and 5 143. Timothy, 56 years old, was admitted because of aortic
3. Clammy skin C. 1,2,5 and 6 aneurysm, fusiform type. The nurse recognizes which of
4. Cyanosis D. 1,3,4 and 6 the following as the correct description of the patient’s
5. Restlessness diagnosis?
6. Hematemesis A. Tear in the intima of the aorta with hemorrhage into
137. The nurse is aware that in acute respiratory distress the tunica media
syndrome (ARDS), the basic changes in the lungs result B. Stretching of both sides of the aorta
from injury to the alveolar wall and capillary membrane C. One-sided protrusion of one distinct area of the
leading to the following pathological changes EXCEPT aorta
A. Fluid and protein leaks into alveoli and interstitial D. Pulsating hematoma on three layers of the aorta
tissue 144. Of the following diagnostic tests prescribed by the
B. Elevated blood hydrostatic pressure physician, which of the following will the nurse expect to
C. Reduced colloid oncotic pressure show precise measurement of a cholelithiasis?
D. Increased alveolar capillary permeability A. Cholecystography
138. The nurse admitted a client because of pulmonary B. Chest x-ray
edema. He has a history of congestive heart failure, C. Abdominal ultrasonography
type 2 diabetes mellitus and hypertension. Based on the D. Cholangiography
history, the nurse noted that the patient regularly took 145. A client was rushed to the emergency department after
Losartan. What is the specific action of this drug? a vehicular accident where he had a traumatic head
A. Improves myocardial contractility, decreases the injury (TBI). To determine the client’s level of
heart rate, and reduces oxygen consumption consciousness, the Glasgow Coma Scale (GCS) is
B. Causes vasoconstriction, increased preload and used. Which of the following is a correct interpretation of
dilation of the ventricles the nurse of the GCS score?
C. Reduces peripheral vascular resistance and A. The higher the score, the higher is the probability of
afterload, reducing myocardial workload permanent damage
D. Interferes with the production of angiotensin II B. The lower the score is, the lower is the probability of
resulting in improved cardiac output and reducing delayed recovery
pulmonary congestion C. The higher the score, the greater is the impairment
139. Due to hypothalamic dysfunction, a syndrome of in the brain
inappropriate antidiuretic hormone develops. Which of D. The lower the score, the more serious is the brain
the following manifestations should the nurse watch injury
closely? 146. An immediate objective for nursing care of an
A. Increased urine output, decreased serum sodium overweight mildly hypertensive client with ureteral colic
B. Increased urine output, increased serum sodium and hematuria is to decrease
C. Decreased urine output, decreased serum sodium A. hypertension C. hematuria
D. Decreased urine output, increased serum sodium B. pain D. weight
140. Neutropenia often results from bone marrow depression 147. A client who had a craniotomy has an increased
as an adverse effect of chemotherapy. As a nurse, you intracranial pressure. Which of the following
should observe for the following symptoms that include interventions can the nurse include in the plan of care to
A. Headache, dizziness, blurred vision control intracranial pressure?
B. Severe sore throat, bacteremia, hepatomegaly A. Maintain his head and neck in neutral alignment
C. Petechiae, ecchymosis, epistaxis B. Initiate measures to enhance valsalva maneuver
D. Weakness, easy fatigability, pallor C. Administer O2 to maintain paCO2 >50 mmHg
141. Joseph has been receiving diuretic therapy and is D. Elevate head of the bed to 60-90 degrees
admitted to the hospital with a serum potassium level of 148. The ER nurse is assessing a client who had a closed
3.1 meq/L. Of the following medications that he has chest injury. Which of the following will the nurse do to
been taking at home, which will you be most concerned assess subcutaneous emphysema?
about? A. Observe for signs of unequal chest expansion.
A. Oral digoxin (Lanoxin) 0.25 mg daily B. Auscultate the lungs and observe for crackles.
B. Lantus insulin 23 U subcutaneously every evening C. Palpate neck for air bubble-popping sensation
C. Ibuprofen (Motrin) 400 mg every 6 hours D. Percuss for a hyperresonant percussion tone
D. Metoprolol (Lopressor) 12.5 mg orally daily 149. The nurse recognizes that adjuvant chemotherapy for
142. The nurse administered 3% saline to a patient who has cancer management may include any of the following
a serum sodium level of 124 meq/L. Which assessment EXCEPT
finding may develop as a result of the treatment? A. Monoclonal antibody C. Antitumor antibiotics
B. Proton inhibitors D. Hormonal 157. Which of the following describes the cognitive theory as
preparations a model of psychiatric care?
150. The nurse teaches a group of clients the difference A. The nurse enforces limit setting on the patient’s
between Type I (IDDM) and Type II (NIDDM) diabetes. inappropriate behavior.
Which of the following is true? B. The therapist delves into the past life of the client to
A. Both types diabetes mellitus clients are all prone to assess her childhood experiences.
developing ketosis. C. The psychologist assesses and corrects the client’s
B. Type II (NIDDM) is more common and is also distorted and negative thinking.
preventable compared to Type I (IDDM) diabetes D. The psychiatrist prescribes anti-anxiety medications
which is genetic in etiology. to a client with panic disorder.
C. Type I (IDDM) is characterized by fasting 158. Crisis is self-limiting. How many weeks does it usually
hyperglycemia. last?
D. Type II (IDDM) is characterized by abnormal A. 4-6 B. 2-4 C. 6-8 D. 8-
immune response. 10
159. What is the priority assessment during the initial phase
of crisis intervention?
MENTAL HEALTH & PSYCHIATRIC NURSING (50 items) A. Client’s support system
B. Individual and the problem
151. Mental health is defined as: C. Plan coping with the crisis
A. The ability to distinguish what is real from what is D. Type of crisis the client is experiencing
not. 160. The nurse initiates the nurse-client relationship with
B. A state of well-being where a person can realize his Marta. Which of the following is the least appropriate
own abilities, can cope with normal stresses of life topic during the orientation phase?
and work productively. A. Establishment of regular schedule for interaction
C. Is the promotion of mental health, prevention B. Exploration of the client’s inadequate coping
of mental disorders, nursing care of patients during mechanism
illness and rehabilitation C. Objectives of the nurse-patient interaction
D. Absence of mental illness D. Perception of the client of the reason for her
152. Liza says, “Give me 10 minutes to recall the name of hospitalization
our college professor who failed many students in our 161. Lalaine, a 29 year-old married woman believes that the
anatomy class.” She is operating on her: doorknobs are contaminated and she touches them only
A. Subconscious C. Conscious with tissue paper. Which of the following is the most
B. Unconscious D. Ego appropriate nursing diagnosis that the nurse should
153. Primary level of prevention in psychiatric nursing is identify?
exemplified by: A. Anxiety, moderate
A. Helping the client resume self care. B. Impaired adjustment
B. Ensuring the safety of a suicidal client in the C. Ineffective coping
institution. D. Self-esteem disturbance
C. Teaching the client stress management techniques 162. Which of the following is the rationale for allowing a
D. Case finding and surveillance in the community client with obsessive-compulsive personality to continue
154. The therapeutic approach in the care of an autistic child her ritualistic behavior?
include the following EXCEPT: A. To prevent increasing her level of anxiety
A. Engage in diversionary activities when acting -out B. To encourage independence
B. Provide an atmosphere of acceptance C. To protect her from physical harm
C. Provide safety measures D. To increase her self-esteem and confidence
D. Rearrange the environment to activate the child 163. Which of the following is the appropriate nursing
155. A 10 year old child has very limited vocabulary and intervention to reduce anxiety and the need for ritualistic
interaction skills. She has an I.Q. of 45. She is behavior?
diagnosed to have Mental retardation of this A. Encourage the client to examine own perceptions.
classification:
A. Profound C. Moderate B. Encourage the client to use problem-solving skills.
B. Mild D. Severe C. Focus on the strengths and potential of the client.
156. A client with organic brain disorder is exhibiting changes
in behavior. What behavior or action will alert the nurse D. Provide opportunities to express feeling.
that the patient may be experiencing delirium? 164. The following statements are true about anxiety, except:
A. Daytime sleepiness and night time incontinence A. Anxiety is a response to a specific negative
B. The client becomes confused within 24 hours from stimulus.
admission. B. Mild anxiety is useful in bringing about better
C. Depression alternating with periods of cheerfulness performance.
D. Depression and inability to get out of bed to do C. Persons use defense mechanisms to cope with
activities of daily living their anxiety.
D. Persons who are anxious resort to flight or fight D. Rapid change of mood
mechanism. 172. In taking care of schizophrenic patients, which of the
165. Four days after admission, Mr. Lee says to the nurse, “I following nursing interventions should the nurse
want to go home. I’m alright.” Which of the following is consider?
the most therapeutic response of the nurse? A. Always agree with the patient’s ideas.
A. “Alright you may go home if you want to.” B. Make use of short phases and specific words.
B. “I know it must be difficult for you to stay in the
hospital.” C. Use carefully detailed explanation.
C. “Why do you want to go home?” D. Use sign language to be understood clearly.
D. “You are not yet ready to go home, Mr. Lirio” 173. One morning, Paul says, “I hear Jose Rizal’s voice.”
166. When should the rehabilitation of a newly admitted Which of the following statements is the most
schizophrenic patient start? therapeutic?
A. Before discharge A. “I don’t hear the voice, but I know you hear what
B. During the recovery stage sounds like a voice.”
C. In the acute stage of his illness B. “No need to worry about the voice. It doesn’t
D. Upon admission belong to anybody alive.”
167. A client with major depression is to be discharged. C. “That could not be true. Jose Rizal has been
Which of the following areas would be most important dead for so many years.”
for the nurse to review with the client? D. “You should ignore that voice. It would not help
A. Conflict with another client you get well.”
B. Medication management 174. Which of the following drugs should the nurse expect to
C. Plans of returning to work be prescribed in order to reverse Parkinson-type
D. Results of psychological testing symptoms in a client receiving anti-psychotic
168. Which of the following disorders may be seen medication?
concurrently in a client with generalized anxiety A. Benztropine (Cogentin)
disorder? B. Chlordiazepoxide (Librium)
A. Bipolar disorder C. Haloperidol (Haldol)
B. Gender identity disorder D. Propanolol (Inderal)
C. Panic disorder 175. Which of the following is the most appropriate nursing
D. Schizoaffective disorder diagnosis for a client reporting thoughts of being
169. A female victim of sexual assault went to the crisis followed by CIA agents?
center for her third visit. She was raped 3 months ago A. Disturbed sensory perception related to increased
and states that she feels as if the rape just happened anxiety
yesterday. What would be the best response of the B. Disturbed thought processes related to increased
nurse? anxiety
A. “In time, our goal will help you move on from these C. Impaired verbal communication related to
strong feelings about your rape.” disordered thinking
B. “It’s been over for 2 months now. Be realistic.” D. Altered thought content related to mistrust
C. “Tell me more about what happened during the 176. A client with paranoid schizophrenia repeatedly uses
rape that causes you now to feel like the rape just profanity during an activity therapy session. Which
occurred.” response by the nurse would be most appropriate?
D. “What can you do to alleviate some of your fears A. “Your behavior won’t be tolerated. Go to your room
without being assaulted again?” immediately.”
170. Since admission 3 days ago, a female client has refused B. “You’re just doing this to get back at me for making
to take a shower, stating, “There are poisonous spiders you come to therapy.”
hidden in the shower head. I will get bitten by them and C. “Your cursing is interrupting the activity. Take time
get killed if I take a shower!” How should the nurse out in your room for 10 minutes.”
respond? D. “I’m disappointed in you. You can’t control yourself
A. Accept the fear and allow the client to take a even for a few minutes.”
sponge bath instead. 177. The nurse is assigned to a client with catatonic
B. Ask a security guard to assist in giving the client a schizophrenia. Which intervention should the nurse
bath. include in the client’s plan of care?
C. Dismantle the shower head and show the client that A. Meeting all of the client’s physical needs
there is nothing in it. B. Giving the client an opportunity to express concerns
D. Tell her that the other clients complain about her C. Administering lithium carbonate (Lithonate) as
body odor, so she must take a shower. prescribed
171. The characteristic traits of schizophrenia include the D. Providing a quiet environment where the client can
following except: be alone
A. Blunting of affect 178. A client, age 36, with paranoid schizophrenia believes
B. Existence of two feeling tones the room is bugged by the Central Intelligence Agency
C. Loose association and that his roommate is a foreign spy. The client has
never had a romantic relationship, has no contact with A. Turning on the lights and opening the windows so
family members, and hasn’t been employed in the last that the client doesn’t feel crowded.
14 years. Based on Erikson’s theories, the nurse should B. Leaving the client alone.
recognize that this client is in which stage of C. Staying with the client and speaking in short
psychosocial development? sentences.
A. Autonomy versus shame and doubt D. Turning on stereo music.
B. Generativity versus stagnation 185. The nurse is teaching a new group of mental health
C. Integrity versus despair aides. The nurse should teach the aides that setting
D. Trust versus mistrust limits is most important for:
179. During a group therapy session in the psychiatric unit, a A. A depressed client. C. A suicidal client.
client constantly interrupts with impulsive behavior and B. A manic client. D. An anxious client.
exaggerated stories that cast her as a hero or princess. 186. The nurse is caring for a client, a Vietnam veteran, who
She also manipulates the group with attention-seeking exhibits signs and symptoms of posttraumatic stress
behaviors, such as sexual comments and angry disorder. Signs and symptoms of posttraumatic stress
outbursts. The nurse realizes that these behaviors are disorder include:
typical of: A. Hyper alertness and sleep disturbances.
A. Narcissistic personality disorder. B. Memory loss of traumatic event and somatic
B. Avoidant personality disorder. distress.
C. Histrionic personality disorder. C. Feelings of hostility and violent behavior.
D. Borderline personality disorder. D. Sudden behavioral changes and anorexia.
180. A client is admitted to a psychiatric facility with a 187. A client is admitted for detoxification after a cocaine
diagnosis of chronic schizophrenia. The history overdose. The client tells the nurse that he frequently
indicates that the client has been taking neuroleptic uses cocaine but that he can control his use if he
medication for many years. Assessment reveals unusual chooses. Which coping mechanism is he using?
movements of the tongue, neck, and arms. Which A. Withdrawal C. Repression
condition should the nurse suspect? B. Logical thinking D. Denial
A. Tardive dyskinesia 188. A client with bipolar disorder is being treated with lithium
B. Dystonia for the first time. The nurse should observe the client for
C. Neuroleptic malignant syndrome which common adverse effect of lithium?
D. Akathisia A. Sexual dysfunction C. Polyuria
181. The nurse is caring for a client who is suicidal. When B. Constipation D. Seizures
accompanying the client to the bathroom, the nurse 189. A client is admitted for an overdose of amphetamines.
should: When assessing this client, the nurse should expect to
A. Give him privacy in the bathroom. see:
B. Allow him to shave. A. Tension and irritability. C. Hypotension
C. Open the window and allow him to get some fresh B. Slow pulse. D. Constipation.
air. 190. During a shift report, the nurse learns that she’ll be
D. Observe him. providing care for a client who is vulnerable to panic
182. The nurse is developing a care plan for a client with attack. Treatment for panic attacks includes behavioral
anorexia nervosa. Which action should the nurse therapy, supportive psychotherapy, and medication
include in the plan? such as:
A. Restrict visits with the family until the client begins A. barbiturates. C. depressants.
to eat. B. antianxiety drugs. D. amphetamines.
B. Provide privacy during meals. 191. A client has been receiving chlorpromazine (Thorazine),
C. Set up a strict eating plan for the client. an antipsychotic, to treat his psychosis. Which finding
D. Encourage the client to exercise, which will reduce should alert the nurse that the client is experiencing
her anxiety. pseudoparkinsonism?
183. A client whose husband recently left her is admitted to A. Restlessness, difficulty sitting still, pacing
the hospital with severe depression. The nurse suspects B. Involuntary rolling of the eyes
that the client is at risk for suicide. Which of the C. Tremors, shuffling gait, mask like face
following questions would be most appropriate and D. Extremity and neck spasms, facial grimacing, jerky
helpful for the nurse to ask during an assessment for movements
suicide risk? 192. A 54-year-old female was found unconscious on the
A. “Are you sure you want to kill yourself?” floor of her bathroom with self-inflicted wrist lacerations.
B. “I know if my husband left me, I’d want to kill myself. An ambulance was called and the client was taken to
Is that what you think?” the emergency department. When she was stable, the
C. “How do you think you would kill yourself?” client was transferred to the inpatient psychiatric unit for
D. “Why don’t you just look at the positives in your observation and treatment with antidepressants. Now
life?” that the client is feeling better, which nursing
184. The nurse is caring for a client experiencing an anxiety intervention is most appropriate?
attack. Appropriate nursing interventions include: A. Observing for extrapyramidal symptoms
B. Beginning a therapeutic relationship 199. The objectives and activities that the nurse plans
C. Canceling any no-suicide contracts depend on the various stages of a therapeutic
D. Continuing suicide precautions relationship. Which is the following is the most
193. A 26-year-old male reports losing his sight in both eyes. appropriate during the orientation phase?
He’s diagnosed as having a conversion disorder and is A. patients perception on the reason of her
admitted to the psychiatric unit. Which nursing hospitalization
intervention would be most appropriate for this client? B. identification of more effective ways of coping
A. Not focusing on his blindness C. exploration of inadequate coping skills
B. Providing self-care for him D. establishment of regular meeting of schedules
C. Telling him that his blindness isn’t real 200. Freud stresses out that the EGO
D. Teaching eye exercises to strengthen his eyes A. Distinguishes between things in the mind and things
194. A client is being admitted to the substance abuse unit in the reality.
for alcohol detoxification. As part of the intake interview, B. Moral arm of the personality that strives for
the nurse asks him when he had his last alcoholic drink. perfection than pleasure.
He says that he had his last drink 6 hours before C. Reservoir of instincts and drives
admission. Based on this response, the nurse should D. Control the physical needs instincts.
expect early withdrawal symptoms to:
A. Not occur at all because the time period for their
occurrence has passed.
B. Begin anytime within the next 1 to 2 days.
C. Begin within 2 to 7 days.
D. Begin after 7 days.
195. The nurse is caring for an adolescent female who
reports amenorrhea, weight loss, and depression. Which
additional assessment finding would suggest that the
woman has an eating disorder?
A. Wearing tight-fitting clothing
B. Increased blood pressure
C. Oily skin
D. Excessive and ritualized exercise
196. In teaching a client about Alcoholics Anonymous, the
nurse states that Alcoholics Anonymous has helped in
the rehabilitation of 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.
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.”
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.

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