100 item Comprehensive Exam with Answers and

Rationale
1. The nurse enters the room as a 3 year-old is having a
generalized seizure. Which intervention should the nurse do
first?
A) Clear the area of any hazards
B) lace the child on the side
C) !estrain the child
") #ive the $rescri%ed anticonvulsant
The correct ans&er is B' lace the child on the side
rotecting the air&ay is the to$ $riority in a seizure. (f a child is
actively convulsing) a $atent air&ay and o*ygenation must %e
assured.
+. A client has ,ust returned to the medical-surgical unit
follo&ing a segmental lung resection. After assessing the client)
the first nursing action &ould %e to
A) Administer $ain medication
B) -uction e*cessive tracheo%ronchial secretions
C) Assist client to turn) dee$ %reathe and cought
") .onitor o*ygen saturation
The correct ans&er is B' -uction e*cessive tracheo%ronchial
secretions
-uctioning the co$ious tracheo%ronchial secretions $resent in
$ost-thoracic surgery clients maintains an o$en air&ay &hich is
al&ays the $riority nursing intervention.
3. A nurse from the surgical de$artment is reassigned to the
$ediatric unit. The charge nurse should recognize that the child
at highest ris/ for cardiac arrest and is the least li/ely to %e
assiged to this nurse is &hich child?
A) Congenital cardiac defects
B) An acute fe%rile illness
C) rolonged hy$o*emia
") -evere multi$le trauma
The correct ans&er is C' rolonged hy$o*emia
.ost often) the cause of cardiac arrest in the $ediatric
$o$ulation is $rolonged hy$o*emia. Children usually have %oth
cardiac and res$iratory arrest.
0. Which of the follo&ing &ould %e the %est strategy for the
nurse to use &hen teaching insulin in,ection techni1ues to a
ne&ly diagnosed client &ith dia%etes?
A) #ive &ritten $re and $ost tests
B) As/ 1uestions during $ractice
C) Allo& another dia%etic to assist
") 2%serve a return demonstration
The correct ans&er is "' 2%serve a return demonstration
-ince this is a $sychomotor s/ill) this is the %est &ay to /no& if
the client has learned the $ro$er techni1ue.
3. The nurse is assessing a + year-old client &ith a $ossi%le
diagnosis of congenital heart disease. Which of these is most
li/ely to %e seen &ith this diagnosis?
A) -everal otitis media e$isodes in the last year
B) Weight and height in 14th $ercentile since %irth
C) Ta/es fre1uent rest $eriods &hile $laying
") Changing food $references and disli/es
The correct ans&er is C' Ta/es fre1uent rest $eriods &hile
$laying
Children &ith heart disease tend to have e*ercise intolerance.
The child self-limits activity) &hich is consistent &ith
manifestations of congenital heart disease in children.
5. The nurse is reassigned to &or/ at the oison Control Center
tele$hone hotline. (n &hich of these cases of childhood
$oisoning &ould the nurse suggest that $arents have the child
drin/ orange ,uice?
A) An 16 month-old &ho ate an undetermined amount of
crystal drain cleaner
B) A 10 month-old &ho che&ed + leaves of a $hilodendron
$lant
C) A +4 month-old &ho is found sitting on the %athroom floor
%eside an em$ty %ottle of diaze$am 78alium)
") A 34 month-old &ho has s&allo&ed a mouthful of charcoal
lighter fluid
The correct ans&er is A' An 16 month-old &ho ate an
undetermined amount of crystal drain cleaner. "rain cleaner is
very al/aline. The orange ,uice is acidic and &ill hel$ to
neutralize this su%stance.
9. A +3 year-old single client is in the 33rd &ee/ of her first
$regnancy. -he tells the nurse that she has everything ready
for the %a%y and has made $lans for the first &ee/s together at
home. Which normal emotional reaction does the nurse
recognize?
A) Acce$tance of the $regnancy
B) :ocus on fetal develo$ment
C) Antici$ation of the %irth
") Am%ivalence a%out $regnancy
The correct ans&er is C' Antici$ation of the %irth
"irecting activities to&ard $re$aration for the ne&%orn;;s needs
and $ersonal ad,ustment are indicators of a$$ro$riate
emotional res$onse in the third trimester.
6. <$on e*amining the mouth of a 3 year-old child) the nurse
discovers that the teeth have chal/y &hite-to-yello&ish staining
&ith $itting of the enamel. Which of the follo&ing conditions
&ould most li/ely e*$lain these findings?
A) (ngestion of tetracycline
B) =*cessive fluoride inta/e
C) 2ral iron thera$y
") oor dental hygiene
The correct ans&er is B' =*cessive fluoride inta/e
The descri%ed findings are indicative of fluorosis) a condition
characterized %y an increase in the e*tent and degree of the
enamel;;s $orosity. This $ro%lem can %e associated &ith
re$eated s&allo&ing of tooth$aste &ith fluoride or drin/ing
&ater &ith high levels of fluoride.
>. Which of the follo&ing should the nurse teach the client to
avoid &hen ta/ing chlor$romazine ?C@ 7Thorazine)?
A) "irect sunlight
B) :oods containing tyramine
C) :oods fermented &ith yeast
") Canned citrus fruit drin/s
The correct ans&er is A' Avoid direct sunlight
henothiazine increases sensitivity to the sun) ma/ing clients
es$ecially susce$ti%le to sun%urn.
14. The nurse is discussing dietary inta/e &ith an adolescent
&ho has acne. The most a$$ro$riate statement for the nurse is
A) A=at a %alanced diet for your age.A
B) A(ncrease your inta/e of $rotein and 8itamin A.A
C) A"ecrease fatty foods from your diet.A
") A"o not use caffeine in any form) including chocolate.A
The correct ans&er is A' A=at a %alanced diet for your age.A
A diet for a teenager &ith acne should %e a &ell %alanced diet
for their age. There are no recommended additions and
su%tractions from the diet.
11. The nurse is caring for a child &ho has ,ust returned from
surgery follo&ing a tonsillectomy and adenoidectomy. Which
action %y the nurse is a$$ro$riate?
A) 2ffer ice cream every + hours
B) lace the child in a su$ine $osition
C) Allo& the child to drin/ through a stra&
") 2%serve s&allo&ing $atterns
The correct ans&er is "' 2%serve s&allo&ing $atterns
1
The nurse should o%serve for increased s&allo&ing fre1uency to
chec/ for hemorrhage.
1+. The nurse is caring for a client &ith acute $ancreatitis. After
$ain management) &hich intervention should %e included in the
$lan of care?
A) Cough and dee$ %reathe every + hours
B) lace the client in contact isolation
C) rovide a diet high in $rotein
") (nstitute seizure $recautions
The correct ans&er is A' Cough and dee$ %reathe every + hours
!es$iratory infections are common %ecause of fluid in the retro
$eritoneum $ushing u$ against the dia$hragm causing shallo&
res$irations. =ncouraging the client to cough and dee$ %reathe
every + hours &ill diminish the occurrence of this com$lication.
13. The nurse is caring for a client &ith trigeminal neuralgia 7tic
douloureau*). To assist the client &ith nutrition needs) the
nurse should
A) 2ffer small meals of high calorie soft food
B) Assist the client to sit in a chair for meals
C) rovide additional servings of fruits and ra& vegeta%les
") =ncourage the client to eat fish) liver and chic/en
The correct ans&er is A' 2ffer small meals of high calorie soft
food
(f the client is losing &eight %ecause of $oor a$$etite due to the
$ain) assist in selecting foods that are high in calories and
nutrients) to $rovide more nourishment &ith less che&ing.
-uggest that fre1uent) small meals %e eaten instead of three
large ones. To minimize ,a& movements &hen eating) suggest
that foods %e $ureed.
10. A client treated for de$ression tells the nurse at the mental
health clinic that he recently $urchased a handgun %ecause he
is thin/ing a%out suicide. The first nursing action should %e to
A) Botify the health care $rovider immediately
B) -uggest in-$atient $sychiatric care
C) !es$ect the client;s confidential disclosure
") hone the family to &arn them of the ris/
The correct ans&er is A' Botify the health care $rovider
immediately
The health care $rovider must %e contacted immediately as the
client is a danger to self and others. ?os$italization is indicated.
13. The initial res$onse %y the nurse to a delusional client &ho
refuses to eat %ecause of a %elief that the food is $oisoned is
A) ACou thin/ that someone &ants to $oison you?A
B) AWhy do you thin/ the food is $oisoned?A
C) AThese feelings are a sym$tom of your illness.A
") ACouDre safe here. ( &onDt let anyone $oison you.A
The correct ans&er is A' ACou thin/ that someone &ants to
$oison you?A
This res$onse ac/no&ledges $erce$tion through a reflective
1uestion &hich $resents o$$ortunity for discussion) clarification
of meaning) and e*$ressing dou%t.
15. A client has ,ust %een admitted &ith $ortal hy$ertension.
Which nursing diagnosis &ould %e a $riority in $lanning care?
A) Altered nutrition' less than %ody re1uirements
B) otential com$lication hemorrhage
C) (neffective individual co$ing
") :luid volume e*cess
The correct ans&er is B' otential com$lication hemorrhage
=so$hageal varices are dilated and tortuous vessels of the
eso$hagus that are at high ris/ for ru$ture if $ortal circulation
$ressures rise.
19. The nurse in a &ell-child clinic e*amines many children on a
daily %asis. Which of the follo&ing toddlers re1uires further
follo& u$?
A) A 13 month-old una%le to &al/
B) A +4 month-old only using + and 3 &ord sentences
C) A +0 month-old &ho cries during e*amination
") A 34 month-old only drin/ing from a si$$y cu$
The correct ans&er is "' A 34 month-old only drin/ing from a
si$$y cu$
A 34 month-old should %e a%le to drin/ from a cu$ &ithout a
cover.
16. Which of the follo&ing conditions assessed %y the nurse
&ould contraindicate the use of %enztro$ine 7Cogentin)?
A) Beuromalignant syndrome
B) Acute e*tra$yramidal syndrome
C) #laucoma) $rostatic hy$ertro$hy
") ar/inson;s disease) aty$ical tremors
The correct ans&er is C' #laucoma) $rostatic hy$ertro$hy
#laucoma and $rostatic hy$ertro$hy are contraindications to
the use of %enztro$ine 7Cogentin) as the drug is an
anticholinergic agent.
1>. A 13 year-old client &ith a lengthy confining illness is at ris/
for altered gro&th and develo$ment of &hich tas/?
A) @oss of control
B) (nsecurity
C) "e$endence
") @ac/ of trust
The correct ans&er is C' "e$endence
The client role fosters de$endency. Adolescents may react to
de$endency &ith re,ection) uncoo$erativeness) or &ithdra&al.
+4. The nurse is caring for a client &ith cirrhosis of the liver
&ith ascites. When instructing nursing assistants in the care of
the client) the nurse should em$hasize that
A) The client should remain on %ed rest in a semi-:o&ler;s
$osition
B) The client should alternate am%ulation &ith %ed rest &ith
legs elevated
C) The client may am%ulate and sit in chair as tolerated
") The client may am%ulate as tolerated and remain in semi-
:o&lers $osition in %ed
The correct ans&er is B' The client should alternate am%ulation
&ith %ed rest &ith legs elevated. =ncourage alternating $eriods
am%ulation and %ed rest &ith legs elevated to mo%ilize edema
and ascites. =ncourage and assist the client &ith gradually
increasing $eriods of am%ulation.
+1. (n $roviding care to a 10 year-old adolescent &ith scoliosis)
&hich of the follo&ing &ill %e most difficult for this client?
A) Com$liance &ith treatment regimens
B) @oo/ing different from their $eers
C) @ac/ing inde$endence in activities
") !eliance on family for their social su$$ort
The correct ans&er is B' @oo/ing different from their $eers
Conformity to $eer influences $ea/s at around age 10. -ince
many $ersons vie& any disa%ility as deviant) the client &ill need
hel$ in learning ho& to deal &ith reactions of others. Treatment
of scoliosis is long-term and involves %racing andEor surgery.
++. The nurse is $re$aring to $erform a $hysical e*amination
on an 6 month-old &ho is sitting contentedly on his mother;s
la$. Which of the follo&ing should the nurse do first?
A) =licit refle*es
B) .easure height and &eight
C) Auscultate heart and lungs
") =*amine the ears
The correct ans&er is C' Auscultate heart and lungs
The nurse should auscultate the heart and lungs during the first
1uiet moment &ith the infant so as to %e a%le to hear sounds
clearly. 2ther assessments may follo& in any order.
2
+3. Which of these $rinci$les should the nurse a$$ly &hen
$erforming a nutritional assessment on a + year-old client?
A) An accurate measurement of inta/e is not relia%le
B) The food $yramid is not used in this age grou$
C) A serving size at this age is a%out + ta%les$oons
") Total inta/e varies greatly each day
The correct ans&er is C' A serving size at this age is a%out +
ta%les$oons
(n children) a general guide to serving sizes is 1 ta%les$oon of
solid food $er year of age. <nderstanding this) the nurse can
assess ade1uacy of inta/e.
+0. The nurse is assessing a client &ith delayed &ound healing.
Which of the follo&ing ris/ factors is most im$ortant in this
situation?
A) #lucose level of 1+4
B) ?istory of myocardial infarction
C) @ong term steroid usage
") "iet high in car%ohydrates
The correct ans&er is C' @ong term steroid usage
-teroid de$endency tends to delay &ound healing. (f the client
also smo/es) the ris/ is increased.
+3. Which of the follo&ing nursing assessments indicate
immediate discontinuance of an anti$sychotic medication?
A) (nvoluntary rhythmic stereoty$ic movements and tongue
$rotrusion
B) Chee/ $uffing) involuntary movements of e*tremities and
trun/
C) Agitation) constant state of motion
") ?y$er$yre*ia) severe muscle rigidity) malignant
hy$ertension
The correct ans&er is "' ?y$er$yre*ia) severe muscle rigidity)
malignant hy$ertension) hy$er$yre*ia) sever muscle rigidity)
and malignant hy$ertension are assessment signs indicative of
B.- 7neurole$tic malignant syndrome).
+5. A client &ith ?(8 infection has a secondary her$es sim$le*
ty$e 1 7?-8-1) infection. The nurse /no&s that the most li/ely
cause of the ?-8-1 infection in this client is
A) (mmunosu$$ression
B) =motional stress
C) <n$rotected se*ual activities
") Contact &ith saliva
The correct ans&er is A' (mmunosu$$ression
The decreased immunity leads to fre1uent secondary infections.
?er$es sim$le* virus ty$e 1 is an o$$ortunistic infection. The
other o$tions may result in ?-8-1. ?o&ever they are not the
most li/ely cause in clients &ith ?(8.
+9. The nurse measures the head and chest circumferences of
a +4 month-old infant. After com$aring the measurements) the
nurse finds that they are a$$ro*imately the same. What action
should the nurse ta/e?
A) Botify the health care $rovider
B) al$ate the anterior fontanel
C) :eel the $osterior fontanel
") !ecord these normal findings
The correct ans&er is "' !ecord these normal findings
The 1uestion is ". The rate of increase in head circumference
slo&s %y the end of infancy) and the head circumference is
usually e1ual to chest circumference at 1 to + years of age.
+6. At a routine clinic visit) $arents e*$ress concern that their 0
year-old is &etting the %ed several times a month. What is the
nurse;s %est res$onse?
A) AThis is normal at this time of day.A
B) A?o& long has this %een occurring?A
C) A"o you offer fluids at night?A
") A?ave you tried &a/ing her to urinate?A
The correct ans&er is B' A?o& long has this %een occurring?A
Bighttime control should %e $resent %y this age) %ut may not
occur until age 3. (nvoluntary voiding may occur due to
infectious) anatomical andEor $hysiological reasons.
+>. A client &as admitted to the $sychiatric unit after refusing
to get out of %ed. (n the hos$ital the client tal/s to unseen
$eo$le and voids on the floor. The nurse could %est handle the
$ro%lem of voiding on the floor %y
A) !e1uiring the client to mo$ the floor
B) !estricting the clientDs fluids throughout the day
C) Withholding $rivileges each time the voiding occurs
") Toileting the client more fre1uently &ith su$ervision
The correct ans&er is "' Toileting the client more fre1uently
&ith su$ervision
With altered thought $rocesses the most a$$ro$riate nursing
a$$roach to alter the %ehavior is %y attending to the $hysical
need.
34. The nurse is caring for a client &ith a sigmoid colostomy
&ho re1uests assistance in removing the flatus from a 1 $iece
draina%le ostomy $ouch. Which is the correct intervention?
A) iercing the $lastic of the ostomy $ouch &ith a $in to vent
the flatus
B) 2$ening the %ottom of the $ouch) allo&ing the flatus to %e
e*$elled
C) ulling the adhesive seal around the ostomy $ouch to allo&
the flatus to esca$e
") Assisting the client to am%ulate to reduce the flatus in the
$ouch
The correct ans&er is B' 2$ening the %ottom of the $ouch)
allo&ing the flatus to %e e*$elled. The only correct &ay to vent
the flatus from a 1 $iece draina%le ostomy $ouch is to instruct
the client to o%tain $rivacy 7the release of the flatus &ill cause
odor)) and to o$en the %ottom of the $ouch) release the flatus
and dose the %ottom of the $ouch.
31. The nurse is teaching $arents of an infant a%out
introduction of solid food to their %a%y. What is the first food
they can add to the diet?
A) 8egeta%les
B) Cereal
C) :ruit
") .eats
The correct ans&er is B' Cereal
Cereal is usually introduced first %ecause it is &ell tolerated)
easy to digest) and contains iron.
3+. When counseling $arents of a child &ho has recently %een
diagnosed &ith hemo$hilia) &hat must the nurse /no& a%out
the offs$ring of a normal father and a carrier mother?
A) (t is li/ely that all sons are affected
B) There is a 34F $ro%a%ility that sons &ill have the disease
C) =very daughter is li/ely to %e a carrier
") There is a +3F chance a daughter &ill %e a carrier
The correct ans&er is "' There is a +3F chance a daughter &ill
%e a carrier
?emo$hilia A is a se*-lin/ed recessive trait seen almost
e*clusively in males. With a normal father and carrier mother)
affected individuals are male. There is a +3F chance of having
an affected male) +3F chance of having a carrier female) +3F
chance of having a normal female and +3F chance of having a
normal male.
33. When teaching a client &ith chronic o%structive $ulmonary
disease a%out o*ygen %y cannula) the nurse should also instruct
the client;s family to
A) Avoid smo/ing near the client
B) Turn off o*ygen during meals
3
C) Ad,ust the liter flo& to 14 as needed
") !emind the client to /ee$ mouth closed
The correct ans&er is A' Avoid smo/ing near the client
-ince o*ygen su$$orts com%ustion) there is a ris/ of fire if
anyone smo/es near the o*ygen e1ui$ment.
30. The nurse is caring for a $ost-o$ colostomy client. The
client %egins to cry saying) A(;ll never %e attractive again &ith
this ugly red thing.A What should %e the first action %y the
nurse?
A) Arrange a consultation &ith a se* thera$ist
B) -uggest se*ual $ositions that hide the colostomy
C) (nvite the $artner to $artici$ate in colostomy care
") "etermine the client;s understanding of her colostomy
The correct ans&er is "' "etermine the client;;s understanding
of her colostomy. 2ne of the greatest fears of colostomy clients
is the fear that se*ual intimacy is no longer $ossi%le. ?o&ever)
the s$ecific concern of the client needs to %e assessed %efore
s$ecific suggestions for dealing &ith the se*ual concerns are
given.
33. A schizo$hrenic client tal/s animatedly %ut the staff are
una%le to understand &hat the client is communicating. The
client is o%served mum%ling to herself and s$ea/ing to the
radio. A desira%le outcome for this clientDs care &ill %e
A) =*$resses feelings a$$ro$riately through ver%al interactions
B) Accurately inter$rets events and %ehaviors of others
C) "emonstrates im$roved social relationshi$s
") =ngages in meaningful and understanda%le ver%al
communication
The correct ans&er is "' =ngages in meaningful and
understanda%le ver%al communication. "ata su$$ort im$aired
ver%al communication deficit. The outcome must %e related to
the diagnosis and su$$orting data. Bo data is $resented related
to feelings or to thin/ing $rocesses.
35. A 9 year-old child is hos$italized follo&ing a ma,or %urn to
the lo&er e*tremities. A diet high in $rotein and car%ohydrates
is recommended. The nurse informs the child and family that
the most im$ortant reason for this diet is to
A) romote healing and strengthen the immune system
B) rovide a &ell %alanced nutritional inta/e
C) -timulate increased $eristalsis a%sor$tion
") -$are $rotein cata%olism to meet meta%olic needs
The correct ans&er is "' -$are $rotein cata%olism to meet
meta%olic needs
Because of the %urn in,ury) the child has increased meta%olism
and cata%olism. By $roviding a high car%ohydrate diet) the
%rea/do&n of $rotein for energy is avoided. roteins are then
used to restore tissue.
39. The $arents of a 9 year-old tell the nurse their child has
started to AtattleA on si%lings. (n inter$reting this ne& %ehavior)
ho& should the nurse e*$lain the child;s actions to the $arents?
A) The ethical sense and feelings of ,ustice are develo$ing
B) Attem$ts to control the family use ne& co$ing styles
C) (nsecurity and attention getting are common motives
") Com$le* thought $rocesses hel$ to resolve conflicts
The correct ans&er is A' The ethical sense and feelings of
,ustice are develo$ing. The child is develo$ing a sense of ,ustice
and a desire to do &hat is right. At seven) the child is
increasingly a&are of family roles and res$onsi%ilities. They also
do &hat is right %ecause of $arental direction or to avoid
$unishment.
36. A school nurse is advising a class of un&ed $regnant high
school students. What is the most im$ortant action they can
$erform to deliver a healthy child?
A) .aintain good nutrition
B) -tay in school
C) Gee$ in contact &ith the child;s father
") #et ade1uate slee$
The correct ans&er is A' .aintaining good nutrition
Burses can serve a $ivotal role in $roviding nutritional
education and case management interventions. Weight gain
during $regnancy is one of the strongest $redictors of infant
%irth &eight. -$ecifically) teens need to increase their inta/e of
$rotein) vitamins) and minerals including iron. regnant teens
&ho gain %et&een +5 and 33 $ounds have the lo&est incidence
of lo&-%irth-&eight %a%ies.
3>. A client continually re$eats $hrases that others have ,ust
said. The nurse recognizes this %ehavior as
A) Autistic
B) =co$ra*ic
C) =cholalic
") Catatonic
The correct ans&er is C' =cholalic
=cholalic - re$eating &ords heard.
04. A client is admitted for hemodialysis. Which a%normal la%
value &ould the nurse antici$ate not %eing im$roved %y
hemodialysis?
A) @o& hemoglo%in
B) ?y$ernatremia
C) ?igh serum creatinine
") ?y$er/alemia
The correct ans&er is A' @o& hemoglo%in
Although hemodialysis im$roves or corrects electrolyte
im%alances it has not effect on im$roving anemia.
01. The nurse is caring for a 9 year-old child &ho is %eing
discharged follo&ing a tonsillectomy. Which of the follo&ing
instructions is a$$ro$riate for the nurse to teach the $arents?
A) !e$ort a $ersistent cough to the health care $rovider
B) The child can return to school in 0 days
C) Administer che&a%le as$irin for $ain
") The child may gargle &ith saline as necessary for discomfort
The correct ans&er is A' !e$ort a $ersistent cough to the health
care $rovider. ersistent coughing should %e re$orted to the
health care $rovider as this may indicate %leeding.
0+. The nurse is caring for a 10 month-old ,ust diagnosed &ith
Cystic :i%rosis. The $arents state this is the first child in either
family &ith this disease) and as/ a%out the ris/ to future
children. What is the %est res$onse %y the nurse?
A) 1in 0 chance for each child to carry that trait
B) 1in 0 ris/ for each child to have the disease
C) 1in + chance of avoiding the trait and disease
") 1in + chance that each child &ill have the disease
The correct ans&er is B' 1 in 0 ris/ for each child to have the
disease
Cystic :i%rosis is an autosomal recessive transmission $attern.
(n this situation) %oth $arents must %e carriers of the trait for
the disease since neither one of them has the disease.
Therefore) for each $regnancy) there is a +3F chance of the
child having the disease) 34F chance of carrying the trait and a
+3F chance of having neither the trait or the disease.
03. The nurse is $erforming an assessment on a client &ith
$neumococcal $neumonia. Which finding &ould the nurse
antici$ate?
A) Bronchial %reath sounds in outer lung fields
B) "ecreased tactile fremitus
C) ?ac/ing) non$roductive cough
") ?y$erresonance of areas of consolidation
The correct ans&er is A' Bronchial %reath sounds in outer lung
fields
4
neumonia causes a mar/ed increase in interstitial and alveolar
fluid. Consolidated lung tissue transmits %ronchial %reath
sounds to outer lung fields.
00. "uring seizure activity &hich o%servation is the $riority to
enhance further direction of treatment?
A) 2%serve the se1uence or ty$es of movement
B) Bote the time from %eginning to end
C) (dentify the $attern of %reathing
") "etermine if loss of %o&el or %ladder control occurs
The correct ans&er is A' rotect the client from in,ury
(t is a $riority to note) and then record) &hat movements are
seen during a seizure %ecause the diagnosis and su%se1uent
treatment often rests solely on the seizure descri$tion.
03. Which of the follo&ing statements descri%es &hat the nurse
must /no& in order to $rovide antici$atory guidance to $arents
of a toddler a%out readiness for toilet training?
A) The child learns voluntary s$hincter control through
re$etition
B) .yelination of the s$inal cord is com$leted %y this age
C) Beuronal im$ulses are interru$ted at the %ase of the ganglia
") The toddler can understand cause and effect
The correct ans&er is B' .yelination of the s$inal cord is
com$leted %y this age. 8oluntary control of the s$hincter
muscles can %e gradually achieved due to the com$lete
myelination of the s$inal cord) sometime %et&een the ages of
16 to +0 months of age.
05. A client com$laining of severe shortness of %reath is
diagnosed &ith congestive heart failure. The nurse o%serves a
falling $ulse o*imetry. The client;s color changes to gray and
she e*$ectorates large amounts of $in/ frothy s$utum. The first
action of the nurse &ould %e &hich of the follo&ing?
A) Call the health care $rovider
B) Chec/ vital signs
C) osition in high :o&ler;s
") Administer o*ygen
The correct ans&er is "' Administer o*ygen
When dealing &ith a medical emergency) the rule is air&ay first)
then %reathing) and then circulation. -tarting o*ygen is a
$riority.
09. The nurse is caring for a client &ith %enign $rostatic
hy$ertro$hy. Which of the follo&ing assessments &ould the
nurse antici$ate finding?
A) @arge volume of urinary out$ut &ith each voiding
B) (nvoluntary voiding &ith coughing and sneezing
C) :re1uent urination
") <rine is dar/ and concentrated
The correct ans&er is C' :re1uent urination
Clients &ith Benign rostatic ?y$ertro$hy have overflo&
incontinence &ith fre1uent urination in small amounts day and
night.
06. An an*ious $arent of a 0 year-old consults the nurse for
guidance in ho& to ans&er the child;s 1uestion) AWhere do
%a%ies come from?A What is the nurse;s %est res$onse to the
$arent?
A) AWhen a child as/s a 1uestion) give a sim$le ans&er.A
B) AChildren as/ many 1uestions) %ut are not loo/ing for
ans&ers.A
C) AThis 1uestion indicates interest in se* %eyond this age.A
") A:ull and detailed ans&ers should %e given to all 1uestions.A
The correct ans&er is A' AWhen a child as/s a 1uestion) give a
sim$le ans&er.A "uring discussions related to se*uality) honesty
is very im$ortant. ?o&ever) honesty does not mean im$arting
every fact of life associated &ith the 1uestion. When children
as/ 1 1uestion) they are loo/ing for 1 ans&er. When they are
ready) they &ill as/ a%out the other $ieces.
0>. A 3 year-old child is treated in the emergency de$artment
after ingestion of 1ounce of a li1uid narcotic. What action
should the nurse do first?
A) rovide the ordered humidified o*ygen via mas/
B) -uction the mouth and the nose
C) Chec/ the mouth and radial $ulse
") -tart the ordered intravenous fluids
The correct ans&er is C' Chec/ the mouth and radial $ulse
The first ste$ in treatment of a to*ic e*$osure or ingestion is to
assess the air&ay) %reathing and circulationH then sta%ilize the
client. The other nursing actions &ill follo&.
34. The charge nurse on the eating disorder unit instructs a
ne& staff mem%er to &eigh each client in his or her hos$ital
go&n only. What is the rationale for this nursing intervention?
A) To reduce the ris/ of the client feeling cold due to decreased
fat and su%cutaneous tissue
B) To cover the %ony $rominence and areas &here there is s/in
%rea/do&n
C) -o the client /no&s &hat ty$e of clothing to &ear &hen
&eighed
") To reduce the tendency of the client to hide o%,ects under
his or her clothing
The correct ans&er is "' To reduce the tendency of the client to
hide o%,ects under his or her clothing. The client may conceal
&eights on their %ody to increase &eight gain.
31. (n teaching $arents to associate $revention &ith the
lifestyle of their child &ith sic/le cell disease) the nurse should
em$hasize that a $riority for their child is to
A) Avoid overheating during $hysical activities
B) .aintain normal activity &ith some restrictions
C) Be cautious of others &ith viruses or tem$eratures
") .aintain routine immunizations
The correct ans&er is A' Avoid overheating
:luid loss caused %y overheating and dehydration can trigger a
crisis.
3+. The nurse understands that during the Atension %uildingA
$hase of a violent relationshi$) &hen the %atterer ma/es
unreasona%le demands) the %attered victim may e*$erience
feelings of
A) Anger
B) ?el$lessness
C) Calm
") =*$losive
The correct ans&er is B' ?el$lessness
The %attered individual internalizes a$$ro$riate anger at the
%attererDs unfairness and instead feels de$ressed &ith a sense
of hel$lessness) &hen the $artner e*$lodes in s$ite of %est
efforts to $lease the %atterer.
33. A $arent has numerous 1uestions regarding normal gro&th
and develo$ment of a 14 month-old infant. Which of the
follo&ing $arameters is of most concern to the nurse?
A) 34F increase in %irth &eight
B) ?ead circumference greater than chest
C) Crying &hen the $arents leave
") A%le to stand u$ %riefly in $lay $en
The correct ans&er is A' 34F increase in %irth &eight
Birth &eight should %e dou%led at 5 months of age) tri$led at 1
year) and 1uadru$led %y 16 months.
30. The nurse has %een assigned to these clients in the
emergency room. Which client &ould the nurse go chec/ first?
A) 8iral $neumonia &ith atelectasis
B) -$ontaneous $neumothora* &ith a res$iratory rate of 36
C) Tension $neumothora* &ith slight tracheal deviation to the
right
5
") Acute asthma &ith e$isodes of %ronchos$asm
The correct ans&er is C' Tension $neumothora* &ith slight
tracheal deviation to the right. Tracheal deviation indicates a
significant volume of air %eing tra$$ed in the chest cavity &ith a
mediastinal shift. (n tension $neumothora* the tracheal
deviation is a&ay from the affected side. The affected side is
the side &here the air lea/ is in the lung. This situation also
results in sudden air hunger) agitation) hy$otension) $ain in the
affected side) and cyanosis &ith a high ris/ of cardiac
tam$onade and cardiac arrest.
33. The nurse is assessing a 0 year-old for $ossi%le
develo$mental dys$lasia of the right hi$. Which finding &ould
the nurse e*$ect?
A) elvic ti$ do&n&ard
B) !ight leg lengthening
C) 2rtolani sign
") Characteristic lim$
The correct ans&er is "' Characteristic lim$
"evelo$mental dys$lasia $roduces a characteristic lim$ in
children &ho are &al/ing.
35. A + year-old child has recently %een diagnosed &ith cystic
fi%rosis. The nurse is teaching the $arents a%out home care for
the child. Which of the follo&ing information is a$$ro$riate for
the nurse to include?
A) Allo& the child to continue normal activities
B) -chedule fre1uent rest $eriods
C) @imit e*$osure to other children
") !estrict activities to inside the house
The correct ans&er is A' Allo& the child to continue their
normal activities hysical activity is im$ortant in a t&o year-old
&ho is develo$ing autonomy. hysical activity is a valua%le
ad,unct to chest $hysical thera$y. =*ercise tends to stimulate
mucous secretion and hel$ develo$ normal %reathing $atterns.
39. The nurses on a unit are $lanning for stoma care for clients
&ho have a stoma for fecal diversion. Which stomal diversion
$oses the highest ris/ for s/in %rea/do&n
A) (leostomy
B) Transverse colostomy
C) (leal conduit
") -igmoid colostomy
The correct ans&er is A' (leostomy
(leostomy out$ut contains gastric and enzymatic agents that
&hen $resent on s/in can denuded s/in in several hours.
Because of the caustic nature of this stoma out$ut ade1uate
$eristomal s/in $rotection must %e delivered to $revent s/in
%rea/do&n.
36. A client is unconscious follo&ing a tonic-clonic seizure. What
should the nurse do first?
A) Chec/ the $ulse
B) Administer 8alium
C) lace the client in a side-lying $osition
") lace a tongue %lade in the mouth
The correct ans&er is C' lace the client in a side-lying $osition
lace the client in a side-lying $osition to maintain an o$en
air&ay) drain secretions) and $revent as$iration if vomiting
occurs.
3>. The nurse is teaching a client &ho has a hi$ $rostheses
follo&ing total hi$ re$lacement. Which of the follo&ing should
%e included in the instructions for home care?
A) Avoid clim%ing stairs for 3 months
B) Am%ulate using crutches only
C) -lee$ only on your %ac/
") "o not cross legs
The correct ans&er is "' "o not cross legs
?i$ fle*ion should not e*ceed 54 degrees.
54. A nurse &ho travels &ith an agency is uncertain a%out &hat
tas/s can %e $erformed &hen &or/ing in a different state. (t
&ould %e %est for the nurse to chec/ &hich resource?
A) The state nurse $ractice act in &hich the assignment is made
B) With a nurse colleague &ho has &or/ed in that state + years
ago
") The Bursing -ocial olicy -tatement &ithin the <nited -tates
C) The $olicies and $rocedures of the assigned agency in that
state
The correct ans&er is A' The state nurse $ractice act in &hich
the assignment is made. The state nurse $ractice act is the
governing document of &hat can %e done in the assigned state.
51. arents of a 9 year-old child call the clinic nurse %ecause
their daughter &as sent home from school %ecause of a rash.
The child had %een seen the day %efore %y the health care
$rovider and diagnosed &ith :ifth "isease 7erythema
infectiosum). What is the most a$$ro$riate action %y the nurse?
A) Tell the $arents to %ring the child to the clinic for further
evaluation
B) !efer the school officials to $rinted materials a%out this viral
illness
C) (nform the teacher that the child is receiving anti%iotics for
the rash
") =*$lain that this rash is not contagious and does not re1uire
isolation
The correct ans&er is "' =*$lain that this rash is not contagious
and does not re1uire isolation. :ifth "isease is a viral illness
&ith an uncertain $eriod of communica%ility 7$erha$s 1 &ee/
$rior to and 1 &ee/ after onset). (solation of the child &ith :ifth
"isease is not necessary e*ce$t in cases of hos$italized children
&ho are immunosu$$ressed or having a$lastic crises. The
$arents may need &ritten confirmation of this from the health
care $rovider.
5+. What $rinci$le of ?(8 disease should the nurse /ee$ in
mind &hen $lanning care for a ne&%orn &ho &as infected in
utero?
A) The disease &ill incu%ate longer and $rogress more slo&ly in
this infant
B) The infant is very susce$ti%le to infections
C) #ro&th and develo$ment $atterns &ill $roceed at a normal
rate
") Careful monitoring of renal function is indicated
The correct ans&er is B' The infant is very susce$ti%le to
infections
?(8 infected children are susce$ti%le to o$$ortunistic infections
due to a com$romised immune system.
53. While teaching a client a%out their medications) the client
as/s ho& long it &ill ta/e %efore the effects of lithium ta/e
$lace. What is the %est res$onse of the nurse?
A) (mmediately
B) -everal days
C) + &ee/s
") 1 month
The correct ans&er is C' + &ee/s
@ithium is started immediately to treat %i$olar disorder %ecause
it is 1uite effective in controlling mania. @ithium ta/es
a$$ro*imately + &ee/s to effect change in a clientDs sym$toms.
50. The nurse is caring for a 1+ year-old &ith an acute illness.
Which of the follo&ing indicates the nurse understands common
si%ling reactions to hos$italization?
A) Counger si%lings ada$t very &ell
B) 8isitation is hel$ful for %oth
C) The si%lings may en,oy $rivacy
") Those cared for at home co$e %etter
6
The correct ans&er is B' 8isitation is hel$ful for %oth
Contact &ith the ill child hel$s si%lings understand the reasons
for hos$italization and maintains the relationshi$.
53. :ollo&ing a cocaine high) the user commonly e*$eriences
an e*tremely un$leasant feeling called
A) Craving
B) Crashing
C) 2ut&ard %ound
") Bodding out
The correct ans&er is B' Crashing
:ollo&ing cocaine use) the intense $leasure is re$laced %y an
e1ually un$leasant feeling referred to as crashing.
55. 2ne reason that domestic violence remains e*tensively
undetected is
A) :e& %attered victims see/ medical care
B) There is ty$ically a series of minor) vague com$laints
C) =*$enses due to $olice and court costs are $rohi%itive
") 8ery little /no&ledge is currently /no&n a%out %atterers and
%attering relationshi$s
The correct ans&er is B' There is ty$ically a series of minor)
vague com$laints. -igns of a%use may not %e clearly
manifested and a series a minor com$laints such as headache)
a%dominal $ain) insomnia) %ac/ $ain) and dizziness may %e
covert indications of a%use undetected. Com$laints may %e
vague.
59. When ma/ing a home visit to a client &ith chronic
$yelone$hritis) &hich nursing action has the highest $riority?
A) :ollo&-u$ on la% values %efore the visit
B) 2%serve client findings for the effectiveness of anti%iotics
C) As/ for a log of urinary out$ut
") As for the log of the oral inta/e
The correct ans&er is C' As/ for a log of urinary out$ut
The nurse must monitor the urine out$ut as a $riority %ecause
it is the %est indictor of renal function. The other o$tions &ould
%e done after an evaluation of the urine out$ut.
56. When a client is having a general tonic clonic seizure) the
nurse should
A) ?old the client;s arms at their side
B) lace the client on their side
C) (nsert a $added tongue %lade in client;s mouth
") =levate the head of the %ed
The correct ans&er is B' lace the client on their side
This $osition /ee$s the air&ay $atent and $revents as$iration.
5>. The nurse is teaching a client &ith dysrhythmia a%out the
electrical $ath&ay of an im$ulse as it travels through the heart.
Which of these demonstrates the normal $ath&ay?
A) A8 node) -A node) Bundle of ?is) ur/in,e fi%ers
B) ur/in,e fi%ers) -A node) A8 node) Bundle of ?is
C) Bundle of ?is) ur/in,e fi%ers) -A node ) A8 node
") -A node) A8 node) Bundle of ?is) ur/in,e fi%ers
The correct ans&er is "' -A node) A8 node) Bundle of ?is)
ur/in,e fi%ers
The $ath&ay of a normal electrical im$ulse through the heart
is' -A node) A8 node) Bundle of ?is) ur/in,e fi%ers.
94. Clients &ith mitral stenosis &ould li/ely manifest findings
associated &ith congestion in the
A) ulmonary circulation
B) "escending aorta
C) -u$erior vena cava
") Bundle of ?is
The correct ans&er is A' ulmonary circulation
Congestion occurs in the $ulmonary circulation due to the
inefficient em$tying of the left ventricle and the lac/ of a
com$etent valve to $revent %ac/ flo& into the $ulmonary vein.
91. (n assessing the healing of a client;s &ound during a home
visit) &hich of the follo&ing is the %est indicator of good
healing?
A) White $atches
B) #reen drainage
C) !eddened tissue
") =schar develo$ment
The correct ans&er is C' !eddened tissue
As the &ound granulates) redness indicates healing.
9+. The nursing intervention that %est descri%es treatment to
deal &ith the %ehaviors of clients &ith $ersonality disorders
include
A) ointing out inconsistencies in s$eech $atterns to correct
thought disorders
B) Acce$ting client and the client;s %ehavior unconditionally
C) =ncouraging de$endency in order to develo$ ego controls
") Consistent limit-setting enforced +0 hours $er day
The correct ans&er is "' Consistent limit-setting enforced +0
hours $er day
Treatment a$$roaches that include restructuring the
$ersonality) assisting the $erson &ith develo$mental level and
setting limits for malada$tive %ehavior such as acting out.
93. A client has received her first dose of flu$henazine 7roli*in)
+ hours ago. -he suddenly e*$eriences torticollis and
involuntary s$astic muscle movement. (n addition to
administering the ordered anticholinergic drug) &hat other
measure should the nurse im$lement?
A) ?ave res$iratory su$$ort e1ui$ment availa%le
B) (mmediately $lace her in the seclusion room
C) Assess the client for an*iety and agitation
") Administer $rn dose of (. anti$sychotic medication
The correct ans&er is A' ?ave res$iratory su$$ort e1ui$ment
availa%le
ersons receiving neurole$tic medication e*$eriencing torticollis
and involuntary muscle movement are demonstrating side
effects that could lead to res$iratory failure.
90. The nurse as/s a client &ith a history of alcoholism a%out
the clientDs drin/ing %ehavior. The client states A( didnDt hurt
anyone. ( ,ust li/e to have a good time) and drin/ing hel$s me
to rela*.A The client is using &hich defense mechanism?
A) "enial
B) ro,ection
C) (ntellectualization
") !ationalization
The correct ans&er is "' !ationalization
!ationalization is ,ustifying illogical or unreasona%le ideas)
actions) or feelings %y develo$ing acce$ta%le e*$lanations that
satisfies the teller as &ell as the listener.
93. The nurse is teaching a smo/ing cessation class and notices
there are + $regnant &omen in the grou$. Which information is
a $riority for these &omen?
A) @o& tar cigarettes are less harmful during $regnancy
B) There is a relationshi$ %et&een smo/ing and lo& %irth
&eight
C) The $lacenta serves as a %arrier to nicotine
") .oderate smo/ing is effective in &eight control
The correct ans&er is B' There is a relationshi$ %et&een
smo/ing and lo& %irth &eight. Bicotine reduces $lacental %lood
flo&) and may contri%ute to fetal hy$o*ia or $lacenta $revia)
decreasing the gro&th $otential of the fetus.
95. The nurse is caring for a client &ith end stage renal disease.
What action should the nurse ta/e to assess for $atency in a
fistula used for hemodialysis?
7
A) 2%serve for edema $ro*imal to the site
B) (rrigate &ith 3 mls of 4.>F Bormal -aline
C) al$ate for a thrill over the fistula
") Chec/ color and &armth in the e*tremity
The correct ans&er is C' al$ate for a thrill over the fistula
To assess for $atency in a fistula or graft) the nurse auscultates
for a %ruit and $al$ates for a thrill. 2ther o$tions are not
related to evaluation for $atency.
99. Which thera$eutic communication s/ill is most li/ely to
encourage a de$ressed client to vent feelings?
A) "irect confrontation
B) !eality orientation
C) ro,ective identification
") Active listening
The correct ans&er is "' Active listening
<se of thera$eutic communication s/ills such as silence and
active listening encourages ver%alization of feelings.
96. The nurse &al/s into a client;s room and finds the client
lying still and silent on the floor. The nurse should first
A) Assess the client;s air&ay
B) Call for hel$
C) =sta%lish that the client is unres$onsive
") -ee if anyone sa& the client fall
The correct ans&er is C' =sta%lish that the client is
unres$onsive
The first ste$ in C! is to esta%lish unres$onsiveness. -econd is
to call for hel$. Third is o$ening the air&ay.
9>. What is the %est &ay for the nurse to accom$lish a health
history on a 10 year-old client?
A) ?ave the mother $resent to verify information
B) Allo& an o$$ortunity for the teen to e*$ress feelings
C) <se the same ty$e of language as the adolescent
") :ocus the discussion of ris/ factors in the $eer grou$
The correct ans&er is B' Allo& an o$$ortunity for the teen to
e*$ress feelings
Adolescents need to e*$ress their feelings. #enerally) they tal/
freely &hen given an o$$ortunity and some $rivacy to do so.
64. A ne& nurse on the unit notes that the nurse manager
seems to %e highly res$ected %y the nursing staff. The ne&
nurse is sur$rised &hen one of the nurses states' AThe
manager ma/es all decisions and rarely as/s for our in$ut.A The
%est descri$tion of the nurse manager;s management style is
A) artici$ative or democratic
B) <ltrali%eral or communicative
C) Autocratic or authoritarian
") @aissez faire or $ermissive
The correct ans&er is C' Autocratic or authoritarian
Autocratic leadershi$ style is suggested in this situation. (t is
a$$ro$riate for grou$s &ith little education and e*$erience and
&ho need strong direction) &hile $artici$ative or democratic
style is usually more successful on nursing units.
61. A + year-old child is %eing treated &ith Amo*icillin
sus$ension) +44 milligrams $er dose) for acute otitis media. The
child &eighs 34 l%. 713 /g) and the daily dose range is +4-04
mgE/g of %ody &eight) in three divided doses every 6 hours.
<sing $rinci$les of safe drug administration) &hat should the
nurse do ne*t?
A) #ive the medication as ordered
B) Call the health care $rovider to clarify the dose
C) !ecognize that anti%iotics are over-$rescri%ed
") ?old the medication as the dosage is too lo&
The correct ans&er is A' #ive the medication as ordered
Amo*icillin continues to %e the drug of choice in the treatment
of acute otitis media. The dose range is +4-04 mgE/gEday
divided every 6 hours. 13/g * 04mg I 544mg) divided %y 3 I
+44 mg $er dose. The $rescri%ed dose is correct and should %e
given as ordered.
6+. The nurse is $erforming a develo$mental assessment on an
6 month-old. Which finding should %e re$orted to the health
care $rovider?
A) @ifts head from the $rone $osition
B) !olls from a%domen to %ac/
C) !es$onds to $arents; voices
") :alls for&ard &hen sitting
The correct ans&er is "' :alls for&ard &hen sitting
-itting &ithout su$$ort is e*$ected at this age.
63. The nurse is $artici$ating in a community health fair. As
$art of the assessments) the nurse should conduct a mental
status e*amination &hen
A) An individual dis$lays restlessness
B) There are o%vious signs of de$ression
C) Conducting any health assessment
") The resident re$orts memory la$ses
The correct ans&er is C' Conducting any health assessment
A mental status assessment is a critical $art of %aseline
information) and should %e a $art of every e*amination.
60. The nurse caring for a 10 year-old %oy &ith severe
?emo$hilia A) &ho &as admitted after a fall &hile $laying
%as/et%all. (n understanding his %ehavior and in $lanning care
for this client) &hat must the nurse understand a%out
adolescents &ith hemo$hilia?
A) .ust have structured activities
B) 2ften ta/e $art in active s$orts
C) =*$lain limitations to $eer grou$s
") Avoid ris/s after %leeding e$isodes
The correct ans&er is B' 2ften ta/e $art in active s$orts
=sta%lish an age-a$$ro$riate safe environment. Adolescent
hemo$hiliacs should %e a&are that contact s$orts may trigger
%leeding. ?o&ever) develo$mental characteristics of this age
grou$ such as im$ulsivity) ine*$erience and $eer $ressure)
$lace adolescents in unsafe environments.
63. When assessing a client &ho has ,ust undergone a
cardioversion) the nurse finds the res$irations are 1+. Which
action should the nurse ta/e first?
A) Try to vigorously stimulate normal %reathing
B) As/ the !B to assess the vital signs
C) .easure the $ulse o*imetry
") Continue to monitor res$irations
The correct ans&er is "' 0. Continue to monitor res$irations
1+ res$irations $er minute is tolerated $ost-o$eratively. A range
from 6 to 14 gives cause for concern. At that $oint $ulse
o*imetry is ta/en) as that rate could %e tolerated. 8igorous
stimulation is not indicated %eyond dee$ %reathing and
coughing. (t is not necessary to as/ the !B to chec/ findings.
65. (n order to enhance a client;s res$onse to medication for
chest $ain from acute angina) the nurse should em$hasize
A) @earning rela*ation techni1ues
B) @imiting alcohol use
C) =ating smaller meals
") Avoiding $assive smo/e
The correct ans&er is A' @earning rela*ation techni1ues
The only factor that can enhance the client;;s res$onse to $ain
medication for angina is reducing an*iety through rela*ation
methods. An*iety can %e great enough to ma/e the $ain
medication totally ineffective.
69. The $rimary nursing diagnosis for a client &ith congestive
heart failure &ith $ulmonary edema is
A) ain
8
B) (m$aired gas e*change
C) Cardiac out$ut altered' decreased
") :luid volume e*cess
The correct ans&er is C' Cardiac out$ut altered' decreased
All nursing interventions should %e focused on im$roving
cardiac out$ut. (ncreasing cardiac out$ut is the $rimary goal of
thera$y. Comfort &ill im$rove as the client im$roves and the
res$iratory status &ill im$rove as cardiac out$ut increases.
66. After tal/ing &ith her $artner) a client voluntarily admitted
herself to the su%stance a%use unit. After the second day on
the unit the client states to the nurse) A.y hus%and told me to
get treatment or he &ould divorce me. ( donDt %elieve ( really
need treatment %ut ( donDt &ant my hus%and to leave me.A
Which res$onse %y the nurse &ould assist the client?
A) A(n early recovery) it;s 1uite common to have mi*ed feelings)
%ut unmotivated $eo$le canDt get &ell.A
B) A(n early recovery) itDs 1uite common to have mi*ed feelings)
%ut ( didnDt /no& you had %een $ressured to come.A
C) A(n early recovery itDs 1uite common to have mi*ed feelings)
$erha$s it &ould %e %est to see/ treatment on an outclient
%ases.A
") A(n early recovery) itDs 1uite common to have mi*ed feelings.
@etDs discuss the %enefits of so%riety for you.A
The correct ans&er is "' A(n early recovery) itDs 1uite common
to have mi*ed feelings. @etDs discuss the %enefits of so%riety for
you.A This res$onse gives the client the o$$ortunity to decrease
am%ivalent feelings %y focusing on the %enefits of so%riety.
"e$endence issues are great for the client fostering
am%ivalence.
6>. Clients ta/ing &hich of the follo&ing drugs are at ris/ for
de$ression?
A) -teroids
B) "iuretics
C) :olic acid
") As$irin
The correct ans&er is A' -teroids
Adverse medication effects can cause a syndrome that may or
may not remit &hen the medication is discontinued. =*am$les
include' $henothiazines) steroids) and reser$ine.
>4. The nurse is assessing a client on admission to a
community mental health center. The client discloses that she
has %een thin/ing a%out ending her life. The nurse;s %est
res$onse &ould %e
A) A"o you &ant to discuss this &ith your $astor?A
B) AWe &ill hel$ you deal &ith those thoughts.A
C) A(s your life so terri%le that you &ant to end it?A
") A?ave you thought a%out ho& you &ould do it?A
The correct ans&er is "' A?ave you thought a%out ho& you
&ould do it?A
This res$onse $rovides an o$ening to discuss intent and means
of committing suicide.
>1. The nurse is caring for a client + hours after a right lo&er
lo%ectomy. "uring the evaluation of the &ater-seal chest
drainage system) it is noted that the fluid level %u%%les
constantly in the &ater seal cham%er. 2n ins$ection of the chest
dressing and tu%ing) the nurse does not find any air lea/s in the
system. The ne*t %est action for the nurse is to
A) Chec/ for su%cutaneous em$hysema in the u$$er torso
B) !e$osition the client to a $osition of comfort
C) Call the health care $rovider as soon as $ossi%le
") Chec/ for any increase in the amount of thoracic drainage
The correct ans&er is A' Chec/ for su%cutaneous em$hysema in
the u$$er torso. Continuous %u%%ling in the &ater seal cham%er
is an a%normal finding + hours after a lo%ectomy. :urther
assessment of a$$ro$riate factors &as done %y the nurse to
rule out an air lea/ in the sytem. Thus the conclusion is that the
$ro%lem is one of an air lea/ in the lung. This client may need
to %e returned to surgery to deal &ith the sustained air lea/.
Action %y the health care $rovider is re1uired to $revent further
com$lications.
>+. The nurse is caring for a ne&%orn &ho has ,ust %een
diagnosed &ith hy$os$adias. After discussing the defect &ith
the $arents) the nurse should e*$ect that
A) Circumcision can %e $erformed at any time
B) (nitial re$air is delayed until ages 5-6
C) ost-o$erative a$$earance &ill %e normal
") -urgery &ill %e $erformed in stages
The correct ans&er is "' -urgery &ill %e $erformed in stages
?y$os$adias) a condition in &hich the urethral o$ening is
located on the ventral surface or %elo& the $enis) is corrected
in stages as soon as the infant can tolerate surgery.
>3. A client has %een receiving lithium 7@ithane) for the $ast
t&o &ee/s for the treatment of %i$olar illness. When $lanning
client teaching) &hat is most im$ortant to em$hasize to the
client?
A) .aintain a lo& sodium diet
B) Ta/e a diuretic &ith lithium
C) Come in for evaluation of serum lithium levels every 1-3
months
") ?ave %lood lithium levels dra&n during the summer months
The correct ans&er is "' ?ave %lood lithium levels dra&n during
the summer months. Clients ta/ing lithium thera$y need to %e
a&are that hot &eather may cause e*cessive $ers$iration) a
loss of sodium and conse1uently an increase in serum lithium
concentration.
>0. When an autistic client %egins to eat &ith her hands) the
nurse can %est handle the $ro%lem %y
A) lacing the s$oon in the clientDs hand and stating) A<se the
s$oon to eat your food.A
B) Commenting A( %elieve you /no& %etter than to eat &ith
your hand.A
C) Jo/ingly stating) AWell ( guess fingers sometimes &or/ %etter
than s$oons.A
") !emoving the food and stating ACou canDt have anymore
food until you use the s$oon.A
The correct ans&er is A' lacing the s$oon in the clientDs hand
and stating A<se the s$oon to eat your food.A This res$onse
identifies ada$tive %ehavior &ith instruction and ver%al
e*$ectation.
>3. A client develo$s volume overload from an (8 that has
infused too ra$idly. What assessment &ould the nurse e*$ect to
find?
A) -3 heart sound
B) Thready $ulse
C) :lattened nec/ veins
") ?y$oventilation
The correct ans&er is A' Auscultation of an -3 heart sound
Auscultation of an -3 heart sound. This is an early sign of
volume overload 7or C?:) %ecause during the first $hase of
diastole) &hen %lood enters the ventricles) an e*tra sound is
$roduced due to the $resence of fluid left in the ventricles.
>5. A neonate %orn 1+ hours ago to a methadone maintained
&oman is e*hi%iting a hy$eractive .2!2 refle* and slight
tremors. The ne&%orn $assed one loose) &atery stool. Which of
these is a nursing $riority?
A) ?old the infant at fre1uent intervals.
B) Assess for neonatal &ithdra&l syndrome
C) 2ffer fluids to $revent dehydration
") Administer $aregoric to sto$ diarrhea
The correct ans&er is B' Assess for neonatal &ithdra&l
syndrome
9
Beonatal &ithdra&l syndrome is a cluster of findings that signal
the &ithdra&al of the infant from the o$iates. The findings seen
in methadone &ithdra&al are often more severe than for other
su%stances. (nitial signs are central nervous system hy$er
irrita%ility and gastro-intestinal sym$toms. (f &ithdra&al signs
are severe) there is an increased mortality ris/. -coring the
infant ensures $ro$er treatment during the $eriod of
&ithdra&al.
>9. While $lanning care for a $reschool aged child) the nurse
understands develo$mental needs. Which of the follo&ing
&ould %e of the most concern to the nurse?
A) laying imaginatively
B) =*$ressing shame
C) (dentifying &ith family
") =*$loring the $layroom
The correct ans&er is B' =*$ressing shame
=ri/son descri%es the stage of the $reschool child as %eing the
time &hen there is normally an increase in initiative. The child
should have resolved the sense of shame and dou%t in the
toddler stage.
>6. A de$ressed client &ho has recently %een acting suicidal is
no& more social and energetic than usual. -milingly he tells the
nurse A(Dve made some decisions a%out my life.A What should
%e the nurseDs initial res$onse?
A) ACouDve made some decisions.A
B) AAre you thin/ing a%out /illing yourself?A
C) A(Dm so glad to hear that youDve made some decisions.A
") ACou need to discuss your decisions &ith your thera$ist.A
The correct ans&er is B' AAre you thin/ing a%out /illing
yourself?A
-udden mood elevation and energy may signal increased ris/ of
suicide. The nurse must validate suicide ideation as a %eginning
ste$ in evaluating seriousness of ris/.
>>. The nurse is caring for + children &ho have had surgical
re$air of congenital heart defects. :or &hich defect is it a
$riority to assess for findings of heart conduction distur%ance?
A) Artrial se$tal defect
B) atent ductus arteriosus
C) Aortic stenosis
") 8entricular se$tal defect
The correct ans&er is "' 8entricular se$tal defect
While assessments for conduction distur%ance should %e
included follo&ing re$air of any defect) it is a $riority for this
condition. A ventricular se$tal defect is an a%normal o$ening
%et&een the right and left ventricles. The atrioventricular
%undle 7%undle of ?is)) a $art of the electrical conduction
system of the heart) e*tends from the atrioventricular node
along each side of the interventricular se$tum and then divides
into right and left %undle %ranches. -urgical re$air of a
ventricular se$tal defect consists of a $urse-string a$$roach or
a $atch se&n over the o$ening. =ither method involves
mani$ulation of the ventricular se$tum) there%y increasing ris/
of interru$ting the conduction $ath&ay. Conse1uently)
$osto$erative com$lications include conduction distur%ances.
144. The nurse is caring for a $ost myocardial infarction client
in an intensive care unit. (t is noted that urinary out$ut has
dro$$ed from 54 -94 ml $er hour to 34 ml $er hour. This
change is most li/ely due to
A) "ehydration
B) "iminished %lood volume
C) "ecreased cardiac out$ut
") !enal failure
The correct ans&er is C' "ecreased cardiac out$ut
Cardiac out$ut and urinary out$ut are directly correlated. The
nurse should sus$ect a dro$ in cardiac out$ut if the urinary
out$ut dro$s. 60 item PEDIATRIC NURSIN !"estions and Rationale
10
-ituation 1' !a$hael) a 5 yearDs old $re$ $u$il is seen at the
school clinic for gro&th and develo$ment monitoring 7Kuestions
1-3)
1. Which of the follo&ing is characterized the rate of gro&th
during this $eriod?
a. most ra$id $eriod of gro&th
%. a decline in gro&th rate
c. gro&th s$urt
d. slo& uniform gro&th rate
Correct ans&er is letter B. "uring the reschooler stage gro&th
is very minimal. Weight gain is only 0.3l%s 7+/gs) $er year and
?eight is 3.3in 75-6cm) $er year.
!evie&'
.ost ra$id gro&th and develo$ment- (nfancy
-lo& gro&th- Toddler hood and reschooler
-lo&er gro&th- -chool age
!a$id gro&th- Adolescence
+. (n assessing !a$haelDs gro&th and develo$ment) the nurse is
guided %y $rinci$les of gro&th and develo$ment. Which is not
included?
a. All individuals follo& ce$halo-caudal and $ro*imo-distal
%. "ifferent $arts of the %ody gro&s at different rate
c. All individual follo& standard gro&th rate
d. !ate and $attern of gro&th can %e modified
#ro&th and develo$ment occurs in ce$halo-caudal meaning
develo$ment occurs through out the %odyDs a*is. =*am$le' the
child must %e a%le to lift the head %efore he is a%le to lift his
chest. ro*imo-distal is develo$ment that $rogresses from
center of the %ody to the e*tremities. =*am$le' a child first
develo$s arm movement %efore fine-finger movement. "ifferent
$arts of the %ody gro&s at different range %ecause some %ody
tissue mature faster than the other such as the neurologic
tissues $ea/s its gro&th during the first years of life &hile the
genital tissue doesnDt till $u%erty. Also #L" is $redicta%le in the
se1uence &hich a child normally $recedes such as motor s/ills
and %ehavior. @astly #L" can never %e modified M?aller?
7&ede mo %ang turuan mag %asa ang (nfant? 2r $atayuin sya
%ago $a na/a/aga$ang?)
3. What ty$e of $lay &ill %e ideal for !a$hael at this $eriod?
a. .a/e %elieve
%. ?ide and see/
c. ee/-a-%oo
d. Building %loc/s
Correct ans&er is @etter A) ma/e %elieve is most a$$ro$riate
%ecause it enhances the imitative $lay and imagination of the
$reschooler. C and " are for infants &hile letter A is B is
recommended for schoolers %ecause it enhances com$etitive
$lay.
0. Which of the follo&ing information indicate that !a$hael is
normal for his age?
a. "etermine o&n sense self
%. "evelo$ sense of &hether he can trust the &orld
c. ?as the a%ility to try ne& things
d. @earn %asic s/ills &ithin his culture
The correct ans&er is letter CH %ecause =ric/son defines the
develo$mental tas/ of a $reschool $eriod is learning (nitiative
vs. #uilt. Children can initiate motor activities of various sorts
on their o&n and no longer res$onds to or imitate the actions of
other children or of their $arents. @etter A and B is.. for youNN
3. Based on Gohl%ergDs theory) &hat is the stage of moral
develo$ment of !a$hael?
a. unishment-o%edience
%. Mgood %oy-Bice girlO
c. naPve instrumental orientation
d. social contact
Correct ans&er is letter C' According to Gohl%er) a $reschooler
is under re-conventional &here a child learns a%out
instrumental $ur$ose and e*change) that is they &ill something
do for another if that that $erson does something &ith the child
in return. @etter A is a$$lica%le for Toddlers and letter B is for a
-chool age child.
-ituation + Ba%y %oy @acson delivered at 35 &ee/s gestation
&eighs 3)044 gm and height of 3> cm 75-14)
5. Ba%y %oy @acsonDs height is
a. @ong
%. -hort
c. Average
d. Too short
Correct ans&er is @etter A %ecause the normal length of a
ne&%orn is 09.3-33.93 cm 71>.3-+1in) &ith an average of 34cm
7:ili$ino standards $o ito) $ag /ay illiteri nyo tinignan) 33cm
for female and 30cm for male)
9. #ro&th and develo$ment in a child $rogresses in the
follo&ing &ays =QC=T
a. :rom cognitive to $sychose*ual
%. :rom trun/ to the ti$ of the e*tremities
c. :rom head to toe
d. :rom general to s$ecific
#ro&th and develo$ment occurs in ce$halo-caudal 7head to
toe)) $ro*imo-distal 7trun/ to ti$s of the e*tremities and
general to s$ecific) %ut it doesnDt occurs in cognitive to
$sychose*ual %ecause they can develo$ at the same time.
6. As descri%ed %y =ri/son) the ma,or $sychose*ual conflict of
the a%ove situation is
a. Autonomy vs. -hame and dou%t
%. (ndustry vs. (nferiority
c. Trust vs. mistrust
d. (nitiation vs. guilt
According to =ri/son) children 4-16 months are under the
develo$mental tas/ of Trust vs. .istrust.
>. Which of the follo&ing is true a%out .ongolian -$ots?
a. "isa$$ears in a%out a year
%. Are lin/ed to $athologic conditions
c. Are managed %y tro$ical steroids
d. Are indicative of $arental a%use
.ongolian s$ots are stale grey or %luish $atches of discoloration
commonly seen across the sacrum or %uttoc/s due to
accumulation of melanocytes and they disa$$ears in 1 year.
They are not lin/ed to steroid use and $athologic conditions.
14. -igns of cold stress that the nurse must %e alert &hen
caring for a Be&%orn is'
a. ?y$othermia
%. "ecreased activity level
c. -ha/ing
d. (ncreased !!
Correct ans&er is letter ". ?y$othermia is inaccurate cause
normally) tem$erature of a ne&%orn dro$) Also a child under
cold stress &ill /ic/ and cry to increase the meta%olic rate
there%y increasing heat so B isnDt a good choice. A ne&%orn
doesnDt have the a%ility to shiver 7ag i/a& ay nag $a ana/ at
ang %ey%e ay nanga-ngatog) na/u ita$on mo yan..di yan %ey%e
iti/ yan.. hehe). -o letter B and C is &rong. A ne&%orn &ill
increase its !! %ecause the BB &ill need more o*ygen %ecause
of too much activity.
-ituation 3 Bursing care after delivery has an im$ortant as$ect
in every stages of delivery
11. After the %a%y is delivered) the cord &as cut %et&een t&o
clam$s using a sterile scissors and %lade) then the %a%y is
11
$laced at the'
a. .otherDs %reast
%. .otherDs side
c. #ive it to the grandmother
d. Ba%yDs o&n mat or %ed
2f course) $lace it at the motherDs %reast for latch-on. 7Bote'
for B-" %reast feed A-A &hile for C- delivery) %reast feed
after 0 hours) @ol) syem$re d naman $&ede sa grandma d%a?
Gasi naman hindi gatas ang i$a$adede nyan) yogurt na sosyal.
e&&&&. @2@
1+. The %a%yDs mother is !?7-). Which of the follo&ing
la%oratory tests &ill $ro%a%ly %e ordered for the ne&%orn?
a. "irect Coom%Ds
%. (ndirect Coom%Ds
c. Blood culture
d. latelet count
Coom%Ds test is the test to determine if !? anti%odies are
$resent. (ndirect Coom%Ds is done to the mother and "irect
Coom%Ds is the one donDt to the %a%y. Blood culture and latelet
count doesnDt hel$ detect !? anti%odies.
13. ?y$othermia is common in ne&%orn %ecause of their
ina%ility to control heat. The follo&ing &ould %e an a$$ro$riate
nursing intervention to $revent heat loss e*ce$t
a. lace the cri% %eside the &all
%. "oing Gangaroo care
c. By using mechanical $ressure
d. "rying and &ra$$ing the %a%y
lacing the cri% %eside the &all is un-a$$ro$riate %ecause it can
$rovide heat loss %y radiation. "oing Gangaroo care or hugging
the %a%y) mechanical $ressure or incu%ators and drying and
&ra$$ing the %a%y &ill hel$ conserve heat)
10. The follo&ing conditions are caused %y cold stress e*ce$t
a. ?y$oglycemia
%. (ncrease (C
c. .eta%olic acidosis
d. Cere%ral $alsy
?y$oglycemia may occur due to increase meta%olic rate) And
%ecause of ne&%orns are %orn slightly acidic) and they
cata%olize %ro&nfat &hich &ill $roduce /etones &hich is an acid
&ill cause meta%olic acidosis. Also a BB &ith severe
hy$othermia is in high ris/ for /ernicterus 7too much %iliru%in in
the %rain) can lead to Cere%ral $alsy. There is no connection in
the increase of (C &ith hy$othermia.
7B2T=' $athognomonic sign of Gernicterus in adult- astere*is)
or involuntary fla$$ing of the hand.)
13. "uring the feto-$lacental circulation) the shunt %et&een t&o
atria is called
a. "uctus venosous
%. :oramen .agnum
c. "uctus arteriosus
d. :oramen 2vale
:oramen ovale is o$ening %et&een t&o atria) "uctus venosus is
the shunt from liver to the inferior vena cava) and your "uctus
Arteriosus is the shunt from the $ulmonary artery to the aorta.
7hindi /asali sa feto-$lacental circulation ang :oramen .agnum)
sa s/ull unN)
15. What &ould cause the closure of the :oramen ovale after
the %a%y had %een delivered?
a. "ecreased %lood flo&
%. -hifting of $ressures from right side to the left side of the
heart
c. (ncreased 2+
d. (ncreased in o*ygen saturation
"uring feto-$lacental circulation) the $ressure in the heart is
much higher in the right side) %ut once %reathingEcrying is
esta%lished) the $ressure &ill shift from the ! to the @ side) and
&ill facilitate the closure of :oramen 2vale. 7Bote' that is &hy
you should $osition the BB in ! side lying $osition to increase
$ressure in the @ side of the heart.)
!evie&'
(ncrease 2+-R closure of ductus arteriosus
"ecreased %loodflo& -R closure of the ductus venosus
Circulation in the lungs is initiated %y -R lung e*$ansion and
$ulmonary ventilation
What &ill sustain 1st %reath-R decreased artery $ressure
What &ill com$lete circulation-R cutting of the cord
19. :ailure of the :oramen 2vale to close &ill cause &hat
Congenital ?eart "isease?
a. Total anomalous ulmunary Artery
%. Atrial -e$tal defect
c. Trans$osition of great arteries
d. ulmunary -tenosis
:oramen ovale is the o$ening %et&een t&o Atria so) if its &ill
not close Atrial -e$tal defect can occur.
-ituation 0 Children are vulnera%le to some minor health
$ro%lems or in,uries hence the nurse should %e a%le to teach
mothers to give a$$ro$riate home care.
16. A mother %rought her child to the clinic &ith nose %leeding.
The nurse sho&ed the mother the most a$$ro$riate $osition for
the child &hich is'
a. -itting u$
%. With lo& %ac/ rest
c. With moderate %ac/ rest
d. @ying semi flat
The correct $osition is ma/ing the child having an u$right
sitting $osition &ith the head slightly tilted for&ard. This
$osition &ill minimize the amount of %lood $ressure in nasal
vessels and /ee$ %lood moving for&ard not %ac/ into the
naso$haryn*) &hich &ill have the cho/ing sensation and
increase ris/ of as$iration. Choices %) c) d) are ina$$ro$riate
cause they can cause %lood to enter the naso$haryn*.
1>. A common $ro%lem in children is the inflammation of the
middle ear. This is related to the malfunctioning of the'
a. Tym$anic mem%rane
%. =ustachian tu%e
c. Adenoid
d. Baso$haryn*
This is %ecause children has short) horizontal =ustachian tu%es.
The dysfunction in the =ustachian tu%e ena%les %acterial
invasion of the middle ear and o%structs drainage of secretions.
+4. :or acute otitis media) the treatment is $rom$t anti%iotic
thera$y. "elayed treatment may result in com$lications of'
a. Tonsillitis
%. =ardrum ro%lems
c. Brain damage
d. "ia%etes mellitus
2ne of the com$lication of recurring acute otitis media is ris/
for having .eningitis) there%y causing $ossi%le %rain damage.
That is &hy $atient must follo& a com$lete treatment regimen
and follo& u$ care. A and B are not com$lications of A2.) 7lalo
na ung "NN)
+1. When assessing gross motor develo$ment in a 3 year old)
&hich of the follo&ing activities &ould the nurse e*$ect to
finds?
a. !iding a tricycle
%. ?o$$ing on one foot
c. Catching a %all
d. -/i$$ing on alternate foot.
Ans&er is A) riding a tricycle is a$$ro$riate for a 3 yEo child.
12
?o$$ing on one foot can %e done %y a 0 yEo child) as &ell as
catching and thro&ing a %all over hand. -/i$$ing can %e done
%y a 3 yEo.
++. When assessing the &eight of a 3-month old) &hich of the
follo&ing indicates healthy gro&th?
a. "ou%ling of %irth &eight
%. Tri$ling of %irth &eight
c. Kuadru$ling of %irth &eight
d. -ta%ilizing of %irth &eight
"uring the first 5 months of life the &eight from %irth &ill %e
dou%led and as soon as the %a%y reaches 1 year) its %irth
&eight is tri$led.
+3. An a$$ro$riate toy for a 0 year old child is'
a. ush-$ull toys
%. Card games
c. "octor and nurse /its
d. Boo/s and Crafts
@etter C is a$$ro$riate %ecause it &ill enhance the creativity
and imagination of a $re-school child. @etter B and " are
ina$$ro$riate %ecause they are too com$le* for a 0 yEo. ush-
$ull toys are recommended for infants.
+0. Which of the follo&ing statements &ould the nurse e*$ects
a 3-year old %oy to say &hose $et ger%il ,ust died
a. MThe %oogieman 7/amatayan- the man &ith the scythe) got
himO
%. M?eDs ,ust a %it deadO
c. M(ll %e good from no& o&n so ( &ont die li/e my ger%ilO
d. M"id you hear the ,o/e a%outSO
A 3 yEo vie&s death in MdegreesO) so the child most li/ely &ill
say that Mhe is ,ust a %it deadO. ersonification of death li/e
%oogeyman or M/amatayanO occurs in ages 9 to > as &ell as
denying death can if they &ill %e good. "enying death using
,o/es and attri%uting life 1ualities to death occurs during age 3-
3.
+3. When assessing the fluid and electrolyte %alance in an
infant) &hich of the follo&ing &ould %e im$ortant to remem%er?
a. (nfant can concentrate urine at an adult level
%. The meta%olic rate of an infant is slo&er than in adults
c. (nfants have more intracellular &ater that adult do
d. (nfant have greater %ody surface area than adults
(nfants have greater %ody surface area than adult) increasing
their ris/ to :L= im%alances. Also infants cant concentrate a
urine at an adult level and their meta%olic rate) also called
&ater turnover) is + to 3 times higher than adult. lus more
fluids of the infants are at the =C: s$aces not in the (C: s$aces.
+5. When assessing a child &ith as$irin overdose) &hich of the
follo&ing &ill %e e*$ected?
a. .eta%olic al/alosis
%. !es$iratory al/alosis
c. .eta%olic acidosis
d. !es$iratory acidosis
!emem%er that As$irin is acid 7Acetylsalicylic AC(")) so &hat
do you e*$ect? 7ang taray @2@) <B BAN
!evie&'
ag galling sa %i%ig' al/alosis 7hy$er-emesis)
ag galling sa$ &et' acidosis 7diarrhea)
+9. Which of the follo&ing is not a $ossi%le systemic clinical
manifestation of severe %urns?
a. #ro&th retardation
%. ?y$ermeta%olism
c. -e$sis
d. Blisters and edema
The 1uestion &as as/ing for a -C-T=.(C clinical manifestation)
@etters A)B and C are systemic manifestations &hile Blisters
and =dema &erenDt.
+6. When assessing a family for $otential child a%use ris/s) the
nurse &ould o%serve for &hich of the follo&ing?
a. eriodic e*$osure to stress
%. @o& socio-economic status
c. ?igh level of self esteem
d. ro%lematic $regnancies
Ans&er is ") Ty$ical factors that may %e ris/ for Child a%use are
$ro%lematic $regnancies) chronic e*$osure to stress not
$eriodic) lo& level of self esteem not high level. Also child
a%use can ha$$en in all socio-economic status not ,ust on lo&
socio-economic status.
+>. Which of the follo&ing is a $ossi%le indicator of .unchausen
syndrome %y $ro*y ty$e of child a%use?
a. Bruises found at odd locations) &ith different stages of
healing
%. -T"Ds and genital discharges
c. <ne*$lained sym$toms of diarrhea) vomiting and a$nea &ith
no organic %asis
d. Constant hunger and $oor hygiene
.unchausen syndrome %y ro*y is the fa%rication or
inducement of an illness %y one $erson to another $erson)
usually mother to child. (t is characterized %y sym$toms such
as a$nea and siezures) &hich may %e due to suffocation) drugs
or $oisoning) vomiting &hich can %e induced &ith $oisons and
diarrhea &ith the use of la*atives. @etter A can %e seen in a
hysical a%use) @etter B for se*ual a%use and @etter C is for
hysical Beglect.
34. Which of the follo&ing is an ina$$ro$riate intervention &hen
caring for a child &ith ?(8?
a. Teaching family a%out disease transmission
%. 2ffering large amount of fresh fruits and vegeta%les
c. =ncouraging child to $erform at o$timal level
d. Teach $ro$er hand &ashing techni1ue
A child &ith ?(8 is immunocom$romised. :resh fruits and
vegeta%les) &hich may %e contaminated &ith organisms and
$esticides can %e harmful) if not fatal to the child) therefore
these items should %e avoided.
-ituation 3 Agata) + years old is rushed to the =! due to
cyanosis $reci$itated %y crying. ?er mother o%served that after
$laying she gets tired. -he &as diagnosed &ith Tetralogy of
:allot.
31. The goal of nursing care fro Agata is to'
a. revent infection
%. romote normal gro&th and develo$ment
c. "ecrease hy$o*ic s$ells
d. ?ydrate ade1uately
The correct ans&er is letter C. Though letter B &ould %e a good
ans&er too) this goal is too vague and not s$ecific. Bursing
interventions &ill not solely $romote normal #L" unless he &ill
undergo surgical re$air. -o decreasing ?y$o*ic -$ells is more
-.A!T. 7alam nyo na /ung ano yunN -$ecific) measura%le)
attaina%le) realistic and time %ounded). @etter A and " are
ina$$ro$riate.
!=8(=WN !=8(=WN !=8(=WN
Tetralogy of :allot is a cyanotic Congenital ?eart disease. Gaya
sa tina&ag na Tetralogy cause it has 0 anomaliesH
1. 8-"- ventricular se$tal defect
+. ulmunary -tenosis
3. 2ver-riding of the Aorta- the aorta overrides %oth ventricles
0. !ight ventricular hy$ertro$hy
We have 10 congenital heart defects. 6 acyanotic and 5
cyanoyic.
6 Acyanotice includes' A-") 8-") "A) endocardial cushion
defect) $ulmonary stenosis) dou$ling of the aorta) Aortic
13
stenosis and Coarctation of the Aorta
5 Cyanotic includes' Tetralogy of fallot) Total anomalous
$ulmonary artery) Trans$osition of the great arteries) Truncus
arteriousus) ?y$o$lastic @eft heart syndrome.
7Acyanotic causes @-R! shunting &hile cyanotic cause !-R@
shunting. ara madaling matandaan lahat ng may MTO eh
cyanotic 2G?
3+. The immediate nursing intervention for cyanosis of Agata
is'
a. Call u$ the $ediatrician
%. lace her in /nee chest $osition
c. Administer o*ygen inhalation
d. Transfer her to the (C<
The immediate intervention &ould %e to $lace her on /nee-
chest or Ms1uattingO $osition %ecause it tra$s %lood into the
lo&er e*tremities. Though also letter C &ould %e a good choice
%ut the 1uestion is as/ing for M(mmediateO so letter B is more
a$$ro$riate. @etter A and " are incorrect %ecause its normal for
a child &ho have To: to have hy$o*ic or MtetsO s$ells so there is
no need to transfer her to the B(C< or to alert the ediatrician.
33. Agata &as scheduled for a $alliative surgery) &hich creates
anastomosis of the su%clavian artery to the $ulmonary artery.
This $rocedure is'
a. Waterston-Cooley
%. !as//ind rocedure
c. Coronary artery %y$ass
d. Blaloc/-Taussig
Correct ans&er is Blaloc/-Taussig $rocedure its ,ust a tem$orary
or $alliative surgery &hich creates a shunt %et&een the aorta
and $ulmonary artery 7oist $arang ductus arteriosus) so that
the %lood can leave the aorta and enter the $ulmonary artery
and thus o*ygenating the lungs and return to the left side of
the heart) then to the aorta then to the %ody. This $rocedure
also ma/es use of the su%clavian vein so $ulse is not $al$a%le
at the right arm.
The full re$air for To: is called the Broc/ $rocedure. !as//ind is
a $alliative surgery for T2#A.
30. Which of the follo&ing is not an indicator that Agata
e*$eriences se$aration an*iety %rought a%out her
hos$italization?
a. :riendly &ith the nurse
%. rolonged loud crying) consoled only %y mother
c. 2ccasional tem$er tantrums and al&ays says B2
d. !e$eatedly ver%alizes desire to go home
Because toddlers vie&s hos$italization is a%andonment)
se$aration an*iety is common. (ts has 3 $hases' "" 7$arang c
$uff daddy @2@)
1. rotest +. des$air 3. detachment 7or denial). Choices B) C) "
are usually seen in a child &ith se$aration an*iety 7usually in
the $rotest stage).
!=8(=W'
-e$aration an*iety %egin at' > months
ea/s' 16 months
33. When Agata &as %rought to the 2!) her $arents &here
crying. What &ould %e the most a$$ro$riate nursing diagnosis?
a. (nfective family co$ing rEt situational crisis
%. An*iety rEt $o&erlessness
c. :ear rEt uncertain $rognosis
d. Antici$atory grieving rEt gravity of childDs $hysical status
(n this item letter A and %e are ina$$ro$riate res$onse so
remove them. The $ossi%le ans&ers are C and ". :ear defined
as the $erceived threat 7real or imagined) that is consciously
recognized as danger 7BAB"A) is a$$lica%le in the situation %ut
its defining characteristics are not a$$lica%le. Crying $er se can
not %e a su%,ective cue to signify fear) and most of the
sym$toms of fear in BAB"A are $hysiological. Antici$atory
grieving on the other hand are intellectual and =.2T(2BA@
res$onses %ased on a $otential loss. And remem%er that
$rocedures li/e this cannot assure total recovery. -o letter " is
a more a$$ro$riate Bursing diagnosis.
B2T=' #ABAT2 BA 2 AB# ATT=!B B# B@=) @A#(B# .AC
?A@2B# T?=!A<=T(C C2..<B(CAT(2B AT B<!-(B#
"(A#B2-(-.
35. Which of the follo&ing res$iratory condition is al&ays
considered a medical emergency?
a. @aryngeotracheo%ronchitis 7@TB)
%. =$iglottitis
c. Asthma
d. Cystic :i%rosis
Correct ans&er is letter B) %ecause acute and sever
inflammation of the e$iglottis can cause life threatening air&ay
o%struction) that is &hy its al&ays treated as a medical
emergency. B-# intervention ' re$are tracheostomy set at %ed
side.
@TB) can also cause air&ay o%struction %ut its not an
emergency. Asthma is also not an emergency 7ung status
asthmaticus ang /aylangan ng $rom$t treatment). C: is a
chronic disease) so its not a medical emergency.
!=8(=W' .edical emergency of #(' $eritonitis
39. Which of the follo&ing statements %y the family of a child
&ith asthma indicates a need for additional teaching?
a. MWe need to identify &hat things triggers his attac/sO
%. M?e is to use %ronchodilator inhaler %efore steroid inhalerO
c. MWeDll ma/e sure he avoids e*ercise to $revent asthma
attac/sO
d. Mhe should increase his fluid inta/e regularly to thin
secretionsO
Asthmatic children donDt have to avoid e*ercise. They can
$artici$ate on $hysical activities as tolerated. <sing a
%ronchodilator %efore administering steroids is correct %ecause
steroids are ,ust anti-inflammatory and they donDt have effects
on the dilation of the %ronchioles. 2: course letters A and B are
o%viously correct.
36. Which of the follo&ing &ould re1uire careful monitoring in
the child &ith A"?" &ho is receiving .ethyl$henidate 7!italin)?
a. "ental health
%. .outh dryness
c. ?eight and &eight
d. =*cessive a$$etite
"ental $ro%lems are more li/ely to occur in children under
going TCA thera$y. .outh dryness is a e*$ected side effects of
!italin since it activates the -B-. Also loss of a$$etite is more
li/ely to ha$$en) not increase in a$$etite. The correct ans&er is
letter C) %ecause !italin can affect the childDs #L".
(ntervention' medication Mholidays or vacationO. 7This means
na.. during &ee/ends or holidays or school vacations) &here
the child &ont %e in school) the drug can %e &ithheld.)
-ituation 5 @aura is assigned as the Team @eader during the
immunization day at the !?<
3>. What $rogram for the "2? is launched at 1>95 in
coo$eration &ith W?2 and <B(C=: to reduce mor%idity and
mortality among infants caused %y immuniza%le disease?
a. ata/ day
%. (mmunization day on Wednesday
c. =*$anded $rogram on immunization
d. Ba/una ng /a%taan
-<- meN "a$at $a %ang (-rationalize? Ang di na/a/uha ng
tamang sagotS halaS J2G=.. hehehe
04. 2ne im$ortant $rinci$le of the immunization $rogram is
%ased on?
a. -tatistical occurrence
%. =$idemiologic situation
c. Cold chain management
14
d. -urveillance study
@etters A) C and " are not included in the $rinci$les of =(.
The $rinci$le of =( are the follo&ing'
1. (ts is %ased on e$idemiological situation
+. .ass a$$roach utilization- the &hole community is to %e
$rotected rather than the individual
3. (mmunization is a %asic health service) and should %e
$rovided %y the !?<
01. The main element of immunization $rogram is one of the
follo&ing?
a. (nformation) education and communication
%. Assessment and evaluation of the $rogram
c. !esearch studies
d. Target setting
Correct ans&er is ".
The follo&ing are the elements of =('
T Target seting
T Cold chain logistic management
T (nformation) education and communication
T Assessment and evaluation of the $rogramDs over all
$erformance
T -urveillance) studies and research
0+. What does herd immunity means?
a. (nterru$tion of transmission
%. All to %e vaccinated
c. -elected grou$ for vaccination
d. -horter incu%ation
03. .easles vaccine can %e given simultaneously. What is the
com%ined vaccine to %e given to children starting at 13
months?
a. .C#
%. ..!
c. BC#
d. BB!
..! or .easles) .um$s) !u%ella is a vaccine furnished in one
vial and is routinely given in one in,ection 7-u%-K). (t can %e
given at 13 months %ut can also %e given as early as 1+th
month.
-ituation 9' Braguda %rought her 3-month old daughter in the
nearest !?< %ecause her %a%y slee$s most of the time) &ith
decreased a$$etite) has colds and fever for more than a &ee/.
The $hysician diagnosed $neumonia.
00. Based on this data given %y Braguda) you can classify
BragudaDs daughter to have'
a. neumonia' cough and colds
%. -evere $neumonia
c. 8ery severe $neumonia
d. neumonia moderate
:or a child aging +months u$ to 3 years old can %e classified to
have sever $neumonia &hen he have any of the follo&ing
danger signs'
T Bot a%le to drin/
T Convulsions
T A%normally slee$y or difficult to &a/e
T -tridor in calm child or
T -evere under-nutrition
03. :or a 3-month old child to %e classified to have neumonia
7not severe)) you &ould e*$ect to find !! of'
a. 54 %$m
%. 04 %$m
c. 94 %$m
d. 34 $%m
Correct ans&er is letter ". A child can %e classified to have
neumonia 7not severe) if'
T the young infant is less than + months- 54 %$m or more
T if the child is + months u$ to less than 1+ months- 34 %$m or
more
T if the child is 1+ months to 0 yEo- 04 %$m or more
05. Cou as/ed Braguda if her %a%y received all vaccines under
=(. What legal %asis is used in im$lementing the <BDs goal on
<niversal Child (mmunization?
a. " no. >>5
%. " no. 5
c. " no. 05
d. !A >193
Correct ans&er is letter B. residential roclamation no. 5 7A$ril
3) 1>65) is the M(m$lementing a <nited Bations goal on
<niversal Child (mmunization %y 1>>4O. " >>5 7-e$tem%er 15)
1>95) is M$roviding for com$ulsory %asic immunization for
infants and children %elo& 6 years of age. " no. 05
7-e$tem%er 15) 1>>+) is the M!eaffirming the commitment of
the hili$$ines to the universal Child and .other goal of the
World ?ealth Assem%ly. !A >193 is of course the MBursing act
of +44+O
09. Braguda as/s you a%out 8itamin A su$$lementation. Cou
res$onded that giving 8itamin A starts &hen the infant reaches
5 months and the first dose isO
a. +44)444 M(<O
%. 144)444 M(<O
c. 344)444 M(<O
d. 14)444 M(<O
An infant aging 5-11 months &ill %e given 8itamin
su$$lementation of 144) 444 (< and for reschoolers ages 1+-
63 months +44)444 M(<O &ill %e given.
06. As $art of CA!( $rogram) assessment of the child is your
main res$onsi%ility. Cou could as/ the follo&ing 1uestion to the
mother e*ce$t'
a. M?o& old is the child?O
%. M(- the child coughing? :or ho& long?O
c. M"id the child have chest indra&ing?O
d. M"id the child have fever? :or ho& long?O
The CA!( $rogram of the "2? includes the MA-GO and M@22G)
@(-T=BO as $art of the assessment of the child &ho has
sus$ected neumonia. Choices A) B and " are included in the
MA-GO assessment &hile Chest indra&ings is included in the
M@22G) @(-T=BO and should not %e as/ed to the mother.
0>. A ne&%ornDs failure to $ass meconium &ithin +0 hours after
%irth may indicate &hich of the follo&ing?
a. Aganglionic .ega colon
%. Celiac disease
c. (ntussusce$tion
d. A%dominal &all defect
:ailure to $ass meconium of Be&%orn during the first +0 hours
of life may indicate ?irschs$rung disease or Congenital
Aganglionic .egacolon) an anomaly resulting in mechanical
o%struction due to inade1uate motility in an intestinal segment.
B) C) and " are not associated in the failure to $ass meconium
of the ne&%orn.
34. The nurse understands that a good snac/ for a + year old
&ith a diagnosis of acute asthma &ould %e'
a. #ra$es
%. A$$le slices
c. A glass of mil/
d. A glass of cola
Correct ans&er is B) a$$le slices. #ra$es is in a$$ro$riate
%ecause of its M%alatO that can cause cho/ing. A glass of mil/ is
not a good snac/ %ecause itDs the most common cause of (ron-
deficiency anemia in children 7mil/ contains fe& iron)) A glass
of cola is also not a$$ro$riate cause it contains com$le* sugar.
7&alang /inalaman ang asthma dahil ala naman itong diatery
15
restricted foods na nasa choices.)
31. Which of the follo&ing immunizations &ould the nurse
e*$ect to administer to a child &ho is ?(8 7U) and severely
immunocomromised?
a. 8aricella
%. !otavirus
c. ..!
d. (8
(8 or (nactivated $olio vaccine does not contain live micro
organisms &hich can %e harmful to an immunocom$romised
child. <nli/e 28) (8 is administered via (. route.
3+. When assessing a ne&%orn for develo$mental dys$lasia of
the hi$) the nurse &ould e*$ect to assess &hich of the
follo&ingE
a. -ymmetrical gluteal folds
%. Trendelem%urg sign
c. 2rtolaniDs sign
d. Characteristic lim$
Correct ans&er is 2rtolaniDs signH it is the a%normal clic/ing
sound &hen the hi$s are a%ducted. The sound is $roduced
&hen the femoral head enters the aceta%ulum. @etter A is
&rong %ecause its should %e Masymmetrical gluteal foldO. @etter
B and C are not a$$lica%le for ne&%orns %ecause they are seen
in older children.
33. While assessing a male neonate &hose mother desires him
to %e circumcised) the nurse o%serves that the neonateDs
urinary meatus a$$ears to %e located on the ventral surface of
the $enis. The $hysician is notified %ecause the nurse &ould
sus$ect &hich of the follo&ing?
a. himosis
%. ?ydrocele
c. =$is$adias
d. ?y$os$adias
?y$os$adias is a c condition in &hich the urethral o$ening is
located %elo& the glans $enis or any&here along the ventral
surface of the $enile shaft. =$is$adias) the urethral meatus is
located at the dorsal surface of the $enile shaft. 7ara di /a
malilto) (-al$ha%etesize mo "orsal) 7A%ove) eh mauuna sa
8entral 7Belo&) ) =$is mauuna sa ?y$o.)
30. When teaching a grou$ of $arents a%out seat %elt use)
&hen &ould the nurse state that the child %e safely restrained
in a regular automo%ile seat%elt?
a. 34 l% and 34 in
%. 33 l% and 3 yEo
c. 04 l% and 04 in
d. 54 l% and 5 yEo
Basta tandaan ang rule of 0N 0 years old) 04 l%s and 04 in.
33. When assessing a ne&%orn &ith cleft li$) the nurse &ould
%e alert &hich of the follo&ing &ill most li/ely %e com$romised?
a. -uc/ing a%ility
%. !es$iratory status
c. @ocomotion
d. #( function
Because of the defect) the child &ill %e una%le to form the
mouth ade1uately arounf the ni$$le there%y re1uiring s$ecial
devices to allo& feeding and suc/ing gratification. !es$iratory
status may %e com$romised &hen the child is fed im$ro$erly or
during $ost o$ $eriod.
!=8(=WN
!e$air of cleft li$-cheilo$lasty-should %e done &ithin 1-3
months- to save suc/ing refle*- $osition $ost-o$ side lying
!e$air of cleft $alate- <rano$lasty- should %e done &ithin 0-5
months-to $reserve s$eech- $osition $ost-o$ is $rone.
35. :or a child &ith recurring ne$hritic syndrome) &hich of the
follo&ing areas of $otential distur%ances should %e a $rime
consideration &hen $lanning ongoing nursing care?
a. .uscle coordination
%. -e*ual maturation
c. (ntellectual develo$ment
d. Body image
Because of edema) associated &ith ne$hroitic syndrome)
$otential self conce$t and %ody image distur%ance related to
changes in a$$earance and social isolation should %e
considered.
?=CN BA!A!A."A.AB G2 BA @A@ABA- <@(T AB# .#A -AG(T
!=@AT=" -A B=W B2!B -C!==B(B# GACA A!A@(B BA (T2. (
W(@@ 2-T A -(.@= @=CT<!= "(T2. 7@AT=!S. Gasi tamad
a/o))) hehehe)
39. An in%orn error of meta%olism that causes $remature
destruction of !BC?
a. #5"
%. ?emocystinuria
c. henyl/etonuria
d. Celiac "isease
#5" is the $remature destruction of !BC &hen the %lood is
e*$osed to antio*idants) A-A 7ano un? As$irin)) legumes and
flava %eans.
36. Which of the follo&ing &ould %e a diagnostic test for
henyl/etonuria &hich uses fresh urine mi*ed &ith ferric
chloride?
a. #uthrie Test
%. henesti* test
c. BeutlerDs test
d. Coom%Ds test
henesti* test is a diagnostic test &hich uses a fresh urine
sam$le 7dia$ers) and mi*ed &ith ferric chloride. (f $ositive)
there &ill %e a $resence of green s$ots at the dia$ers. #uthrie
test is another test for G< and is the one that mostly used.
The s$ecimen used is the %lood and it tests if C?2B is
converted to amino acid.
3>. "ietary restriction in a child &ho has ?emocystenuria &ill
include &hich of the follo&ing amino acid?
a. @ysine
%. .ethionine
c. (solensine try$to$hase
d. 8aline
?emocystenuria is the elevated e*cretion of the amino acid
hemocystiene) and there is ina%ility to convert the amino acid
methionine or cystiene. -o dietary restriction of this amino
acids is advised. This disease can lead to mental retardation.
54. A mil/ formula that you can suggest for a child &ith
#alactosemia'
a. @ofenalac
%. @actum
c. Beutramigen
d. -ustagen
Beutramigen is suggested for a child &ith #alactosemia.
@ofenalac is suggested for a child &ith G<. -ustagen is for
-usy and #eno) @actum.. lactum.. inom /a ng inomN
16