Sas 1 60 Multiple Choice Converted Compressed

SAS1
1. This aims to transform our world and to improve people’s lives and prosperity on a healthy planet.
Sustainable Developmental Goals
2. This aims to eradicate poverty, hunger, illiteracy and disease.

3.The following are Pillars of the 2020 National Health Goals, SELECT ALL THAT APPLY
Increase quality and years of healthy life

Eliminate health disparities
4. Which of the following is one of 4 Provisions of Maternal and Child Health Nursing Practice Throughout the
Childbearing‒Childrearing Continuum?
Provision of nursing care of children from birth through adolescence
5. A part of a wider 2030 Agenda for Sustainable Development that applies to all countries through partnerships
and peace
6. The following are Legal Considerations Specific to Maternal-Child Nursing Practice. SELECT ALL THAT APPLY
A. Informed consent related to fetal well-being

B. Informed consent and legal guardianship for procedures performed on children
C. Length of time between healthcare incident and child’s ability to bring lawsuit
D. Identifying and reporting suspected child abuse
E. Concepts of “wrongful birth”, “wrongful life,” and “wrongful conception”
7. Which of the following is the Scope of Nursing Practice that is stated at Philippine Nursing Act of 2002?
It states that the Nursing practice is a holistic approach, the ideal functions of being a nurse, collaborator of care,
provider of health care education, nurse educator and finding more evidence-based practice by being a
nurseresearcher.
8. The following are Steps of Nursing Process, EXCEPT
Health Restoration
9. All but one are Statistics related to the Measurement of Maternal and Child Health.
This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 1 of 2
Paternal Death Rate
10. The following are part of Sustainable Developmental Goals, EXCEPT
Improve Maternal Health
Sas 2
1. Amy Alvarez, 26 years of age, is pregnant with her first child and is experiencing significant stress following
her recent diagnostic findings. The nurse would be providing high-quality care if completing which of the
following?
Described genetics in a way that directly meets her learning needs
2. f it is predicted during a pregnancy that a couple will have a child with Down syndrome, the couple is
asked to make a choice whether they want to continue the pregnancy or terminate it at that point. To
discover how couples feel about having a child with Down syndrome, researchers surveyed 2,044 parents
on the mailing lists of six nonprofit Down syndrome organizations. The majority of parents reported they
are happy with their decision to have their child and find their sons and daughters great sources of love
and pride. Ninety-nine percent reported they love their affected son or daughter, 97% reported being
proud of them, 79% felt their outlook on life was more positive because of them, only 5% felt embarrassed
by them, and only 4% regretted having them. In a following study, siblings also reported their relationship
with their affected sibling as a positive one. Less than 10% felt embarrassed, and less than 5% expressed a
desire to trade their sibling in for another brother or sister (Skotko, Levine, & Goldstein, 2011a, 2011b).
Based on the findings of the previous studies, how would the nurse answer Mrs. Alvarez’s question, “Can
you imagine how this will change my life?”
“Would it help if you talk to a family who has a child with Down syndrome?”
3. Amy Alvarez’s child is born with Down syndrome. What is a common physical feature of newborns with this
disorder that the nurse would want all of the team members to recognize?
An unusual pattern of palm creases
4. A woman is aware that she is the carrier of a sex-linked recessive disease (Hemophilia A): her husband is free of
the disease. What frequency of this disease could she expect to see in her children?
There is a 50% chance her male children will inherit the disease.
5. The nurse is caring for a child with Down syndrome (trisomy 21). This is an example of which type of
inheritance?
Chromosome nondisjunction

6. The nurse prepares a couple to have Karyotype performed. What describes a karyotype?
A visual representation of the chromosome pattern of an individual
7.A nurse is interviewing a couple who has come for a preconception visit. The couple asks the nurse about
inheritance and how it occurs. When describing the concept of genes and inheritance, the nurse explains that a
gene that is expressed when paired with another gene for the same trait is called:
Dominant
8. Down syndrome may occur because of a translocation defect. This means the
Additional chromosome was inherited because it was attached to a normal chromosome
9. Both people in a married couple carry the recessive gene for cystic fibrosis. When asked about the incidence of
any children developing the disorder, what should the nurse respond?
There is a 1 in 4 chance.”
10. When assessing a newborn identified genetically as 46XY21+, What can the nurse expect to note on the
assessment findings? Select all that apply
Poor muscle tone
Palmar crease
Protruding tongue
Sas 3
1. Which of the following arteries primarily feeds the anterior wall of the heart?
Left anterior descending artery
2. When do coronary arteries primarily receive blood flow?

During diastole
3. Which of the following illnesses is the leading cause of death in the US?
Coronary artery disease
4. Which of the following conditions most commonly results in CAD?

Atherosclerosis
5.Atherosclerosis impedes coronary blood flow by which of the following mechanisms?
Plaques obstruct the artery
6. Which of the following risk factors for coronary artery disease cannot be corrected?
Heredity
7. Exceeding which of the following serum cholesterol levels significantly increases the risk of coronary
artery disease?
200 mg/dl
8. Which of the following actions is the first priority care for a client exhibiting signs and symptoms of
coronary artery disease?
Enhance myocardial oxygenation
9. Medical treatment of coronary artery disease includes which of the following procedures?
Oral medication administration
10. . Prolonged occlusion of the right coronary artery produces an infarction in which of the following areas of
the heart?
inferior
Sas 4
1. A 34-year-old female is currently 16 weeks pregnant. You’re collecting the patient’s health history. She has
the following health history: gravida 5, para 4, BMI 28, hypertension, depression, and family history of Type 2
diabetes. Select below all the risk factors in this scenario that increases this patient’s risk for developing
gestational diabetes? SELECT ALL THAT APPLY
34-years-old
Gravida 5, para 4
BMI 28
Family history of Type 2 diabetes
2. When do most patients tend to develop gestational diabetes during pregnancy?

usually during the 2-3 trimester of pregnancy

3. You’re providing an educational class for pregnant women about gestational diabetes. You discuss the role
of insulin in the body. Select all the CORRECT statements about the role and function of insulin
Insulin is a hormone secreted by the beta cells of the pancreas.”

“Insulin influences cells by causing them to uptake glucose from the blood.”
4. A 32-year-old female is diagnosed with gestational diabetes. As the nurse you know that what test below is
used to diagnose a patient with this condition?
3 hour glucose tolerance test
5. A 26-year-old pregnant female is diagnosed with gestational diabetes at 28 weeks gestation. You’re
educating the patient about this condition. Which statement by the patient demonstrates they understood
your teaching about gestational diabetes?
It is important I try to get my fasting blood glucose around 70-95 mg/dL and <140 mg/dL 1 hour after meals.”
6. . Fill-in the blank: When a woman develops gestational diabetes it is during a time in the pregnancy when
insulin sensitivity is _____________. This is majorly influenced by hormones such as estrogen, progesterone,
_______________ and _______________.
low; human placental lactogen (hPL) and cortisol
7. Your patient is 36 weeks pregnant and has gestational diabetes. Which lab result below is euglycemic?
Blood glucose 82mg/dl
8. A patient has gestational diabetes and is currently 34 weeks pregnant. Which assessment findings below
should you immediately report to the physician? Select all that apply:
Blood pressure 190/102

Proteinuria
9 A patient is 35 weeks pregnant. She has gestational diabetes and uncontrolled hyperglycemia. Her current
blood glucose is 290 mg/dL. You administer insulin per physician’s order and recheck the blood glucose level
per protocol. It is now 135 mg/dL. Which statement by the patient requires you to notify the physician?
. “It burns when I urinate.”
10. A baby is born at 37 weeks gestation to a mother with gestational diabetes. As the nurse you know at birth
that the newborn is at risk for? Select all that apply:
Hypoglycemia
Respiratory distress

SAS 5
1. Nurse Robina has observed her pregnant co-worker arriving to work drunk at least three times in the past
month. Which action by Nurse Robina would best ensure client safety and obtain necessary assistance for
the co-worker?
A. Ignore the co-worker’s behavior, and frequently assess the clients assigned to the co-worker.
B. Make general statements about safety issues at the next staff meeting.
C. Report the coworker’s behavior to the appropriate supervisor.
D. Warn the co-worker that this practice is unsafe.
2. Maxima, a 24-year-old pregnant woman is being treated in a chemical dependency unit. She tells the nurse
that she only uses drugs when under stress and therefore does not have a substance problem. Which
defense mechanism is the client using?
A. Compensation
B. Denial
C. Suppression
D. Undoing
3. Nurse Tara is teaching a Chrisanta Agas about substance abuse. She explains that a genetic component
has been implicated in which of the following commonly abused substances?
A. Alcohol
B. Barbiturates
C. Heroin
D. Marijuana
4. Gianna a 22-year old pregnant woman, who is a chronic alcohol abuser is being assessed by Nurse Gina.
Which problems are related to thiamin deficiency?
A. Cardiovascular symptoms, such as decreased hemoglobin and hematocrit levels
B. CNS symptoms, such as ataxia and peripheral neuropathy
C. Gastrointestinal symptoms, such as nausea and vomiting
D. Respiratory symptoms, such as cough and sore throat
5. Which medication is commonly used in treatment programs for heroin abusers to produce a non-euphoric
state and to replace heroin use?
A. Diazepam
B. Carbamazepine
C. Clonidine
D. Methadone
6. Nurse Christine is teaching a pregnant adolescent women health class about the dangers of inhalant abuse;
the nurse warns about the possibility of:
A. Contracting an infectious disease, such as hepatitis or AIDS
B. Recurrent flashback events
C. Psychological dependence after initial use
D. Sudden death from cardiac or respiratory depression
7. The newly hired Nurse at Medical Center is assessing a pregnant client who abuses barbiturates and
benzodiazepine. The nurse would observe for evidence of which withdrawal symptoms?
A. Anxiety, tremors, and tachycardia
B. Respiratory depression, stupor, and bradycardia
C. Muscle aches, cramps, and lacrimation

D. Paranoia, depression, and agitation
8. The Nurse practicing primary prevention of alcohol abuse would target which groups for educational
efforts? A. Adolescents in their late teens and young adults in their early twenties
B. Elderly men who live in retirement communities
C. Women working in careers outside the home
D. Women working in the home
9. Lheren is reviewing her lessons in Pharmacology. She is aware that the general classification of
drugs belonging to the opioid category is analgesic and:
A. Depressant.
B. Hallucinogenic.
C. Stimulant.
D. Tranquilizing.
10. During an initial assessment of a pregnant client admitted to a substance abuse unit for detoxification
and treatment, the nurse asks questions to determine patterns of use of substances. Which of the
following questions are most appropriate at this time? Select all that apply. A. How long have you used
substances?
B. How often do you use substances?
C. How do you get substances into your body?
D. Do you feel bad or guilty about your use of substances?
E. How much of each substance do you use?
F. Have you ever felt you should cut down substance use?
G. What substances do you use?
Sas 6
1. Which of the following is TRUE in Rh incompatibility?
A. The condition can occur if the mother is Rh(+) and the fetus is Rh(-)
B. Every pregnancy of a Rh(-) mother will result to erythroblastosis fetalis
C. On the first pregnancy of the Rh(-) mother, the fetus will not be affected
D. RhoGam is given only during the first pregnancy to prevent incompatibility
2. Which of the following conditions can be triggered by Rh incompatibility between mother and fetus?
A. Hyperemesis Gravidarum
B. Hemolytic disease of the newborn
C. Gestational Diabetes
D. Ectopic Pregnancy
3. Which of the following maternal/fetal blood types can lead to hemolytic disease of the newborn?
A. Rh negative mother, Rh negative fetus
B. Rh negative mother, Rh positive fetus
C. Rh positive mother, Rh negative fetus
D. Rh positive mother, Rh positive fetus
4. What treatment can prevent the development of sensitization to Rh-D antigen in an Rh negative mother
carrying an Rh positive fetus?
A. Short-course immunosuppressant treatment
B. Therapeutic abortion
C. Rho(D) immune globulin
D. Rh-D fetal serum injections
5. You’re educating a group of outpatients about ABO blood typing and compatibility. Which statement is
INCORRECT?
A. A person with B- blood can donate to people with either B- or AB- blood.

B. A person with B- blood can receive blood from donors with O- and B- blood.
C. A person with O- blood can donate to every blood type regardless of the RH factor.
D. A person with AB+ blood can only donate to other people with either AB+ or AB- blood.
6. A 26 year old female is 27 weeks pregnant with her second child. The woman is A-. As the nurse you know
that:
A. If the patient was A+ she would need to receive RhoGAM.
B. The patient will need to receive RhoGAM during this visit to prevent hemolytic disease of the newborn.
C. The baby will need to receive RhoGAM after it’s born.
D. Since the mother is A- the baby can be Rh positive, which could lead to an immune attack on the
mother’s body
7. The nurse is instructing an unlicensed health care worker on the care of the client with HIV who also has
active genital herpes. Which statement by the health care worker indicates effective teaching of standard
precautions?
A. ''I need to know my HIV status, so I must get tested before caring for any clients."
B. ''Putting on a gown and gloves will cover up the itchy sores on my elbows.''
C. ''Washing my hands and putting on a gown and gloves is what I must do before starting care.''
D. “'I will wash my hands before going into the room, and then put on gown and gloves only for direct
contact with the client's genitals."
8. Which statement made to the nurse by a health care worker assigned to care for the client with HIV
indicates a breach of confidentiality and requires further education by the nurse?
A. ''I told the family members they needed to wash their hands when they enter and leave the
room.''
B. ''The other health care worker and I were out in the hallway discussing how we were concerned
about getting
HIV from our client, so no one could hear us in the client's room.''
C. ''Yes, I understand the reasons why I have to wear gloves when I bathe my client.'' D. ''The
client's spouse told me she got HIV from a blood transfusion.''
9. Which interventions does the home health nurse teach to family members to reduce confusion in the
client diagnosed with AIDS dementia? (Select all that apply.) A. Report any behavior changes.
B. Use the Glasgow Coma Scale on a daily basis.
C. Change the decorations in the home according to the season.
D. Put the bed close to the window.
E. Write out all instructions and have the client read them over before performing a task.
F. Ask the client when he or she wants to shower or bathe.
G. Mark off the days of the calendar, leaving open the current date.
H. For continuity, the primary caregiver should be the only person reorienting the client.
10. The home health nurse is making an initial home visit to the client currently living with family members
after being hospitalized with pneumonia and newly diagnosed with AIDS. Which statement by the nurse
best acknowledges the client's fear of discovery by his family?
A. ''Do you think that I could post a sign on your bedroom door for everyone about the need to wash their hands?''
B. ''Is there somewhere private in the home we can go and talk?''
C. ''I hope that all of your family members know about your disease and how you need to be protected, since you
have been so sick.''
D. ''It is your duty to protect your family members from getting AIDS.''
Sas 7
1. A mother asks the nurse if her child’s iron deficiency anemia is related to the child’s frequent
infections.
The nurse responds based on the understanding of which of the following?

A. Little is known about iron-deficiency anemia and its relationship to infection in children.
B. Children with iron deficiency anemia are more susceptible to infection than are other children.
C. Children with iron-deficiency anemia are less susceptible to infection than are other children.
D. Children with iron-deficient anemia are equally as susceptible to infection as are other children.
2. Which statements by the pregnant woman would lead the nurse to suspect that the she has
irondeficiency anemia? Select all that apply.
A. “I drinks over 3 cups of milk per day.”
B. “I can’t keep enough apple juice in the house; I drink over 10 ounces per day.” C. “I do not want to eat
more than 2 different kinds of vegetables.”
D. “I do not like meat, but I can eat small amounts
of it.” E. “I sleep 12 hours every night and take a 2-
hour nap.”
3. Which of the following foods would the nurse encourage the pregnant mother with iron deficiency
anemia?
A. Rice cereal, whole milk, and yellow vegetables
B. Potato, peas, and chicken
C. Macaroni, cheese, and ham
D. Pudding, green vegetables, and rice
4. A pregnant woman is admitted with iron- deficiency anemia and has been receiving iron
supplementation. The patient voices concern about how their stool is dark black. As the nurse you
would? A. Notify the doctor
B. Hold the next dose of iron
C. Reassure the patient this is a normal side effect of iron
supplementation
D. D. None of the options are correct
5. A 21-year old client. 6 weeks' pregnant is diagnosed with hyperemesis gravidarum. This excessive
vomiting during pregnancy will often result in which of the following conditions?
A. Bowel perforation
B. Electrolyte Imbalance
C. Miscarriage
D. Pregnancy Induced Hypertension
6. A 25 y.o. has arrives to the ER with c/o cramping abdominal pain and mild vaginal bleeding. Pelvic
exam shows a left adnexal mass that's tender when palpated. Culdocentesis shows blood in the
culdesac. This client probably has which of the following conditions?
A. Abruptio placentae
B. Ectopic pregnancy
C. Hydatidiform mole
D. Pelvic Inflammatory Disease
7. A woman is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled.
Preoperatively, which of the following goals is MOST important for the nurse to include on the client’s
plan of care?
A. Fluid replacement
B. Pain relief
C. Emotional support
D. Respiratory therapy
8. The client with hyperemesis gravidarum is at risk for developing:

A. Respiratory alkalosis without dehydration
B. Metabolic acidosis with dehydration

C. Respiratory acidosis without dehydration
D. Metabolic alkalosis with dehydration
E. A client is being admitted to the antepartum
9. Which of the following statements best describes hyperemesis gravidarum?

A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other
medical problems.
B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence
of other medical problems.
C. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing
maternal nutrients
D. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding
10. The main reason for an expected increased need for iron in pregnancy is:
A. The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the
fetal requires about 350-400 mg of iron to grow
B. The mother may suffer anemia because of poor appetite
C. The fetus has an increased need for RBC which the mother must supply
D. . The mother may have a problem of digestion because of pica
Sas 8
1.A client makes a routine visit to the prenatal clinic. Although she’s 14 weeks pregnant, the size of her
uterus approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses gestational trophoblastic
disease and orders ultrasonography. The nurse expects ultrasonography to reveal:
A. an empty gestational sac.
B. grapelike clusters.
C. a severely malformed fetus.
D. an extrauterine pregnancy.
2.Of the following terms, which is used to refer to a type of gestational

trophoblastic neoplasm?
A. Hydatidiform mole
B. Dermoid cyst
C. Doderlein’s bacilli
D. Bartholin’s cyst
3. Which of the following signs will require a mother to seek immediate medical attention?
A. When the first fetal movement is felt
B. No fetal movement is felt on the 6th month
C. Mild uterine contraction
D. Slight dyspnea on the last month of gestation
4. Which of the following signs and symptoms will most likely make the nurse suspect that the patient is
having hydatidiform mole?
A. Slight bleeding
B. Passage of clear vesicular mass per vagina
C. Absence of fetal heart beat
D. Enlargement of the uterus

5.Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the umbilicus, last
menstrual period (LMP) 5 months ago, fetal heart beat (FHB) not appreciated. Which of the following is the
most possible diagnosis of this condition?
A. Hydatidiform mole
B. Missed abortion
C. Pelvic inflammatory disease
D. Ectopic pregnancy
6.Check all that apply to incompetent cervix:

A. occurs in 2nd trimester
B. dilatation is painless and bloodless
C. shortened cervical length
D. minimal symptoms
E. snow-like pattern on ultrasound
7. The best time to treat incompetent cervix is between ___ and ____ weeks of
pregnancy before the dilatation occurs.
A. 12, 14
B. 10,12
C. 2,3
D. 18,25
8. Restriction of activities and cervical cerclage are the

treatments for __________
.A. Abruptio Placenta

B. Placenta Previa
C. Incompetent Cervix
D. H-mole
9. A client with incompetent cervix with a previous pregnancy had a cerclage procedure done at 18 wks in the
current pregnancy. The client calls the clinic at 37 wks gestation because of irregular contractions
occurring every five to seven minutes. Which response by the nurse is the most appropriate?
A. "Go to the hospital to have the cerclage removed so your cervix isn't injured and to allow the birth to progress"
B. "Wait and come in when the contractions are closer and harder"
C. "You sound like you are worried about this baby. It must be frightening for you" D. "You will need to have a C/S
with the cerclage in place"
10. Which of the following procedure applies sterile tape is threaded in a purse-string manner under the
submucous layer of the cervix & sutured in place to achieve a closed cervix?

A. B.
SAS 9
1. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client
regarding management of care. Which statement, if made by the client, indicates a need for further
education?
A. “I will maintain strict bedrest throughout the remainder of pregnancy.”
B. “I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of
bleeding.”
C. “I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the
pad.”
D. “I will watch for the evidence of the passage of tissue.”
2. Bleeding and cramping occur with the cervix closed and membranes intact.
A. complete
B. inevitable
C. habitual
D. missed
E. threatened
3. Some of the products are expelled, but the placenta remains attached. Heavy bleeding and cramping
doesn’t subside until entire placenta is removed.
A. habitual
B. missed

C. incomplete
D. complete
E. threatened
4. Any of the 5 spontaneous abortions occurring with 3 consecutive pregnancies. This condition is a
result of weakened cervix that dilates in the 2nd trimester, and expels the fetus. This condition is call
INCOMPLETE CERVIX.
A. habitual
B. missed
C. incomplete
D. complete
E. threatened
5. Embryo or fetus dies but isn’t expelled. It’s often discovered by the physician when no FHT is present.
Fetus must be expelled within 6wks or DIC and/or infections can occur.
A. habitual
B. missed
C. incomplete
D. inevitable
E. threatened
:
6. All of the products of conception are expelled.

A. inevitable
B. complete
C. threatened
D. habitual
E. missed
7. During a prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at
increased risk for which complications? SELECT ALL THAT APPLY
A. Still Birth
B. Rh incompatibility
C. Gestational hypertension
D. Placenta previa
E. Spontaneous abortion
8. The following are causes of Spontaneous Abortion, Select All that Apply:
A. Abnormal fetal formation
B. Immunologic factors: Rh/ABO incompatibility

C. Implantation abnormalities
D. Toxoplasmosis
9. An abortion complicated by infection that occurs in women who have tried to self-
abort or whose pregnancy was aborted illegally using a nonsterile instrument such
as a knitting needle.
A. Spontaneous
B.Complete
C.Habitual
D.Septic
10. The following are types of abortion, Select All that Apply.
A. Threatened
B. Incomplete
C. Complete
D. Habitual
E. Early Pregnancy Loss
Sas 10
1. A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows that the
placenta is located at the edge of the cervical opening. As the nurse you know that which statement is FALSE
about this finding:
A. This is known as marginal placenta previa.

B. The placenta may move upward as the pregnancy progresses and needs to be re-evaluated with another
ultrasound at about 32 weeks gestation.
C. The patient will need to have a c-section and cannot deliver vaginally.
D. The woman should report any bleeding immediately to the doctor.
2. Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A positive.
What nursing interventions below will you include in the patient’s care? Select all that apply:
A. Routine vaginal examinations

B. Monitoring vital signs
C. Administer RhoGAM per MD order
D. Assess internal fetal monitoring
E. Placing patient on side-lying position
F. Monitoring pad count
G. Monitoring CBC and clotting levels

3. A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled hypertension. What
risk factor below found in the patient’s health history places her at risk for abruptio placentae?
A. childhood polio
B. preeclampisa
C. c-section
D. her age
.
4. A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient experienced
abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms can present with
abruptio placentae? Select all that apply:
A. Decrease in fundal height

B. Hard abdomen
C. Fetal distress
D. Abnormal fetal position
E. E. Tender uterus
5. Select all the patients below who are at risk for developing placenta previa:
A. A 37 year old woman who is pregnant with her 7th child.

B. A 28 year old pregnant female with chronic hypertension.
C. A 25 year old female who is 36 weeks pregnant that has experienced trauma to abdomen.
D. A 20 year old pregnant female who is a cocaine user.
6. You’re performing a head-to-toe assessment on a patient admitted with abruptio placentae. Which of the
following assessment findings would you immediately report to the physician?
A. Oozing around the IV site

B. Tender uterus
C. Hard abdomen
D. Vaginal bleeding
7. Which statement is TRUE regarding abruptio placenta?
A. This condition occurs due to an abnormal attachment of the placenta in the uterus near or over the
cervical opening.

B. A marginal abruptio placenta occurs when the placenta is located near the edge of the cervical opening.
C. Nursing interventions for this condition includes measuring the fundal height.
D. Fetal distress is not common in this condition as it is in placenta previa.
8. Select all the signs and symptoms associated with placenta previa:
A. Painless bright red bleeding

B. Concealed bleeding
C. Hard, tender uterus
D. Normal fetal heart rate
E. Abnormal fetal position
F. Rigid abdomen
9. Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because
when the placenta becomes damaged and detaches from the uterine wall, large amounts of _____________
are released into mom’s circulation, leading to clot formation and then clotting factor depletion.
A. Placenta previa, fibrinogen

B. Placenta previa, platelets
C. Abruptio placentae, fibrinogen
D. Abruptio placentae, thromboplastin
10. A patient who is 25 weeks pregnant has partial placenta previa. As the nurse you’re educating the patient
about the condition and self-care. Which statement by the patient requires you to re-educate the patient?
A. “I will avoid sexual intercourse and douching throughout the rest of the pregnancy.”
B. “I may start to experience dark red bleeding with pain.”
C. “I will have another ultrasound at 32 weeks to re-assess the placenta’s location.”
D. “My uterus should be soft and non-tender.”
Sas 11
1. PROM may occur if the uterus is over-stretched by malpresentation of the fetus, multiple pregnancy or
excess amniotic fluid.
A. True
B. False
2. Cervical incompetence in combination with PROM can be a cause of umbilical cord prolapse.

A. True
B. False
3. The fetal membranes are so strong that blunt trauma to the abdomen is unlikely to cause PROM.
A. True
B. False
4. Hypoxia and asphyxia of the woman in labour is a common complication of prolonged PROM.
A. True
B. False
5. A sudden gush of clear watery fluid from the vagina is always seen in cases of PROM.
A. True
B. False
6. Select all the risk factors below that increases a woman’s risk for developing preeclampsia:
A. Nulligravida
B. Primigravida
C. BMI 34
D. Pregnant with twins
E. Maternal history of preeclampsia
F. Age: 25-years-old
G. History of Lupus and Diabetes
7. Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to assess
for HELLP Syndrome. Which findings on the patient’s lab results correlate with HELLP Syndrome? A.
Hemoglobin 12 g/dL
B. Platelets 90,000 μL
C. ALT 100 IU/L
D. AST 90 IU/L
E. Glucose 350 mg/dL
F. Abnormal RBC peripheral smear

8. Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have what medication
on standby?
A. Acetylcysteine
B. Calcium carbonate
C. Oxytocin
D. Calcium gluconate
9. A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV Magnesium
Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician?
A. Deep tendon reflex 4+
B. Respiratory rate of 13 breaths per minute
C. Urinary output of 600 mL over 12 hours
D. Clonus presenting in the lower extremities
E. Patient reports flushing or feeling hot
10. In a patient with preeclampsia, what signs and symptoms indicate that the patient has a high risk of
experiencing a seizure due to central nervous system irritability? Select all that apply:
A. You note bouncing of the foot when it is quickly dorsiflexed.
B. Patellar and bicep deep tendon reflexes are graded 4+.
C. Platelet count 200,000
D. Patient reports a decrease in headache pain.
SAS 12
1. A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes
the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial
nursing action?
A. Place the client in Trendelenburg’s position
B. Call the delivery room to notify the staff that the client will be transported immediately
C. Gently push the cord into the vagina
D. Find the closest telephone and stat page the physician
2. When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal introitus for
possible cord prolapse. If there is part of the cord that has prolapsed into the vaginal opening the correct
nursing intervention is:
A. Push back the prolapse cord into the vaginal canal
B. Place the mother on semi-fowler’s position to improve circulation
C. Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on
Trendelenburg position
D. Push back the cord into the vagina and place the woman on sims position

3. Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
A. Begin monitoring maternal vital signs and FHR
B. Place the client in a knee-chest position in bed
C. Notify the physician and prepare the client for delivery
D. Apply a sterile warm saline dressing to the exposed cord
4. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
A. Attempt to replace the cord
B. Place the client on her left side
C. Elevate the client’s hips
D. Cover the cord with a dry, sterile gauze
5. What are the signs that suggest cephalopelvic disproportion?

A. Firm engagement and intact bow.
B. Ruptured bow and lack of engagement.
C. Lack of engagement and poor fetal descent.
D. Poor fetal descent and intact bow.
6. Which of the following situations is considered a vaginal delivery emergency?

A. Third stage of labor lasting 20 minutes
B. Fetal heart dropping during contractions
C. Three-vessel cord
D. Shoulder dystocia
7. During a vaginal delivery, the Obstetrician declares that a shoulder dystocia has occurred. Which of the
following actions by the nurse is appropriate at this time? A. Administer oxytocin intravenously per doctor’s
order
B. Flex the woman’s thighs sharply toward her abdomen
C. Apply oxygen using a tight-fitting face mask
D. Apply downward pressure on the woman’s fundus
8. A type of placental abnormality in which there is unusually deep attachment of the placenta to the uterine
myometrium?
A. Battledore Placenta
B. Velamentous Insertion of the Cord
C. Placenta Accreta
D. Placenta Succenturiata
9. A type of placental abnormality that It has 1 or more accessory lobes connected to the main placenta that
the small lobes may be retained in the uterus leading to hemorrhage?
C. Placenta Accreta
10. A type of placental abnormality wherein the cord, instead of entering the placenta directly, separates into
small vessels that reach the placenta by spreading cross a fold of amnion that is usually found with
multiple gestation & is associated with anomalies?
C. Placenta Accreta

Sas 13
1. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor.
The nurse is reviewing the physician’s orders and would expect to note which of the following prescribed
treatments for this condition?
A. Medication that will provide sedation
B. Increased hydration
C. Oxytocin (Pitocin) infusion
D. Administration of a tocolytic medication
.
2. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is
told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration,
and intensity. The priority nursing intervention would be to:
A. Monitor the Pitocin infusion closely
B. Provide pain relief measures
C. Prepare the client for an amniotomy
D. Promote ambulation every 30 minutes
3. A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing
interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following
nursing interventions as the highest priority?
A. Keeping the significant other informed of the progress of the labor
B. Providing comfort measures
C. Monitoring fetal heart rate
D. Changing the client’s position frequently
4. A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and complains
of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic
contractions, the client again complains of severe pain. After the client vomits, she states that the pain is
better and then passes out. Which is the probable cause of her signs and symptoms?
A. Hysteria compounded by the flu
B. Placental abruption
C. Uterine rupture
D. Dysfunctional labor
5. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only
progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician
ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important
aspect of nursing intervention at this time?
A. Timing and recording length of contractions.
B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
6. The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric history will
help the nurse suspects dysfunctional labor in the current pregnancy?
A. Total time of ruptured membranes was 24 hours with the second birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation.
7. The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the
client at risk for disseminated intravascular coagulation (DIC)?
A. Intrauterine fetal death.

B. Placenta accreta.
C. Dysfunctional labor.
D. Premature rupture of the membranes.
8. The following are common causes of dysfunctional labor. Which of these can a nurse, on her own
manage?
A. Pelvic bone contraction
B. Full bladder
C. Extension rather than flexion of the head
D. Cervical rigidity
.
9. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia. the nurse should expect:
A. A painless delivery
B. Cervical effacement
C. Infrequent contractions
D. Progressive cervical dilation
10. During the period of induction of labor, a client should be observed carefully for signs of:
A. Severe pain
B. Uterine tetany
C. Hypoglycemia
D. Umbilical cord prolapse
Sas 14
1. A woman with a fetus in occipitoposterior position would commonly demonstrate which of the following?
A. Acute chest pain
B. Increased energy levels
C. Intense back pressure
D. Precipitate labor
2. What is the most common complication for the mother of an oversized fetus?
A. Uterine dysfunction
B. Precipitate labor
C. Prolonged labor
D. Diabetes mellitus
3. Which of the following suggests that the woman has shoulder dystocia?

A. Primiparity
B. Premature pregnancy.
C. Prolonged second stage of labor
D. Immediate descent
4. To aid in fetal rotation in an occipitoposterior position, the nurse should instruct the woman to:
A. Assume Trendelenburg’s position
B. Assume a fetal position.
C. Assume a side lying position on the side where the fetal back lies.
D. Assume a hands and knees position
5. This condition predisposes the woman to an oversized fetus: A.

Occipitoposterior position.
B. Gestational diabetes
C. Primiparity
D. CPD
6. A woman in the second trimester of her pregnancy with a fetus in breech position worries that she would
deliver the fetus through cesarean delivery. What should the nurse tell her?
A. Cesarean delivery is one of the safest and most economical methods of giving birth.
B. The fetus would have to be delivered via cesarean section because it will remain in a breech position until birth.
C. The fetus may still turn into a cephalic position by week 38 because the lower extremities fit more properly in the
fundus.
D. She can still deliver vaginally even though the fetus is in breech position.
7. A pregnant woman with a fetus in face presentation asks if there is any chance that she would deliver her baby
vaginally. The nurse should tell her that:
A. Vaginal birth is impossible because the head diameter that the fetus presents to the pelvis is too large.
B. The baby can be born vaginally if the chin is anterior and the pelvic diameters are within normal limits.
C. The baby can be born vaginally because face presentation is the same with cephalic presentation.
D. Vaginal birth is contraindicated to a fetus with face presentation and there is no chance for the mother to give
birth vaginally.

8. In brow presentation, the head becomes jammed in the brim of the pelvis as the occipitomental diameter
presents, and this usually results in:
A. Prolonged labor
B. Precipitate labor
C. Normal labor
D. Obstructed labor
9. A baby born in a brow presentation has extreme ecchymosis on the face. The nurse should tell the parents that:
A. The bruising can be relieved by a cold compress.
B. The bruising is normal and would disappear after several days.
C. They should refer the condition to a pediatrician for immediate treatment.
D. The bruising is a permanent condition and nothing could relieve it.
10. In face presentation, when is cesarean birth necessary?

A. If the chin is anterior.
B. If the chin is posterior.
C. If the pelvic diameters are within normal limits.
D. If the pelvic diameters are higher than normal.
Sas 15
1. A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours
ago. The nurse notes that the mother’s temperature is 100.2*F. Which of the following actions would be
most appropriate?
A. Retake the temperature in 15 minutes
B. Notify the physician
C. Document the findings
D. Increase hydration by encouraging oral fluids
2. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy infant. The
client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions
would be most appropriate?
A. Obtain hemoglobin and hematocrit levels
B. Instruct the mother to request help when getting out of bed

C. Elevate the mother’s legs
D. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of
lightheadedness and dizziness have subsided.
3. A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in
performing this assessment is which of the following?
A. Ask the client to turn on her side
B. Ask the client to lie flat on her back with the knees and legs flat and straight.
C. Ask the mother to urinate and empty her bladder
D. Massage the fundus gently before determining the level of the fundus.
4. The nurse is assessing the lochia on a 1 day postpartum patient. The nurse notes that the lochia is red and
has a foul-smelling odor. The nurse determines that this assessment finding is:
A. Normal
B. Indicates the presence of infection
C. Indicates the need for increasing oral fluids
D. Indicates the need for increasing ambulation
.
5. When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia.
The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing
actions is most appropriate?
A. Document the findings
B. Notify the physician
C. Reassess the client in 2 hours
D. Encourage increased intake of fluids.
6. A nurse in a postpartum unit is instructing a mother regarding lochia and the amount of expected lochia
drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never
exceed the need for:
A. One peripad per day
B. Two peripads per day
C. Three peripads per day
D. Eight peripads per day
7. A postpartum nurse is providing instructions to a woman after delivery of a healthy newborn infant. The
nurse instructs the mother that she should expect normal bowel elimination to return:
A. One the day of the delivery
B. 3 days postpartum
C. 7 days postpartum
D. within 2 weeks postpartum
8. Select all of the physiological maternal changes that occur during the postpartum period.
A. Cervical involution ceases immediately
B. Vaginal distention decreases slowly
C. Fundus begins to descend into the pelvis after 24 hours
D. Cardiac output decreases with resultant tachycardia in the first 24 hours
E. Digestive processes slow immediately.
9. A nurse is caring for a postpartum woman who has received epidural anesthesia and is monitoring the
woman for the presence of a vulva hematoma. Which of the following assessment findings would best
indicate the presence of a hematoma?
A. Complaints of a tearing sensation
B. Complaints of intense pain
C. Changes in vital signs

D. Signs of heavy bruising
10. A nurse is developing a plan of care for a postpartum woman with a small vulvar hematoma. The nurse
includes which specific intervention in the plan during the first 12 hours following the delivery of this
client?
A. Assess vital signs every 4 hours
B. Inform health care provider of assessment findings
C. Measure fundal height every 4 hours
D. Prepare an ice pack for application to the area.
Sas 16
1. A nurse is developing a plan of care for a postpartum woman with a small vulvar hematoma. The nurse
includes which specific intervention in the plan during the first 12 hours following the delivery of this
client?
A. Assess vital signs every 4 hours
B. Inform health care provider of assessment findings
C. Measure fundal height every 4 hours
D. Prepare an ice pack for application to the area.
2. A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours.
At 6 hours PP. her systolic blood pressure has dropped 20 points. her diastolic BP has dropped 10 points.
and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment. a vulvar
hematoma is verified. After notifying the health care provider. the nurse immediately plans to: A. Monitor
fundal height
B. Apply perineal pressure
C. Prepare the client for surgery.
D. Reassure the client
3. The postpartum patient who delivered 2 days ago has developed endometritis. Which charting entry would
the nurse expect to find in this patient’s chart? Select All that Apply:
A. Cesarean birth performed secondary to arrest of dilation
B. Rupture of membranes occurred 2 hour prior to delivery
C. External fetal monitoring used throughout labor
D. Patient has history of pregnancy-induced hypertension
4. Which of the following statements is/are most accurate about endometritis?

A. It is the single most common complication after cesarean delivery
B. It is the single most common complication after vaginal delivery
C. It is a polymicrobial infection
D. A and C
E. B and C

5. True or False. Endometritis is typically caused by only multiple aerobic organisms.
A. True
B. False
6. The frequency of endometritis is dependent on several factors including, but not limited to, which of the
following?
A. Presence of preexisting lower genital tract infection
B. Type of anesthesia
C. Length of labor
D. A and C
E. All of the above
7. The usual standard of care for treatment of early-onset endometritis is IV antibiotics, and patients
typically are treated until they have been afebrile and asymptomatic for a minimum of ______ hours.
A. 12 hours
B. 24 hours
C. 36 hours
D. D. 48 hours
.
8. A systematic review has found that clinicians practicing in low-resource settings can provide safe and
effective treatment for endometritis with oral and oral-IM regimens, and that such treatment should be
limited to which patients?
A. Patients whose infection occurred after vaginal delivery
B. Patients who have evidence of only mild post caesarean endometritis
C. C. A or B

9. The following are management of the infection of the perineum. EXCEPT:
A. Topical or systemic antibiotic even before culture results are available
B. Analgesic to relieve discomfort
C. Sitz baths, moist, warm compresses, Hubbard tank treatments to hasten drainage & cleanse the area
D. Remind woman to change perineal pads frequently to prevent recontamination or vaginal infection
E. antibiotics after C & S, such as clindamycin
10. The following are conditions that increases the Risk for Post-partal Infection, EXCEPT:
A. Rupture of membranes > 24h before birth
B. Retained placental fragments
C. Postpartal hemorrhage- weakens the woman’s general condition
D. Preexisting anemia-lowers body defense
E.Virulence of the invading microorganism
Sas 17
1. Which of the following is the primary predisposing factor related to mastitis?

A. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts
B. Endemic infection occurring randomly and localizing in the peri glandular connective tissue
C. Temporary urinary retention due to decreased perception of the urge to avoid
D. Breast injury caused by overdistention, stasis, and cracking of the nipples
2. A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following
statements if made by the mother indicates a need for further teaching?
A. “I need to take antibiotics, and I should begin to feel better in 24-48 hours.”
B. “I can use analgesics to assist in alleviating some of the discomfort.”
C. “I need to wear a supportive bra to relieve the discomfort.”
D. “I need to stop breastfeeding until this condition resolves.”
3. A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis.
Select all instructions that would be included on the list.
A. Take the prescribed antibiotics until the soreness subsides.
B. Wear supportive bra
C. Avoid decompression of the breasts by breastfeeding or breast pump
D. Rest during the acute phase
E. Continue to breastfeed if the breasts are not too sore.

4. Signs and symptoms of mastitis include all of the following except:
A. Fever
B. Elevated white blood count
C. Diffuse breast tenderness and warmth
D. Focal breast tenderness and warmth
.
5. A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis.
Which of the following instructions would be included on the list?
A. Wear a supportive bra
B. Rest during the acute phase
C. Maintain a fluid intake of at least 3000 ml
D Continue to breast-feed if the breasts are not too sore.
E. Take the prescribed antibiotics until the soreness subsides.
F. Avoid decompression of the breasts by breast-feeding or breast pump.
6. A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the
nurse include?
A. The diet should include additional fluids
B. Prenatal vitamins should be discontinued
C. Soap should be used to cleanse the breasts.
D. Birth control measures are unnecessary while breast-feeding.
7. A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness,
the nurse suggests that the client:
A. Avoid rotating breast-feeding positions.
B. Stop nursing until the nipples heal
C. Substitute a bottle-feeding until the nipples heal.
D. Position the infant with the ear, shoulder, and hip in straight alignment with the infant's stomach against the
mother.
8. A nurse assigned to care for a postpartum client plans to promote parental-infant bonding by encouraging
the parents to:

A. Use a low-pitched voice to speak to the infant
B. Allow the nursing staff to assume the infant care during hospitalization so they may rest
C. Hold and cuddle the infant closely
D. Allow the infant to sleep in the parental bed between the parents
9. The nurse should instruct a breast-feeding mother that the best way to prevent mastitis is to do which of the
following?
A. Bottle-feed until the milk comes in.
B. Take antibiotics during labor.
C. Prevent nipple fissures by carefully positioning the infant during feedings.
D. Drink plenty of fluids.
E. Use a nipple shield.
F. Remove the infant from the breast by inserting a finger in his mouth to break the suction.
10. A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are
any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding
and bottle-feeding. Which statement is most accurate? Bottle-feeding using commercially prepared infant
formulas: A. Increases the risk that the infant will develop allergies.
B. Helps the infant sleep through the night.
C. Ensures that the infant is getting iron in a form that is easily absorbed.
Requires that multivitamin supplements be given to the infant
Sas 18
1. You’re developing a plan of care for a patient who is at risk for the development of a deep vein
thrombosis after surgery. What nursing intervention below would the nurse NOT include in the patient’s
plan of care to prevent DVT formation?
A. The patient will eat all meals out of the bed daily by sitting in the bedside chair.
B. The nurse will apply sequential compression devices (SCDs) per physician’s order to the patient’s lower extremities
every night at bedtime.
C. The nurse will administer per physician’s order Enoxaparin in the subcutaneous tissue of the abdomen.
D. The patient will ambulate daily.

2. The nurse is assessing a patient, who has many risk factors for the development of a DVT, for signs and
symptoms of a deep vein thrombosis. What signs and symptoms below would possibly indicate a deep vein
thrombosis is present?
A. Cool extremity
B. Decreases pulses
C. Redness
D. Pain
E. Warm extremity
F. Swelling
G. Cyanosis
3. Assessment of Homan’s Sign is the most reliable indicator of a deep vein

thrombosis.
A. True
B. False
:
4. A postpartum client is being treated for DVT. The nurse understands that the client’s response to treatment
will be evaluated by regularly assessing the client for:
A. Dysuria, ecchymosis, and vertigo
B. Epistaxis, hematuria, and dysuria
C. Hematuria, ecchymosis, and epistaxis
D. Hematuria, ecchymosis, and vertigo
5. A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion
of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if
an effective and appropriate dose of the heparin is being delivered?
A. Prothrombin time
B. International normalized ratio
C. Activated partial thromboplastin time
D. Platelet count
6. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would
the nurse Mica expect to administer if the client develops complications related to heparin therapy?
A. Calcium gluconate
B. Protamine sulfate
C. Methylegonovine (Methergine)
D. Nitrofurantoin (macrodantin)

7. Deep vein thrombosis occurs in the ______________.
A. Chest
B. Abdomen
C. Leg
D. Feet
8. You are at-risk for developing deep vein thrombosis or pulmonary embolism if you:
A. Obese
B. Have had recent surgery
C. Smoking
D. Any of these
9. Pulmonary embolism can occur without deep vein

thrombosis.
A. True
B. False
10. Signs and symptoms of deep vein thrombosis (DVT) can include:
A. Redness, warmth, tenderness and swelling
B. Shortness of breath, chest pain, coughing blood
C. Muscle spasms, vertigo, ringing ears
D. All of the above
Sas 19
1. The nurse observes several interactions between a postpartum woman and her new son. What behavior,
if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-
infant attachment?
A. Talks and coos to her son
B. Seldom makes eye contact with her son
C. Cuddles her son close to her
D. Tells visitors how well her son is feeding

2.Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when
attempting to formulate a plan of care?
A. PPD symptoms are consistently severe.
B. This syndrome affects only new mothers.
C. PPD can easily go undetected.
D. Only mental health professionals should teach new parents about this condition.
3. Mothers that have experienced postpartum depression in the past have a decreased risk for postpartum
depression in the future.
A. True
B. False
4. Postpartum depression symptoms are similar to ________ symptoms.

A. Bipolar Disorder
B. Depression unrelated to childbirth
C. Anorexia Nervosa
D. Borderline Personality
5. Symptoms of postpartum depression include: (select all that apply)

A. Euphoria
B. Tiredness
C. Changes in Diet
D. Issues with sleep
E. None of these apply
6. Why is postpartum depression commonly a missed or under diagnosed problem?

Select All That Apply
A. Women do not report symptoms
B. Providers do not take reports from patients seriously
C. Symptoms are masked by common experiences of new mothers (lack of sleep, etc)
D. All of the above

7. Risk factors for postpartum depression include:(SELECT ALL
THAT APPLY)
A. History of abuse
B. Marriage
C. History of mental illness
D. D. Concurrent life
events
E. Giving birth to a male child
F. Red hair
8. The following are management of Postpartum Depression, EXCEPT:

A. discovery of the problem,
B. conscientious observation and discussion,
C. counseling
D. possible antidepressant therapy
E. Seldom makes eye contact with her son
9. The following are risk factors of Postpartum Depression, EXCEPT:

A. history of depression
B. troubled childhood
C. low self-esteem
D. stress in the home or at work
E. extreme fatigue
10. A nurse is caring for a postpartum client suspected of developing postpartum

psychosis. Which statements accurately characterize this disorder? SELECT ALL
THAT APPLY
A. Symptoms start 2 days after delivery
B. The disorder is common in postpartum women
C. Symptoms include delusions and hallucinations
D. Suicide and infanticide are uncommon in this disorder
E. The disorder rarely occurs without psychiatric history

Sas 20
1. A woman’s temperature has just risen 0.4°F and will remain elevated during the remainder of her
cycle. She expects to menstruate in about 2 weeks. Which of the following hormones is responsible for the
change? A. Estrogen.
B. Follicle-stimulating hormone (FSH).
C. Progesterone.
D. Luteinizing hormone (LH).
2. An infertility specialist is evaluating whether a woman’s cervical mucus contains enough estrogen
to support sperm motility. Which of the following tests is the physician conducting?
A. Hysterotomy.
B. Culposcopy.
C. Ferning capacity.
D. Basal body temperature.
3. A client is to receive Pergonal (menotropins) injections for infertility prior to invitro fertilization.
Which of the following is the expected action of this medication?
A. Prolongation of the luteal phase.
B. Stimulation of ovulation.
C. Promotion of cervical mucus production.
D. Suppression of menstruation.
4. Which test used to diagnose the basis of infertility is done during the luteal or secretory phase of
the menstrual cycle?
A. Hysterosalpingogram
B. Endometrial biopsy
C. Laparoscopy
D. Follicle-stimulating hormone (FSH) level
5. A man smokes two packs of cigarettes a day. He wants to know if smoking is contributing to the difficulty
he and his wife are having getting pregnant. The nurse's most appropriate response is:
A. "Your sperm count seems to be okay in the first semen analysis."

B. "Only marijuana cigarettes affect sperm count."
C. "Smoking can give you lung cancer, even though it has no effect on sperm."
D. "Smoking can reduce the quality of your sperm."

6. A couple comes in for an infertility workup, having attempted to get pregnant for 2 years. The woman, 37,
has always had irregular menstrual cycles but is otherwise healthy. The man has fathered two children from a
previous marriage and had a vasectomy reversal 2 years ago. The man has had two normal semen analyses,
but the sperm seem to be clumped together. What additional test is needed?
A. Testicular biopsy
B. Antisperm antibodies
C. Follicle-stimulating hormone (FSH) level
D. Examination for testicular infection
7. A couple is trying to cope with an infertility problem. They want to know what they can do to preserve their
emotional equilibrium. The nurse's most appropriate response is:
A. "Tell your friends and family so they can help you."

B. "Talk only to other friends who are infertile because only they can help."
C. "Get involved with a support group. I'll give you some names."
D. "Start adoption proceedings immediately because it is very difficult to obtain an infant."
8. A woman inquires about herbal alternative methods for improving fertility. Which statement by the nurse is
the most appropriate when instructing the client in which herbal preparations to avoid while trying to
conceive?
A. "You should avoid nettle leaf, dong quai, and vitamin E while you are trying to get pregnant."
B. "You may want to avoid licorice root, lavender, fennel, sage, and thyme while you are trying to
conceive." C. "You should not take anything with vitamin E, calcium, or magnesium. They will make
you infertile."
D. "Herbs have no bearing on fertility."
9. In vitro fertilization-embryo transfer (IVF-ET) is a common approach for women with blocked fallopian tubes
or unexplained infertility and for men with very low sperm counts. A husband and wife have arrived for their
preprocedural interview. The husband asks the nurse to explain what the procedure entails. The nurse's most
appropriate response is:

A. "IVF is a type of assisted reproductive therapy that involves collecting eggs from your wife's ovaries, fertilizing them
in the lab with your sperm, and transferring the embryo to her uterus."
B. "A donor embryo will be transferred into your wife's uterus."
C. "Donor sperm will be used to inseminate your wife."
D. "Don't worry about the technical stuff; that's what we are here for."
10. Nurses should be aware that infertility:
A. Is perceived differently by women and men.

B. Has a relatively stable prevalence among the overall population and throughout a women's potential reproductive
years.
C. Is more likely the result of a physical flaw in the woman than in her male partner.
D. Is the same thing as sterility.
Sas 21
1. A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse
prepares to prevent heat loss in the newborn resulting from evaporation by:
A. Warming the crib pad
B. Turning on the overhead radiant warmer
C. Closing the doors to the room
D. Drying the infant in a warm blanket
.
2. A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation
newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse’s highest
priority shou be to:
A. Connect the resuscitation bag to the oxygen outlet

B. Turn on the apnea and cardiorespiratory monitors
C. Set up the intravenous line with 5% dextrose in water
D. Set the radiant warmer control temperature at 36.5* C (97.6*F)
3. The primary critical observation for Apgar scoring is the:

A. Heart rate
B. Respiratory rate
C. Presence of meconium
D. Evaluation of the Moro reflex

.
4. To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
A. Monitoring for the passage of meconium each shift
B. Instituting phototherapy for 30 minutes every 6 hours
C. Substituting breastfeeding for formula during the 2nd day after birth
D. Supplementing breastfeeding with glucose water during the first 24 hours
.
5. When newborns have been on formula for 36-48 hours, they should have a:
A. Screening for PKU
B. Vitamin K injection
C. Test for necrotizing enterocolitis
D. Heel stick for blood glucose level
6. A woman delivers a 3,250 g neonate at 42 weeks’ gestation. Which physical finding is expected during an
examination if this neonate?
A. Abundant lanugo
B. Absence of sole creases
C. Breast bud of 1-2 mm in diameter
D. Leathery, cracked, and wrinkled skin
7. While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the
following nursing actions should be performed initially?
A. Activate the code blue or emergency system
B. Do nothing because acrocyanosis is normal in the neonate
C. Immediately take the newborn’s temperature according to hospital policy
D. Notify the physician of the need for a cardiac consult
8. The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?
A. Anemia
B. Hypoglycemia

C. Nitrogen loss
D. Thrombosis
9. After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the
nurse anticipate as a potential problem in the neonate?
A. Hypoglycemia
B. Jitteriness
C. Respiratory depression
D. Tachycardia
10. Neonates of mothers with diabetes are at risk for which complication following birth?
A. Atelectasis
B. Microcephaly
C. Pneumothorax
D. Macrosomia
Sas 22
1.Which of the following infants is least probable to develop sudden infant death syndrome (SIDS)?
A. Baby Angela who was premature
B. A sibling of Baby Angie who died of SIDS
C. Baby Gabriel with prenatal drug exposure
D. Baby Gabby who sleeps on his back
.
2. Baby Chen Ek is a neonate who has a very low-birth-weight. Nurse Cheekie Dhal carefully monitors
inspiratory pressure and oxygen (O2) concentration to prevent which of the following?
A. Meconium aspiration syndrome
B. Bronchopulmonary dysplasia (BPD)
C. Respiratory syncytial virus (RSV)
D. Respiratory distress syndrome (RDS)
.
3. A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome.
Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this
syndrome? A. Hypotension and Bradycardia
B. Tachypnea and retractions
C. Acrocyanosis and grunting
D. The presence of a barrel chest with grunting

.
4. A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who
is being breastfed. The nurse provides which most appropriate instructions to the mother?
A. Switch to bottle feeding the baby for 2 weeks
B. Stop the breast feedings and switch to bottle-feeding permanently
C. Feed the newborn infant less frequently
D. Continue to breast-feed every 2-4 hours
.
5. A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs
of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the
physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by:
A. Subcutaneous injection
B. Intravenous injection
C. Instillation of the preparation into the lungs through an endotracheal
tube
D. Intramuscular injection
6. A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of
the following assessment findings would the nurse expect to note during the assessment of this
newborn?
A. Sleepiness
B. Cuddles when being held
C. Lethargy
D. Incessant crying
7. A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why
her newborn infant needs the injection. The best response by the nurse would be:
A. "You infant needs vitamin K to develop immunity."
B. "The vitamin K will protect your infant from being jaundiced."
C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."
D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
.
8. What are the symptoms of RDS in premature babies? SELECT ALL THAT APPLY
A. Breathing problems at birth that get worse
B. Blue skin color (cyanosis)
C. Flaring nostrils

D. Rapid breathing
E. Grunting sounds with breathing
.
9. All of the following are ways to diagnose Respiratory Distress Syndrome in premature babies. SELECT ALL
THAT APPLY
A. Baby’s appearance, color, and breathing efforts

B. Chest X-rays of the lungs
C. Blood gas tests
D. Bacterial Culture
.
10. The following are sign and symptoms of infant with a drug dependent mother, EXCEPT:
A. Constant movement possibly leading to abrasions on the elbows and
knees
B. Tremors
C. Frequent sneezing
D. Short palpebral fissure
Sas 23
1. Dustin who was diagnosed with Hirschsprung’s disease has a fever and watery explosive diarrhea.
Which of the following would Nurse Cheyenne do first? A. Administer an antidiarrheal.
B. Notify the physician immediately.
C. Monitor the child every 30 minutes.
D. Nothing. These findings are common in Hirschsprung’s disease.
2. Baby Jonathan was born with cleft lip (CL); Nurse Barbara would be alert that which of the following will
most likely be compromised?
A. GI function
B. Locomotion
C. Sucking ability
D. Respiratory status
3. Gianne is being assessed by Nurse Luca-Luca for possible intussusception; which of the following would
be least likely to provide valuable information?

A. Abdominal palpation
B. Family history
C. Pain pattern
D. Stool inspection
4. Mr. and Ms. Bane’s child failed to pass meconium within the first 24 hours after birth; this may indicate
which of the following?
A. Celiac disease
B. Intussusception
C. Hirschsprung’s disease
D. Abdominal-wall defect
5. Which of the following parameters would Nurse Max monitor to evaluate the effectiveness of thickened
feedings for an infant with gastroesophageL REFLUX (GER)?
A. Urine
B. Vomiting
C. Weight
D. Stools
6. Baby Ellie is diagnosed with gastroesophageal reflux (GER); which of the following nursing diagnoses
would be inappropriate?
A. Risk for aspiration
B. Impaired oral mucous membrane
C. Deficient fluid volume
D. Imbalanced nutrition: Less than body requirements
7. Nurse Karen is providing postoperative care for Dustin who has cleft palate (CP); she should position the
child in which of the following?
A. In an infant seat
B. In the supine position
C. In the prone position
D. On his side

8. Nurse Joyce is assessing a child’s cultural background, she should keep in mind that:
A. Cultural background usually has little bearing on a family’s health practices
B. Physical characteristics mark the child as part of a particular culture
C. Heritage dictates a group’s shared values
D. Behavioral patterns are passed from one generation to the next
9. In pediatric gastroesophageal reflux disease (GERD), the immaturity of lower esophageal sphincter function
is manifested by frequent transient lower esophageal relaxations, which result in retrograde flow of gastric
contents into the esophagus. Which statement about the esophagus is TRUE? Select all that apply.
A. It is a cartilaginous tube.
B. It has upper and lower sphincters.
C. It lies anterior to the trachea.
D. It extends from the nasal cavity to the stomach.
E. All statements describe the esophagus.
10. A nurse review a 3-week old infant’s record and notes the physician documented a diagnosis of
suspected Hirschsprung’s Disease. The nurse knows which symptoms led mom to seek health care?
A. Diarrhea
B. Vomiting
C. Regurgitation
D. Foul smelling, ribbon like stool
Sas 24
1. A baby was born 2 hours ago by Cesarean section. The newborn has a myelomeningocele with the sac
intact and has been placed in an incubator. The nurse, when planning care for the baby, should focus on
potential for:
A. Disuse syndrome
B. Infection
C. Fluid volume deficit
D. Decreased cardiac output
2.Appropriate nursing interventions for a newborn's myelomeningocele sac prior to surgery include using
sterile technique and:
E. Leaving the sac open to air

F. Applying petrolatum to cover the sac
G. Applying moist saline dressings
H. Applying dry dressings
3. To maintain proper alignment of the hips and lower extremities in a baby with a myelomeningocele, the
nurse should position the baby with the:
A. Hips abducted and feet in a neutral position
B. Hips adducted and feet flexed
C. Hips subluxed and feet extended
D. Hips adducted and feet in a natural position
4.Dayan’s child is scheduled for surgery due to myelomeningocele; the primary reason for surgical
repair is which of the following?
A. To prevent hydrocephalus
B. To reduce the risk of infection

C. To correct the neurologic defect
D. To prevent seizure disorders
5.Tiffany is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her
parents would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a
10 to 20-degree angle?
A. Help alleviate headache
B. Increase intrathoracic
pressure
C. Maintain neutral position
D. Reduce intra-abdominal
pressure.

6. In diagnosing seizure disorder, which of the following is the most beneficial?
A. Skull radiographs
B. EEG
C. Brain scan
D. Lumbar puncture
7. After explaining to the parents about their child’s unique psychological needs related to a seizure disorder
and possible stressors, which of the following interests uttered by them would indicate further teaching?
A. Feeling different from peers
B. Poor self-image
C. Cognitive delays
D dependency
8. Spina bifida is one of the possible neural tube defects that can occur during early embryological
development. Which of the following definitions most accurately describes meningocele?
A. Complete exposure of spinal cord and meninges

B. Herniation of spinal cord and meninges into a sac
C. Sac formation containing meninges and spinal fluid
D. B and C
E. Spinal cord tumor containing nerve roots
9. Janae has a seizure disorder; which of the following would be the lowest priority when caring for her?
A. Observing and taking down data on all seizures
B. Assuring safety and protection from injuring
C. Assessing for signs and symptoms of increased intracranial pressure (ICP)
D. D. Educating the family about anticonvulsant therapy

10. Bennett was rushed to the emergency department with possible increased intracranial pressure (ICP);
which of the following is an early clinical manifestation of increased ICP in older children? (Select all that
apply.)
a.Macewen’s sign
b.Setting sun sign
C. Papilledema
D. Diplopia
Sas 25
1. You are a daycare provider. One of your children tells you about the spanking she received from her
mother last night. The girl tells you that her mother got very angry when she "talked-back" to her and this
is what usually happens when she is "bad." You suspect the child has been maltreated, and following
organizational policy, you take her to the administrator. There are no marks on the child and she says she
is not in pain? A. Call ChildLine
B. Make a GPS referral
C. Provide community resource recommendations
D. Call the police
E. Take no action
2. Nurse Sol is assessing a parent who abused her child. Which of the following risk factors would the nurse
expect to find in this case?
A. Flexible role functioning between parents
B. History of the parent having been abused as a child
C. Single-parent home situation
D. Presence of parental mental illness
3. A group of nursing students ais currently learning about family violence. Which of the following is true
about the topic mentioned?
A. Family violence affects every socioeconomic level.
B. Family violence is caused by drugs and alcohol abuse.
C. Family violence predominantly occurs in lower socioeconomic levels.
D. Family violence rarely occurs during pregnancy.
4. During a well-child checkup, a mother tells the Nurse Rio about a recent situation in which her child
needed to be disciplined by her husband. The child was slapped in the face for not getting her husband
breakfast on Saturday, despite being told on Thursday never to prepare food for him. Nurse Rio analyzes
the family system and concludes it is dysfunctional. All of the following factors contribute to this
dysfunction except:
A. Conflictual relationships of parents.
B. Inconsistent communication patterns.
C. Rigid, authoritarian roles.
D. Use of violence to establish control.

.
5. During a home visit to a family of three: a mother, father, and their child, The mother tells the community
nurse that the father (who is not present) had hit the child on several occasions when he was drinking.
The mother further explains that she has talked her husband into going to Alcoholics Anonymous and
asks the nurse not to interfere, so her husband won’t get angry and refuse treatment. Which of the
following is the best response of the nurse?
A. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening.
B. The nurse commends the mother’s efforts and agrees to let her handle things.
C. The nurse commends the mother’s efforts and also contacts protective services.
D. The nurse confronts the mother’s failure to protect the child.
6. Which nursing assessment findings are physical signs of sexual abuse of a female child? Select all that
apply.
A. Enuresis
B. Red and swollen labia and rectum
C. Vaginal tears
D. Injuries in different stages of healing
E. Cigarette burns
F. Lice infestation
7. A mother complains to the clinic nurse that her 2 ½-year-old son is not yet toilet trained. She is
particularly concerned that, although he reliably uses the potty seat for bowel movements, he isn’t able to
hold his urine for long periods. Which of the following statements by the nurse is correct?
A. The child should have been trained by age 2 and may have a psychological problem that is responsible for
his “accidents.”
B. Bladder control is usually achieved before bowel control, and the child should be required to sit on the potty
seat until he passes urine.
C. Bowel control is usually achieved before bladder control, and the average age for completion of toilet training
varies widely from 24 to 36 months.
D. The child should be told “no” each time he wets so that he learns the behavior is unacceptable.
8. The mother of a 14-month-old child reports to the nurse that her child will not fall asleep at night without a
bottle of milk in the crib and often wakes during the night asking for another. Which of the following
instructions by the nurse is correct?
A. Allow the child to have the bottle at bedtime, but withhold the one later in the night.
B. Put juice in the bottle instead of milk.
C. Give only a bottle of water at bedtime.
D. Do not allow bottles in the crib.
9. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the
nurse provide to the parents? SELECT ALL THAT APPLY
A. Regular developmental screening is important to avoid secondary developmental delays.

B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as
possible ocular and speech difficulties.
C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
D. Parent support groups are helpful for sharing strategies and managing health care issues.
10. A mother tells the nurse that she is very worried because her 2-year old child does not finish his meals.
What should the nurse advise the mother?
A. make the child seat with the family in the dining room until he finishes his meal
B. provide quiet environment for the child before meals
C. do not give snacks to the child before meals
D. put the child on a chair and feed him
Sas 26
1. The client diagnosed with leukemia has central nervous system involvement. Which instructions
should the nurse teach?
A. "Sleep with the head of the bed elevated to prevent increased intracranial pressure.”
B. “Take an analgesic medication for pain only when the pain becomes severe.”
C. “Explain that radiation therapy to the head may result in permanent hair loss.”
D. “Discuss end-of-life decisions prior to cognitive deterioration"
2. The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy . The
nurse notes that the platelet count is 20,000/ul. Based on the laboratory result, which intervention will
the nurse document in the plan of care?
A. Monitor closely for signs of infection
B. Monitor the temperature every 4hours
C. Initiate protective isolation precautions
D. Use soft small toothbrush for mouth care
3. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most
important for the nurse to inquire?
A. "Have you noticed a change in sleeping habits recently?”
B. "Have you had a respiratory infection in the last 6 months?”
C. "Have you lost weight recently?""
D. "Have you noticed changes in your alertness?"
4. Which statement is correct about the rate of cell growth in relation to chemotherapy?
A. Faster growing cells are less susceptible to chemotherapy.
B. Nondividing cells are more susceptible to chemotherapy.
C. Faster growing cells are more susceptible to chemotherapy.
D. Slower growing cells are more susceptible to chemotherapy.

.
5. A child with cancer has the following lab result: WBC 10,000, RBC 5, and platelet count of 20,000. When
planning this child's care, which risk should the nurse consider most significant?
A. Hemorrhage
B. Anemia
C. Infectio
n
D. Pain
6. A patient with asthma is prescribed to take inhaled Salmeterol and Fluticasone for long-term
management of asthma. You observe the patient taking these medications. Which option below best
describes the correct order in how to take these medications?
A. The patient inhales the Salmeterol first and then waits 5 minutes before inhaling the Fluticasone.
B. The patient inhales the Fluticasone first and then waits 5 minutes before inhaling the Salmeterol.
C. The patient inhales the Salmeterol first and then waits 1 minute before inhaling the Fluticasone.
D. The patient inhales the Fluticasone and immediately inhales the Salmeterol.
7. You're assisting your patient who has asthma to bed. The patient is experiencing a frequent cough and
chest tightness. You auscultate the patient's lung fields and note expiratory wheezes. The patient's peak flow
rate is 78% less than their best peak flow reading. Which medication will provide the patient with the fastest
relief from these signs and symptoms of an asthma attack?
A. Theophylline
B. Tiotropium
C. Albuterol
D. Cromolyn
8. You assist your patient with using their inhaler. The inhaler contains the medication Budesonide. Before
administering the inhaler, you will want to connect what device to the inhaler to help decrease the patient from
developing ________?
A. Peak flow meter; pneumonia
B. Incentive spirometer; thrush
C. Spacer; thrush
D. Peak flow meter; mouth sores
9. A patient with asthma is receiving a nebulizer of Cromolyn. The patient reports a burning sensation in the
nose along with a horrible taste in their mouth. As the nurse you will?
A. Immediately stop the
nebulizer
B. Re-adjust the nebulizer
C. Call a rapid response because the patient is having a potential anaphylactic reaction to the medication.
D. Reassure the patient this is a temporary side effect of this medication.

10. You’re providing discharge teaching to a guardian of a 5-year-old patient who was admitted with asthma.
You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all
the correct early warning signs verbalized by the patient:
A. Easily fatigued with physical activity
B. Reduced peak flow meter reading
C. Chest retractions
D. Cyanosis
E. Wheezing with activity
F. Nighttime coughing
G. No relief with short-acting bronchodilator inhaler
Sas 27
Which of the following instructions would Nurse Courtney include in a teaching plan that focuses on initial
prevention for Sheri who is diagnosed with rheumatic fever?
A. Treating streptococcal throat infections with an antibiotic

B. Giving penicillin to patients with rheumatic fever
C. Using corticosteroid to reduce inflammation
D. Providing an antibiotic before dental work
2. Arrange these parts of the conduction system of the heart in the correct order as an action potential
would pass through them. AV node
• Purkinje fibers
• Atrioventricular bundle
• R and L bundle of His
• SA node
A. SA Node – Purkinje Fibers – R and L bundle of His – Atrioventricular bundle – AV Node
B. SA Node – AV Node – Purkinje fibers – R and L bundle of His – Atrioventricular bundle
C. SA Node – Purkinje Fibers – Atrioventricular Bundle – R and L bundle of His – AV Node
D. SA Node – AV Node – Atrioventricular bundle – R and L bundle of His – Purkinje Fibers
3. Which of these statements regarding the conduction system of the heart is NOT correct? Select all that
apply. A. The sinoatrial (SA) node of the heart acts as the pacemaker.
B. The SA node is located on the upper wall of the left atrium.
C. The AV node conducts action potentials rapidly through it.
D. Action potentials are carried slowly through the atrioventricular bundle

4. A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by
carditis are the:
A. coronary arteries.
B. heart muscle and the mitral valve.
C. aortic and pulmonic valves.
D. contractility of the ventricles.
5.Most forms of Juvenile Arthritis are autoimmune disorder.

A. TRUE
B. FALSE
6. Juvenile arthritis runs in families and is passed from one generation to the next.
A. TRUE
B. FALSE
7. The overall goal of juvenile arthritis treatment is to control symptoms and stop joint damage from
happening. A. TRUE
B. FALSE
8. A 4 year old is admitted to your unit with a severe case of impetigo. It is important the nurse follows
_______________ while providing care to this patient:
A. Droplet precautions
B. Standard precautions only
C. Contact precautions
D. Airborne precaution
9. You’re providing education to a group of parents about impetigo. Which statement is CORRECT about this
disease?
A. “It tends to affect the preadolescent and adolescent population.”
B. “Cases of impetigo most likely to occur during the summer when the weather is warm.”
C. “Most cases of impetigo are not contagious.”
D. “Impetigo is caused by a mite parasite.”

.
10.A parent brings her child into the clinic due to skin lesions that fail to heal. The lesions are red, reported to
be itchy, and exhibit exudate. You suspect the child may have impetigo. What is a hallmark finding with this
condition?
A. Round patches with light pink centers
B. Short grey lines on the skin
C. Silver colored scales over the lesions
D. Yellow crusts over the lesions
Sas 28
1.An adolescent has had a lower leg amputation secondary to a motorcycle accident and is complaining of
pain in the missing extremity. The nurse should recognize that this is
A. indicative of narcotic addiction
B. indicative of the need for psychological counseling
C. abnormal and suggests nerve damage
D. normal and called phantom limb sensation
2. The nurse should assess a teenage child suspected of having early stage scoliosis for which of the following clinical
manifestations? Select all that apply:
A. Curved spinal column
B. Unequal shoulder level
C. Altered gait with a limp
D. Limited use of one arm
E. Truncal asymmetry
F. Prominence of one scapula
3. The majority of osteosarcomas occur in what age group?

A. Children under 10
B. Middle age
C. Individuals over 65 years of age
D. Pre-teens and adolescents
4. The nurse is evaluating nutritional outcomes for a with anorexia nervosa. Which data best indicates that the
plan of care is effective?
A. The client selects a balanced diet from the menu.
B. The client’s hemoglobin and hematocrit improve.
C. The client’s tissue turgor improves.
D. The client gains weight.

5. STIs are most common in which age group?
A. Teens and young adults up to age 24
B. People ages 30 to 45
C. People 60 and older
D. All of the above
:
6. Which is the most common STI caused by bacteria?

A. Gonorrhea
B. Syphilis
C. Chlamydia
D. Genital warts
7. Gonorrhea is treated with antibiotics. What problem has occurred recently in treatment?
A. Antibiotics have been in short supply
B. The bacteria that cause gonorrhea have become resistant to certain
antibiotics
C. C. People have developed an allergic reaction to certain antibiotics
D. All of the above
8. Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which
information related to a client's home environment should a nurse associate with the development of this
disorder?
A. The home environment maintains loose personal boundaries.
B. The home environment places an overemphasis on food.
C. The home environment is overprotective and demands perfection.
D. The home environment condones corporal punishment.
9. A 25-year old A client's altered body image is evidenced by claims of "feeling fat" even though the
client is emaciated. Which is the appropriate outcome criterion for this client's problem? A. The client will
consume adequate calories to sustain normal weight.
B. The client will cease strenuous exercise programs.
C. The client will perceive an ideal body weight and shape as normal.

D. The client will not express a preoccupation with food
10. Why are behavior modification programs the treatment of choice for clients diagnosed with eating
disorders? A. These programs help clients correct distorted body image.
B. These programs address underlying client anger.
C. These programs help clients manage uncontrollable behaviors.
D. These programs allow clients to maintain control.
Sas 29
1.A patient is being discharged from the emergency department after being treated for epistaxis. In teaching
the family first aid measures in the event the epistaxis would recur, what measures should the nurse suggest
(select all that apply)?
A. Tilt patient's head backwards.
B. Apply ice compresses to the nose.
C. Tilt head forward while lying down.
D. Pinch the entire soft lower portion of the nose.
E. Partially insert a small gauze pad into the bleeding nostril.
.
2. A 3-year-old is brought to the ER with coughing and gagging. The parent reports that the child was eating
carrots when she began to gag. Which diagnostic evaluation will be used to determine if the child has
aspirated carrots?
A. Chest x-ray.
B. Bronchoscopy.
C. Arterial blood gas (ABG).
D. Sputum culture.
3. A 5-year-old is brought to the ER with a temperature of 99.5°F (37.5°C), a barky cough, stridor, and
hoarseness.
Which nursing intervention should the nurse prepare
for? A. Immediate IV placement.
B. Respiratory treatment of racemic epinephrine.
C. A tracheostomy set at the bedside.
D. Informing the child’s parents about a tonsillectomy.
4. A 6-week-old is admitted to the hospital with influenza. The child is crying, and the father tells the nurse
that his son is hungry. The nurse explains that the baby is not to have anything by mouth. The parent does
not understand why the child cannot eat. Which is the nurse’s best response to the parent?
A. “We are giving your child intravenous fluids, so there is no need for anything by mouth.”

B. “The shorter and narrower airway of infants increases their chances of aspiration so your child should not have
anything to eat now.”
C. “When your child eats, he burns too many calories; we want to conserve the child’s energy.”
D. “Your child has too much nasal congestion; if we feed the child by mouth, the distress will likely increase.”
5. A 7-month-old has a low-grade fever, nasal congestion, and a mild cough. What should the nursing
care management of this child include?
A. Maintaining strict bedrest.
B. Avoiding contact with family members.
C. Instilling saline nose drops and bulb suctioning.
D. Keeping the head of the bed flat.
6. A child is complaining of throat pain. Which statement by the mother indicates that she needs more
education regarding the care and treatment of her daughter’s pharyngitis?
A. “I will have my daughter gargle with salt water three times a day.”
B. “I will offer my daughter ice chips several times a day.”
C. “I will give my daughter Tylenol every 4 to 6 hours as needed.”
D. “I will ask the nurse practitioner for some amoxicillin.”
7. A school-age child has been diagnosed with nasopharyngitis. The parent is concerned because the child
has had little or no appetite for the last 24 hours. Which is the nurse’s best response?
A. “Do not be concerned; it is common for children to have a decreased appetite during a respiratory illness.”
B. “Be sure your child is taking an adequate amount of fluids. The appetite should return soon.”
C. “Try offering the child some favorite food. Maybe that will improve the appetite.”
D. “You need to force your child to eat whatever you can; adequate nutrition is essential.”
8. A parent asks how to care for a child at home who has the diagnosis of viral tonsillitis. Which is the nurse’s
best response?
A. “You will need to give your child a prescribed antibiotic for 10 days.”
B. “You will need to schedule a follow-up appointment in 2 weeks.”
C. “You can give your child Tylenol every 4 to 6 hours as needed for pain.”
D. “You can place warm towels around your child’s neck for comfort.”
9. A school-age child has been diagnosed with strep throat. The parent asks the nurse when the child can
return to school. Which is the nurse’s best response?
A. “Forty-eight hours after the first documented normal temperature.”
B. “Twenty-four hours after the first dose of antibiotics.”
C. “Forty-eight hours after the first dose of antibiotics.”
D. “Twenty-four hours after the first documented normal temperature.”
10. A school-age child is admitted to the hospital for a tonsillectomy. During the nurse’s post-operative
assessment, the child’s parent tells the nurse that the child is in pain. Which of the following observations
would be of most concern to the nurse?

A. The child’s heart rate and blood pressure are elevated.
B. The child complains of having a sore throat.
C. The child is refusing to eat solid foods.
D. The child is swallowing excessively.
Sas 30
The nurse is admitting a client with suspected tuberculosis (TB) to the acute care unit. The nurse places the
client in airborne precautions until a confirmed diagnosis of active TB can be made. Which of the following
tests is a priority to confirm the diagnosis?
A. Chest x-ray that is positive for lung lesions
B. Positive purified protein derivative (PPD) test
C. Sputum culture positive for Mycobacterium Tuberculosis
D. Sputum positive for blood (hemoptysis)
2.The nurse assesses a college-age client complaining of shortness of breath after jogging and tightness in
his chest. Upon further questioning, the client denies a sore throat, fever, or productive cough. The nurse
notifies the physician that this client’s clinical manifestations are most likely related to:
A. Bronchitis.
B. Pneumonia.
C. Pneumoconiosis.
D. Asthma.
3. Which of the following is a priority to include in the instructions given to a client who has bronchitis?
A. Avoid cigarette smoking
B. Increase activity
C. Decrease overweight status
D. Avoid malnutrition
4. The nurse is admitting a client who complains of fever, chills, chest pain, and dyspnea. The client has a
heart rate of 110, respiratory rate of 28, and a nonproductive hacking cough. A chest x-ray confirms a
diagnosis of left lower lobe pneumonia. Upon auscultation of the left lower lobe, the nurse documents
which of the following breath sounds?
A. Vesicular
B. Absent breath sounds
C. Broncho vesicular
D. Bronchial

5. A client with suspected active lung tuberculosis is being scheduled for diagnostic tests. The nurse
anticipates that which diagnostic test will most likely be prescribed to confirm the diagnosis?
A. Skin testing
B. White blood cell count
C. Sputum culture
D. Chest x-ray
6. The nurse is instructing a client with moderate persistent asthma on the proper method for using
MDI’s (multidose inhalers). Which medication should be administered FIRST?
A. Steroid
B. Mast cell stabilizer
C. Anticholinergic
D. Beta agonist
.
7. The nurse is caring for a client with a pneumothorax. The nurse expects the client to have a chest tube
inserted because?
A. It will drain the purulent drainage from the empyema that caused it
B. It is the appropriate post-operative treatment for a pneumothorax
C. It will increase the intrathoracic pressure, restoring it back to normal
D. It will drain air out of the thorax, restoring normal intrathoracic pressure
8. Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the
following statements concerning PPD testing is true?
A. A positive reaction indicates that the client has active tuberculosis (TB)
B. A positive reaction indicates that the client has been exposed to the disease
C. A negative reaction always excludes the diagnosis of TB
D. The PPD can be read within 12 hours after the injection.
9. Nurse Murphy administers albuterol (Proventil), as prescribed to a client with emphysema. Which finding
indicates that the drug is producing a therapeutic effect?
A. Respiratory rate of 22 breaths/minute
B. .Dilated and reactive pupils.
C. Urine output of 40 ml/hour.
D. Heart rate of 100 beats/minute.
10. A 5 year old client is admitted to an acute care facility with influenza. The nurse monitors the client
closely for complications. What is the most common complication of influenza?
A. Septicemia
B. Pneumonia

C. Meningitis
D. Pulmonary edema
Sas 31
Atrial septal defects are characterized by a hole in the interatrial septum that allows blood to mix in the right
and left atria, which are the lower chambers of the heart.
A. TRUE
B. FALSE
2. A patient is diagnosed with a large atrial septal defect. You’re providing information for the patient on the
complications related to this condition. What topics will you include in the patient’s education? Select all that
apply:
A. Tet spells
B. Heart failure
C. Stroke
D. Pulmonary Hypertension
E. Rheumatic Fever
3. You’re caring for a 2-year-old patient who has a large atrial septal defect that
needs repair. This defect is causing complications. These complications are arising
from an abnormal shunting of blood throughout the heart. As the nurse, you know
that a __________________ shunt is occurring in the heart due to the defect.
A. Right-to-left
B. Right
C. Left
D. Left-to-right
4. A 10-year-old has undergone a cardiac catheterization. At the end of the

procedure, the nurse should first assess:
A. Pain
B. Pulses

C. Hemoglobin and hematocrit levels
D. Catheterization report.
5. A heart transplant may be indicated for a child with severe heart failure and:
A. Patent ductus arteriosus
(PDA)
B. Ventricular septal defect
(VSD)
C. Hypoplastic left heart
syndrome
D. Pulmonic stenosis (PS).
6. Bryce is a child diagnosed with coarctation of aorta. While assessing him, Nurse Zach would expect to find
which of the following?
A. Squatting posture
B. Absent or diminished femoral pulses
C. Severe cyanosis at birth
D. Cyanotic (“tet”) episodes
7. Appropriate intervention is vital for many children with heart disease in order to go on to live active, full
lives. Which of the following outlines an effective nursing intervention to decrease cardiac demands and
minimize cardiac workload?
A. Feeding the infant over long periods
B. Allowing the infant to have her way to avoid conflict
C. Scheduling care to provide for uninterrupted rest periods
D. Developing and implementing a consistent care plan
ANSWER:
RATIONALE:
8. The procedure that has to be performed in order to shift the high pressure from the right ventricle to the left
ventricle in Transposition of the Great Arteries (TGA) is:
A. Rashkind Procedure
B. Rastelli Procedure
C. Pulmonary Artery Banding
D. Jatene Procedure
9. The ductus arteriosus is another fetal structure that is important in the intrauterine life. It functions to:
A. Shunts the combined cardiac output from the pulmonary artery to the aorta going to the lungs
B. Shunts the combined cardiac output from the pulmonary artery to the systemic circulation
C. Shunts the combined cardiac output from the aorta to the pulmonary artery and later to the pulmonary veins
D. Shunts the combined cardiac output from the aorta to the pulmonary artery to the right ventricle

10. What's an important teaching point for the patient receiving a heart transplant?
A. He'll need to stay indoors during the winter months.
B. He'll need to take immunosuppressants for at least 6 months following surgery.
C. He'll be at risk for life-threatening infections because of the medications he'll be taking.
After 6 weeks, he'll no longer be at risk for rejection
Sas 32
A 10-year-old has undergone a cardiac catheterization. At the end of the procedure, the nurse should first
assess:
A. Pain
B. Pulses
C. Hemoglobin and hematocrit levels
D. Catheterization report

2. A 16-year-old being treated for hypertension has laboratory values of hemoglobin B 16 g/dL,
hematocrit level 43%, sodium 139 mEq/L, potassium 4.4 mEq/L, and total cholesterol of 220 mg/dL.
Which drug does the nurse suspect the patient takes based on the total cholesterol?
A. Beta blockers
B. Calcium channel blockers
C. ACE inhibitors
D. Diuretics
3. A child born with Down syndrome should be evaluated for which associated cardiac
manifestation?
A. Congenital heart defect (CHD)
B. Systemic hypertension
C. Hyperlipidemia
D. Cardiomyopathy
4. A child diagnosed with congestive heart failure (CHF) is receiving maintenance doses of digoxin and
furosemide. She is rubbing her eyes when she is looking at the lights in the room, and her HR is 70
beats per minute. The nurse expects which laboratory finding?
A. Hypokalemia
B. Hypomagnesemia
C. Hypocalcemia
D. Hypophosphatemia.
5. A child has been diagnosed with valvular disease following rheumatic fever (RF). During patient
teaching, the nurse discusses the child’s long-term prophylactic therapy with antibiotics for dental
procedures, surgery, and childbirth. The parents indicate they understand when they say:
A. “She will need to take the antibiotics until she is 18
years old.”

B. “She will need to take the antibiotics for 5 years
after the last attack.”
C. “She will need to take the antibiotics for 10 years after
the last attack.”
D. “She will need to take the antibiotics for the rest of her
life.”
6. A child has been seen by the school nurse for dizziness since the start of the school term. It
happens when standing in line for recess and homeroom. The child now reports that she would
rather sit and watch her friends play hopscotch because she cannot count out loud and jump at the
same time. When the nurse asks her if her chest ever hurts, she says yes. Based on this history, the
nurse suspects that she has:
A. Ventricular septal defect (VSD)
B. Aortic stenosis (AS)
C. Mitral valve prolapse
D. Tricuspid atresia
7. A heart transplant may be indicated for a child with severe heart failure and:
A. Patent ductus arteriosus (PDA)
B. Ventricular septal defect (VSD)
C. Hypoplastic left heart syndrome
D. Pulmonic stenosis (PS)

8. Aspirin has been ordered for the child with rheumatic fever (RF) in order to:
A. Keep the patent ductus arteriosus (PDA) open
B. Reduce joint inflammation
C. Decrease swelling of strawberry tongue
D. Treat ventricular hypertrophy of endocarditis.
9. Congenital heart defects (CHDs) are classified by which of the following? Select all that apply.
A. Cyanotic defect
B. Acyanotic defect
C. Defects with increased pulmonary blood flow
D. Defects with decreased pulmonary blood flow
E. Mixed defects
F. Obstructive defects
10. Family discharge teaching has been effective when the parent of a toddler diagnosed with
Kawasaki disease (KD) states:
A. “The arthritis in her knees is permanent. She will need knee replacements.”
B. “I will give her diphenhydramine (Benadryl) for her peeling palms and soles of her feet.”
C. “I know she will be irritable for 2 months after her symptoms started.”
D. “I will continue with high doses of Tylenol for her inflammation.”
SAS 33
1.A 13-month-old is discharged following repair of his epispadias. Which statement made by the
parents indicates they understand the discharge teaching?
A. “If a mucous plug forms in the urinary drainage tube, we will irrigate it gently to prevent a blockage.”
B. “If a mucous plug forms in the urinary drainage tube, we will allow it to pass on its own because this is
a sign of healing.”
C. “We will make sure the dressing is loosely applied to increase the toddler’s comfort.” D. “If we notice
any yellow drainage, we will know that everything is healing well.”

ANSWER:
RATIONALE: Any mucous plugs should be removed by irrigation to prevent blockage of the urinary
drainage system
2. A child had a urinary tract infection (UTI) 3 months ago and was treated with an oral antibiotic.
A follow-up urinalysis revealed normal results. The child has had no other problems until this visit
when the child was diagnosed with another UTI. Which is the most appropriate plan?
A. Urinalysis, urine culture, and VCUG
B. Evaluate for renal failure
C. Admit to the pediatric unit
D. Discharge home on an antibiotic
ANSWER:
RATIONALE: Urinalysis and urine culture are routinely used to diagnose UTIs. VCUG is used to determine
the extent of urinary tract involvement when a child has a second UTI within 1 year
3. An infant is scheduled for a hypospadias and chordee repair. The parent tells the nurse, “I
understand why the hypospadias repair is necessary, but do they have to fix the chordee as
well?” Which is the nurse’s best response?
A. “I understand your concern. Parents do not want their children to undergo extra surgery.”
B. “The chordee repair is done strictly for cosmetic reasons that may affect your son as he ages.”
C. “The repair is done to optimize sexual functioning when he is older.”
D. “This is the best time to repair the chordee because he will be having surgery anyway.”
ANSWER:
RATIONALE: Releasing the chordee surgically is necessary for future sexual function.

4. In addition to increased blood pressure, which findings would most likely be found in a child
with hydronephrosis?
A. Metabolic alkalosis, polydipsia, and
polyuria
B. Metabolic acidosis, and bacterial
growth in the urine C. Metabolic
alkalosis, and bacterial growth in the
urine
D. Metabolic acidosis, polydipsia, and polyuria.
ANSWER:
RATIONALE: The blood pressure is increased as the body attempts to compensate for the decreased
glomerular filtration rate. Metabolic acidosis is caused by a reduction in hydrogen ion secretion from the
distal nephron. Polydipsia and polyuria occur as the kidney’s ability to concentrate urine decreases. There
is bacterial growth in the urine due to the urinary stasis caused by the obstruction.
5. You have a patient that might have a urinary tract infection (UTI). Which statement by the
patient suggests that a UTI is likely?
A. “I pee a lot.”
B. “It burns when I pee.”
C. “I go hours without the urge to pee.”
D. “My pee smells sweet.”
ANSWER:
RATIONALE: A common symptom of a UTI is dysuria. A patient with a UTI often reports frequent voiding of small
amounts and the urgency to void. Urine that smells sweet is often associated with diabetic ketoacidosis
6. Which of the following causes the majority of UTI’s in

hospitalized patients?
A. Lack of fluid intake
B. Inadequate perineal care
C. Invasive procedures
D. Immunosuppression
ANSWER:
RATIONALE: Invasive procedures such as catheterization can introduce bacteria into the urinary tract. A lack of
fluid intake could cause concentration of urine, but wouldn't necessarily cause infection.

7. A 10-year-old Nik has cystitis; which of the following would Nurse Chinny expect when
assessing the child?
A. Dysuria
B. Costovertebral tenderness
C. Flank pain
D. D. High fever
ANSWER:
RATIONALE: Dysuria is the medical term for pain or discomfort when urinating. Dysuria is a
common symptom of a bladder infection (cystitis).
8. Niklaus was born with hypospadias; which of the following should be avoided when a
child has such condition?
A. Surgery
B. Circumcision
C. Intravenous pyelography (IVP)
D. Catheterization
ANSWER:
RATIONALE: Children with hypospadias should not be circumcised because the foreskin, which is
removed during circumcision, is a source of tissue that surgeons use to rebuild the missing part of the
urethra.
9. Which of the following organisms is the most common cause of urinary tract infection (UTI)
in children?
A. Klebsiella
B. Staphylococcus
C. Escherichia coli
D. Pseudomonas
ANSWER:
RATIONALE: Escherichia Coli is the most common cause of urinary tract infection in children.
Most infection are caused by bacteria from the digestive tract.
10. The following are considered functions of the Urinary System EXCEPT: (Select
all that apply).
A. Vitamin D synthesis
B. Regulation of red blood cell synthesis
C. Excretion
D. Absorption of digested molecules

E. Regulation of blood volume and pressure
ANSWER:
RATIONALE: Absorption of digested molecules is not part of the function of Urinary System
SAS 34
1.A client is admitted with a diagnosis of hydronephrosis secondary to calculi. The calculi have
been removed and post obstructive diuresis is occurring. Which of the following interventions
should be done?
A. Take vital signs every 8 hours
B. Weigh the client
every other day
C. Assess for urine
output every shift
D. Monitor the client’s
electrolyte levels.
ANSWER:
RATIONALE; Monitor the client's fluid and electrolyte levels
Postobstructive diuresis seen in hydronephrosis can cause electrolyte imbalances; lab values must be
checked so electrolytes can be replaced as needed. VS should initially be taken every 30 minutes for the
first 4 hours and then every 2 hours. Urine output needs to be assessed hourly. The client's weight should
be taken daily to assess fluid status more closely.
2. Your patient with chronic renal failure reports pruritus. Which instruction should you include in
this patient’s teaching plan?
A. Rub the skin vigorously with a towel
B. Take frequent baths
C. Apply alcohol-based emollients to the skin
D. Keep fingernails short and clean
ANSWER:
RATIONALE: Ridged nails: Also called koilonychia, rough nails with ridges can exist in the presence
of kidney disease. These nails are also frequently spoon-shaped and concave, and they can point to
iron-deficiency anemia

3. A twelve year old student is admitted with dark urine, fever, and flank pain and is
diagnosed with acute glomerulonephritis. Which would most likely be in this student’s
health history?
A. Renal calculi
B. Renal trauma
C. Recent sore throat
D. Family history of acute glomerulonephritis
ANSWER: C
The most common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal
infection elsewhere in the body.
4. Clinical manifestations of acute glomerulonephritis include which of the following?

A. Chills and flank pain
B. Oliguria and generalized edema
C. Hematuria and proteinuria
D. Dysuria and hypotension
ANSWER:
RATIONALE: Hematuria and proteinuria indicate acute glomerulonephritis. These finding result from increased
permeability of the glomerular membrane due to the antigen-antibody reaction. Generalized edema is seen most
often in nephrosis.
5. You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output less
than:
A. 200ml
B. 400ml
C. 800ml
D. 1000ml
ANSWER:
RATIONALE: a urine output of less than 400ml should be expected.
6. The most common early sign of kidney disease is:

A. Sodium retention
B. Elevated BUN level
C. Development of metabolic acidosis
D. Inability to dilute or concentrate urine

ANSWER:
RATIONALE: Bun is usually indicator of an early decreased renal function
7. Which finding leads you to suspect acute glomerulonephritis in your 30 year

old patient?
A. Dysuria, frequency, and urgency
B. Back pain, nausea, and vomiting
C. Hypertension, oliguria, and fatigue
D. Fever, chills, and right upper quadrant pain radiating to the back
ANSWER: C
Mild to moderate HTN may result from sodium or water retention and inappropriate renin release from the
kidneys. Oliguria and fatigue also may be seen. Other signs are proteinuria and azotemia.
8. Polystyrene sulfonate (Kayexalate) is used in renal failure to:

A. Correct acidosis
B. Reduce serum phosphate levels
C. Exchange potassium for sodium
D. Prevent constipation from sorbitol use
ANSWER:
RATIONALE: is a cation exchange resin that trades sodium ions for potassium ions
9. The client enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so
tired, I have no appetite, and everything hurts." The triage nurse assesses the client and finds a
butterfly rash over the bridge of nose and on the cheeks. Which diagnosis does the nurse expect?
A. Systemic lupus erythematosus
B. Fibromyalgia
C. Lyme disease
D. Gout
ANSWER:
RATIONALE: The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the
diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder
will have this rash. While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do
not cause a rash over the nose and cheeks.

SAS 35
1. A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is
under nurse Mark’s care. Which nursing intervention should be included the care plan of Mark for
his patient?
A. Administering I.V. and oral fluids
B. Clustering necessary activities throughout the day
C. Assessing color, odor, and amount of sputum
D. Monitoring serum albumin and total protein levels
ANSWER:
RATIONALE: The client’s assessment findings would lead the nurse to suspect that the client is dehydrated.
Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with problems
associated with impaired gas exchange or ineffective airway clearance. Monitoring albumin and protein
levels is appropriate for clients experiencing inadequate nutrition. Clustering activities helps with energy
conservation and promotes rest.
2. Shane is admitted in the hospital due to having lower than normal potassium level in her
bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which
foods should the nurse instruct the client to increase?
A. Whole grains and nuts
B. Milk products and green, leafy vegetables
C. Pork products and canned vegetables
D. Orange juice and bananas
ANSWER:
RATIONALE: Answer: D. Orange juice and bananas
The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and
bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes. Whole grains
and nuts would be encouraged for the client with hypomagnesemia; milk products and green, leafy
vegetables are good sources of calcium for the client with hypocalcemia. Pork products and canned
vegetables are high in sodium and are encouraged for the client with hyponatremia
3. A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration.
Which intervention should the nurse perform when caring for a client diagnosed with fluid volume
deficit?
A. Assessing urinary intake and output
B. Obtaining the client’s weight weekly at different times of the day
C. Monitoring arterial blood gas (ABG) results
D. Maintaining I.V. therapy at the keep-vein-open rate
ANSWER:
RATIONALE: Assessing urinary intake and output intervention, the nurse should perform when caring for a client
diagnosed with fluid volume deficit.

4. Which client situation requires the nurse to discuss the importance of avoiding foods high in
potassium?
A. 14-year-old Elena who is taking diuretics
B. 16-year-old John Joseph with ileostomy
C. 16-year-old Gabriel with metabolic acidosis
D. 18-year-old Albert who has renal disease
ANSWER:
RATIONALE: Clients with renal disease are predisposed to hyperkalemia & should avoid foods high in
potassium.
5. Camille is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

A. Instituting seizure precaution to prevent injury
B. Instructing the client on the importance of preventing infection
C. Avoiding the use of tight tourniquet when drawing blood
D. Teaching the client the importance of early ambulation
ANSWER:
RATIONALE: The appropriate nursing intervention would be instituting seizure precaution to prevent injury.
6. Which electrolyte would the nurse identify as the major electrolyte responsible for determining
the concentration of the extracellular fluid?
A. Potassium
B. Phosphate
C. Chloride
D. Sodium
ANSWER:
RATIONALE: Sodium is the major electrolyte responsible for determining the concentration of the
extracellular fluid
.
7. Ellerid has a potassium level of 6.5 mEq/L, which medication would nurse
Martie anticipate?
A. Potassium supplements
B. Kayexalate
C. Calcium gluconate

D. Sodium tablets
ANSWER:
RATIONALE: The client’s potassium level is elevated; therefore, Kayexalate would be ordered to help reduce the
potassium level. Kayexalate is a cation-exchange resin, which can be given orally, by nasogastric tube, or by
retention enema. Potassium is drawn from the bowel and excreted through the feces. Because the client’s potassium
level is already elevated, potassium supplements would not be given. Neither calcium gluconate nor sodium tablets
would address the client’s elevated potassium level.
8. Which clinical manifestation would lead the nurse to suspect that a client is experiencing
hypermagnesemia? A. Muscle pain and acute rhabdomyolysis
B. Hot, flushed skin and diaphoresis
C. Soft-tissue calcification and hyperreflexia
D. Increased respiratory rate and depth
ANSWER:
RATIONALE: Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit
hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are
indicative of hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia.
Increased respiratory rate and depth are associated with metabolic acidosis.
9. Which patient is at more risk for an electrolyte imbalance?

A. An 8 month old with a fever of 102.3 ‘F and diarrhea
B. A 5 year old diabetic with nausea and vomiting
C. A 5 year old with RSV
D. A healthy 7 year old with intermittent episodes of nausea
ANSWER:
RATIONALE: The answer is A. The 8 month old with a fever of 102.3 ‘F and diarrhea is the correct answer.
Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other
age group. This is because infants have the highest amount of total body fluid (80% of the body is made
up of fluid) and if any type of illness especially GI effects the body this increases the chances of an
electrolyte imbalance
10. A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon
palpation), 80/62 blood pressure, 25 ml/hr urinary output, and Sodium level of 160. What
interventions do you expect the medical doctor to order for this patient?
A. Restrict fluid intake and monitor daily weights
B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output
C. Administer hypotonic IV fluid and administer sodium tablets.
D. No interventions are expected

ANSWER:
RATIONALE: The patient must be re-hydrated and the sodium levels should be decreased at the
same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is
hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the
dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This
allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment
10. A female client asks the nurse if there are any conditions that can exacerbate systemic lupus
erythematosus (SLE). Which is the best nurse response?
A. "Conditions that cause hypotension can often exacerbate SLE."
B. "GI upset is often associated with SLE exacerbation."
C. "Pregnancy is often associated with an SLE exacerbation."
D. "Fever is a known trigger for an SLE exacerbation."
ANSWER:
RATIONALE: Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen levels.
Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
SAS 36
1. There is a 12 year old patient on the unit with herpes zoster. You would avoid assigning this
patient to a staff member who has never had or been vaccinated for:
A. Mumps
B. Chicken pox
C. Roseola
D. German measles
ANSWER:
RATIONALE: The nurse who has never had chicken pox should not be assigned to this patient. Herpes
zoster is caused by the same virus that causes chicken pox; therefore, assigning this nurse to this patient
would increase her chances of contracting chicken pox from the patient.
2. A nurse is teaching a client with genital herpes. Education for this client should include an
explanation of:
A. why the disease is transmittable only when visible lesions are present.
B. the need for the use of petroleum products.
C. the option of disregarding safer-sex practices now that he's
already infected.
D. the importance of informing his partners of the disease

ANSWER:
RATIONALE: Clients with genital herpes should inform their partners of the disease to help prevent
transmission. Petroleum products should be avoided because they can cause the virus to spread. The
notion that genital herpes is only transmittable when visible lesions are present is false. Anyone not in a
long-term, monogamous relationship, regardless of current health status, should follow safer-sex
practices
3. What is an infectious cause of orchitis?

A. Chlamydia
B. Epstein-Barr virus
C. Measles
D. Mumps
ANSWER:
RATIONALE: Orchitis due to mumps has decreased significantly due to vaccination, but it is still a significant
risk in unvaccinated individuals. Mumps-related orchitis can result in testicular failure later in life. None of
the other microbial infections listed have an association with orchitis
4. A child appears with a flat pink rash that first appeared on the trunk. Subsequently, the rash
migrated to the rest of the body. Which of the following is the most likely cause?
A. Smallpox
B. Rubella
C. Chickenpox
D. Measles
ANSWER:
RATIONALE: This question requires the student to distinguish between the rashes that are common in
children; specifically those that may be present due to fear of immunizations. Measles begins with
Koplik's spot in the mouth. Then the rash first appears on the forehead. Rubella first appears on the trunk,
then spreads throughout the body
5. Which strain of human papillomavirus (HPV) is associated with the most forms of cancer?

A. 16
B. 11
C. 18
D. 6
ANSWER:
RATIONALE: While HPV 18 is associated with a large percentage of cervical dysplasia alongside HPV 16, HPV 16 is
the strain associated with the majority of HPV-related anal cancer, cancer of the throat, tongue cancer, vaginal
cancer, vulvar cancer, and penile cancer
6. Which of the following viruses is responsible for infectious

mononucleosus? A. Herpes zoster
B. Parvovirus B19
C. Epstein Barr virus
D. Cytomegalovirus
ANSWER:
RATIONALE: Infectious mononucleosis is associated with infection by Epstein Barr virus, a form of human
herpes virus. Cytomegalovirus is associated primarily with congenital defects, parvovirus B19 is the cause
of fifth's disease, also known as "slapped cheek syndrome." Herpes zoster is the virus responsible for
both chicken pox and shingles.
7. Zika virus is primarily transmitted via what route?

A. Oral-fecal
B. Tick bite
C. Respiratory droplets
D. Mosquito bite
ANSWER:
RATIONALE: Zika virus is primarily transmitted via mosquito bite. However, it can also be
transmitted by sexual contact and it can cross the placenta, allowing an infected mother to pass
the virus to an unborn child.
8. High fever, cough, runny nose, maculopapular rash, and Koplik's spots are seen in which of the
following viral infections?
A. Scarlet fever
B. Epstein-Barr
C. Measles
D. Mumps
ANSWER:

RATIONALE: Koplik's spots are oral lesions seen early-on in infection with the measles virus. These
spots are only present in a minority of cases, though.
9. How is the measles virus primarily spread?

A. Insect vectors
B. Respiratory droplets
C. Fecal-oral
D. Contaminated blood
ANSWER:
RATIOANLE: The measles virus is one of the most highly contagious of all childhood exanthems. It is
spread primarily by respiratory droplets, or by touching a surface that has been in contact with an infected
individual's saliva or mucus. It is not spread in feces, nor is it blood or vector borne.
10. Which of the following is an infection of the finger, toe, or nail cuticle with the herpes
simplex virus? A. Infectious paronychia
B. Herpetic paronychia
C. Herpangina
D. Herpetic whitlow
ANSWER:
RATIONALE: An infection of the finger, toe, or cuticle with the herpes simplex virus is known as a herpetic
whitlow. This infection causes painful swelling and erythema at the site of contact and is often caused by
the finger coming into contact with a cold sore (oral herpes simplex lesion).
SAS 37
1. A school nurse is holding a question and answer meeting for parents following a recent
outbreak of scarlet fever. Which of the following would the nurse confirm as false?
A. A rash develops secondary to toxin sensitivity
B. Children over two years of age are higher risk than children under two years of age
C. A child may or may not develop a rash after exposure
D. Scarlet fever is a viral infection
E. Scarlet fever is transmitted through the air
ANSWER:
RATIONALE: Scarlet fever is a bacterial infection caused by group A Streptococcus that is transmitted
through the air. Children who are sensitive to the bacterial toxin may develop a rash, although some will
not. Infants and toddlers under the age of two are rarely seen with the disease.

2. A mother brings her child in for paroxysmal bouts of 10-15 coughs followed by 1-2 deep
gasping breaths. It started as a simple cold and cough, which seemed to be getting better before
the gasping paroxysmal coughing started. The coughing is severe enough that he has vomited
several times. What is the most likely diagnosis? A. Croup
B. P
e
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s
s
i
s
C. P
n
e
u
m
o
n
i
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D. B
r
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n
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i
t
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s
ANSWER:
RATIONALE: The most likely diagnosis in this case is pertussis, also known as whooping cough. This is
caused by Bordetella pertussis, a gram-negative encapsulated coccobacillus. It begins as a seemingly
normal upper respiratory infection, which progresses two weeks after onset into paroxysms of 5-15 violent
coughs followed by a forceful inspiratory gasp, often described as a "whoop." Coughing is often forceful
enough to induce vomiting, nosebleeds, or subconjunctival hemorrhage. Croup, pneumonia, and
bronchitis are all conditions that include cough, though none of them will generally present with this
degree of gasping, vomiting, or blood vessel damage due to cough.

3.Strawberry tongue and maculopapular ("sandpaper") rash are commonly seen in what childhood
exanthem?
A. Varicella
B. Roseola
C. Impetigo
D. Scarlet fever
ANSWER:
RATIONALE: Strawberry tongue (glossitis) and maculopapular ("sandpaper") rash are commonly seen in
scarlet fever, a condition caused by group A Streptococcus bacteria, often after a bout of strep throat. The
other exanthems listed can all cause erythematous rash, though none are associated with glossitis.
4. What organism causes Rocky Mountain spotted fever?

A. Rickettsia helvetica
B. Borrelia burgdorferi
C. Ehrlichiachaffeensis
D. Rickettsia rickettsii
ANSWER:
RATIONALE: Rocky Mountain spotted fever (RMSF) is an infectious disease that belongs to a group of
diseases known as the spotted fever group rickettsioses. It is caused by infection with the bacterium
Rickettsia rickettsii (R. rickettsii), which is usually transmitted by a tick bite.
5. Which of the following bacteria is Gram positive cocci that is found

in clusters?
A. Streptococcyous pyogenes
B. E. Coli
C. Staphlococcyous aureus
D. Pseudomonas
ANSWER:
RATIONALE: Staphlococcyous aureus is the Gram positive cocci
that is found in clusters?
6. Which of the following is a fungus that may be responsible for certain cases of
diaper rash? A. Candida albicans
B. Aspergillus fumigatus
C. Pneumocystis jirovecii
D. Sporothrixschenckii

E. Blastomyces dermatitidis
ANSWER:
RATIONALE: Candida albicans is a fungus present in the normal flora of humans. An overgrowth of this
fungus may cause yeast infections of the skin, vagina, or mouth. After a child receives antibiotics, they
may contract a mycotic diaper rash due to Candida albicans overgrowth since the normal bacterial flora
have been eliminated by the antibiotics.
7. A 7 year old child contracted scabies with his mother, which is diagnosed the day after
discharge. The client is living at her son’s home, where six other persons are living. During her
visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate
response from the nurse is:
A. “All family members will need to be treated.”
B. “If someone develops symptoms, tell him to see a physician right away.”
C. “Just be careful not to share linens and towels with family members.”
D. “After you’re treated, family members won’t be at risk for contracting scabies.”
ANSWER:
RATIONALE:
8. When caring for a male client with severe impetigo, the nurse should include which intervention
in the plan of care?
A. Placing mitts on the client’s hands
B. Administering systemic antibiotics as prescribed
C. Applying topical antibiotics as prescribed
D. Continuing to administer antibiotics for 21 days as prescribed
ANSWER:
RATIONALE: Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If
the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent
glomerulonephritis, a dangerous complication. The client’s nails should be kept trimmed to avoid
scratching; however, mitts aren’t necessary. Topical antibiotics are less effective than systemic antibiotics
in treating impetigo
.
9. Nurse Percy discovers scabies when assessing a 10 year old patient who has just been
transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in
other patient, the nurse should: A. wash hands, apply a pediculicide to the client’s scalp, and remove
any observable mites.
B. isolate the client’s bed linens until the client is no longer infectious.
C. notify the nurse in the day surgery unit of a potential scabies outbreak.

D. place the client on enteric precautions.
ANSWER:
RATIONALE: To prevent the spread of scabies to other hospitalized clients, the nurse should isolate the
client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other
required precautions include using good hand-washing technique and wearing gloves when applying the
pediculicide and during all contact with the client.
10. Dr. Desi prescribes an emollient for a client with pruritus of recent onset. The client asks why
the emollient should be applied immediately after a bath or shower. How should the nurse
respond?
A. “This makes the skin feel soft.”
B. “This prevents evaporation of water from the hydrated epidermis.”
C. “This minimizes cracking of the dermis.”
D. “This prevents inflammation of the skin.”
SAS 38
1. Which statement is correct about the rate of cell growth in relation to

chemotherapy?
A. Faster growing cells are less susceptible to chemotherapy.
B. Nondividing cells are more susceptible to chemotherapy.
C. Faster growing cells are more susceptible to chemotherapy.
D. Slower growing cells are more susceptible to chemotherapy.
ANSWER:
RATIONALE: The faster the cell grows, the more susceptible it is to chemotherapy and radiation therapy.
Slow-growing and non-dividing cells are less susceptible to chemotherapy. Repeated cycles of
chemotherapy are used to destroy nondividing cells as they begin active cell division.
2. The client diagnosed with leukemia has central nervous system involvement. Which
instructions should the nurse teach?
A. Sleep with the head of the bed elevated to prevent increased intracranial pressure.
B. Take an analgesic medication for pain only when the pain becomes severe.
C. Explain that radiation therapy to the head may result in permanent hair loss.
D. Discuss end-of-life decisions prior to cognitive deterioration
ANSWER:
RATIONALE:

3.The nurse analyzes the laboratory values of a child with leukemia who is receiving
chemotherapy . The nurse notes that the platelet count is 20,000/ul. Based on the laboratory
result, which intervention will the nurse document in the plan of care?
A. Monitor closely for signs of infection
B. Monitor the temperature every 4hours
C. Initiate protective isolation precautions

D. Use soft small toothbrush for mouth care
ANSWER:
RATIONALE: If a child is severely thrombocytopenic and has a platelet count less than 20,000/ul, bleeding
precautions need to be initated because of increased risk of bleeding or hemorrhage. Options 1,2,3 are related to
the prevention of infection rather than bleeding
4. The nurse is aware that a

major difference between
Hodgkin's lymphoma and non-
Hodgkin's lymphoma is that: A.
Hodgkin's lymphoma occurs only
in young adults
B. Hodgkin's lymphoma is considered potentially curable
C. Non-Hodgkin's lymphoma can manifest in multiple organs
D. Non-Hodgkin's lymphoma is treated only with radiation therapy
ANSWER:
RATIONALE: Non-Hodgkin's lymphoma can originate outside the lymph nodes, the method of spread
can be unpredictable, and most affected patients have widely disseminated disease.

5.
W
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a

s
e
?
A.
A
n
e
m
ia
B. Infection
C. Myocardial Infarction
D. Nausea
ANSWER:
RATIONALE: Complications of Hodgkin's are pancytopenia, nausea, and infection. Cardiac involvement usually
doesn't occur.
6. Which of the
following
manifestations
would be
directly
associated with
Hodgkin's
disease?
A. bone pain
B. generalized edema
C. petechiae and purpura
D. painless, enlarged lymph nodes
ANSWER:
RATIONALE: Hodgkin's disease usually presents as painless enlarged lymph nodes. The diagnosis is made by lymph
node biopsy.
7. The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy
for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following
cells would the pathologist expect to find?
A. Reed-Sternberg cells.
B. Lymphoblastic cells.
C. Gaucher’s cells.
D. Rieder’s cells
ANSWER:
RATIONALE: A definitive diagnosis of Hodgkin's disease is made if Reed-Sternberg cells are found on pathologic
examination of the excised lymph node. Lymphoblasts are immature cells found in the bone marrow of patients with
acute lymphoblastic leukemia. Gaucher's cells are large storage cells found in patients with Gaucher's disease.
Rieder's cells are myeloblasts found in patients with acute myelogenous leukemia

8. A male client is admitted to the hospital with a suspected diagnosis of Hodgkin’s disease.
Which assessment findings would the nurse expect to note specifically in the client?
A. Fatigue
B. Weakness
C. Weight gain
D. Enlarged lymph nodes
ANSWER:
RATIONALE: Hodgkin’s disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the
painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight
loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.
9. A newly admitted client

is diagnosed with
Hodgkin’s disease
undergoes an excisional
cervical lymph node biopsy
under local anesthesia.
What does the nurse
assess first after the
procedure?
A. Vital signs
B. Incision site
C. Airway
D. Level of consciousness
ANSWER:
RATIONALE: Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may
have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air
exchange
10. A client admitted with newly diagnosed with Hodgkin’s disease. Which of the following would
the nurse expect the client to report?
A. Lymph node pain
B. Weight gain
C. Night sweats
D. Headache
ANSWER:
RATIONALE: Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph node, fever,
malaise and night sweats.
SAS 39

1. A 2-month-old infant is brought to the emergency room after experiencing a seizure. The infant
appears lethargic with very irregular respirations and periods of apnea. The parents report the
baby is no longer interested in feeding and before the seizure, rolled off the couch. What
additional testing should the nurse immediately prepare for?
A. Computed tomography (CT) scan of the head and dilation of the eyes.
B. Computed tomography (CT) scan of the head and electroencephalogram (EEG).
C. X-rays of the head.
D. X-rays of all long bones.
ANSWER:
RATIONALE: A computed tomography scan of the head will reveal trauma. Dilating the eyes is
performed to check for retinal hemorrhages that are seen in an infant who has experienced SBS
2. A child diagnosed with Astrocytoma is having a generalized tonic-clonic seizure. Which should
the nurse do first?
A. Administer blow-by oxygen and call for additional help.
B. Reassure the parents that seizures are common in children with meningitis
C. Call a code and ask the parents to leave the room.
D. Assess the child’s temperature and blood pressure.
ANSWER:
RATIONALE: The child experiencing a seizure usually requires more oxygen as the seizure
increases the body’s metabolic rate and demand for oxygen. The seizure may also affect the
child’s airway causing the child to be hypoxic. It is always appropriate to give the child blow by
oxygen immediately.
3. A child has been diagnosed with a midline brain tumor. In addition to showing signs of
increased intracranial pressure (ICP), she has been voiding large amounts of very dilute urine.
Which medication does the nurse expect to administer?
A. Mannitol.
B. Vasopressin.
C. Lasix.
d.
Dopami
ne.
ANSWE
R:
RATIONALE: The child is experiencing diabetes insipidus, a common occurrence in children with midline
brain tumors. Vasopressin is a hormone that is used to help the body retain water

4. The nurse is caring for a 3-year-old with an altered state of consciousness. The nurse
determines that the child is oriented by asking the child to:
A. Name the president of the United States.
B. Identify her parents and state her own name.
C. State her full name and phone number.
D. Identify the current month but not the date.
ANSWER:
RATIONALE: Asking the 3-year-old to identify her parents and state her name is a developmentally
appropriate way to assess orientation.
5. "The mother of a child diagnosed with a potentially life-threatening form of cancer says to the
nurse, "I don't understand how this could happen to us. We have been so careful to make sure our
child is healthy. Which response by the nurse is most appropriate?
A. "This must be a difficult time for you and your family. Would you like to talk about how you are feeling?"
B. "Why do you say that? Do you think that you could have prevented this?"
C. "You shouldn't feel that you could have prevented the cancer. It is not your fault."
D. "Many children are diagnosed with cancer. It is not always life-threatening."
ANSWER:
RATIONALE: Parents of children diagnosed with cancer require major emotional support, and should be
allowed to express their feelings. Prevention and blaming oneself is not supportive, nor is telling the
parents that there are many other children with cancer
6. A preschool-age child undergoing chemotherapy experiences nausea and vomiting. Which

of the following would be the best intervention to include in the child's plan of care?
A. Administer tube feedings.
B. Offer small, frequent meals.
C. Offer fluids only between meals.
D. Allow the child to choose what to eat for meals.
ANSWER:
RATIONALE: While all options can be done to encourage nutrition, allowing the preschooler choices meets two
issues: nutrition and developmental tasks."

7. Which nursing diagnosis is highest-priority for a child undergoing chemotherapy and
experiencing nausea and vomiting?
A. Fluid and Electrolyte Imbalance
B. Alterations in Nutrition
C. Alterations in Skin Integrity
D. Body Image Disturbances
ANSWER:
RATIONALE: While all of the nursing diagnoses listed here are important, dehydration and fluid and electrolyte
loss secondary to vomiting is the priority for this client.
8. A child with cancer has the following lab result: WBC 10,000, RBC 5, and platelet of 20,000.
When planning this child's care, which risk should the nurse consider most significant?
A. Hemorrhage
B. Anemia
C. Infection
D. Pain
ANSWER:
RATIONALE: The lab values presented all are normal except for the platelet count. Decreases in platelet counts
place the child at greatest risk for hemorrhage
9. Skin reactions are common in radiation therapy. Nursing responsibilities on promoting skin
integrity should be promoted apart from:
A. Avoiding the use of ointments, powders and lotion to the area
B. Using soft cotton fabrics for clothing
C. Washing the area with a mild soap and water and patting it dry not rubbing it.
D. Avoiding direct sunshine or cold.
ANSWER:
RATIONALE: No soap should be used on the skin of the patient undergoing radiation. Soap and
irritants and may cause dryness of the patient’s skin.
10. Nausea and vomiting is an expected side effect of chemotherapeutic drug use. Which of the
following drug should be administered to a client on chemotherapy to prevent nausea and
vomiting?
A. Metochlopramide
B.Vincristine
C.Anastrazole

D. Busulfan
ANSWER:
RATIONAL Metochlopramide-antiemitic is the drug that should be administered to a client on
chemotherapy to prvent nausea and vomiting.
SAS 40
1. David, age 15 months, is recovering from surgery to remove Wilms' tumor. Which findings best
indicates that the child is free from pain?
A. Decreased appetite
B. Increased heart rate
C. Decreased urine output
D. Increased interest in play
ANSWER:
RATIONALE: One of the most valuable clues to pain is a behavior change: A child who's pain-free likes to play. A
child in pain is less likely to consume food or fluids. An increased heart rate may indicate increased pain; decreased
urine output may signify dehydration.
2. A child is diagnosed with Wilms' tumor. In planning teaching interventions, what key point
should the nurse emphasize to the parents?
A. Do not put pressure on the abdomen.
B. Frequent visits from friends and family will improve morale.
C. Appropriate protective equipment should be worn for contact sports.
D. Encourage the child to remain active
ANSWER:
RATIONALE: Palpation of Wilms' tumor can cause rupture and spread of cancerous cells. Frequent
visitation might allow the child to be exposed to more infections, and activity and sports are discouraged
because of the risk of rupture of the encapsulated tumor.
3.A child is diagnosed

with Wilms' tumor.
During assessment,
the nurse in charge
expects to detect:
A. Gross hematuria
B. Dysuria
C. Nausea and vomiting

D. An abdominal mass
ANSWER:
RATIONALE: he most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes
accompanied by an increase in abdominal girth. Gross hematuria is uncommon, although microscopic
hematuria may be present. Dysuria is not associated with Wilms' tumor. Nausea and vomiting are rare in
children with Wilms' tumor
4.When assessing a child with

Wilm's tumor, the nurse should
keep in mind that it is most
important to avoid which of the
following? SELECT ALL THAT
APPLY
A. Measuring the child's chest circumference
B. Palpating the child's abdomen
C. Placing the child in an upright position
D. Measuring the child's occipitofrontal circumference
ANSWER:
RATIONALE: The abdomen of the child with Wilm's tumor should not be palpated because of the danger of
disseminating tumor cells. Children with Wilm's tumor should always be handled gently and carefully.
5. The mother of a 4 year old child brings the child to the clinic and tells the pediatric nurse
specialist that the child's abdomen seems to be swollen. During further assessment of the
subjective data, the mother tells the nurse that the child has been eating well and that the activity
level of the child is unchanged. The nurse, suspecting the possibility of a Wilm's tumor, would
avoid which of the following during the physical assessment?
A. Palpating the abdomen for a mass.
B. Assessing the urine for hematuria
C. Monitoring the temperature for presence of fever
D. Monitoring the blood pressure for presence of hypertension
ANSWER:
RATIONALE: Wilms' tumor is the most common intraabdominal and kidney tumor of childhood. If Wilms'
tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can
cause seeding of the tumor and spread of the cancerous cells. Hematuria, fever, and hypertension are
clinical manifestations associated with Wilms' tumor

6. A nurse is discussing childhood cancer with the parents of a child in an oncology unit. Which
statement by the nurse would be the most accurate?
A. "The most common site for children's cancer is the bone marrow."
B. "All childhood cancers have a high mortality rate.""
C. "Children with leukemia have a higher survival rate if they are older than 11 when diagnosed."
D. "The prognosis for children with cancer isn't affected by treatment strategies."
ANSWER:
RATIONALE: Childhood cancers occur most commonly in rapidly growing tissue, especially in the bone
marrow. Mortality depends on the time of diagnosis, the type of cancer, and the age at which the child
was diagnosed.
7. The nurse should monitor a child with a brain stem glioma receiving vincristine sulfate
(Oncovin) for which of the following adverse reactions?
A. Appendicitis
B. Diarrhea
C. Typhlitis
D. Constipation
ANSWER:
RATIONALE: Vincristine sulfate (Oncovin) is an antineoplastic drug that inhibits mitosis at metaphase. It can
cause neuropathy, including the gut, leading to constipation. Appendicitis and typhlitis are infectious
processes that may arise during neutropenic episodes.
8. While assessing a 2 year-old child with a tentative diagnosis of Wilm’s tumor, the
nurse would be MOST concerned about the mother’s report that?
A. Urinary output has apparently decreased
B. The child prefers some foods more than others
C. The child has lost 3 pounds in the last month
D. Clothing has become tight around the waist
ANSWER:
RATIONALE: Clothing has become tight around the waist is the correct option. Parents often recognize the
increasing abdominal girth first. This is an early sign of Wilm”s tumor.

9. Which of the following does the nurse assess as a major presenting clinical manifestation in the
child with a retinoblastoma?
A. Icteric sclera
B. Chronic conjunctivitis
C. Achronoligia
D. Cat’s eye reflex
ANSWER:
RATIONALE: Retinoblastoma
tumors are tumors of the eye
that create a cat’s eye reflex
when the light hits the eye at
the right angle; the reflex is also
identifiable in photographs
10. A 12 year old female with cancer is scheduled for radiation therapy. The nurse knows that
radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse
should prepare the client to expect: A. hair loss.
B. stomatitis.
C. fatigue.
D. vomiting.
ANSWER:
RATIONALE: Radiation therapy
may cause fatigue, skin
toxicities, and anorexia
regardless of the treatment site.
Hair loss, stomatitis, and
vomiting are site-specific, not
generalized, adverse effects of
radiation therapy.
SAS 41
1. The liver receives blood from two sources. The _____________ is responsible for
pumping blood rich in nutrients to the liver.
A. hepatic artery
B. hepatic portal vein
C. mesenteric artery
D. hepatic iliac vein
ANSWER:

RATIONALE: The liver receives blood from two sources. The hepatic portal vein is responsible for
pumping blood rich in nutrients to the liver
2. Which statements are INCORRECT regarding the anatomy and physiology of the liver? Select
all that apply:
A. The liver has 3 lobes and 8 segments.
B. The liver produces bile which is released into the small intestine to help digest fats.
C. The liver turns urea, a by-product of protein breakdown, into ammonia.
D. The liver plays an important role in the coagulation process.
ANSWER:
RATIONALE: The liver has 2 lobes (not 3), and the liver turns ammonia (NOT urea), which is a by-
product of protein breakdown, into ammonia. All the other statements are true about liver’s
anatomy and physiology.
3. You’re providing an in-service on viral hepatitis to a group of healthcare workers. You are
teaching them about the types of viral hepatitis that can turn into chronic infections. Which types
are known to cause ACUTE infections ONLY? Select all that apply:
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
ANSWER:
RATIONALE: Only Hepatitis A and E cause ACUTE infections…not chronic. Hepatitis B, C, and D can
cause both acute and chronic infections
4. Which patients below are at risk for developing complications related to a chronic hepatitis
infection, such as cirrhosis and liver cancer? Select all that apply:
A. A 15-year-old male with Hepatitis A.
B. An infant who contracted Hepatitis B at birth.
C. A 18-year-old female with Hepatitis C who reports using IV drugs.
D. A 17-year-old male with alcoholism and Hepatitis D.
E. A 10-year-old who contracted Hepatitis E.
ANSWER:
RATIONALE: . Which patients below are at risk for developing complications related to a chronic
hepatitis infection, such as cirrhosis and liver cancer? Select all that apply

5. A patient is diagnosed with Hepatitis A. The parents of the patient asks how a person can
become infected with this condition. You know the most common route of transmission is?
A. Blood
B. Percutaneous
C. Mucosal
D. Fecal-oral
ANSWER:
RATIONALE: Hepatitis A is most commonly transmitted via the fecal-oral route
6.Which of the following is NOT a common source of transmission for Hepatitis A? Select
all that apply:
A. Water
B. Food
C. Semen
D. Blood
ANSWER:
RATIONALE: The most common source for transmission of Hepatitis A is water and food.
7. A 16-year-old patient’s lab work show anti-HAV and IgG present in the blood. As the nurse you
would interpret this blood work as?
A. The patient has an active infection of Hepatitis A.
B. The patient has recovered from a previous Hepatitis A infection and is now immune to it.
C. The patient is in the pre-icteric phase of viral Hepatitis.
D. The patient is in the icteric phase of viral Hepatitis.
ANSWER:
RATIONALE: When a patient has anti-HAV (antibodies of the Hepatitis A virus) and IgG, this means
the patient HAD a past infection of Hepatitis A but it is now gone, and the patient is immune to
Hepatitis A now. If the patient had anti-HAV and IgM, this means the patient has an active infection
of Hepatitis A.
8. A 10-year-old patient was exposed to the Hepatitis A virus at a local restaurant one week ago
together with his parents. What education is important to provide to this patient?
A. Inform the patient to notify the physician when signs and symptoms of viral Hepatitis start to appear.
B. Reassure the patient the chance of acquiring the virus is very low.
C. Inform the patient it is very important to obtain the Hepatitis A vaccine immediately to prevent infection.
D. Inform the patient to promptly go to the local health department to receive immune globulin.
ANSWER:

RATIONALE: Since the patient was exposed to Hepatitis A, the patient would need to take
preventive measures to prevent infection because infection is possible. The patient should not
wait until signs and symptoms appear because the patient can be contagious 2 weeks BEFORE
signs and symptoms appear
9. Select all the ways a person can become infected with Hepatitis B:
A. Contaminated food/water
B. During the birth process
C. Undercooked pork or wild game
D. Hemodialysis
E. Sexual intercourse
ANSWER:
RATIONALE: Hepatitis B is spread via blood and body fluids. It could be transmitted via the
birthing process, IV drug use, hemodialysis, or sexual intercourse etc
10. A 1-year old patient has completed the Hepatitis B vaccine series. What blood result below
would demonstrate the vaccine series was successful at providing immunity to Hepatitis B?
A. Positive IgG
B. Positive HBsAg
C. Positive IgM
D. Positive anti-HBs
Answer:
RATIONALE: A positive anti-HBs (Hepatitis B surface antibody) indicates either a past infection of
Hepatitis B that is now cleared and the patient is immune, OR that the vaccine has been successful at
providing immunity
SAS 42
1. A nurse is performing a nutritional assessment on a 3-year old patient. Which of the following
clinical findings are suggestive of malnutrition? SELECT ALL THAT APPLY
A. Poor wound healing
B. Dry hair
C. weak hand grips
D. Impaired coordination
ANSWER:
RATIONALE: All of the options are correct. Poor wound healing describes changes reflective of malnutrition. Dry
hair describes changes reflective malnutrition, also the weak hand grips and impaired coordination.

2. The nurse is teaching a 16-year old who has iron deficiency anemia about foods she should
include in her diet. The nurse determines that the patient understands the dietary instructions if
she selects which of the following from her menu?
A. Nuts and fish.
B. Oranges and dark green leafy vegetables.
C. Butter and margarine.
D. Sugar and candy.
ANSWER:
RATIONALE: Dark green leafy vegetables are a good source of iron, oranges are a good source of
vitamin C, which enhances absorption
3. A 4-year-old child was born at term, with no congenital anomalies. She is now only 70% of
normal body weight. On examination she shows dependent edema of the lower extremities as well
as an enlarged abdomen with palpable fluid wave. Her desquamating skin shows irregular areas
of depigmentation, and hyperpigmentation. Which of the following nutritional problems is most
likely present in this child?
A Marasmus
B Scurvy
C Vitamin A toxicity
D Niacin deficiency
E Kwashiorkor
ANSWER:
RATIONALE: Kwashiorkor occurs with protein deprivation. Lack of mainly protein in the diet leads to
hypoalbuminemia and fatty liver. Throughout human history obtaining sufficient protein in the diet has been a
struggle.
4. . It is observed that intestinal absorption of iron can be enhanced in patients with iron
deficiency anemia by supplementing their diet with another nutrient. Which of the
following vitamins is most likely to have this effect?
A A
B B1
C C
D D
E E
ANSWER:
RATIONALE: Vitaminc C (ascorbic acid) enhances the absorption of iron in the small intestine, primarily in the
duodenum.

5. A study is performed to determine dietary sources of vitamin A. It is observed that some
commonly available foods have more vitamin A than others. Which of the following is most likely
to provide the best source for vitamin A in the diet?
A Milk
B Bread
C Meat
D Beer
E Carrots
ANSWER:
RATIONALE: Carrots and other vegetables that are yellow and orange have a lot of carotenes, a good source of
vitamin A.
6. A 15-year-old girl has been under a physician's care for the past year after diagnosis of
anorexia nervosa. Her BMI is now 18. On physical examination she has cheilosis.
Laboratory studies show hemoglobin 13.7 g/dL, hematocrit 41.0%, MCV 88 fL, platelet
count 191,055/microliter, and WBC count 4930/microliter. Her serum glucose is 66 mg/dL.
Which of the following nutrient deficiencies is most likely to cause her findings?
A Riboflavin
B Ascorbic acid
C Folic acid
D Iron
E Niacin
ANSWER:
RATIONALE: Vitamin B2 Deficiency by itself is uncommon and cheilosis may also appear may also appear with
vitamin B6 Deficiency. Anorexia Nervosa is very difficult to treat, with significant morbidity and mortality. It is
likey she has multiple nutrient deficiency.
7. A 5-year-old child develops gradual loss of vision over the past 2 years resulting in
blindness. On physical examination there is bilateral keratomalacia and corneal
scarring. This child's blindness is most likely to have been prevented by adequate
dietary intake of which of the following vitamins?
A A
B B1
C B6
D B12
E K

ANSWER:
RATIONALE: The retinol compounds which collectively constitute what is known as Vitamin A, contribute to
differentiation and maintenance of mucus-secreting epithelia.
8. An 11-month-old infant is only 60% of ideal body weight. The baby is proportionately small in
size. Upon physical examination, the baby is listless and does not respond with vocalization when
touched. A small purplish contusion is noted over the right lower extremity. Which of the
following is the most likely diagnosis? A Physical abuse
B Marasmus
C Hypocalcemia
D Premature birth
E Vitamin C deficiency
ANSWER:
RATIONALE: The body is wasting away from total calorie deprivation and is only 60% of body weight which is
markedly low and much lower than would be expected from any single nutritional deficiency.
9. While at a family reunion, parents are talking about their children. One family unit notes that
none of their children has had any dental caries, though all of the children have all had the same
childhood infections and have similar dietary habits. They all brush their teeth regularly. Children
in other family units have had multiple visits to the dentist for treatment of dental caries. Which of
the following is most likely to account for this observation?
A Lack of regular exercise
B Fluoridation of drinking water
C An inborn error of metabolism
D Bulimia nervosa
E Reduced sunlight exposure
ANSWER:
RATIONALE: Supplementation of drinking water with fluoride will diminish the incidence of dental
caries.Curiously, the issue has remained controversial in the U.S for decades with opponents of
fluoridation touting everything from conspiracy theories to lack of personal choices.
10. Which of the following is the most abundant mineral in the

human body?
A. Potassium
B. Calcium
C. Iron
D. Magnesium

ANSWER:
RATIONALE: Magnesium is the most abundant major mineral in the human body.
SAS 43
1. Which of the following situations increase risk of lead poisoning in children?

A. playing in the park with heavy traffic and with many vehicles passing by
B. playing sand in the park
C. playing plastic balls with other children
D. playing with stuffed toys at home
ANSWER:
RATIONALE: Lead poisoning may be caused by inhalation of dust and smoke from leaded gas. It may also caused
by lead-based paint, soil, water (especially from the plumbing’s of old houses)
2. The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a
seizure. Which of these actions should the nurse take?
A. The nurse should insert a padded tongue blade in the patient’s mouth to prevent the child from
swallowing or choking on his tongue.
B. The nurse should help the mother restrain the child to prevent him from injuring himself.
C. The nurse should call the operator to page for seizure assistance.
D. The nurse should clear the area and position the client safely.
ANSWER:
RATIONALE: The primary role of the nurse when a patient has a seizure is to protect the patient from harming her
self.
3. A 5-year-old is admitted to the hospital with a subarachnoid hemorrhage has complaints of

severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP)
would be contraindicated in this client in which of the following circumstances?
A. Vomiting continues
B. Intracranial pressure (ICP) is increased
C. The client needs mechanical ventilation
D. Blood is anticipated in the cerebrospinal fluid (CSF)
ANSWER:
RATIONALE: Sudden removal of CSF results in pressures lower in the lumbar area than the brain and
favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be
caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated

Select the main structures below that play a role with altering intracranial
pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater
ANSWERS:
RATIONALE: Inside the skull are three structures that can alter intracranial pressure. They are the brain,
Cerebrospinal Fluid and blood.
A patient is being treated for increased intracranial pressure. Which activities below should the
patient avoid performing?
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between 30- 35 degrees
ANSWERS:
RATIONALE: Options a,b,d and e can increase ICP
6. Which of the following is contraindicated in a patient with increased ICP?

A. Lumbar puncture
B. Midline position of the head
C. Hyperosmotic diuretics
D. Barbiturates medications
ANSWER:
RATIONALE: LPs are avoided in patients with ICP because they can lead to possible brain herniation.

7. You’re collecting vital signs on a patient with ICP. The patient has a Glasgow coma Scale rating
of 4. How will you assess the patient’s temperature?
A. Rectal
B. Oral
C. Axillary
D. Tympanic
ANSWER
RATIONALE: : This GCS rating demonstrates the patient is unconscious. If a patient is

unconscious the nurse should take the patient’s either via rectal, tympanic or temporal method.
8. During the assessment of a patient with increased ICP, you note that the patient’s arms are
extended straight out and toes pointed downward. You will document this as:
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing
D. Prone posturing
ANSWER:
RATIONALE: Decerebrate posturing is an abnormal body posture that involves the arms and legs being held
straight out, the toes being pointed downward and the head and neck being arched backward
9. While positioning a patient in bed with increased ICP, it important to avoid?

A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips
ANSWER:
RATIONALE: Avoid flexing the hips because this can increase intra-abdominal/thoracic pressure which will increase
ICP

10. During the eye assessment of a patient with increased ICP, you need to assess the
oculocephalic reflex. If the patient has brain stem damage what response will you find?
A. The eyes will move in the same direction as the head is moved side to side.
B. The eyes will move in the opposite direction as the head is moved side to side.
C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed position as the head is moved side to side.
ANSWER:
RATIONALE: This is known as a negative doll’s eye and represents brain stem damage. It is a very
bad sign.
SAS 44
1. The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has
just had a ventriculoperitoneal shunt placed. Which information is most important for the parents
to be taught?
A. "limit the amount of t.v. he watches"
B. "watch for changes in his behavior or eating patterns"
C. "call the doctor if he gets a headache."
D. "always keep his head raised 30 degrees"
ANSWER:
RATIONALE: Changes in behavior or in eating patterns can suggest a problem with his shunt, such as infection or
blockage. Irritability, lack of appetite, increased crying or inability to settle down may indicate increased
intracranial pressure.
2. The nurse is examining a 15-month-old child who was able to walk at the last visit and now can
no longer walk.
What would be the nurse's best intervention in this case?
A. Ask the parents if they have changed the child's schedule to a less active one.
B. Schedule a full evaluation since this may indicate a neurologic disorder.
C. Note the regression in the child's chart and recheck in another month.
D. Document the findings as a developmental delay since this is a normal occurrence.
ANSWER:
RATIONALE: Any child who “loves” a developmental milestone. For example, the child able to sit without support
who now connot- needs an immediate full evaluation, since this indicates a significant neurologic problem.

3. Which of the following terms describes the congenital abnormality of the forebrain in which an
infant is born with a diminished brain size?
A. Spina Bifida
B. Spina Bifida Occulta
C. Microcephaly
D. Anencephaly
ANSWER:
RATIONALE: Microcephaly denotes a congenital abnormality of the forebrain in which an infant is
born with a diminished brain site. Potential causes include fetal alcohol syndrome congenital
rubella and trisomy 18.
4. Anencephaly and other neural tube defects have been linked to maternal deficiency of
what nutrient?
A. Folate
B. Biotin
C. Beta carotene
D. Calcium
ANSWER:
RATIONALE: Anencephaly and other neural tube defects have been linked to maternal deficiency of folate. This is
most likely due to folate’s role in methylation and nucleic acid synthesis the other nutrients listed are all important
to maternal health but have no known correlation with neural tube defects such as anencephaly.
5. Spina bifida is one of the possible neural tube defects that can occur during early
embryological development. Which of the following definitions most accurately describes
meningocele?
A. Complete exposure of spinal cord and meninges
B. Herniation of spinal cord and meninges into a sac
C. Sac formation containing meninges and spinal fluid
D. B and C
E. Spinal cord tumor containing nerve roots
ANSWER:
RATIONALE: Option C is the correct answer. Sac formation containing meninges and spinal fluid must accurately
describe meningocele.

6. All of the following are types of Spina Bifida, EXCEPT:
A. Myelomeningocele
B. Hemophilia
C. Meningocele
D. Spina Bifida Occulta
ANSWER:
A. RATIONALE: Myelomeningocele, Meningocele
Spina Bifida Occulta are all types of Spina Bifida. Hemophilia is an inherited bleeding disorder in which
the blood does not clot properly.
7. Are there any treatment for Spina Bifida?

A. Yes
B. No
C. Neither
D. Either
ANSWER:
RATIONALE: When a fetus is diagnosed with an exposed spinal cord( open spina bifida) doctors can perfomed
surgery during pregnancy to close the opening in the back before birth. A recent study found that performing the
newly designed surgery before birth may reduce the need to drain fluid away from the brain with a shunt after the
baby is born.
8. Which of the following are health issues a person with Spina Bifida
might have?
A. Hydrocephalus
B. Using the bathroom
C. Skin Conditions
D. Depression
E. All of the above
ANSWER:
RATIONALE: Hydrocephalus(also called water on the brain) using the bathroom, the skin conditions and
depression are all heath issues for people with Spina Bifida will be different for each person. Some people
have issues that are most severe than other people.
9. Can a person with Spina Bifida fully participate in life?

A. Yes
B. No
C. Either
D. Neither
ANSWER:
RATIONALE: A study published in the journal of holistic nursing. Showed that many teens and young adults with
Spina Bifida report being satisfied with their life are entering and succeeding in college and are participating in
sports and other recreational activities.
10. Do people with Spina Bifida have mental issues?

A. Yes
B. No
C. Sometimes
D. Either
ANSWER:
RATIONALE: Mental Health is how people think, feel and act as they cope with life.People with Spina Bifida might
feel isolated from others, ir have low self-esteem. This can cause them to become depressed.
SAS 45
1. What are the symptoms of

cerebral palsy?
A. Baby doesn’t roll over in either
direction?
B. Baby cannot bring her hands together
C. Baby has difficulty bringing her hands to her mouth
D. All of the above
ANSWER:
RATIONALE: Signs of Cerebral Palsy vary greatly because there are many different types and
levels of disability. The main sign that a child might have Cerebral Palsy is a delay reaching motor
or movement milestone(such as rolling over, sitting, standing or walking)
2. What causes cerebral palsy?

A. Brain damage that happened before, during or immediate after birth
B. An infection such as meningitis
C. Head Injury
D. The cause is unknown

E. All of the above
ANSWER:
RATIONALE: Cerebral Palsy is caused by abnormal Development of the brain that affects a child’s
ability to control his or her muscles. There are several possible causes of the abnormal
development or damage
3. Cerebral Palsy is usually diagnosed during the first or second

year after birth. A. True
B. False
C. Either
D .Maybe
ANSWER:
RATIONALE: Cerebral Palsy generally diagnosed during the first or second year after birth. But if
a child’s symptoms are mild. It is sometimes difficult to make a diagnosis until the child is a few
years older.
4. A 7-month-old child has been diagnosed with cerebral palsy (CP). Which of the following signs/
symptoms would the nurse assess as consistent with the diagnosis?
A. Positive grasp reflex
B. Harlequin sign
C. Pigeon chest
D. Circumoral cyanosis
ANSWER:
RATIONALE In healthy babies, the neonatal grasp reflex begins to fade at about 3 months of age
and is replaced by a voluntary grasp by about 5 months of age. A grasp reflex that does not fade
is consistent with a diagnosis of CP.
5. The nurse is planning care for a ten month-old infant with bacterial meningitis. Which of the
following nursing measures would be appropriate for the nurse to do?
A. Measure head circumference
B. Place in contact isolation
C. Provide active range of motion
D. Provide an over-the-crib mobile
ANSWER:
RATIONALE: Option A is the most appropriate measures for the nurse to do for a planning care
for a ten month infant with bacterial meningitis.

6. You’re educating a patient about treatment options for Guillain-Barré Syndrome. Which
statement by the patient requires you to re-educate the patient about treatment?
A. “Treatments available for this syndrome do not cure the condition but helps speed up recovery time.”
B. “Immunoglobin therapies are treatment options available for this syndrome but are most effective when
given within 4 weeks of the onset of symptoms.”
C. “When I start plasmapheresis treatment a machine will filter my blood to remove the antibodies from
my plasma that are attacking the myelin sheath.”
D. “Immunoglobulin therapy is where IV immunoglobulin from a donor is given to a patient to stop the
antibodies that are damaging the nerves.
ANSWER:
RATIONALE: The answers is B. The statement is incorrect. Plasmapheresis and immunoglobin
therapies are treatment options available for GBS. But the are only really effective when given
with in 2 weeks from the onset of symptoms ( not 4 weeks )
7. Which tests below can be ordered to help the physician diagnose Guillain-Barré Syndrome?
Select all that apply:
A. Edrophonium Test
B. Sweat Test
C. Lumbar puncture
D. Electromyography
E. Nerve Conduction Studies
ANSWER:
RATIONALE: The answers are C,D and E. These are the test that can be ordered to help the MD
determine if the patient is experiencing GBS.
8. You’re teaching a group of nursing students about Guillain-Barré Syndrome and how it can
affect the autonomic nervous system. Which signs and symptoms verbalized by the students
demonstrate they understood the autonomic involvement of this syndrome? Select all that apply:
A. Altered body temperature regulation
B. Inability to move facial muscles
C. Cardiac dysrhythmias
D. Orthostatic hypotension
E. E. Bladder distension
ANSWER:
RATIONALE: The answers are A, C, D and E. All of these are signs and symptoms that can be
present in severe cases of GBS when the autonomic nervous system is involved.

.
9. You’re about to send a patient for a lumbar puncture to help rule out Guillain-Barré Syndrome.
Before sending the patient you will have the patient?
A. Clean the back with antiseptic
B. Drink contrast dye
C. Void
D. Wash their hair
ANSWER:
RATIONALE: The patient will need to void and empty the bladder before going for a LP. This will help decrease the
chances of the bladder becoming punctured during the procedure.
10. Your patient is back from having a lumbar puncture. Select all the correct nursing
interventions for this patient? Select all that apply:
A. Place the patient in lateral recumbent position.
B. Keep the patient flat.
C. Remind the patient to refrain from eating or drinking for 4 hours.
D. Encourage the patient to consume liquids regularly.
ANSWER:
RATIONALE: The answers are B and D, the patient will need to stay flat after the procedure for a
prescribed amount of time to prevent a headache and the nurse will need to encourage the patient
to drink fluids regularly to help replace the fluid lost during the lumbar puncture
SAS 46
1. You’re educating a 15-year-old female about possible triggers for seizures. Which statement
requires you to reeducate the patient about the triggers?
A. “I’m at risk for seizure activity during my menstrual cycle.”
B. “I will limit my alcohol intake to 2 glasses of wine per day.”
C. “It’s important I get plenty of sleep.”
D. “I will be sure to stay hydrated, especially during hot weather.”
Answer:
RATIONALE: The answers is B. The patient should avoid all alcohol because it can lead to a
seizure. Hormone Shifts( Menstrual Cycle, Ovulation, Pregnancy) Sleep deprivation and
dehydration can lead to a seizure.

2. A patient who is experiencing a tonic-clonic seizure is experiencing a focal
(partial) seizure.
A. TRUE
B. FALSE
Answer:
RATIONALE: A patient who is experiencing a tonic-clonic seizure is experiencing a Generalized seizure. This type
of seizure affects both sides of the brain.
3. A 7-year-old male patient is being evaluated for seizures. While in the child’s room talking with
the child’s parents, you notice that the child appears to be daydreaming. You time this event to be
10 seconds. After 10 seconds, the child appropriately responds and doesn’t recall the event. This
is known as what type of seizure?
A. Focal Impaired Awareness (complex partial)
B. A
t
o
n
i
c
C. T
o
n
i
c
-
c
l
o
n
i
c
D. A
b
s
e
n
c
e
ANSWER:
RATIONALE: This is an absence seizure and is most common in children. The hallmark of it is
staring that appears to be like a daydreaming state. It is very short and the post ictus stage of this
type of seizure is immediate.

4. Your patient has a history of epilepsy. While helping the patient to the restroom, the patient
reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing
action is to?
A. Continue assisting the patient to the restroom and let them sit down.
B. Initiate the emergency response system.
C. Lay the patient down on their side with a pillow underneath the head.
D. Assess the patient’s medication history.
ANSWER:
RATIONALE: The patient is reporting signs and symptoms of an aura (this is a warning sign
before a seizure event) Lay the patient down and their side with a pillow underneath the head and
remove any restrictive clothing. Also, time the seizure. If the seizure last more than 5 minutes or if
the patient starts to have seizure back to back activate the emergency response system.
5. Keeping the previous question in mind, the patient is now experiencing characteristics of a
tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still
experiencing a seizure. The nurse should?
A. Continue to monitor the patient
B. Suction the patient
C. Initiate the emergency response system
D. Restrain the patient to prevent further injury
Answer: Tonic- Clonic Seizure should last about 1-3minutes. If the seizure lasts more than 5
minutes, the patient needs medical treatment fast to stop the seizure. This is known as status
epilepticus.
RATIONALE:
6. Your patient has entered the post ictus stage for seizures. The patient’s seizure presented with
an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and
bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based
on the type of seizure this patient experienced?
A. Crying and anxiety
B. Immediate return to baseline behavior
C. Sleepy, headache, and soreness
D. Unconsciousness
ANSWER:
RATIONALE: Based on the findings during the seizure the patient experienced a tonic-clonic
seizure. In the post ictus stage(after the seizure) the patient is expected to be sleepy (very tired)
have soreness and a headache.The nurse should let the patient sleep.

.
7. You’re developing discharge instructions to the parents of a child who experiences atonic
seizures. What information below is important to include in the teaching?
A. “This type of seizure is hard to detect because the child may appear like he or she is daydreaming.”
B. “Be sure your child wears a helmet daily.”
C. “It is common for the child to feel extremely tired after experiencing this type of seizure.”
D. “Avoid high fat and low carbohydrate diets.”
ANSWER:
RATIONALE:This type of seizure leads to a sudden loss of muscle tone. The patient will go limp and fall, which when
this happens the head is usually the first part of the body to hit the floor or an object nearby. It is important the
child wears a helmet daily to protect their head from injury.
8. You’re assessing a patient who recently experienced a focal type seizure (partial seizure). As
the nurse, you know that which statement by the patient indicates the patient may have
experienced a focal impaired awareness (complex partial) seizure?
A. “My friend reported that during the seizure I was staring off and rubbing my hands together, but I don’t
remember doing this.”
B. “I remember having vision changes, but it didn’t last long.”
C. “I woke up on the floor with my mouth bleeding.”
D. “After the seizure I was very sleepy, and I had a headache for several hours.”
ANSWER:
RATIONALE: The patient will experience an alternation consciousness (hence the name focal
Impaired awareness) and will perform an action without knowing they are doing it called
automatism like lip smacking,rubbing tha hands together etc.
9. You have a patient who has a brain tumor and is at risk for seizures. In the patient’s plan of
care you incorporate seizure precautions. Select below all the proper steps to take in
initiating seizure precautions:
A. Oxygen and suction at bedside
B. Bed in highest position
C. Remove all pillows from the patient’s head
D. Have restraints on stand-by
E. Padded bed rails
F. Remove restrictive objects or clothing from patient’s body
G. IV access
ANSWERS:

RATIONALE: The bed needs to be in the lowest position possible, a pillow should be underneath
the patient’s head to protect it from injury. Avoid using restrain( this can cause musculoskeletal
damage)
10. You’re patient is scheduled for an EEG (electroencephalogram). As the

nurse you will: Select all that apply.
A. Keep the patient nothing by mouth.
B. Hold seizure medications until after the test.
C. Allow the patient to have coffee, milk, and juice only.
D. Wash the patient’s hair prior to the test.
E. Administer a sedative prior to the test.
ANSWERS:
RATIONALE: An EEG is a painless procedure that will assess the patient’s brain activity( if a
seizure occurs during the test this can allow the physician to determine what type of seizure it is.
Therefore, the nurse would hold seizure medications ( this can affect the test) and would not allow
the patient to have caffeine like coffee or stimulant drugs.
SAS 47
1. A client has suffered a spinal cord injury after a fall. When he is brought in for care, the client
experiences diaphoresis and headache. The nurse notes that his blood pressure is 174/102
mmHg. Which action should the nurse perform first?
A. Raise the head of the bed, lower the legs, and remove constrictive clothing
B. Apply hemodynamic monitoring
C. Ask the client to perform the Valsalva maneuver
D. Assess the client for fecal impaction
ANSWER:
RATIONALE: A patient with a spinal cord injury is at risk for autonomic dysreflexia, which is
characterized by sudden and severe hypertension as a result of noxious stimuli. The patient may develop
the condition from various factors, including bladder distention or stool impaction.
2. An 18-year-old client has suffered a spinal cord injury in which he is experiencing spinal shock
and cannot feel his legs. Twenty-four hours after the injury, the client tells the nurse, “This will be
good for me. I can handle this and I’m doing fine.” Which response from the nurse is most likely
indicated?
A. Ask the client if he would like to speak with a spiritual advisor or social worker
B. Continue to treat the client as is but remind him that he may never walk again

C. Make arrangements for the client to be discharged to home
D. Document the client's positive attitude regarding this life-changing disability
ANSWER:
RATIONALE: The client in the situation described may most likely to suffering from denial as an
initial response after injury. Not all people who are injured and who developed paraplegia will
react the same way, but many people who are injured in the method develop anxiety and
depression
3. A client with a spinal cord injury has difficulty determining when the bladder needs emptied.
The nurse teaches the client about tapping to stimulate voiding. How would the nurse describe
tapping to this client?
A. The client alternately taps the abdomen and the back to signal messages across the body to promote
urination
B. The client wears a device that acts as a tap or faucet to stop and start urine flow
C. The area over the bladder is tapped to stimulate the bladder muscles
D. The client bears down to increase pressure and then taps the base of the abdomen to release urine
ANSWER:
RATIONALE: A patient with a spinal cord injury may be unable to control urine flow if he has little to no
sensation in the bladder that tells the brain when it is time to empty the bladder
4. The most appropriate prevention against spinal cord injury in a 17-year-old patient.which of the
following actions is correct?
A. Avoid horseback riding without a helmet
B. Avoid surfing
C. Drink in moderation before driving
D. Use seat belts in the car
ANSWER:
RATIONALE: The most appropriate prevention against spinal cord injury is to use seat belts in the
car, as motor vehicle accidents are the leading cause of spinal cord injuries accounting for 39%
5. The nurse knows that a client suffering from complete paralysis from the waist down would
have the condition of which of the following?
A. Hemiparesis
B. Hemiplegia
C. Paraparesis
D. Paraplegia

ANSWER:
RATIONALE: Para refers to the lower half of the body and -plegia refers complete paralysis
6. The nurse is on a rapid response team that has responded to a code blue. The 15-year-old
victim is a visitor who has fallen down a flight of stairs and is unresponsive. A cervical spine
injury is suspected. In order to perform CPR safely, what is the best initial intervention?
A. Chin tilt Maneuver
B. Nasotracheal Intubation
C. Cricothyroidotomy
D. Jaw thrust Maneuver
ANSWER:
RATIONALE: The best intervention in a client with suspected cervical spine injuries and upper airway
obstruction is to perform the jaw thrust maneuver. The chin tilt maneuver is contraindicated and the other
choices are not an initial intervention.
7. An 18-year-old patient with her parents has suffered a spinal cord injury after a diving accident.
When first brought to the emergency room, the patient is suffering from spinal shock. Which
symptoms best describe this condition?
A. Flaccid paralysis and anesthesia in the lower extremities
B. Hypertension, headache, and blurred vision
C. Back pain, muscle spasms, and difficulty walking
D. Decreased venous return and skin breakdown in the extremities
ANSWER:
RATIONALE: Following a spinal cord injury, a client can develop spinal shock, which is a temporary
condition characterized by loss of neurological activity below the level of injury. The client in spinal shock
typically has no feeling or movement in the body below the level of injury. It differs from permanent spinal
cord injury in that it is a temporary condition that may last up to 6 weeks after the initial injury but does not
involve the destruction of the spinal cord that leads to permanent effects
.
8. The client has a spinal cord injury and is suffering from spinal shock. Which of the following is
an expected symptom in spinal shock?
A. Bradycardia
B. Spasticity
C. Increased Visceral Reflexes
D. Hypertension
ANSWER:
RATIONALE: A client with spinal shock is expected to be hypotensive, have bradycardia, decreased
visceral reflexes and flaccid paralysis of skeletal muscles

9. A client is being seen in the emergency department after a spinal cord injury. The client initially
states an inability to feel anything below the shoulders. At which point would this client need to
be intubated with an endotracheal tube?
A. The point at which the client has a Glasgow Coma Score of 8
B. The point at which the client has a respiratory rate of 10/minute
C. The point at which the client's oxygen saturation is 88 percent on room air
D. Upon discovering that the client has a pneumothorax as seen on x-ray
ANSWER:
RATIONALE: A spinal cord injury produces paresthesia below the level of the injury; paraplegia indicates
an injury in which the patient cannot move the lower extremities, while quadriplegia is a higher-level injury
where the patient often cannot move the upper or lower extremities
10. The nursing care plan of a client with spinal cord injury should include which of the following?
Select all that apply.
A. Maintain a stable vital signs
B. Provide skeletal traction
C. Begin aggressive steroid therapy
D. Prepare client for surgical stabilization of spine
E. Administer antispasmodics
ANSWERS:
RATIONALE: A client with a spinal cord injury will have multiple issues that need managed by the nurse.
The client experiences loss of sensory function below the level of the injury, and is at risk for hypotension,
bradycardia, and other symptoms of autonomic dysreflexia and neurogenic shock. In caring for a client
with spinal cord injury, the nurse should maintain stable vital signs, provide skeletal traction, give steroid
therapy, prepare the client for surgical stabilization, and administer antispasmodics
SAS 48
1. When using a Snellen alphabet chart, the nurse records the client’s vision as 20/40. Which of
the following statements best describes 20/40 vision?
A. The client has alterations in near vision and is legally blind.
B. The client can see at 20 feet what the person with normal vision can see at 40 feet.
C. The client can see at 40 feet what the person with normal vision sees at 20 feet.
D. The client has a 20% decrease in acuity in one eye, and a 40% decrease in the other eye.
ANSWER:
RATIONALE: The numerator refers to the client’s vision while comparing the normal vision in the denominator

2. The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of
the following identifies the accurate procedure for this visual acuity test?
A. Both eyes are assessed together, followed by the assessment of the right and then the left eye.
B. The right eye is tested followed by the left eye, and then both eyes are tested.
C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on
the chart.
D. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read
200 ft away by an individual with unimpaired vision.
ANSWER:
RATIONALE: Visual Acuity is assessed in one eye at a time and then in both eyes together with the client
comfortably standing or sitting. The right eye is tested with the left eye covered, then the left eye is tested with
the right eye covered.
3. The clinic nurse notes that the following several eye examinations, the physician has
documented a diagnosis of legal blindness in the client’s chart. The nurse reviews the results of
the Snellen’s chart test expecting to note which of the following?
A. 20/20 vision
B. 20/40 vision
C. 20/60 vision
D. 20/200 vision
ANSWER:
RATIONALE: Legal Blindness is define as 20/200 or less with corrected vision ( glasses or contact lenses) or visual
acuity of less than 20 degrees of the visual field in the better eye.
4. The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as
20/60. The nurse interprets this as:
A. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet.
B. The client is legally blind.
C. The client’s vision is normal

D. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.
ANSWER:
RATIONALE: Vision that is 20/20 is normal, that is the client is able to read from 20 feet what a
person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 only can
read at a distance of 20 feet of what a person with normal vision can read at 60 feet.
5. How do tears benefit the eyes?

A. By moistening them
B. By coating them with antibodies
C. By delivering nutrients to them
D. All of the above
ANSWER:
RATIONALE: Tears can also be a reaction to an irritant in the eye, to light and spicy food, as well as the emotional
upset( crying)
6. What does 20/20 vision mean?

A. Can see objects clearly at 20 feet
B. Can see objects clearly at 20 yards
C. Can see objects clearly at 20 inches
D. Can see objects clearly at 20 miles
ANSWER:
RATIONALE: It can see objects clearly at 20 feet
7. Which of these will help reduce eyestrain when you work at a computer?
A. Frequent blinking
B. Shifting focus from near to far object
C. Eliminating glare on the screen
D. All of the above
ANSWER:
RATIONALE; All of the choices above will help reduce eyestrain when you work at a computer

8. Which of these vision problems does refractive surgery correct?
A. Nearsightedness
B. Farsightedness
C. Astigmatism
D. All of the above
ANSWER:
RATIONALE: All of the choices does refractive surgery correct.
9. Which of these diseases is a common cause of blindness?

A. Heart disease
B. Asthma
C. Diabetes
D. Lung cancer
ANSWER:
RATIONALE: Common cause of blindness is Diabetes
10. Which of these eye care professionals is qualified to do surgery?

A. Optician
B. Ophthalmologist
C. Optometrist
D. B and C
ANSWER:
RATIONALE: Depending on the scope of practice within the state, both optometrists and
ophthalmologists can perform eye surgery. However, optometrists are limited in the surgeries they
can perform while ophthalmologists can perform any and all surgical procedures they are trained for.
SAS 49
1. The best way to differentiate between a Chalazion and a Hordeolum is:

A. The presence of pus
B. Hordeolum only appear on the lower eyelid
C. Pain
D. Visual Changes
E. both A and C

ANSWER:
RATIONALE:
2. Which of the following is not effective in the treatment of chalazion?

A. Systemic antibiotic
B. Warm compresses
C. Incision and Curettage
D. Corticosteroid therapy injection
ANSWER:
RATIONALE:
3. A patient presents with a nontender, painless, nodule involving a meibomian gland. Which of
the following is the most likely diagnosis?
A. Chalazion
B. Dacryocystitis
C. Entropion
D. Hordeolum
ANSWER:
RATIONALE:
4. The underlying pathology causing blepharitis is:

A. A dysfunction in the meibomian glands
B. Impaired aqueous outflow through the trabecular meshwork
C. Infectious obstruction of the nasolacrimal gland
D. Inflammation or infection of the outer membrane of the eyeball and the inner eyelid
ANSWER:
RATIONALE:

Which of the following organisms is not a common pathogen causing bacterial
conjunctivitis? A. Streptococcus pneumoniae
B.
Staphylococ
cus aureus
C.
Haemophilu
saegyptius
D. Moraxella sp.
E. Chlamydia trachomatis
ANSWER:
RATIONALE:
6. A 17-year-old girl comes to your office with a 1-day history of red eye. She describes not being
able to open her right eye in the morning because of crusting and discharge. The right eye feels
swollen and uncomfortable, although there is no pain. On examination, she has a significant
redness and injection of the right bulbar and palpebral conjunctivae. There is a mucopurulent
discharge present. No other abnormalities are present on physical examination. Her visual acuity
is normal.
A. Bacterial Conjunctivitis
B. Viral Conjunctivitis
C. Allergic Conjunctivitis
D. Autoimmune Conjunctivitis
ANSWER:
RATIONALE:
7. A patient is evaluated in the office with a red eye. The patient awoke with redness and a watery
discharge from the eye. The eyelids were not matted together. Examination reveals a palpable
preauricular node. Which of the following is the most likely diagnosis?
A. Bacterial Conjunctivitis
B. Viral Conjunctivitis
C. Allergic Conjunctivitis
D. Autoimmune Conjunctivitis
ANSWER:
RATIONALE:

.
8. A 7 month old female is brought to your clinic by his mother who reports the child has had
swelling of the nasal corner of the left eye. If left untreated what condition can develop?
A. Hyphema
B. Papilledema
C. Pterygium
D. Dacrocystitis
ANSWER:
RATIONALE:
9. An important nursing intervention in the care of a child with conjunctivitis is:

A. administering oral antihistamine to minimize itching
B. applying intermittent warm, moist compresses to remove crusts in the eye area
C. applying continuous warm compresses to relieve discomfort
D. administering optic cocrticosteroids to reduce inflammation
ANSWER:
RATIONALE:
10. Which of the following instructions by the nurse is most appropriate for a client using contact
lenses who is diagnosed with bacterial conjunctivitis?
A. Discard all opened or used lens care products
B. Disinfect contact lenses by soaking in a cleaning solution for 48 hours
C. Put all cosmetics in a plastic bag for 1 week to kill any bacteria before resuming
D. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection
ANSWER:
RATIONALE:
SAS 50
1. A 15-year-old patient presents with unilateral hearing loss. Weber reveals lateralization to the
right ear. Rinne test reveals the following: RIGHT: bone conduction = 10 seconds, air conduction
= 5 seconds; LEFT: bone conduction = 5 seconds, air conduction = 10 seconds. Which of these
other physical exam findings is to be expected?
A. Impacted cerumen in the right ear
B. Effusion in the left ear

C. Otitis Media in the left ear
D. Pain on palpation of tragus or mastoid area
ANSWER:
RATIONALE: Cerumen impaction will block the ear canal. This would result in lateralization of the Weber test to the
affected ear and would also cause bone conduction to be greater than air conduction in the same ear.
2. A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority
action for the nurse to take?
A. Provide emotional support to the family.
B. Educate the family on care of the child.
C. Prevent clinical complications.
D. Administer analgesics.
ANSWER:
RATIONALE: The priority action the nurse should take when using Maslow's hierarchy of needs is
to meet the toddler's physiological need first. Therefore, administering analgesics to alleviate or
decrease physical pain is the priority action for the nurse to take.
3. The part of the ear that contains the receptors for

hearing is the:
A. Utricle
B. Cochlea
C. Middle ear
D. Tympanic cavity
ANSWER:
RATIONALE: The Dendrites of the cochlear nerve terminate on the hair cells of the organ of corti
in the cochlea
4. The ear bones that transmit vibrations to the oval window of the cochlea are found in the:
A. Inner ear
B. Outer ear
C. Middle ear

D. Eustachian tube
ANSWER:
RATIONALE: The bones in the middle ear transmit and amplify air pressure waves from the tympanic membrane to
the oval windows of the cochlea, which is the inner ear. The tympanic membrane separates the other from the
middle ear
5. Nerve deafness would most likely result from an injury or infection that
damaged the:
A. Vagus nerve
B. Cochlear nerve
C. Vestibular nerve
D. Trigeminal nerve
ANSWER:
RATIONALE: Because the organ of hearing is the organ of corti, located in the deafness would mostly likely
accompany damage to the cochlear nerve
6. Physiologically, the middle ear, containing the three ossicles, serves primarily to:
A. Maintain balance
B. Translate sound waves into nerve impulses
C. Amplify the energy of sound waves entering the ear
D. Communicate with the throat via the Eustachian tube
ANSWER:
RATIONALE: The middle ear contains the 3 ossicles- malleus, incus and strapes, which along with the tympanic
membrane and oval windows from an aplifying system.
7. There is a considerable debate about the use of tympanostomy tubes in the management of
recurrent otitis media in children. Tympanostomy tube placement has been proven to:
A. Improve hearing
B. Prevent mastoiditis
C. Prevent recurrence of effusion
D. Prevent delayed language development
ANSWER:
RATIONALE: Option A is the correct Answer. Tympanostomy tube placement has been proven to improve hearing

8. Which of the following is the most likely organism in a 2 year-old child with acute
otitis media?
A. Staphylococcus aureus
B. Moraxella catarrhalis
C. Pseudomonas aeruginosa
D. Streptococcus pneumoniae
ANSWER:
RATIONALE: Streptococcus pneumoniae is the most likely organism in a 2 year old child with acute otitis
media. Acute otitis media (AOM) is the most common childhood bacterial infection from which antibiotics
are prescribed worldwide
9.This usually occurs following a respiratory tract infection?

A. Otitis Media with Effusion
B. Acute Otitis Media
C. Chronic Otitis Media
D. External Otitis Media
ANSWER:
RATIONALE: Acute Otitis Media is a common complication of upper respiratory tract infection whose pathogenesis
involves both viruses and bacteria.
10.It is inflammation of the external ear canal:

A. Otitis Media with Effusion
B. Acute Otitis Media
C. Chronic Otitis Media
D. External Otitis Media
ANSWER:
RATIONALE: External Otitis Media is an inflammation of the external ear canal
SAS 51
1. Jaz is a nine (9)-year-old child admitted to a psychiatric treatment unit accompanied by Mr. and
Mrs. Chenes.

To establish trust and position of neutrality, which action would
the nurse take?
A. Encourage Mr. and Mrs. Chenes to leave while Jaz is being
interviewed.
B. Interview Jaz with his parents together, observing their interaction.
C. Provide diversion for Jaz, and interview Mr. and Mrs. Chenes alone.
D. Review the clinical record prior to interviewing Mr. and Mrs. Chenes.
ANSWER:
RATIONALE:
It is important for the nurse to be seen as a neutral person who is interested in the family as an adaptive
functioning unit. By conducting the admission interview with the parents and child together, the nurse
establishes this neutral role from the beginning
2. Nurse Rain is a nurse practicing primary prevention for psychiatric disorders in children. On
which of the following risk factors would he focus?
A. Being raised in a single-parent home
B. Family history of mental illness
C. Lack of peer friendship
D. Family culture
ANSWER:
RATIONALE: Abnormal genes
and family history of mental
illness have been implicated in
many psychiatric disorders
occurring in children and
adolescents

3. Nurse Kaya, a school nurse,
is meeting with the school and
health treatment team about a
child who has been receiving
methylphenidate (Ritalin) for
two (2) months. The meeting is
to evaluate the results of the
child’s medication use. Which
behavior change noted by the
teacher will help determine the
medication’s effectiveness. A.
Decrease repetitive behaviors
B. Decreased signs of anxiety
C. Increased depressed mood
D. Increased ability to concentrate on tasks
ANSWER:
RATIONALE: methylphenidate (Ritalin) is used as a method of treatment of ADHD. Evidence of increased
ability to concentrate on tasks while taking this medication would establish the drug’s effectiveness.
4. Which behavioral assessment in a child is most consistent with a diagnosis of conduct

disorder?
A. Arguing with adults
B. Gross impairment in communication
C. Physical aggression toward others
D. Refusal to separate from caretaker
ANSWER:
RATIONALE: Physical aggression toward others is a significant criterion consistent with the diagnoses of
conduct disorder
5.The parents of Mika, a child with attention deficit hyperactivity disorder, tell the nurse they
have tried everything to calm their child and nothing has worked. Which action by the nurse is
most appropriate initially? A. Actively listen to the parents’ concern before planning interventions.
B. Encourage the parents to discuss these issues with the mental health team.
C. Provide literature regarding the disorder and its management.
D. Tell the parents they are overacting to the problem.
ANSWER:
RATIONALE: The nurse would encourage parents to fully discuss and describe their perception of the
problem in order to assess the family system before determining appropriate interventions

6. Nurse Gloria questions the parents of a child with oppositional defiant disorder about the roles
of each parent in setting rules of behavior. The purpose for this type of questioning is to assess
which element of the family system?
A. Anxiety levels
B. Generational boundaries
C. Knowledge of growth and development
D. Quality of communication
ANSWER:
RATIONALE: An important element in assessing the family system is determining if the parents establish
and maintain appropriate generational boundaries. establishing clear rules and expectations as part of the
parental role
7. Nurse Ting-ting reinforces the behavioral contract for a child having difficulty controlling
aggressive behaviors on the psychiatric unit. Which of the following is the best rationale for this
method of treatment?
A. It will assist the child to develop more adaptive coping methods.
B. It will avoid having the nurse be responsible for setting the rules.
C. It will maintain the nurse’s role in controlling the child’s behavior.
D. It will prevent the child from manipulating the nurse.
ANSWER:
RATIONALE: Behavioral therapy is employed for the purpose of developing adaptive behavior that will
improve coping. The nurse does not avoid setting rules; it is the responsibility of the nurse to establish
and maintain appropriate limits.
8.The school nurse assesses Brook, a child newly diagnosed with attention deficit hyperactivity
disorder (ADHD). Which of the following symptoms are characteristic of the disorder? Select all
that apply.
A. Constant fidgeting and squirming
B. Excessive fatigue and somatic complaints

C. Difficulty paying attention to details
D. Easily distracted
E. Running away
F. Talking constantly, even when inappropriate
ANSWERS:
RATIONALE: These behaviors are all characteristic of ADHD and indicate that the child is inattentive, hyperactive
and impulsive
9. Ritalin is the drug

of choice for children
with ADHD. The side
effects of the
following may be
noted:
A. Increased attention
span and concentration
B. Increase in appetite
C. Sleepiness and lethargy
D. Bradycardia and diarrhea
ANSWER:
RATIONALE:
10. The nurse is developing a care plan for a teenage patient with attention deficit hyperactivity
disorder who is at high risk for self-harm due to poor judgment, high risk-taking behaviors, and
impulsivity. Which of the following is the priority nursing intervention?
A. Schedule a regular nurse-patient session daily, and encourage her to explore stressors that may
worsen her depressed mood.
B. Develop a “no self-harm” contract with the patient, and encourage her to engage in all unit activities
C. ,Assign a staff member one-to-one close observation until the treatment team determines she is no
longer a risk for self-harm.
D. The patient is to wear hospital-issue clothing (pajamas) and sit/sleep within view of staff until the
physician determines she is no longer a risk for self-harm.
ANSWER:
RATIONALE:
SAS 52

1. A client is experiencing a severe panic attack. Which nursing intervention would meet this
client's immediate need?
A. Teach deep breathing relaxation exercises
B. Place the client in a Trendelenburg position
C. Stay with the client and offer reassurance of safety
D. Administer the ordered PRN medication
ANSWER:
RATIONALE: The nurse can meet this client's immediate need by staying with the client and offering
reassurance of safety and security. The client may fear for his or her life and the presence of a trusted
individual provides assurance of personal safety
2. A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What
short-term, realistic, correctly written outcome should be included in this client's plan of care?
A. The client will have no flashbacks.
B. The client will be able to feel a full range of emotions by discharge.
C. The client will not require medication to obtain adequate sleep by discharge.
D. The client will refrain from discussing the traumatic event.
ANSWER:
RATIONALE: The nurse should include obtaining adequate sleep without zolpidem (Ambien) by discharge as a
realistic outcome for this client. Having no flashbacks and experiencing a full range of emotions are long-term not
short-term outcomes for this client. Clients are encouraged to discuss the traumatic event.
3. Which nursing diagnosis would best describe the problems evidenced by the following client
symptoms:
avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response,
detachment, emotional numbing, and flashbacks?
A. Ineffective coping
B. Post-trauma syndrome
C. Complicated grieving
D. Panic anxiety
ANSWER:
RATIONALE: Post-trauma syndrome is defined as a sustained maladaptive response to a traumatic, overwhelming
event. This nursing diagnosis addresses the problems experienced by clients diagnosed with post-traumatic stress
disorder.

4. A client presents at the urgent care clinic and states, "My heart feels like it's skipping beats."
The client also reports always feeling cold, and has a BMI of 18. The nurse suspects anorexia.
Which other clinical manifestation should the nurse assess? (Select all that apply.)
A. Strenuous exercise
B. Feelings of euphoria
C. Extreme perfectionism
D. Obsession over body shape
E. Rigidity and the need to control situations
ANSWER:
RATIONALE:
5. The parents of a teenage girl bring their daughter to the healthcare provider, citing their
increasing concern about the teen's weight and their suspicion that their daughter has anorexia
nervosa (AN). During assessment, the nurse notes a BMI of 16.75 kg/m2. In which category does
the client fall, according to DSM-5 criteria and considering the severity of anorexia nervosa?
A. Extreme
B. Severe
C. Mild
D. Moderate
ANSWER:
RATIONALE:
6.The client with anorexia nervosa is

improving if:
A. She eats meals in the dining room.
B. Weight gain
C. She attends ward activities.
D. She has a more realistic self concept.

ANSWER:
RATIONALE:
7. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is
that bulimic individuals
A. have episodic binge eating and purging
B. have repeated attempts to stabilize their weight
C. have peculiar food handling patterns
D. have threatened self-esteem
ANSWER:
RATIONALE:
8. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of
eating habits. The goal for this problem is:
A. Patient will learn problem solving skills
B. Patient will have decreased symptoms of anxiety.
C. Patient will perform self care activities daily.
D. Patient will verbalize how to set limits on others.
ANSWER:
RATIONALE:
9. In the management of bulimic patients, the following nursing interventions will promote a
therapeutic relationship EXCEPT:
A. Establish an atmosphere of trust
B. Discuss their eating behavior.
C. Help patients identify feelings associated with binge-purge behavior
D. Teach patient about bulimia nervosa
ANSWER:
RATIONALE:

10. A nurse at Sky Castle Medical Center is developing a care plan for a female client with post-
traumatic stress disorder. Which of the following would she do initially?
A. Instruct the client to use distraction techniques to cope with flashbacks.
B. Encourage the client to put the past in proper perspective.
C. Encourage the client to verbalize thoughts and feelings about the trauma.
D. Avoid discussing the traumatic event with client.
ANSWER:
RATIONALE:
SAS 53
1. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse
assign to this client to address a behavioral symptom of this disorder?
A. Altered communication related to feelings of worthlessness as evidenced by anhedonia
B. Social isolation related to poor self-esteem as evidenced by secluding self in room
C. Altered thought processes related to hopelessness as evidenced by persecutory delusions
D. Altered nutrition: less than body requirements related to high anxiety as evidenced by anorexia
RATIONALE:A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a
behavioral symptom of major depressive episode. Other behavioral symptoms include psychomotor
retardation, virtually nonexistent communication, curled-up position, and no attention to personal hygiene and
grooming.
2. A nurse assesses a client suspected of having major depressive disorder. Which client
symptom would eliminate this diagnosis?
A. The client is disheveled
and malodorous.
B. The client refuses to
interact with others.
C. The client is unable to feel
any pleasure.
D. The client has maxed-out charge cards and exhibits promiscuous behaviors.
RATIONALE: The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous
behavior is exhibiting signs of mania. The DSM-5 criteria state that there must never have been a manic episode
or a hypomanic episode to meet the criteria for the diagnosis of major depressive episode.
3. A nurse reviews the laboratory data of a client suspected of having major depressive disorder.
Which laboratory value would potentially rule out this diagnosis?
A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL
B. Potassium (K+) level of 4.2 mEq/L
C. Sodium (Na+) level of 140 mEq/L
D. Calcium (Ca2+) level of 9.5 mg/dL
RATIONALE: A diagnosis of major depressive episode may be ruled out if the client’s lab results reveal a TSH
level of 25 U/mL. Normal levels of TSH range from 2 to 10 U/mL. High levels of TSH indicate low thyroid
function. The client’s high TSH value may indicate hypothyroidism, which can lead to depressive symptoms. The
DSM-5 criterion for the diagnosis of major depressive episode states that this diagnosis must not be attributable
to the direct physiological effects of another medical condition.

4. What is the rationale for a nurse to perform a full physical health assessment on a client
admitted with a diagnosis of major depressive disorder?
A. The attention during the assessment is beneficial in decreasing social isolation.
B. Depression can generate somatic symptoms that can mask actual physical disorders.
C. Physical health complications are likely to arise from antidepressant therapy.
D. Depressed clients avoid addressing physical health and ignore medical problems.
RATIONALE:The nurse should determine that a client with a diagnosis of major depressive episode needs a full
physical health assessment, because depression can generate somatic symptoms that can mask actual physical
disorders.
5. Which statement about an individual with a personality

disorder is true?
A. Psychotic behavior is common during acute episodes.
B. Prognosis for recovery is good with therapeutic intervention.
C. The individual typically remains in the mainstream of society, although he has problems in social and
occupational roles.
D. The individual usually seeks treatment willingly for symptoms that are personally distressful.
RATIONALE: Option C is the correct statement about an individual with a personality disorder
6. Chai is with an anxious, fearful personality who has difficulty accomplishing work assignments
because of his fear of failure. She has been referred to the employee assistance program because
of repeated absences from work and evidence of an alcohol problem. Which nursing diagnosis
would be most appropriate?
A. Ineffective coping
B. Decisional conflict
C. Disturbed thought process
D. Risk for self-directed violence
RATIONALE: Ineffective coping is the most appropriate nursing diagnosis in which the nurse can
help the client who have an alcohol problem
7. Another term that has been previously used for bipolar disorder is
___________________.
A. Schizophrenia
B. Paranoid schizophrenia
C. Manic depression
D. Multiple personality disorder
RATIONALE:Bipolar disorder, previously called manic depression, is a mental illness that is
characterized by severe mood swings, repeated episodes of depression, and at least one episode
of mania.
8. Bipolar disorder is what type of disorder?

A. Personality
B. Mood
C. Identity
D. Thought
RATIONALE:Bipolar disorder is a brain disorder that causes changes in a person's mood, energy,
and ability to function. People with bipolar disorder experience intense emotional states that
typically occur during distinct periods of days to weeks, called mood episodes.

9. Medically speaking, mania is defined as...
A. Low, deflated moods
B. Anger followed by sleepiness
C. Alternating high and low moods
D. Abnormally elevated moods
RATIONALE:Mania is a psychological condition that causes a person to experience unreasonable
euphoria, very intense moods, hyperactivity, and delusions. Mania (or manic episodes) is a
common symptom of bipolar disorder. Mania can be a dangerous condition for several reasons.
People may not sleep or eat while in a manic episode.
10. Bipolar Disorder is hereditary.

A. True
B. False
C. Either
D. Neither
RATIONALE:Bipolar disorder is frequently inherited, with genetic factors accounting for
approximately 80% of the cause of the condition. Bipolar disorder is the most likely
psychiatric disorder to be passed down from family. If one parent has bipolar disorder, there's a
10% chance that their child will develop the illness.
SAS 54
1. A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the
following signs, if noted in the mother, would be an early sign of excessive blood loss?
A. A temperature of 100.4*F
B. An increase in the pulse from 88 to 102 BPM
C. An increase in the respiratory rate from 18 to 22 breaths per minute
D. A blood pressure change from 130/88 to 124/80 mm Hg
RATIONALE:During the 4th stage of labor, the maternal blood pressure, pulse, and respiration
should be checked every 15 minutes during the first hour. A rising pulse is an early sign of
excessive blood loss because the heart pumps faster to compensate for reduced blood volume.
The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure
would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The
respiratory rate is increased slightly.
2. Methergine or Pitocin is prescribed for a woman to treat PP hemorrhage. Before

administration of these medications, the priority nursing assessment is to check the:
A. Amount of lochia
B. Blood pressure
C. Deep tendon reflexes
D. Uterine tone
RATIONALE:Methergine and pitocin are agents that are used to prevent or control postpartum
hemorrhage by contracting the uterus. They cause continuous uterine contractions and may
elevate blood pressure. A priority nursing intervention is to check blood pressure. The
physician should be notified if hypertension is present.

3. Methergine or Pitocin are prescribed for a client with PP hemorrhage. Before
administering the medication(s), the nurse contacts the health provider who prescribed the
medication(s) in which of the following conditions is documented in the client’s medical history?
A. Peripheral vascular disease
B. Hypothyroidism
C. Hypotension
D. Type 1 diabetes
RATIONALE:These medications are avoided in clients with significant cardiovascular disease, peripheral
disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction
effects of these medications.
4. Which of the following complications is most likely responsible for a delayed postpartum
hemorrhage?
A. Cervical laceration
B. Clotting deficiency
C. Perineal laceration
D. Uterine subinvolution
RATIONALE:Late postpartum bleeding is often the result of subinvolution of the uterus. Retained
products of conception or infection often cause subinvolution. Cervical or perineal lacerations
can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may also have
an immediate PP hemorrhage if the deficiency isn't corrected at the time of delivery.
5. A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which
finding would the nurse interpret as indicating a therapeutic level of medication?
A. Urinary output of 20 mL per hour
B. Respiratory rate of 10 breaths/minute
C. Deep tendons reflexes 2+
D. Difficulty in arousing
RATIONALE:With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and
therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of
less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium
toxicity.
6. A woman hospitalized with severe preeclampsia is being treated with hydralazine to control
blood pressure. Which of the following would the lead the nurse to suspect that the client is
having an adverse effect associated with this drug?
A. Gastrointestinal bleeding
B. Blurred vision
C. Tachycardia
D. Sweating
RATIONALE:Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation,
tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding,
blurred vision, or sweating. Magnesium sulfate may cause sweating.

7. After reviewing a client's history, which factor would the nurse identify as placing her at risk for
gestational hypertension?
A. Mother had gestational hypertension during pregnancy.
B. Client has a twin sister.
C. Sister-in-law had gestational hypertension.
D. This is the client's second pregnancy.
RATIONALE:A family history of gestational hypertension, such as a mother or sister, is considered a
risk factor for the client. Having a twin sister or having a sister-in-law with gestational
hypertension would not increase the client's risk. If the client had a history of preeclampsia in her
first pregnancy, then she would be at risk in her second pregnancy.
8. Which of the following would the nurse has readily available for a client who is receiving
magnesium sulfate to treat severe preeclampsia?
A. Calcium gluconate
B. Potassium chloride
C. Ferrous sulfate
D. Calcium carbonate
RATIONALE:The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case
the woman has signs and symptoms of magnesium toxicity.
9. The nurse is assessing a pregnant woman with gestational hypertension. Which of the
following would lead the nurse to suspect that the client has developed severe preeclampsia?
A. Urine protein 300 mg/24 hours
B. Blood pressure 150/96 mm Hg
C. Mild facial edema
D. Hyperreflexia
RATIONALE:Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels
greater than 500 mg/24 hours and hyperreflexia. Mild facial edema is associated with mild preeclampsia.
10. The perinatal nurse is caring for a woman in the immediate postpartum period. Assessment
reveals that the woman is experiencing profuse bleeding. The most likely etiology for the
bleeding is:
A. Uterine atony
B. Uterine inversion
C. Vaginal hematoma
D. Vaginal laceration
RATIONALE:Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum
hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this
client's bleeding.
SAS 55
1. What is the correct depth of chest compressions in an adult?

A. As deep as possible
B. Up to 2 inches

C. Between 2 and 2.4 inches
D. At least 3 inches
RATIONALE:Since the update to the CPR guidelines in 2015, the depth of chest compressions shifted from 2
inches, to 2-2.4 inches deep. You’ll do these compressions at a rate of 100-120 compressions per minute, on the
sternum in the center of the chest. This is the same for both men and women, so don’t be afraid when the need
to do CPR arises.
2. A victim probably has a neck injury. What is the correct way to open the airway?
A. Head tilt-chin lift
B. Jaw thrust
C. Turn the Head to the side
D. Head tilt-jaw thrust
RATIONALE: Open the Airway. Head or moving the neck if a neck injury is suspected -‐ after two
unsuccessful attempts, use head tilt-‐chin lift to open the airway. Breathing: Check for Breathing.
3. How long should a pulse check last?

A. As long as it takes to find a pulse
B. No more than 2 seconds
C. No more than 5 seconds
D. No more than 10 seconds
RATIONALE:
4. Where should you check for a pulse in an adult?

A. Carotid artery
B. Brachial artery
C. Femoral artery
D. Radial artery
RATIONALE:In an unconscious/unresponsive adult, the preferred pulse point is the carotid artery.
5. Where should you check for a pulse in an infant?

A. Carotid artery
B. Brachial artery
C. Femoral artery
D. Radial artery
RATIONALE:An infant's pulse is checked at the brachial artery, which is located inside of the
upper arm, between the elbow and the shoulder
6. A child is gasping for breath but has a pulse rate of 100 per minute. The rescuers should:
A. Start CPR beginning with compressions
B. Give 1 breath every 5 to 6 seconds
C. Give 1 breath every 3 to 5 seconds
D. Do nothing; the child is not in distress
RATIONALE:The rescuers should give the infant a 1 breath every 3 to 5 seconds.
7. A child is not breathing but has a pulse rate of 50 per minute. The rescuers should:
A. Start CPR beginning with compressions
B. Give 1 breath every 5 to 6 seconds
C. Give 1 breath every 3 to 5 seconds
D. Do nothing; the child is not in distress

RATIONALE:Start CPR beginning with compressions when a child is not breathing but has a pulse
rate.
8. An 18-year-old girl who has been eating steak in a restaurant abruptly stands up and grabs her
neck. The rescuer determines that the victim is choking. The best response is to:
A. Use back blows
B. Do nothing; wait until the victim becomes unresponsive, then start CPR
C. Use abdominal thrusts
D. Use upward chest thrusts
RATIONALE:Abdominal thrusts is an emergency technique to help clear someone's airway. The
procedure is done on someone who is choking and also conscious.
9. An infant who had been choking becomes unresponsive. The rescuer should:
A. Alternate back slaps and chest thrusts
B. Perform a blind finger sweep to attempt to remove the obstruction
C. Attempt to dislodge the obstruction using abdominal thrusts
D. Begin CPR
RATIONALE:Immediately do CPR when an infant becomes unresponsive from a choking incident.
10. Efforts to relieve choking should be stopped when:

A. The obstruction is removed
B. The victim becomes unresponsive
C. The victim begins breathing normally
D. Any of the above occurs
RATIONALE:All of the following are to be followed when choking is relieved.
SAS 56
1. You are caring for a patient who has been taking methylergonovine maleate (Methergine) for
postpartum hemorrhage. It is not helping to control the hemorrhage. What procedure will most
likely be ordered for this patient?
A. Dilatation and curettage
B. Laparotomy
C. Hysterotomy
D. Hysterectomy
ANSWER:
RATIONALE: This vaginal procedure is to remove retained tissue from the uterus. The other procedures
would be inappropriate for this type of hemorrhage.

2. The client has undergone a dilation and curettage (D & C) following a spontaneous abortion at 8
weeks. To promote an optimal recovery, what information should the nurse include in the
discharge teaching? (Select all that apply.)
A. Expect heavy bleeding for at least a week
B. Use sanitary pads until vaginal bleeding has stopped
C. Strenuous sport activities should be postponed until bleeding stops
D. Resume vaginal intercourse 6 weeks after the procedure
E. Referral for grief counseling
ANSWERS:
RATIONALE: -client should avoid vag intercourse + not to use tampons for ~2 weeks
3. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery.

Which assessment finding would indicate a need to contact the physician?
A. Fetal heart rate of 180 beats per minute
B. White blood cell count of 12,000
C. Maternal pulse rate of 85 beats per minute
D. Hemoglobin of 11.0 g/dL
ANSWER:
RATIONALE: A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute
could indicate fetal distress and would warrant physician notification
4. A client in labor is transported to the delivery room and is prepared for a cesarean delivery.
The client is transferred to the delivery room table, and the nurse places the client in the:
A. Trendelenburg’s position with the legs in stirrups
B. Semi-Fowler position with a pillow under the knees
C. Prone position with the legs separated and elevated
D. Supine position with a wedge under the right hip
ANSWER:
RATIONALE:
Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the
lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the
uterus and the fetus

5. Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy. The nurse
avoids which of the following in the care of this client?
A. Elevating the knee gatch on the bed
B. Assisting with range-of-motion leg exercises
C. Removal of antiembolism stockings twice daily
D. Checking placement of pneumatic compression boots
ANSWER:
RATIONALE: the client is at risk of deep vein thrombosis or thrombophlebitis after this surgery, as for any
other major surgery. For this reason, the nurse implements measures that will prevent this complication.
6.After a hysterectomy, clients may feel incomplete as women. The statement that should alert
nurse Gina to this feeling would be:
A. “I can’t wait to see all my friends again”
B. “I feel washed out; there isn’t much left”
C. “I can’t wait to get home to see my grandchild”
D. “My husband plans for me to recuperate at our daughter’s home”
ANSWER:
RATIONALE: The client’s statement infers an emptiness with an associated loss
7. When planning care with a client during the postoperative recovery period following an
abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the
explanation that:
A. Surgical menopause will occur
B. Urinary retention is a common problem
C. Weight gain is expected, and dietary plan are needed
D. Depression is normal and should be expected
ANSWER:
RATIONALE: When a bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian
hormones and initiating response.
8. A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section and
complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates
tetanic contractions, the client again complains of severe pain. After the client vomits, she states

that the pain is better and then passes out. Which is the probable cause of her signs and
symptoms?
A. Hysteria compounded by the flu
B. Placental abruption
C. Uterine rupture
D. Dysfunctional labor
ANSWER:
RATIONALE: Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms
typically include abdominal pain that may ease after uterine rupture
9. The nurse should realize that the most common and potentially harmful maternal complication
of epidural anesthesia would be:
A. Severe postpartum headache
B. Limited perception of bladder fullness
C. Increase in respiratory rate
D. Hypotension
ANSWER:
RATIONALE: Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with
adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent
this problem and maintain an adequate blood pressure
10.Which measure would be least effective in preventing postpartum hemorrhage?

A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered
B. Encourage the woman to void every 2 hours
C. Massage the fundus every hour for the first 24 hours following birth
D. Teach the woman the importance of rest and nutrition to enhance healing
ANSWER
RATIONALE: The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to
relax
SAS 57
1. The nurse is giving dietary instructions on a client who is on a vegan diet. The nurse provides
dietary teaching focus on foods high in which vitamin that may be lacking in a vegan diet?
A. Vitamin A.
B. Vitamin D.
C. Vitamin E.
D. Vitamin C.
ANSWER:

RATIONALE: Deficiencies in vegetarian diets include vitamin B12 which are found in animal products and
vitamin D (if limited exposure to sunlight)
2. The nurse is teaching a client who has iron deficiency anemia about foods she should include
in her diet. The nurse determines that the client understands the dietary instructions if she selects
which of the following from her menu?
A. Nuts and fish.
B. Oranges and dark green leafy vegetables.
C. Butter and margarine.
D. Sugar and candy.
ANSWER:
RATIONALE: Dark green leafy vegetables are rich in iron while oranges are a good source of vitamin C, which
enhances iron absorption.
3. When planning a diet with a pregnant woman, the nurse's FIRST action would be to:
A. Review the woman's current dietary intake.
B. Teach the woman about the food pyramid.
C. Caution the woman to avoid large doses of vitamins, especially those that are fat-soluble.
D. Instruct the woman to limit the intake of fatty foods.
ANSWER:
RATIONALE:
4. A pregnant woman with a body mass index (BMI) of 22 asks the nurse how she should be
gaining weight during pregnancy. The nurse's BEST response would be to tell the woman that her
pattern of weight gain should be approximately:
A. A pound a week throughout pregnancy.
B. 2 to 5 lbs during the first trimester, then a pound each week until the end of pregnancy.
C. A pound a week during the first two trimesters, then 2 lbs per week during the third trimester.
D. A total of 25 to 35 lbs.
ANSWER:

RATIONALE: pound a week is not the correct guideline during pregnancy. A BMI of 22 represents a
normal weight. Therefore, a total weight gain for pregnancy would be about 25 to 35 lbs or about 2 to 5
lbs in the first trimester and about 1 lb/wk during the second and third trimesters
5. A pregnant woman at 7 weeks of gestation complains to her nurse midwife about frequent
episodes of nausea during the day with occasional vomiting. She asks what she can do to feel
better. The nurse midwife could suggest that the woman:
A. Drink warm fluids with each of her meals.
B. Eat a high-protein snack before going to bed.
C. Keep crackers and peanut butter at her bedside to eat in the morning before getting out of bed.
D. Schedule three meals and one midafternoon snack a day.
ANSWER:
RATIONALE: Fluids should be taken between (not with) meals to provide for maximum nutrient uptake in
the small intestine. A bedtime snack of slowly digested protein is especially important to prevent the
occurrence of hypoglycemia during the night that would contribute to nausea
6. A pregnant woman experiencing nausea and vomiting should:

A. Drink a glass of water with a fat-free carbohydrate before getting out of bed in the morning.
B. Eat small, frequent meals (every 2 to 3 hours).
C. Increase her intake of high-fat foods to keep the stomach full and coated.
D. Limit fluid intake throughout the day.
ANSWER:
RATIONALE: Eating small, frequent meals is a correct suggestion for a pregnant woman experiencing
nausea and vomiting.
7. A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. The nurse
would be most concerned regarding what this woman consumes during and after tennis matches.
Which is the MOST important?
A. Several glasses of fluid
B. Extra protein sources, such as peanut butter
C. Salty foods to replace lost sodium
D. Easily digested sources of carbohydrate
ANSWER:
RATIONALE: If no medical or obstetric problems contraindicate physical activity, pregnant women should
get 30 minutes of moderate physical exercise daily. Liberal amounts of fluid should be consumed before,
during, and after exercise, because dehydration can trigger premature labor.

8. Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an
infant with:
A. Spina bifida.
B. Intrauterine growth restriction.
C. Diabetes mellitus.
D. Down syndrome.
ANSWER:
RATIONALE: Both normal-weight and underweight women with inadequate weight gain have an
increased risk of giving birth to an infant with intrauterine growth restriction.
9. Which minerals and vitamins usually are recommended to supplement a pregnant woman's
diet?
A. Fat-soluble vitamins A and D
B. Water-soluble vitamins C and B6
C. Iron and folate
D. Calcium and zinc
ANSWER:
RATIONALE: Iron generally should be supplemented, and folic acid supplements often are needed
because folate is so important
10. With regard to nutritional needs during lactation, a maternity nurse should be aware that:
A. The mother's intake of vitamin C, zinc, and protein now can be lower than during pregnancy.
B. Caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active
and wakeful.
C. Critical iron and folic acid levels must be maintained.
D. Lactating women can go back to their prepregnant calorie intake
ANSWER:
RATIONALE: A lactating woman needs to avoid consuming too much caffeine. Vitamin C, zinc, and
protein levels need to be moderately higher during lactation than during pregnancy.
SAS 58
1. A laboring woman becomes anxious during the transition phase of the first stage of labor and
develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed.
The nurse's immediate response would be to:
A. encourage the woman to breathe more slowly.

B. help the woman breathe into a paper bag.
C. turn the woman on her side.
D. administer a sedative.
ANSWER:
RATIONALE: the woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level
and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on her side will
not solve this problem.
2. woman is experiencing back labor and complains of constant, intense pain in her lower back.
An effective relief measure is to use:
A. counterpressure against the sacrum.
B. pant-blow (breaths and puffs) breathing techniques.
C. effleurage.
D. biofeedback.
ANSWER:
RATIONALE: Counterpressure is steady pressure applied by a support person to the sacral area with the
fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure
and pain in the lower back
3. Nurses should be aware of the difference experience can make in labor pain, such as:
A. sensory pain for nulliparous women often is greater than for multiparous women during early labor.
B. affective pain for nulliparous women usually is less than for multiparous women throughout the first
stage of labor.
C. women with a history of substance abuse experience more pain during labor.
D. multiparous women have more fatigue from labor and therefore experience more pain.
ANSWER:
RATIONALE: Sensory pain is greater for nulliparous women because their reproductive tract structures
are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for
both nulliparous and multiparous during the second stage
4. With regard to what might be called the tactile approaches to comfort management, nurses
should be aware that:
A. either hot or cold applications may provide relief, but they should never be used together in the same
treatment.
B. acupuncture can be performed by a skilled nurse with just a little training.

C. hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for
touch is limited.
D. therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.
ANSWER:
RATIONALE: The woman and her partner should experiment with massage before labor to see what might work
best. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.
5. It is based on the belief that people have control and can regulate internal events such as heart
rate and pain responses:
A. Acupuncture
B. Acupressure
C. Biofeedback
D. Intracutaneous Nerve Stimulation
ANSWER:
RATIONALE: Biofeedback is based on the belief that people have control and can regulate internal
events such as heart rate and pain responses
6. It the application of pressure or massage at these same points and it is the most effective for
low back pain:
A. Acupuncture
B. Acupressure
C. Biofeedback
ANSWER:
RATIONALE: Acupressure is the application of pressure or massage at these same points and it is
the most effective for low back pain

7. It is based on the concept that illness results from an imbalance of energy and to correct the
imbalance, needles are inserted into the skin at designated susceptible body points (tsubos) located
along meridians that course throughout the body to supply the organs of the body with energy:
A. Acupuncture
B. Acupressure
C. Biofeedback
ANSWER:
RATIONALE: Acupuncture is based on the concept that illness results from an imbalance of energy and
to correct the imbalance
8. Mia Thermopolis is having labor and she was instructed by the Nurse-Midwife to stand under a
warm shower or soaking in a tub of warm water, jet hydrotherapy tub, or whirlpool is another way
to apply heat to help reduce the pain of labor: You as a Student Nurse knows that this is:
A. Yoga and Meditation
B. Application of Heat and Cold
C. Therapeutic Touch and Massage
D. Hydrotherapy
ANSWER:
RATIONALE: Hydrotherapy is the use of water in the treatment of different conditions, including arthritis,
related rheumatic complaints and especially for the labor women.
9. It offers a significant variety of proven health benefits, including increasing the efficiency of the
heart, slowing the respiratory rate, improving fitness, lowering blood pressure, promoting
relaxation, reducing stress, and allaying anxiety
D. Hydrotherapy
ANSWER:
RATIONALE: Yoga and Meditation offers a significant variety of proven health benefits, including
increasing the efficiency of the heart, slowing the respiratory rate, improving fitness, lowering
blood pressure, promoting relaxation, reducing stress, and allaying anxiety
10. It is based on the concept that everyone’s body contains energy fields that, when plentiful,
lead to health or, when in low supply, result in illness:

D. Hydrotherapy
ANSWER:
RATIONALE: Therapeutic Touch and Massage is based on the concept that everyone’s body
contains energy fields that, when plentiful, lead to health or, when in low supply, result in illness
SAS 59
1. A 46-year-old woman tells the nurse that she has not had a menstrual period for 3 months and
asks whether she is going into menopause. The best response by the nurse is,
A. "Have you thought about using hormone replacement therapy?"
B. "Most women feel a little depressed about entering menopause."
C. "What was your menstrual pattern before your periods stopped?"
D. "Since you are in your mid-40s, it is likely that you are menopausal."
ANSWER:
RATIONALE: The initial response by the nurse should be to assess the patient's baseline menstrual
pattern. Although many women do enter menopause in the mid-40s, more information about this
patient is needed before telling her that it is likely she is menopausal
2. Which information will the nurse include when teaching a 51-year-old woman who is
considering the use of combined estrogen-progesterone hormone replacement therapy (HRT)
during menopause?
A. Use of estrogen-containing vaginal creams provides most of the same benefits as oral HRT.
B. Use of HRT for up to 10 years to prevent symptoms such as hot flashes is generally considered safe.
C. HRT decreases osteoporosis risk and increases the risk for cardiovascular disease and breast cancer.
D. Increased incidence of colon cancer in women taking HRT requires frequent stool assessment for
occult blood.
ANSWER:
RATIONALE: Data from the Women's Health Initiative indicate an increased risk for cardiovascular
disease and breast cancer in women taking combination HRT but a decrease in hip fractures

3. The nurse provides drug teaching for a 30-year-old woman who is prescribed clomiphene
(Clomid). It is most important for the nurse to follow up on which patient statement?
A. “Hormone production and release will be increased.”
B. “This drug is like estrogen and is used to treat infertility.”
C. “I should avoid intercourse while taking this medication.”
D. “This medication will stimulate my ovaries to produce eggs.”
ANSWER:
RATIONALE: lomiphene is an oral medication administered for infertility. The medication is a

selective estrogen-stimulation modulator that stimulates ovulation, making pregnancy after
intercourse or artificial insemination more likely.
.
4. Because of the risks associated with hormone therapy (HT), a 50-year-old patient does not want
to take HT and asks the nurse how she can handle her perimenopausal symptoms of hot flashes
and sweating at night. What should the nurse first advise this patient?
A. Increase warmth to avoid chills.
B. Good nutrition to avoid osteoporosis
C. Vitamin B complex and vaginal lubrication
D. Decrease heat production and increase heat loss.
ANSWER:
RATIONALE: To avoid hot flashes and sweating at night, decrease heat production with a cool
environment, limit caffeine and alcohol, and practice relaxation techniques.
5. Men and Women are equally likely to have fertility problems.

A. True
B. False
C. Either
D. Neither
ANSWER:
RATIONALE: Men can be infertile too. In fact, men and women are equally likely to have fertility
problems. According to the Office on Women's Health , about one-third of infertility cases can be
attributed to female infertility while men's problems account for another third of infertility cases.

.
6. These are the major factor for infertility in women. SELECT ALL THAT APPLY
A. Age
B. Weight
C. Anovulation
D. Hormonal Therapy
ANSWER:
RATIONALE: Rarely, in the uterus, fibroid growths, endometriosis, tumors, cervical problems, or
irregular uterine shape where shape can keep the egg from implanting in the uterus. In women
fertility declines with age, and even more so after the age of 35. Conception after age 45 is rare.
7. Women who are trying to conceive should boost their intake of:
A. Nickel
B. Lycopene
C. Potassium
D. Folic Acid
ANSWER:
RATIONALE: Women trying to conceive should add a supplement of at least 600mcg folic acid
either alone or as part of their prenatal vitamins to decrease the risk of fetal malformations. Folic
acid may also decrease the risk of a miscarriage.
8. The most fertile days of a woman’s cycle can vary from month to month:
A. True
B. False
C. Either
D. Neither
ANSWER:
RATIONALE: A woman is most fertile around one to two days before ovulation (when the egg is
released from the ovary). Ovulation occurs on different days for different women. It can vary
month to month for many women, and some women can have longer or shorter cycles.

9. Men do not experience age-related decrease in fertility.
A. True
B. False
C. Either
D. Neither
ANSWER:
RATIONALE: Men who are 40 years of age or older Often have decreased fertility. However in men
the most common reasons for infertility are sperm disorders. These problems include low sperm
count, low sperm mobility, malformation of the sperm and block sperm ducts.
10. Which sexually transmitted disease can result in infertility in women?

A. Human Papilloma virus (HPV)
B. Genital Herpes
C. Pelvic Inflammatory Disease
D. All of the above
ANSWER:
RATIONALE: Pelvic Inflammatory Disease or PID is an infection of the female reproductive
organs. PID is one of the most serious complications of certain sexually transmitted diseases in
women
SAS 60
1. A group of nursing students at Elmira College is currently learning about family violence. Which
of the following is true about the topic mentioned?
A. Family violence affects every socioeconomic level.
B. Family violence is caused by drugs and alcohol abuse.
C. Family violence predominantly occurs in lower socioeconomic levels.
D. Family violence rarely occurs during pregnancy
ANSWER:
RATIONALE: Family violence occurs in all socioeconomic levels, races, religions, and cultural groups.
Although violence is associated with substance abuse, it is not the singular cause
2. During a well-child checkup, a mother tells the Nurse Rio about a recent situation in which her
child needed to be disciplined by her husband. The child was slapped in the face for not getting
her husband breakfast on Saturday, despite being told on Thursday never to prepare food for
him. Nurse Rio analyzes the family system and concludes it is dysfunctional. All of the following
factors contribute to this dysfunction except:

A. conflictual relationships of parents.
B. inconsistent communication patterns.
C. rigid, authoritarian roles.
D. use of violence to establish control
ANSWER:
RATIONALE: There is no evidence in this situation that the parents are in conflict; in fact, the mother is
describing that the child "needed to be disciplined." Often, in dysfunctional families, one child is singled
out to be the victim and is the recipient of blame for problems.
3. During a home visit to a family of three: a mother, a father, and their child, The mother tells the
community nurse that the father (who is not present) has hit the child on several occasions when
he was drinking. The mother further explains that she has talked her husband into going to
Alcoholics Anonymous and asks the nurse not to interfere, so her husband won't get angry and
refuse treatment. Which of the following is the best response of the nurse?
A. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that
evening.
B. The nurse commends the mother's efforts and agrees to let her handle things.
C. The nurse commends the mother's efforts and also contacts protective services.
D. The nurse confronts the mother's failure to protect the child.
ANSWER:
RATIONALE: : WE ARE MANDATED REPORTERS OF ABUSE
4. Nurse Ching is observing 6-year-old Anna during a community visit. Which of the following
findings would lead the nurse to suspect that Anna is a victim of sexual abuse?
A. The child is fearful of the caregiver and other adults.
B. The child has a lack of peer relationships.
C. The child has self-injurious behavior.
D. The child has interest in things of a sexual nature
ANSWER:
RATIONALE: Option D. is the findings that would lead the nurse to suspect that Anna is a victim of
sexual abuse
5. Nurse Chika is working in the emergency department of Sky Castle Medical Center. She
is conducting an interview with a victim of spousal abuse. Which step should the nurse take
first?
A. Contact the appropriate legal services.

B. Ensure privacy for interviewing the victim away from the abuser.
C. Establish a rapport with the victim and the abuser.
D. Request the presence of a security guard.
ANSWER:
RATIONALE: Option B. is the correct answer and the step that the nurse should take first.
6. Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While
assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in
1 month that the child has visited the nurse. Each time, the child provides vague explanations for
various injuries. Which of the following is the school nurse’s priority intervention?
A. Contact the child’s parents and ask about the child’s injury.
B. Encourage the child to be truthful with her.
C. Question the teacher about the parent’s behavior.
D. Report suspicion of abuse to the proper authorities.
ANSWER:
RATIONALE: The nurse is obligated to report suspicion of child abuse to the appropriate
protective services. Failure to do so can risk further endangerment of the child and failure to
report is a misdemeanor violation on the part of the nurse.
7. Carrie is studying about abuse for the upcoming exam. For her to fully instill the topic, she
should know that the priority nursing intervention for a child or elder victim of abuse is:
A. Assess the scope of the abuse problem.
B. Analyze family dynamics.
C. Implement measures to ensure the victim’s safety.
D. Teach appropriate coping skills.
ANSWER:
RATIONALE: The priority Intervention when a child or elderly person is involved in a situation of
abuse is establishing the safety of the victim. Legislation in most states mandates the reporting of
such abuse to ensure prompt intervention and safety

8. A community nurse conducts a primary prevention, home-visit assessment for a newborn and
mother. Mrs. Smith has three other children, the oldest of whom is age 12. She tells the nurse that
her 12-year-old daughter is expected to prepare family meals, to look after the young children, and
to clean the house once a week. Which of the following is the most appropriate nursing diagnosis
for this family situation?
A. Delayed growth and development, related to performance expectations of the child.
B. Anxiety (moderate), related to difficulty managing the home situation.
C. Impaired parenting, related to the role reversal of mother and child.
D. Social isolation, related to lack of extended family assistance.
ANSWER:
RATIONALE: The role of a 12 year old child in a family should not be that of a parent. In this
situation, the child and mother have reverse roles.
9. Mrs. Chen’s was admitted to the emergency department of Wu Medical Center with a
fractured arm. She explains to the nurse that her injury resulted when she provoked her
drunken husband, Mr. Smith, who then pushed her. Which of the following best describes
the nurse’s understanding of the wife’s explanation?
A. Mrs. Chen’s explanation is appropriate acceptance of her responsibility.
B. Mrs. Chen’s explanation is an atypical reaction of an abused woman.
C. Mrs. Chen’s explanation is evidence that the woman may be an abuser as well as a victim.
D. Mrs. Chen’s explanation is a typical response of a victim accepting blame for the abuser.
ANSWER:
RATIONALE: Self- blamed is a common psychological response to a woman who is a victim of
abuse. In this situation, the message that violence occurred because the woman provoked the
abuser is accepted and owned by a victim, however the victim is not responsible for the violence
10. Cha tells the community nurse that her boyfriend has been abusive and she is afraid of him,
but she doesn’t want to leave. The client asks the nurse for assistance. Which nursing
interventions are appropriate in this situation? Select all that apply.
A. Help Cha to develop a plan to ensure safety, including phone numbers for emergency help.
B. Help Cha to get her boyfriend into an appropriate treatment program.
C. Communicate acceptance, avoiding any implication that Cha is at fault for not leaving.
D. Help Cha to explore available options, including shelters and legal protection.
E. Tell Cha that she should leave because things will not improve.
F. Reinforce concern for Cha’s safety and her right to be free of abuse.
ANSWER:
RATIONALE: Options A, C, D and F. These are all appropriate nursing interventions for the victim
of domestic violence. The client is not responsible for seeking help for the abuses, and
encouraging her to do so may reinforce the client’s feeling responsible for the abuse.


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SAS1

Sustainable Developmental Goals

2. This aims to eradicate poverty, hunger, illiteracy and disease.

Increase quality and years of healthy life

Sustainable Developmental Goals

A. Informed consent related to fetal well-being

8. The following are Steps of Nursing Process, EXCEPT

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10. The following are part of Sustainable Developmental Goals, EXCEPT

Improve Maternal Health

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A visual representation of the chromosome pattern of an individual

Additional chromosome was inherited because it was attached to a normal chromosome

Poor muscle tone

Left anterior descending artery

2. When do coronary arteries primarily receive blood flow?

4. Which of the following conditions most commonly results in CAD?

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5.Atherosclerosis impedes coronary blood flow by which of the following mechanisms?

Plaques obstruct the artery

Enhance myocardial oxygenation

Oral medication administration

2. When do most patients tend to develop gestational diabetes during pregnancy?

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Insulin is a hormone secreted by the beta cells of the pancreas.”

3 hour glucose tolerance test

low; human placental lactogen (hPL) and cortisol

Blood glucose 82mg/dl

Blood pressure 190/102

. “It burns when I urinate.”

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This document and the information thereon is the property of

This document and the information thereon is the property of

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8. The client with hyperemesis gravidarum is at risk for developing:

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9. Which of the following statements best describes hyperemesis gravidarum?

D. . The mother may have a problem of digestion because of pica

2.Of the following terms, which is used to refer to a type of gestational

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6.Check all that apply to incompetent cervix:

8. Restriction of activities and cervical cerclage are the

.A. Abruptio Placenta

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6. All of the products of conception are expelled.

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A. This is known as marginal placenta previa.

A. Routine vaginal examinations

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A. Decrease in fundal height

A. A 37 year old woman who is pregnant with her 7th child.

A. Oozing around the IV site

7. Which statement is TRUE regarding abruptio placenta?

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A. Painless bright red bleeding

A. Placenta previa, fibrinogen

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This document and the information thereon is the property of