TEST I - Foundation of Professional Nursing Practice
b. “My ankle feels warm”.
1. The nurse In-charge in labor and delivery unit administered a dose
of terbutaline to a client without checking the client’s pulse. The
standard that would be used to determine if the nurse was negligent
is:
a. The physician’s orders.
b. The action of a clinical nurse specialist who is recognized expert in
the field.
c. The statement in the drug literature about administration of
terbutaline.
d. The actions of a reasonably prudent nurse with similar education
and experience.
2. Nurse Trish is caring for a female client with a history of GI
bleeding, sickle cell disease, and a platelet count of 22,000/μl. The
female client is dehydrated and receiving dextrose 5% in half-normal
saline solution at 150 ml/hr. The client complains of severe bone
pain and is scheduled to receive a dose of morphine sulfate. In
administering the medication, Nurse Trish should avoid which route?
a. I.V b. I.M c. Oral d. S.C
3. Dr. Garcia writes the following order for the client who has been
recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a
dosage error, how should the nurse document this order onto the
medication administration record?
a. “Digoxin .1250 mg P.O. once daily”
b. “Digoxin 0.1250 mg P.O. once daily”
c. “Digoxin 0.125 mg P.O. once daily”
d. “Digoxin .125 mg P.O. once daily”
4. A newly admitted female client was diagnosed with deep vein
thrombosis. Which nursing diagnosis should receive the highest
priority?
a. Ineffective peripheral tissue perfusion related to venous
congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral vascular disease.
d. Impaired gas exchange related to increased blood flow.
5. Nurse Betty is assigned to the following clients. The client that the
nurse would see first after endorsement?
a. A 34 year-old post operative appendectomy client of five hours
who is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining
of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous
(IV) has infiltrated.
d. A 63 year-old post operative’s abdominal hysterectomy client of
three days whose incisional dressing is saturated with
serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint following orders
from the physician. The client care plan should include:
a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.
7. A male client who has severe burns is receiving H2 receptor
antagonist therapy. The nurse In-charge knows the purpose of this
therapy is to:
a. Prevent stress ulcer b. Block prostaglandin synthesis
c. Facilitate protein synthesis. d. Enhance gas exchange
8. The doctor orders hourly urine output measurement for a
postoperative male client. The nurse Trish records the following
amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60
ml. Based on these amounts, which action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output
9. Tony, a basketball player twist his right ankle while playing on the
court and seeks care for ankle pain and swelling. After the nurse
applies ice to the ankle for 30 minutes, which statement by Tony
suggests that ice application has been effective?
a. “My ankle looks less swollen now”.
c. “My ankle appears redder now”.
d. “I need something stronger for pain relief”
10.The physician prescribes a loop diuretic for a client. When
administering this drug, the nurse anticipates that the client may
develop which electrolyte imbalance?
a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypervolemia
11.She finds out that some managers have benevolent-authoritative
style of management. Which of the following behaviors will she
exhibit most likely?
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about functional
nursing
a. Provides continuous, coordinated and comprehensive nursing
services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.
13.Which type of medication order might read "Vitamin K 10 mg I.M.
daily × 3 days?"
a. Single order b. Standard written order
c. Standing order d. Stat order
14.A female client with a fecal impaction frequently exhibits which
clinical manifestation?
a. Increased appetite b. Loss of urge to defecate
c. Hard, brown, formed stools d. Liquid or semi-liquid stools
15.Nurse Linda prepares to perform an otoscopic examination on a
female client. For proper visualization, the nurse should position the
client's ear by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward
16.Which instruction should nurse Tom give to a male client who is
having external radiation therapy:
a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area when it is red or sore.
17.In assisting a female client for immediate surgery, the nurse In-
charge is aware that she should:
a. Encourage the client to void following preoperative medication.
b. Explore the client’s fears and anxieties about the surgery.
c. Assist the client in removing dentures and nail polish.
d. Encourage the client to drink water prior to surgery.
18. A male client is admitted and diagnosed with acute pancreatitis
after a holiday celebration of excessive food and alcohol. Which
assessment finding reflects this diagnosis?
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back pain.
19.Which dietary guidelines are important for nurse Oliver to
implement in caring for the client with burns?
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.
20.Nurse Hazel will administer a unit of whole blood, which priority
information should the nurse have about the client?
a. Blood pressure and pulse rate. b. Height and weight.
c. Calcium and potassium levels d. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain a fall and
suspects that the leg may be broken. The nurse takes which priority
action?
a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.
22.A male client is being transferred to the nursing unit for
admission after receiving a radium implant for bladder cancer. The
nurse in-charge would take which priority action in the care of this
client?
a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent rest periods.
d. Encourage family and friends to visit.
23.A newly admitted female client was diagnosed with
agranulocytosis. The nurse formulates which priority nursing
diagnosis?
a. Constipation b. Diarrhea c. Risk for infection d. Deficient
knowledge
24.A male client is receiving total parenteral nutrition suddenly
demonstrates signs and symptoms of an air embolism. What is the
priority action by the nurse?
a. Notify the physician.
b. Place the client on the left side in the Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.
25.Nurse May attends an educational conference on leadership
styles. The nurse is sitting with a nurse employed at a large trauma
center who states that the leadership style at the trauma center is
task-oriented and directive. The nurse determines that the
leadership style used at the trauma center is:
a. Autocratic. b. Laissez-faire.
c. Democratic. d. Situational
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr.
The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20
mEq/10 cc. How many cc’s of KCl will be added to the IV solution?
a. .5 cc b. 5 cc c. 1.5 cc d. 2.5 cc
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour
shift. The IV drip factor is 60. The IV rate that will deliver this amount
is:
a. 50 cc/ hour b. 55 cc/ hour c. 24 cc/ hour d. 66 cc/ hour
28.The nurse is aware that the most important nursing action when
a client returns from surgery is:
a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency and urine output
d. Assess the dressing for drainage.
29.Which of the following vital sign assessments that may indicate
cardiogenic shock after myocardial infarction?
a. BP – 80/60, Pulse – 110 irregular b. BP – 90/50, Pulse – 50 regular
c. BP – 130/80, Pulse – 100 regular d. BP – 180/100, Pulse – 90
irregular
30.Which is the most appropriate nursing action in obtaining a blood
pressure measurement?
a. Take the proper equipment, place the client in a comfortable
position, and record the appropriate information in the client’s
chart.
b. Measure the client’s arm, if you are not sure of the size of cuff to
use. c. Have the client recline or sit comfortably in a chair with the
forearm at the level of the heart.
d. Document the measurement, which extremity was used, and the
position that the client was in during the measurement.
31.Asking the questions to determine if the person understands the
health teaching provided by the nurse would be included during
which step of the nursing process?
a. Assessment b. Evaluation c. Implementation d. Planning and
goals
32.Which of the following item is considered the single most
important factor in assisting the health professional in arriving at a
diagnosis or determining the person’s needs?
a. Diagnostic test results b. Biographical date c. History of present
illness d. Physical examination
33.In preventing the development of an external rotation deformity
of the hip in a client who must remain in bed for any period of time,
the most appropriate nursing action would be to use:
a. Trochanter roll extending from the crest of the ileum to the
midthigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow
34.Which stage of pressure ulcer development does the ulcer extend
into the subcutaneous tissue?
a. Stage I b. Stage II c. Stage III d. Stage IV
35.When the method of wound healing is one in which wound edges
are not surgically approximated and integumentary continuity is
restored by granulations, the wound healing is termed
a. Second intention healing b. Primary intention healing
c. Third intention healing d. First intention healing
36.An 80-year-old male client is admitted to the hospital with a
diagnosis of pneumonia. Nurse Oliver learns that the client lives
alone and hasn’t been eating or drinking. When assessing him for
dehydration, nurse Oliver would expect to find:
a. Hypothermia b. Hypertension
c. Distended neck veins d. Tachycardia
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every
4 hours as needed, to control a client’s postoperative pain. The
package insert is “Meperidine, 100 mg/ml.” How many milliliters of
meperidine should the client receive?
a. 0.75 b. 0.6 c. 0.5 d. 0.25
38.A male client with diabetes mellitus is receiving insulin. Which
statement correctly describes an insulin unit?
a. It’s a common measurement in the metric system.
b. It’s the basis for solids in the avoirdupois system.
c. It’s the smallest measurement in the apothecary system.
d. It’s a measure of effect, not a standard measure of weight or
quantity.
39.Nurse Oliver measures a client’s temperature at 102° F. What is
the equivalent Centigrade temperature?
a. 40.1 °C b. 38.9 °C c. 48 °C d. 38 °C
40.The nurse is assessing a 48-year-old client who has come to the
physician’s office for his annual physical exam. One of the first
physical signs of aging is:
a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
d. Having more frequent aches and pains.
41.The physician inserts a chest tube into a female client to treat a
pneumothorax. The tube is connected to water-seal drainage. The
nurse in-charge can prevent chest tube air leaks by:
a. Checking and taping all connections.
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
d. Keeping the chest drainage system below the level of the chest.
42.Nurse Trish must verify the client’s identity before administering
medication. She is aware that the safest way to verify identity is to:
a. Check the client’s identification band.
b. Ask the client to state his name.
c. State the client’s name out loud and wait a client to repeat it.
d. Check the room number and the client’s name on the bed.
43.The physician orders dextrose 5 % in water, 1,000 ml to be
infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse
John should run the I.V. infusion at a rate of:
a. 30 drops/minute b. 32 drops/minute
c. 20 drops/minute d. 18 drops/minute
44.If a central venous catheter becomes disconnected accidentally,
what should the nurse in-charge do immediately?
a. Clamp the catheter b. Call another nurse c. Call the physician d.
Apply a dry sterile dressing to the site.
45.A female client was recently admitted. She has fever, weight loss,
and watery diarrhea is being admitted to the facility. While assessing
the client, Nurse Hazel inspects the client’s abdomen and notice that
it is slightly concave. Additional assessment should proceed in which
order:
a. Palpation, auscultation, and percussion. b. Percussion, palpation,
and auscultation. c. Palpation, percussion, and auscultation. d.
Auscultation, percussion, and palpation.
Nursing Crib – Student Nurses’ Community 14
46. Nurse Betty is assessing tactile fremitus in a client with
pneumonia. For this examination, nurse Betty should use the:
a. Fingertips b. Finger pads c. Dorsal surface of the hand d. Ulnar
surface of the hand
47. Which type of evaluation occurs continuously throughout the
teaching and learning process?
a. Summative b. Informative c. Formative d. Retrospective
48.A 45 year old client, has no family history of breast cancer or
other risk factors for this disease. Nurse John should instruct her to
have mammogram how often?
a. Twice per year b. Once per year c. Every 2 years d. Once, to
establish baseline
49.A male client has the following arterial blood gas values: pH 7.30;
Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on
these values, Nurse Patricia should expect which condition?
a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis
d. Metabolic alkalosis
50.Nurse Len refers a female client with terminal cancer to a local
hospice. What is the goal of this referral?
a. To help the client find appropriate treatment options. b. To
provide support for the client and family in coping with terminal
illness. c. To ensure that the client gets counseling regarding health
care costs. d. To teach the client and family about cancer and its
treatment.
Nursing Crib – Student Nurses’ Community 15
51.When caring for a male client with a 3-cm stage I pressure ulcer
on the coccyx, which of the following actions can the nurse institute
independently?
a. Massaging the area with an astringent every 2 hours. b. Applying
an antibiotic cream to the area three times per day. c. Using normal
saline solution to clean the ulcer and applying a protective dressing
as necessary. d. Using a povidone-iodine wash on the ulceration
three times per day.
52.Nurse Oliver must apply an elastic bandage to a client’s ankle and
calf. He should apply the bandage beginning at the client’s:
a. Knee b. Ankle c. Lower thigh d. Foot
53.A 10 year old child with type 1 diabetes develops diabetic
ketoacidosis and receives a continuous insulin infusion. Which
condition represents the greatest risk to this child?
a. Hypernatremia b. Hypokalemia c. Hyperphosphatemia d.
Hypercalcemia
54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to
the newly admitted client. Immediately afterward, the client may
experience:
a. Throbbing headache or dizziness b. Nervousness or paresthesia. c.
Drowsiness or blurred vision. d. Tinnitus or diplopia.
55.Nurse Michelle hears the alarm sound on the telemetry monitor.
The nurse quickly looks at the monitor and notes that a client is in a
ventricular tachycardia. The nurse rushes to the client’s room. Upon
reaching the client’s bedside, the nurse would take which action
first?
a. Prepare for cardioversion b. Prepare to defibrillate the client c.
Call a code d. Check the client’s level of consciousness
Nursing Crib – Student Nurses’ Community 16
56.Nurse Hazel is preparing to ambulate a female client. The best
and the safest position for the nurse in assisting the client is to
stand:
a. On the unaffected side of the client. b. On the affected side of the
client. c. In front of the client. d. Behind the client.
57.Nurse Janah is monitoring the ongoing care given to the potential
organ donor who has been diagnosed with brain death. The nurse
determines that the standard of care had been maintained if which
of the following data is observed?
a. Urine output: 45 ml/hr b. Capillary refill: 5 seconds c. Serum pH:
7.32 d. Blood pressure: 90/48 mmHg
58.Nurse Amy has an order to obtain a urinalysis from a male client
with an indwelling urinary catheter. The nurse avoids which of the
following, which contaminate the specimen?
a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag. c.
Clamping the tubing of the drainage bag. d. Obtaining the specimen
from the urinary drainage bag.
59.Nurse Meredith is in the process of giving a client a bed bath. In
the middle of the procedure, the unit secretary calls the nurse on
the intercom to tell the nurse that there is an emergency phone call.
The appropriate nursing action is to:
a. Immediately walk out of the client’s room and answer the phone
call. b. Cover the client, place the call light within reach, and answer
the phone call. c. Finish the bed bath before answering the phone
call. d. Leave the client’s door open so the client can be monitored
and the nurse can answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and
sensitivity testing from a client who has a productive cough. Nurse
Janah plans to implement which intervention to obtain the
specimen?
a. Ask the client to expectorate a small amount of sputum into the
emesis basin.
Nursing Crib – Student Nurses’ Community 17
b. Ask the client to obtain the specimen after breakfast. c. Use a
sterile plastic container for obtaining the specimen. d. Provide
tissues for expectoration and obtaining the specimen.
61. Nurse Ron is observing a male client using a walker. The nurse
determines that the client is using the walker correctly if the client:
a. Puts all the four points of the walker flat on the floor, puts weight
on the hand pieces, and then walks into it. b. Puts weight on the
hand pieces, moves the walker forward, and then walks into it. c.
Puts weight on the hand pieces, slides the walker forward, and then
walks into it. d. Walks into the walker, puts weight on the hand
pieces, and then puts all four points of the walker flat on the floor.
62.Nurse Amy has documented an entry regarding client care in the
client’s medical record. When checking the entry, the nurse realizes
that incorrect information was documented. How does the nurse
correct this error?
a. Erases the error and writes in the correct information. b. Uses
correction fluid to cover up the incorrect information and writes in
the correct information. c. Draws one line to cross out the incorrect
information and then initials the change. d. Covers up the incorrect
information completely using a black pen and writes in the correct
information
63.Nurse Ron is assisting with transferring a client from the
operating room table to a stretcher. To provide safety to the client,
the nurse should:
a. Moves the client rapidly from the table to the stretcher. b.
Uncovers the client completely before transferring to the stretcher.
c. Secures the client safety belts after transferring to the stretcher.
d. Instructs the client to move self from the table to the stretcher.
64.Nurse Myrna is providing instructions to a nursing assistant
assigned to give a bed bath to a client who is on contact precautions.
Nurse Myrna instructs the nursing assistant to use which of the
following protective items when giving bed bath?
a. Gown and goggles b. Gown and gloves c. Gloves and shoe
protectors d. Gloves and goggles
Nursing Crib – Student Nurses’ Community 18
65. Nurse Oliver is caring for a client with impaired mobility that
occurred as a result of a stroke. The client has right sided arm and
leg weakness. The nurse would suggest that the client use which of
the following assistive devices that would provide the best stability
for ambulating?
a. Crutches b. Single straight-legged cane c. Quad cane d. Walker
66.A male client with a right pleural effusion noted on a chest X-ray
is being prepared for thoracentesis. The client experiences severe
dizziness when sitting upright. To provide a safe environment, the
nurse assists the client to which position for the procedure?
a. Prone with head turned toward the side supported by a pillow. b.
Sims’ position with the head of the bed flat. c. Right side-lying with
the head of the bed elevated 45 degrees. d. Left side-lying with the
head of the bed elevated 45 degrees.
67.Nurse John develops methods for data gathering. Which of the
following criteria of a good instrument refers to the ability of the
instrument to yield the same results upon its repeated
administration?
a. Validity b. Specificity c. Sensitivity d. Reliability
68.Harry knows that he has to protect the rights of human research
subjects. Which of the following actions of Harry ensures
anonymity?
a. Keep the identities of the subject secret b. Obtain informed
consent c. Provide equal treatment to all the subjects of the study.
d. Release findings only to the participants of the study
69.Patient’s refusal to divulge information is a limitation because it is
beyond the control of Tifanny”. What type of research is appropriate
for this study?
a. Descriptive- correlational b. Experiment c. Quasi-experiment d.
Historical
Nursing Crib – Student Nurses’ Community 19
70.Nurse Ronald is aware that the best tool for data gathering is?
a. Interview schedule b. Questionnaire c. Use of laboratory data d.
Observation
71.Monica is aware that there are times when only manipulation of
study variables is possible and the elements of control or
randomization are not attendant. Which type of research is referred
to this?
a. Field study b. Quasi-experiment c. Solomon-Four group design d.
Post-test only design
72.Cherry notes down ideas that were derived from the description
of an investigation written by the person who conducted it. Which
type of reference source refers to this?
a. Footnote b. Bibliography c. Primary source d. Endnotes
73.When Nurse Trish is providing care to his patient, she must
remember that her duty is bound not to do doing any action that will
cause the patient harm. This is the meaning of the bioethical
principle:
a. Non-maleficence b. Beneficence c. Justice d. Solidarity
74.When a nurse in-charge causes an injury to a female patient and
the injury caused becomes the proof of the negligent act, the
presence of the injury is said to exemplify the principle of:
a. Force majeure b. Respondeat superior c. Res ipsa loquitor d.
Holdover doctrine
Nursing Crib – Student Nurses’ Community 20
75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial
power. An example of this power is:
a. The Board can issue rules and regulations that will govern the
practice of nursing b. The Board can investigate violations of the
nursing law and code of ethics c. The Board can visit a school
applying for a permit in collaboration with CHED d. The Board
prepares the board examinations
76.When the license of nurse Krina is revoked, it means that she:
a. Is no longer allowed to practice the profession for the rest of her
life b. Will never have her/his license re-issued since it has been
revoked c. May apply for re-issuance of his/her license based on
certain conditions stipulated in RA 9173 d. Will remain unable to
practice professional nursing
77.Ronald plans to conduct a research on the use of a new method
of pain assessment scale. Which of the following is the second step
in the conceptualizing phase of the research process?
a. Formulating the research hypothesis b. Review related literature
c. Formulating and delimiting the research problem d. Design the
theoretical and conceptual framework
78.The leader of the study knows that certain patients who are in a
specialized research setting tend to respond psychologically to the
conditions of the study. This referred to as :
a. Cause and effect b. Hawthorne effect c. Halo effect d. Horns effect
79.Mary finally decides to use judgment sampling on her research.
Which of the following actions of is correct?
a. Plans to include whoever is there during his study. b. Determines
the different nationality of patients frequently admitted and decides
to get representations samples from each. c. Assigns numbers for
each of the patients, place these in a fishbowl and draw 10 from it.
Nursing Crib – Student Nurses’ Community 21
d. Decides to get 20 samples from the admitted patients
80.The nursing theorist who developed transcultural nursing theory
is:
a. Florence Nightingale b. Madeleine Leininger c. Albert Moore d. Sr.
Callista Roy
81.Marion is aware that the sampling method that gives equal
chance to all units in the population to get picked is:
a. Random b. Accidental c. Quota d. Judgment
82.John plans to use a Likert Scale to his study to determine the:
a. Degree of agreement and disagreement b. Compliance to
expected standards c. Level of satisfaction d. Degree of acceptance
83.Which of the following theory addresses the four modes of
adaptation?
a. Madeleine Leininger b. Sr. Callista Roy c. Florence Nightingale d.
Jean Watson
84.Ms. Garcia is responsible to the number of personnel reporting to
her. This principle refers to:
a. Span of control b. Unity of command c. Downward
communication d. Leader
85.Ensuring that there is an informed consent on the part of the
patient before a surgery is done, illustrates the bioethical principle
of:
a. Beneficence b. Autonomy c. Veracity d. Non-maleficence
Nursing Crib – Student Nurses’ Community 22
86.Nurse Reese is teaching a female client with peripheral vascular
disease about foot care; Nurse Reese should include which
instruction?
a. Avoid wearing cotton socks. b. Avoid using a nail clipper to cut
toenails. c. Avoid wearing canvas shoes. d. Avoid using cornstarch on
feet.
87.A client is admitted with multiple pressure ulcers. When
developing the client's diet plan, the nurse should include:
a. Fresh orange slices b. Steamed broccoli c. Ice cream d. Ground
beef patties
88.The nurse prepares to administer a cleansing enema. What is the
most common client position used for this procedure?
a. Lithotomy b. Supine c. Prone d. Sims’ left lateral
89.Nurse Marian is preparing to administer a blood transfusion.
Which action should the nurse take first?
a. Arrange for typing and cross matching of the client’s blood. b.
Compare the client’s identification wristband with the tag on the
unit of blood. c. Start an I.V. infusion of normal saline solution. d.
Measure the client’s vital signs.
90.A 65 years old male client requests his medication at 9 p.m.
instead of 10 p.m. so that he can go to sleep earlier. Which type of
nursing intervention is required?
a. Independent b. Dependent c. Interdependent d. Intradependent
91.A female client is to be discharged from an acute care facility
after treatment for right leg thrombophlebitis. The Nurse Betty
notes that the client's leg is pain-free, without redness or edema.
The nurse's actions reflect which step of the nursing process?
Nursing Crib – Student Nurses’ Community 23
a. Assessment b. Diagnosis c. Implementation d. Evaluation
92.Nursing care for a female client includes removing elastic
stockings once per day. The Nurse Betty is aware that the rationale
for this intervention?
a. To increase blood flow to the heart b. To observe the lower
extremities c. To allow the leg muscles to stretch and relax d. To
permit veins in the legs to fill with blood.
93.Which nursing intervention takes highest priority when caring for
a newly admitted client who's receiving a blood transfusion?
a. Instructing the client to report any itching, swelling, or dyspnea. b.
Informing the client that the transfusion usually take 1 ½ to 2 hours.
c. Documenting blood administration in the client care record. d.
Assessing the client’s vital signs when the transfusion ends.
94.A male client complains of abdominal discomfort and nausea
while receiving tube feedings. Which intervention is most
appropriate for this problem?
a. Give the feedings at room temperature. b. Decrease the rate of
feedings and the concentration of the formula. c. Place the client in
semi-Fowler's position while feeding. d. Change the feeding
container every 12 hours.
95.Nurse Patricia is reconstituting a powdered medication in a vial.
After adding the solution to the powder, she nurse should:
a. Do nothing. b. Invert the vial and let it stand for 3 to 5 minutes. c.
Shake the vial vigorously. d. Roll the vial gently between the palms.
96.Which intervention should the nurse Trish use when
administering oxygen by face mask to a female client?
a. Secure the elastic band tightly around the client's head. b. Assist
the client to the semi-Fowler position if possible. c. Apply the face
mask from the client's chin up over the nose.
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d. Loosen the connectors between the oxygen equipment and
humidifier.
97.The maximum transfusion time for a unit of packed red blood
cells (RBCs) is:
a. 6 hours b. 4 hours c. 3 hours d. 2 hours
98.Nurse Monique is monitoring the effectiveness of a client's drug
therapy. When should the nurse Monique obtain a blood sample to
measure the trough drug level?
a. 1 hour before administering the next dose. b. Immediately before
administering the next dose. c. Immediately after administering the
next dose. d. 30 minutes after administering the next dose.
99.Nurse May is aware that the main advantage of using a floor
stock system is:
a. The nurse can implement medication orders quickly. b. The nurse
receives input from the pharmacist. c. The system minimizes
transcription errors. d. The system reinforces accurate calculations.
100. Nurse Oliver is assessing a client's abdomen. Which finding
should the nurse report as abnormal?
a. Dullness over the liver. b. Bowel sounds occurring every 10
seconds. c. Shifting dullness over the abdomen. d. Vascular sounds
heard over the renal arteries.
Nursing Crib – Student Nurses’ Community 25
NURSING PRACTICE II
Community Health Nursing and Care of the Mother and Child
TEST II - Community Health Nursing and Care of the Mother and
Child
1. May arrives at the health care clinic and tells the nurse that her
last menstrual period was 9 weeks ago. She also tells the nurse that
a home pregnancy test was positive but she began to have mild
cramps and is now having moderate vaginal bleeding. During the
physical examination of the client, the nurse notes that May has a
dilated cervix. The nurse determines that May is experiencing which
type of abortion?
a. Inevitable b. Incomplete c. Threatened d. Septic
2. Nurse Reese is reviewing the record of a pregnant client for her
first prenatal visit. Which of the following data, if noted on the
client’s record, would alert the nurse that the client is at risk for a
spontaneous abortion?
a. Age 36 years b. History of syphilis c. History of genital herpes d.
History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who is newly admitted
to the hospital with a possible diagnosis of ectopic pregnancy. Nurse
Hazel develops a plan of care for the client and determines that
which of the following nursing actions is the priority?
a. Monitoring weight b. Assessing for edema c. Monitoring apical
pulse d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant client about nutrition
and insulin needs during pregnancy. The nurse determines that the
client understands dietary and insulin needs if the client states that
the second half of pregnancy require:
a. Decreased caloric intake b. Increased caloric intake c. Decreased
Insulin d. Increase Insulin
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5. Nurse Michelle is assessing a 24 year old client with a diagnosis of
hydatidiform mole. She is aware that one of the following is
unassociated with this condition?
a. Excessive fetal activity. b. Larger than normal uterus for
gestational age. c. Vaginal bleeding d. Elevated levels of human
chorionic gonadotropin.
6. A pregnant client is receiving magnesium sulfate for severe
pregnancy induced hypertension (PIH). The clinical findings that
would warrant use of the antidote , calcium gluconate is:
a. Urinary output 90 cc in 2 hours. b. Absent patellar reflexes. c.
Rapid respiratory rate above 40/min. d. Rapid rise in blood pressure.
7. During vaginal examination of Janah who is in labor, the
presenting part is at station plus two. Nurse, correctly interprets it
as:
a. Presenting part is 2 cm above the plane of the ischial spines. b.
Biparietal diameter is at the level of the ischial spines. c. Presenting
part in 2 cm below the plane of the ischial spines. d. Biparietal
diameter is 2 cm above the ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin) for induction of
labor. A condition that warrant the nurse in-charge to discontinue
I.V. infusion of Pitocin is:
a. Contractions every 1 ½ minutes lasting 70-80 seconds. b. Maternal
temperature 101.2 c. Early decelerations in the fetal heart rate. d.
Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered to a client with
pregnancy induced hypertension (PIH). A nursing action that must be
initiated as the plan of care throughout injection of the drug is:
a. Ventilator assistance b. CVP readings c. EKG tracings d. Continuous
CPR
10. A trial for vaginal delivery after an earlier caesareans, would
likely to be given to a gravida, who had:
a. First low transverse cesarean was for active herpes type 2
infections; vaginal culture at 39 weeks pregnancy was positive. b.
First and second caesareans were for cephalopelvic disproportion. c.
First caesarean through a classic incision as a result of severe fetal
distress. d. First low transverse caesarean was for breech position.
Fetus in this pregnancy is in a vertex presentation.
11.Nurse Ryan is aware that the best initial approach when trying to
take a crying toddler’s temperature is:
a. Talk to the mother first and then to the toddler. b. Bring extra
help so it can be done quickly. c. Encourage the mother to hold the
child. d. Ignore the crying and screaming.
12.Baby Tina a 3 month old infant just had a cleft lip and palate
repair. What should the nurse do to prevent trauma to operative
site?
a. Avoid touching the suture line, even when cleaning. b. Place the
baby in prone position. c. Give the baby a pacifier. d. Place the
infant’s arms in soft elbow restraints.
13.Which action should nurse Marian include in the care plan for a 2
month old with heart failure?
a. Feed the infant when he cries. b. Allow the infant to rest before
feeding. c. Bathe the infant and administer medications before
feeding. d. Weigh and bathe the infant before feeding.
14.Nurse Hazel is teaching a mother who plans to discontinue breast
feeding after 5 months. The nurse should advise her to include
which foods in her infant’s diet?
a. Skim milk and baby food. b. Whole milk and baby food. c. Iron-rich
formula only. d. Iron-rich formula and baby food.
15.Mommy Linda is playing with her infant, who is sitting securely
alone on the floor of the clinic. The mother hides a toy behind her
back and the
Nursing Crib – Student Nurses’ Community 29
infant looks for it. The nurse is aware that estimated age of the
infant would be:
a. 6 months b. 4 months c. 8 months d. 10 months
16.Which of the following is the most prominent feature of public
health nursing?
a. It involves providing home care to sick people who are not
confined in the hospital. b. Services are provided free of charge to
people within the catchments area. c. The public health nurse
functions as part of a team providing a public health nursing
services. d. Public health nursing focuses on preventive, not curative,
services.
17.When the nurse determines whether resources were maximized
in implementing Ligtas Tigdas, she is evaluating
a. Effectiveness b. Efficiency c. Adequacy d. Appropriateness
18.Vangie is a new B.S.N. graduate. She wants to become a Public
Health Nurse. Where should she apply?
a. Department of Health b. Provincial Health Office c. Regional
Health Office d. Rural Health Unit
19.Tony is aware the Chairman of the Municipal Health Board is:
a. Mayor b. Municipal Health Officer c. Public Health Nurse d. Any
qualified physician
20.Myra is the public health nurse in a municipality with a total
population of about 20,000. There are 3 rural health midwives
among the RHU personnel. How many more midwife items will the
RHU need?
Nursing Crib – Student Nurses’ Community 30
a. 1 b. 2 c. 3 d. The RHU does not need any more midwife item.
21.According to Freeman and Heinrich, community health nursing is
a developmental service. Which of the following best illustrates this
statement?
a. The community health nurse continuously develops himself
personally and professionally. b. Health education and community
organizing are necessary in providing community health services. c.
Community health nursing is intended primarily for health
promotion and prevention and treatment of disease. d. The goal of
community health nursing is to provide nursing services to people in
their own places of residence.
22.Nurse Tina is aware that the disease declared through
Presidential Proclamation No. 4 as a target for eradication in the
Philippines is?
a. Poliomyelitis b. Measles c. Rabies d. Neonatal tetanus
23.May knows that the step in community organizing that involves
training of potential leaders in the community is:
a. Integration b. Community organization c. Community study d.
Core group formation
24.Beth a public health nurse takes an active role in community
participation. What is the primary goal of community organizing?
a. To educate the people regarding community health problems b.
To mobilize the people to resolve community health problems c. To
maximize the community’s resources in dealing with health
problems. d. To maximize the community’s resources in dealing with
health problems.
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25.Tertiary prevention is needed in which stage of the natural
history of disease?
a. Pre-pathogenesis b. Pathogenesis c. Prodromal d. Terminal
26.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.
27.A fullterm client is in labor. Nurse Betty is aware that the fetal
heart rate would be:
a. 80 to 100 beats/minute b. 100 to 120 beats/minute c. 120 to 160
beats/minute d. 160 to 180 beats/minute
28.The skin in the diaper area of a 7 month old infant is excoriated
and red. Nurse Hazel should instruct the mother to:
a. Change the diaper more often. b. Apply talc powder with diaper
changes. c. Wash the area vigorously with each diaper change. d.
Decrease the infant’s fluid intake to decrease saturating diapers.
29.Nurse Carla knows that the common cardiac anomalies in
children with Down Syndrome (tri-somy 21) is:
a. Atrial septal defect b. Pulmonic stenosis c. Ventricular septal
defect d. Endocardial cushion defect
30.Malou was diagnosed with severe preeclampsia is now receiving
I.V. magnesium sulfate. The adverse effects associated with
magnesium sulfate is:
a. Anemia
Nursing Crib – Student Nurses’ Community 32
b. Decreased urine output c. Hyperreflexia d. Increased respiratory
rate
31.A 23 year old client is having her menstrual period every 2 weeks
that last for 1 week. This type of menstrual pattern is bets defined
by:
a. Menorrhagia b. Metrorrhagia c. Dyspareunia d. Amenorrhea
32.Jannah is admitted to the labor and delivery unit. The critical
laboratory result for this client would be:
a. Oxygen saturation b. Iron binding capacity c. Blood typing d.
Serum Calcium
33.Nurse Gina is aware that the most common condition found
during the second-trimester of pregnancy is:
a. Metabolic alkalosis b. Respiratory acidosis c. Mastitis d.
Physiologic anemia
34.Nurse Lynette is working in the triage area of an emergency
department. She sees that several pediatric clients arrive
simultaneously. The client who needs to be treated first is:
a. A crying 5 year old child with a laceration on his scalp. b. A 4 year
old child with a barking coughs and flushed appearance. c. A 3 year
old child with Down syndrome who is pale and asleep in his mother’s
arms. d. A 2 year old infant with stridorous breath sounds, sitting up
in his mother’s arms and drooling.
35.Maureen in her third trimester arrives at the emergency room
with painless vaginal bleeding. Which of the following conditions is
suspected?
a. Placenta previa b. Abruptio placentae c. Premature labor d.
Sexually transmitted disease
Nursing Crib – Student Nurses’ Community 33
36.A young child named Richard is suspected of having pinworms.
The community nurse collects a stool specimen to confirm the
diagnosis. The nurse should schedule the collection of this specimen
for:
a. Just before bedtime b. After the child has been bathe c. Any time
during the day d. Early in the morning
37.In doing a child’s admission assessment, Nurse Betty should be
alert to note which signs or symptoms of chronic lead poisoning?
a. Irritability and seizures b. Dehydration and diarrhea c. Bradycardia
and hypotension d. Petechiae and hematuria
38.To evaluate a woman’s understanding about the use of
diaphragm for family planning, Nurse Trish asks her to explain how
she will use the appliance. Which response indicates a need for
further health teaching?
a. “I should check the diaphragm carefully for holes every time I use
it” b. “I may need a different size of diaphragm if I gain or lose
weight more than 20 pounds” c. “The diaphragm must be left in
place for atleast 6 hours after intercourse” d. “I really need to use
the diaphragm and jelly most during the middle of my menstrual
cycle”.
39.Hypoxia is a common complication of laryngotracheobronchitis.
Nurse Oliver should frequently assess a child with
laryngotracheobronchitis for:
a. Drooling b. Muffled voice c. Restlessness d. Low-grade fever
40.How should Nurse Michelle guide a child who is blind to walk to
the playroom?
a. Without touching the child, talk continuously as the child walks
down the hall. b. Walk one step ahead, with the child’s hand on the
nurse’s elbow. c. Walk slightly behind, gently guiding the child
forward. d. Walk next to the child, holding the child’s hand.
Nursing Crib – Student Nurses’ Community 34
41.When assessing a newborn diagnosed with ductus arteriosus,
Nurse Olivia should expect that the child most likely would have an:
a. Loud, machinery-like murmur. b. Bluish color to the lips. c.
Decreased BP reading in the upper extremities d. Increased BP
reading in the upper extremities.
42.The reason nurse May keeps the neonate in a neutral thermal
environment is that when a newborn becomes too cool, the neonate
requires:
a. Less oxygen, and the newborn’s metabolic rate increases. b. More
oxygen, and the newborn’s metabolic rate decreases. c. More
oxygen, and the newborn’s metabolic rate increases. d. Less oxygen,
and the newborn’s metabolic rate decreases.
43.Before adding potassium to an infant’s I.V. line, Nurse Ron must
be sure to assess whether this infant has:
a. Stable blood pressure b. Patant fontanelles c. Moro’s reflex d.
Voided
44.Nurse Carla should know that the most common causative factor
of dermatitis in infants and younger children is:
a. Baby oil b. Baby lotion c. Laundry detergent d. Powder with
cornstarch
45.During tube feeding, how far above an infant’s stomach should
the nurse hold the syringe with formula?
a. 6 inches b. 12 inches c. 18 inches d. 24 inches
46.In a mothers’ class, Nurse Lhynnete discussed childhood diseases
such as chicken pox. Which of the following statements about
chicken pox is correct?
Nursing Crib – Student Nurses’ Community 35
a. The older one gets, the more susceptible he becomes to the
complications of chicken pox. b. A single attack of chicken pox will
prevent future episodes, including conditions such as shingles. c. To
prevent an outbreak in the community, quarantine may be imposed
by health authorities. d. Chicken pox vaccine is best given when
there is an impending outbreak in the community.
47.Barangay Pinoy had an outbreak of German measles. To prevent
congenital rubella, what is the BEST advice that you can give to
women in the first trimester of pregnancy in the barangay Pinoy?
a. Advice them on the signs of German measles. b. Avoid crowded
places, such as markets and movie houses. c. Consult at the health
center where rubella vaccine may be given. d. Consult a physician
who may give them rubella immunoglobulin.
48.Myrna a public health nurse knows that to determine possible
sources of sexually transmitted infections, the BEST method that
may be undertaken is:
a. Contact tracing b. Community survey c. Mass screening tests d.
Interview of suspects
49.A 33-year old female client came for consultation at the health
center with the chief complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise. A week after the
start of fever, the client noted yellowish discoloration of his sclera.
History showed that he waded in flood waters about 2 weeks before
the onset of symptoms. Based on her history, which disease
condition will you suspect?
a. Hepatitis A b. Hepatitis B c. Tetanus d. Leptospirosis
50.Mickey a 3-year old client was brought to the health center with
the chief complaint of severe diarrhea and the passage of “rice
water” stools. The client is most probably suffering from which
condition?
a. Giardiasis b. Cholera c. Amebiasis
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d. Dysentery
51.The most prevalent form of meningitis among children aged 2
months to 3 years is caused by which microorganism?
a. Hemophilus influenzae b. Morbillivirus c. Steptococcus
pneumoniae d. Neisseria meningitidis
52.The student nurse is aware that the pathognomonic sign of
measles is Koplik’s spot and you may see Koplik’s spot by inspecting
the:
a. Nasal mucosa b. Buccal mucosa c. Skin on the abdomen d. Skin on
neck
53.Angel was diagnosed as having Dengue fever. You will say that
there is slow capillary refill when the color of the nailbed that you
pressed does not return within how many seconds?
a. 3 seconds b. 6 seconds c. 9 seconds d. 10 seconds
54.In Integrated Management of Childhood Illness, the nurse is
aware that the severe conditions generally require urgent referral to
a hospital. Which of the following severe conditions DOES NOT
always require urgent referral to a hospital?
a. Mastoiditis b. Severe dehydration c. Severe pneumonia d. Severe
febrile disease
55.Myrna a public health nurse will conduct outreach immunization
in a barangay Masay with a population of about 1500. The estimated
number of infants in the barangay would be:
a. 45 infants b. 50 infants c. 55 infants d. 65 infants
Nursing Crib – Student Nurses’ Community 37
56.The community nurse is aware that the biological used in
Expanded Program on Immunization (EPI) should NOT be stored in
the freezer?
a. DPT b. Oral polio vaccine c. Measles vaccine d. MMR
57.It is the most effective way of controlling schistosomiasis in an
endemic area?
a. Use of molluscicides b. Building of foot bridges c. Proper use of
sanitary toilets d. Use of protective footwear, such as rubber boots
58.Several clients is newly admitted and diagnosed with leprosy.
Which of the following clients should be classified as a case of
multibacillary leprosy?
a. 3 skin lesions, negative slit skin smear b. 3 skin lesions, positive slit
skin smear c. 5 skin lesions, negative slit skin smear d. 5 skin lesions,
positive slit skin smear
59.Nurses are aware that diagnosis of leprosy is highly dependent on
recognition of symptoms. Which of the following is an early sign of
leprosy?
a. Macular lesions b. Inability to close eyelids c. Thickened painful
nerves d. Sinking of the nosebridge
60.Marie brought her 10 month old infant for consultation because
of fever, started 4 days prior to consultation. In determining malaria
risk, what will you do?
a. Perform a tourniquet test. b. Ask where the family resides. c. Get
a specimen for blood smear. d. Ask if the fever is present everyday.
61.Susie brought her 4 years old daughter to the RHU because of
cough and colds. Following the IMCI assessment guide, which of the
following is a danger sign that indicates the need for urgent referral
to a hospital?
Nursing Crib – Student Nurses’ Community 38
a. Inability to drink b. High grade fever c. Signs of severe dehydration
d. Cough for more than 30 days
62.Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using
the IMCI guidelines, how will you manage Jimmy?
a. Refer the child urgently to a hospital for confinement. b.
Coordinate with the social worker to enroll the child in a feeding
program. c. Make a teaching plan for the mother, focusing on menu
planning for her child. d. Assess and treat the child for health
problems like infections and intestinal parasitism.
63.Gina is using Oresol in the management of diarrhea of her 3-year
old child. She asked you what to do if her child vomits. As a nurse
you will tell her to:
a. Bring the child to the nearest hospital for further assessment. b.
Bring the child to the health center for intravenous fluid therapy. c.
Bring the child to the health center for assessment by the physician.
d. Let the child rest for 10 minutes then continue giving Oresol more
slowly.
64.Nikki a 5-month old infant was brought by his mother to the
health center because of diarrhea for 4 to 5 times a day. Her skin
goes back slowly after a skin pinch and her eyes are sunken. Using
the IMCI guidelines, you will classify this infant in which category?
a. No signs of dehydration b. Some dehydration c. Severe
dehydration d. The data is insufficient.
65.Chris a 4-month old infant was brought by her mother to the
health center because of cough. His respiratory rate is 42/minute.
Using the Integrated Management of Child Illness (IMCI) guidelines
of assessment, his breathing is considered as:
a. Fast b. Slow c. Normal d. Insignificant
Nursing Crib – Student Nurses’ Community 39
66.Maylene had just received her 4th dose of tetanus toxoid. She is
aware that her baby will have protection against tetanus for
a. 1 year b. 3 years c. 5 years d. Lifetime
67.Nurse Ron is aware that unused BCG should be discarded after
how many hours of reconstitution?
a. 2 hours b. 4 hours c. 8 hours d. At the end of the day
68.The nurse explains to a breastfeeding mother that breast milk is
sufficient for all of the baby’s nutrient needs only up to:
a. 5 months b. 6 months c. 1 year d. 2 years
69.Nurse Ron is aware that the gestational age of a conceptus that is
considered viable (able to live outside the womb) is:
a. 8 weeks b. 12 weeks c. 24 weeks d. 32 weeks
70.When teaching parents of a neonate the proper position for the
neonate’s sleep, the nurse Patricia stresses the importance of
placing the neonate on his back to reduce the risk of which of the
following?
a. Aspiration b. Sudden infant death syndrome (SIDS) c. Suffocation
d. Gastroesophageal reflux (GER)
71.Which finding might be seen in baby James a neonate suspected
of having an infection?
a. Flushed cheeks b. Increased temperature
Nursing Crib – Student Nurses’ Community 40
c. Decreased temperature d. Increased activity level
72.Baby Jenny who is small-for-gestation is at increased risk during
the transitional period for which complication?
a. Anemia probably due to chronic fetal hyposia b. Hyperthermia
due to decreased glycogen stores c. Hyperglycemia due to decreased
glycogen stores d. Polycythemia probably due to chronic fetal
hypoxia
73.Marjorie has just given birth at 42 weeks’ gestation. When the
nurse assessing the neonate, which physical finding is expected?
a. A sleepy, lethargic baby b. Lanugo covering the body c.
Desquamation of the epidermis d. Vernix caseosa covering the body
74.After reviewing the Myrna’s maternal history of magnesium
sulfate during labor, which condition would nurse Richard anticipate
as a potential problem in the neonate?
a. Hypoglycemia b. Jitteriness c. Respiratory depression d.
Tachycardia
75.Which symptom would indicate the Baby Alexandra was adapting
appropriately to extra-uterine life without difficulty?
a. Nasal flaring b. Light audible grunting c. Respiratory rate 40 to 60
breaths/minute d. Respiratory rate 60 to 80 breaths/minute
76. When teaching umbilical cord care for Jennifer a new mother,
the nurse Jenny would include which information?
a. Apply peroxide to the cord with each diaper change b. Cover the
cord with petroleum jelly after bathing c. Keep the cord dry and
open to air d. Wash the cord with soap and water each day during a
tub bath.
77.Nurse John is performing an assessment on a neonate. Which of
the following findings is considered common in the healthy
neonate?
Nursing Crib – Student Nurses’ Community 41
a. Simian crease b. Conjunctival hemorrhage c. Cystic hygroma d.
Bulging fontanelle
78.Dr. Esteves decides to artificially rupture the membranes of a
mother who is on labor. Following this procedure, the nurse Hazel
checks the fetal heart tones for which the following reasons?
a. To determine fetal well-being. b. To assess for prolapsed cord c.
To assess fetal position d. To prepare for an imminent delivery.
79.Which of the following would be least likely to indicate
anticipated bonding behaviors by new parents?
a. The parents’ willingness to touch and hold the new born. b. The
parent’s expression of interest about the size of the new born. c. The
parents’ indication that they want to see the newborn. d. The
parents’ interactions with each other.
80.Following a precipitous delivery, examination of the client's
vagina reveals a fourth-degree laceration. Which of the following
would be contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours. b.
Instructing the client to use two or more peripads to cushion the
area. c. Instructing the client on the use of sitz baths if ordered. d.
Instructing the client about the importance of perineal (kegel)
exercises.
81. A pregnant woman accompanied by her husband, seeks
admission to the labor and delivery area. She states that she's in
labor and says she attended the facility clinic for prenatal care.
Which question should the nurse Oliver ask her first?
a. “Do you have any chronic illnesses?” b. “Do you have any
allergies?” c. “What is your expected due date?” d. “Who will be
with you during labor?”
82.A neonate begins to gag and turns a dusky color. What should the
nurse do first?
Nursing Crib – Student Nurses’ Community 42
a. Calm the neonate. b. Notify the physician. c. Provide oxygen via
face mask as ordered d. Aspirate the neonate’s nose and mouth with
a bulb syringe.
83. When a client states that her "water broke," which of the
following actions would be inappropriate for the nurse to do?
a. Observing the pooling of straw-colored fluid. b. Checking vaginal
discharge with nitrazine paper. c. Conducting a bedside ultrasound
for an amniotic fluid index. d. Observing for flakes of vernix in the
vaginal discharge.
84. A baby girl is born 8 weeks premature. At birth, she has no
spontaneous respirations but is successfully resuscitated. Within
several hours she develops respiratory grunting, cyanosis,
tachypnea, nasal flaring, and retractions. She's diagnosed with
respiratory distress syndrome, intubated, and placed on a ventilator.
Which nursing action should be included in the baby's plan of care to
prevent retinopathy of prematurity?
a. Cover his eyes while receiving oxygen. b. Keep her body
temperature low. c. Monitor partial pressure of oxygen (Pao2)
levels. d. Humidify the oxygen.
85. Which of the following is normal newborn calorie intake?
a. 110 to 130 calories per kg. b. 30 to 40 calories per lb of body
weight. c. At least 2 ml per feeding d. 90 to 100 calories per kg
86. Nurse John is knowledgeable that usually individual twins will
grow appropriately and at the same rate as singletons until how
many weeks?
a. 16 to 18 weeks b. 18 to 22 weeks c. 30 to 32 weeks d. 38 to 40
weeks
87. Which of the following classifications applies to monozygotic
twins for whom the cleavage of the fertilized ovum occurs more
than 13 days after fertilization?
a. conjoined twins b. diamniotic dichorionic twins
Nursing Crib – Student Nurses’ Community 43
c. diamniotic monochorionic twin d. monoamniotic monochorionic
twins
88. Tyra experienced painless vaginal bleeding has just been
diagnosed as having a placenta previa. Which of the following
procedures is usually performed to diagnose placenta previa?
a. Amniocentesis b. Digital or speculum examination c. External fetal
monitoring d. Ultrasound
89. Nurse Arnold knows that the following changes in respiratory
functioning during pregnancy is considered normal:
a. Increased tidal volume b. Increased expiratory volume c.
Decreased inspiratory capacity d. Decreased oxygen consumption
90. Emily has gestational diabetes and it is usually managed by
which of the following therapy?
a. Diet b. Long-acting insulin c. Oral hypoglycemic d. Oral
hypoglycemic drug and insulin
91. Magnesium sulfate is given to Jemma with preeclampsia to
prevent which of the following condition?
a. Hemorrhage b. Hypertension c. Hypomagnesemia d. Seizure
92. Cammile with sickle cell anemia has an increased risk for having
a sickle cell crisis during pregnancy. Aggressive management of a
sickle cell crisis includes which of the following measures?
a. Antihypertensive agents b. Diuretic agents c. I.V. fluids d.
Acetaminophen (Tylenol) for pain
Nursing Crib – Student Nurses’ Community 44
93. Which of the following drugs is the antidote for magnesium
toxicity?
a. Calcium gluconate (Kalcinate) b. Hydralazine (Apresoline) c.
Naloxone (Narcan) d. Rho (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis during her first prenatal visit.
An intradermal injection of purified protein derivative (PPD) of the
tuberculin bacilli is given. She is considered to have a positive test
for which of the following results?
a. An indurated wheal under 10 mm in diameter appears in 6 to 12
hours. b. An indurated wheal over 10 mm in diameter appears in 48
to 72 hours. c. A flat circumcised area under 10 mm in diameter
appears in 6 to 12 hours. d. A flat circumcised area over 10 mm in
diameter appears in 48 to 72 hours.
95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her
physician’s office with complaints of fever, nausea, vomiting,
malaise, unilateral flank pain, and costovertebral angle tenderness.
Which of the following diagnoses is most likely?
a. Asymptomatic bacteriuria b. Bacterial vaginosis c. Pyelonephritis
d. Urinary tract infection (UTI)
96. Rh isoimmunization in a pregnant client develops during which
of the following conditions?
a. Rh-positive maternal blood crosses into fetal blood, stimulating
fetal antibodies. b. Rh-positive fetal blood crosses into maternal
blood, stimulating maternal antibodies. c. Rh-negative fetal blood
crosses into maternal blood, stimulating maternal antibodies. d. Rh-
negative maternal blood crosses into fetal blood, stimulating fetal
antibodies.
97. To promote comfort during labor, the nurse John advises a client
to assume certain positions and avoid others. Which position may
cause maternal hypotension and fetal hypoxia?
a. Lateral position b. Squatting position c. Supine position
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d. Standing position
98. Celeste who used heroin during her pregnancy delivers a
neonate. When assessing the neonate, the nurse Lhynnette expects
to find:
a. Lethargy 2 days after birth. b. Irritability and poor sucking. c. A
flattened nose, small eyes, and thin lips. d. Congenital defects such
as limb anomalies.
99. The uterus returns to the pelvic cavity in which of the following
time frames?
a. 7th to 9th day postpartum. b. 2 weeks postpartum. c. End of 6th
week postpartum. d. When the lochia changes to alba.
100. Maureen, a primigravida client, age 20, has just completed a
difficult, forceps-assisted delivery of twins. Her labor was unusually
long and required oxytocin (Pitocin) augmentation. The nurse who's
caring for her should stay alert for:
a. Uterine inversion b. Uterine atony c. Uterine involution d. Uterine
discomfort
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NURSING PRACTICE III
Care of Clients with Physiologic and Psychosocial Alterations
Nursing Crib – Student Nurses’ Community 47
TEST III - Care of Clients with Physiologic and Psychosocial
Alterations
1. Nurse Michelle should know that the drainage is normal 4 days
after a sigmoid colostomy when the stool is:
a. Green liquid b. Solid formed c. Loose, bloody d. Semiformed
2. Where would nurse Kristine place the call light for a male client
with a right-sided brain attack and left homonymous hemianopsia?
a. On the client’s right side b. On the client’s left side c. Directly in
front of the client d. Where the client like
3. A male client is admitted to the emergency department following
an accident. What are the first nursing actions of the nurse?
a. Check respiration, circulation, neurological response. b. Align the
spine, check pupils, and check for hemorrhage. c. Check respirations,
stabilize spine, and check circulation. d. Assess level of
consciousness and circulation.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know
that it reduces preload and relieves angina by:
a. Increasing contractility and slowing heart rate. b. Increasing AV
conduction and heart rate. c. Decreasing contractility and oxygen
consumption. d. Decreasing venous return through vasodilation.
5. Nurse Patricia finds a female client who is post-myocardial
infarction (MI) slumped on the side rails of the bed and
unresponsive to shaking or shouting. Which is the nurse next action?
a. Call for help and note the time. b. Clear the airway c. Give two
sharp thumps to the precordium, and check the pulse. d. Administer
two quick blows.
6. Nurse Monett is caring for a client recovering from gastro-
intestinal bleeding. The nurse should:
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a. Plan care so the client can receive 8 hours of uninterrupted sleep
each night. b. Monitor vital signs every 2 hours. c. Make sure that
the client takes food and medications at prescribed intervals. d.
Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before admission, and
has been receiving heparin I.V. for 2 days. The partial
thromboplastin time (PTT) is 68 seconds. What should Nurse Carla
do?
a. Stop the I.V. infusion of heparin and notify the physician. b.
Continue treatment as ordered. c. Expect the warfarin to increase
the PTT. d. Increase the dosage, because the level is lower than
normal.
8. A client undergone ileostomy, when should the drainage
appliance be applied to the stoma?
a. 24 hours later, when edema has subsided. b. In the operating
room. c. After the ileostomy begin to function. d. When the client is
able to begin self-care procedures.
9. A client undergone spinal anesthetic, it will be important that the
nurse immediately position the client in:
a. On the side, to prevent obstruction of airway by tongue. b. Flat on
back. c. On the back, with knees flexed 15 degrees. d. Flat on the
stomach, with the head turned to the side.
10.While monitoring a male client several hours after a motor
vehicle accident, which assessment data suggest increasing
intracranial pressure?
a. Blood pressure is decreased from 160/90 to 110/70. b. Pulse is
increased from 87 to 95, with an occasional skipped beat. c. The
client is oriented when aroused from sleep, and goes back to sleep
immediately. d. The client refuses dinner because of anorexia.
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of
the following symptoms may appear first?
a. Altered mental status and dehydration
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b. Fever and chills c. Hemoptysis and Dyspnea d. Pleuritic chest pain
and cough
12. A male client has active tuberculosis (TB). Which of the following
symptoms will be exhibit?
a. Chest and lower back pain b. Chills, fever, night sweats, and
hemoptysis c. Fever of more than 104°F (40°C) and nausea d.
Headache and photophobia
13. Mark, a 7-year-old client is brought to the emergency
department. He’s tachypneic and afebrile and has a respiratory rate
of 36 breaths/minute and has a nonproductive cough. He recently
had a cold. Form this history; the client may have which of the
following conditions?
a. Acute asthma b. Bronchial pneumonia c. Chronic obstructive
pulmonary disease (COPD) d. Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and
her respiratory rate is 4 breaths/minute. If action isn’t taken quickly,
she might have which of the following reactions?
a. Asthma attack b. Respiratory arrest c. Seizure d. Wake up on his
own
15. A 77-year-old male client is admitted for elective knee surgery.
Physical examination reveals shallow respirations but no sign of
respiratory distress. Which of the following is a normal physiologic
change related to aging?
a. Increased elastic recoil of the lungs b. Increased number of
functional capillaries in the alveoli c. Decreased residual volume d.
Decreased vital capacity
16. Nurse John is caring for a male client receiving lidocaine I.V.
Which factor is the most relevant to administration of this
medication?
a. Decrease in arterial oxygen saturation (SaO2) when measured
with a pulse oximeter. b. Increase in systemic blood pressure.
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c. Presence of premature ventricular contractions (PVCs) on a
cardiac monitor. d. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an anticoagulant. The
nurse should teach the client to:
a. Report incidents of diarrhea. b. Avoid foods high in vitamin K c.
Use a straight razor when shaving. d. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for the insertion of an I.V.
catheter. The nurse should treat excess hair at the site by:
a. Leaving the hair intact b. Shaving the area c. Clipping the hair in
the area d. Removing the hair with a depilatory.
19. Nurse Michelle is caring for an elderly female with osteoporosis.
When teaching the client, the nurse should include information
about which major complication:
a. Bone fracture b. Loss of estrogen c. Negative calcium balance d.
Dowager’s hump
20. Nurse Len is teaching a group of women to perform BSE. The
nurse should explain that the purpose of performing the
examination is to discover:
a. Cancerous lumps b. Areas of thickness or fullness c. Changes from
previous examinations. d. Fibrocystic masses
21. When caring for a female client who is being treated for
hyperthyroidism, it is important to:
a. Provide extra blankets and clothing to keep the client warm. b.
Monitor the client for signs of restlessness, sweating, and excessive
weight loss during thyroid replacement therapy. c. Balance the
client’s periods of activity and rest. d. Encourage the client to be
active to prevent constipation.
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22. Nurse Kris is teaching a client with history of atherosclerosis. To
decrease the risk of atherosclerosis, the nurse should encourage the
client to:
a. Avoid focusing on his weight. b. Increase his activity level. c.
Follow a regular diet. d. Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical floor. Nurse Greta must
logroll a client following a:
a. Laminectomy b. Thoracotomy c. Hemorrhoidectomy d.
Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular
lens implant. Nurse Oliver is giving the client discharge instructions.
These instructions should include which of the following?
a. Avoid lifting objects weighing more than 5 lb (2.25 kg). b. Lie on
your abdomen when in bed c. Keep rooms brightly lit. d. Avoiding
straining during bowel movement or bending at the waist.
25. George should be taught about testicular examinations during:
a. when sexual activity starts b. After age 69 c. After age 40 d. Before
age 20.
26. A male client undergone a colon resection. While turning him,
wound dehiscence with evisceration occurs. Nurse Trish first
response is to:
a. Call the physician b. Place a saline-soaked sterile dressing on the
wound. c. Take a blood pressure and pulse. d. Pull the dehiscence
closed.
27. Nurse Audrey is caring for a client who has suffered a severe
cerebrovascular accident. During routine assessment, the nurse
notices CheyneStrokes respirations. Cheyne-strokes respirations are:
a. A progressively deeper breaths followed by shallower breaths
with apneic periods.
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b. Rapid, deep breathing with abrupt pauses between each breath.
c. Rapid, deep breathing and irregular breathing without pauses. d.
Shallow breathing with an increased respiratory rate.
28. Nurse Bea is assessing a male client with heart failure. The
breath sounds commonly auscultated in clients with heart failure
are:
a. Tracheal b. Fine crackles c. Coarse crackles d. Friction rubs
29. The nurse is caring for Kenneth experiencing an acute asthma
attack. The client stops wheezing and breath sounds aren’t audible.
The reason for this change is that:
a. The attack is over. b. The airways are so swollen that no air cannot
get through. c. The swelling has decreased. d. Crackles have replaced
wheezes.
30. Mike with epilepsy is having a seizure. During the active seizure
phase, the nurse should:
a. Place the client on his back remove dangerous objects, and insert
a bite block. b. Place the client on his side, remove dangerous
objects, and insert a bite block. c. Place the client o his back, remove
dangerous objects, and hold down his arms. d. Place the client on his
side, remove dangerous objects, and protect his head.
31. After insertion of a cheat tube for a pneumothorax, a client
becomes hypotensive with neck vein distention, tracheal shift,
absent breath sounds, and diaphoresis. Nurse Amanda suspects a
tension pneumothorax has occurred. What cause of tension
pneumothorax should the nurse check for?
a. Infection of the lung. b. Kinked or obstructed chest tube c.
Excessive water in the water-seal chamber d. Excessive chest tube
drainage
32. Nurse Maureen is talking to a male client, the client begins
choking on his lunch. He’s coughing forcefully. The nurse should:
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a. Stand him up and perform the abdominal thrust maneuver from
behind. b. Lay him down, straddle him, and perform the abdominal
thrust maneuver. c. Leave him to get assistance d. Stay with him but
not intervene at this time.
33. Nurse Ron is taking a health history of an 84 year old client.
Which information will be most useful to the nurse for planning
care?
a. General health for the last 10 years. b. Current health promotion
activities. c. Family history of diseases. d. Marital status.
34. When performing oral care on a comatose client, Nurse Krina
should:
a. Apply lemon glycerin to the client’s lips at least every 2 hours. b.
Brush the teeth with client lying supine. c. Place the client in a side
lying position, with the head of the bed lowered. d. Clean the client’s
mouth with hydrogen peroxide.
35. A 77-year-old male client is admitted with a diagnosis of
dehydration and change in mental status. He’s being hydrated with
L.V. fluids. When the nurse takes his vital signs, she notes he has a
fever of 103°F (39.4°C) a cough producing yellow sputum and
pleuritic chest pain. The nurse suspects this client may have which of
the following conditions?
a. Adult respiratory distress syndrome (ARDS) b. Myocardial
infarction (MI) c. Pneumonia d. Tuberculosis
36. Nurse Oliver is working in a out patient clinic. He has been
alerted that there is an outbreak of tuberculosis (TB). Which of the
following clients entering the clinic today most likely to have TB?
a. A 16-year-old female high school student b. A 33-year-old day-
care worker c. A 43-yesr-old homeless man with a history of
alcoholism d. A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be sent for a chest
X-ray. The nurse is aware that which of the following reasons this is
done?
a. To confirm the diagnosis
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b. To determine if a repeat skin test is needed c. To determine the
extent of lesions d. To determine if this is a primary or secondary
infection
38. Kennedy with acute asthma showing inspiratory and expiratory
wheezes and a decreased forced expiratory volume should be
treated with which of the following classes of medication right
away?
a. Beta-adrenergic blockers b. Bronchodilators c. Inhaled steroids d.
Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking
one to two packs of cigarettes per day has a chronic cough
producing thick sputum, peripheral edema and cyanotic nail beds.
Based on this information, he most likely has which of the following
conditions?
a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic
obstructive bronchitis d. Emphysema
Situation: Francis, age 46 is admitted to the hospital with diagnosis
of Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone marrow
transplantation. Which statement about bone marrow
transplantation is not correct?
a. The patient is under local anesthesia during the procedure b. The
aspirated bone marrow is mixed with heparin. c. The aspiration site
is the posterior or anterior iliac crest. d. The recipient receives
cyclophosphamide (Cytoxan) for 4 consecutive days before the
procedure.
41. After several days of admission, Francis becomes disoriented and
complains of frequent headaches. The nurse in-charge first action
would be:
a. Call the physician b. Document the patient’s status in his charts. c.
Prepare oxygen treatment d. Raise the side rails
42. During routine care, Francis asks the nurse, “How can I be
anemic if this disease causes increased my white blood cell
production?” The nurse in-charge best response would be that the
increased number of white blood cells (WBC) is:
Nursing Crib – Student Nurses’ Community 55
a. Crowd red blood cells b. Are not responsible for the anemia. c.
Uses nutrients from other cells d. Have an abnormally short life span
of cells.
43. Diagnostic assessment of Francis would probably not reveal:
a. Predominance of lymhoblasts b. Leukocytosis c. Abnormal blast
cells in the bone marrow d. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the
left leg undergoes an emergency embolectomy. Six hours later, the
nurse isn’t able to obtain pulses in his left foot using Doppler
ultrasound. The nurse immediately notifies the physician, and asks
her to prepare the client for surgery. As the nurse enters the client’s
room to prepare him, he states that he won’t have any more
surgery. Which of the following is the best initial response by the
nurse?
a. Explain the risks of not having the surgery b. Notifying the
physician immediately c. Notifying the nursing supervisor d.
Recording the client’s refusal in the nurses’ notes
45. During the endorsement, which of the following clients should
the on-duty nurse assess first?
a. The 58-year-old client who was admitted 2 days ago with heart
failure, blood pressure of 126/76 mm Hg, and a respiratory rate of
22 breaths/ minute. b. The 89-year-old client with end-stage right-
sided heart failure, blood pressure of 78/50 mm Hg, and a “do not
resuscitate” order c. The 62-year-old client who was admitted 1 day
ago with thrombophlebitis and is receiving L.V. heparin d. The 75-
year-old client who was admitted 1 hour ago with new-onset atrial
fibrillation and is receiving L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain
and states that her heart feels like “it’s racing out of the chest”. She
reports no history of cardiac disorders. The nurse attaches her to a
cardiac monitor and notes sinus tachycardia with a rate of
136beats/minutes. Breath sounds are clear and the respiratory rate
is 26 breaths/minutes. Which of the following drugs should the
nurse question the client about using?
a. Barbiturates
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b. Opioids c. Cocaine d. Benzodiazepines
47. A 51-year-old female client tells the nurse in-charge that she has
found a painless lump in her right breast during her monthly self-
examination. Which assessment finding would strongly suggest that
this client's lump is cancerous?
a. Eversion of the right nipple and mobile mass b. Nonmobile mass
with irregular edges c. Mobile mass that is soft and easily delineated
d. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the nurse, "What is
the usual treatment for this type of cancer?" Which treatment
should the nurse name?
a. Surgery b. Chemotherapy c. Radiation d. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy
report classifies the lesion according to the TNM staging system as
follows: TIS, N0, M0. What does this classification mean?
a. No evidence of primary tumor, no abnormal regional lymph
nodes, and no evidence of distant metastasis b. Carcinoma in situ,
no abnormal regional lymph nodes, and no evidence of distant
metastasis c. Can't assess tumor or regional lymph nodes and no
evidence of metastasis d. Carcinoma in situ, no demonstrable
metastasis of the regional lymph nodes, and ascending degrees of
distant metastasis
50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When
teaching the client how to care for the neck stoma, the nurse should
include which instruction?
a. "Keep the stoma uncovered." b. "Keep the stoma dry." c. "Have a
family member perform stoma care initially until you get used to the
procedure." d. "Keep the stoma moist."
Nursing Crib – Student Nurses’ Community 57
51. A 37-year-old client with uterine cancer asks the nurse, "Which is
the most common type of cancer in women?" The nurse replies that
it's breast cancer. Which type of cancer causes the most deaths in
women?
a. Breast cancer b. Lung cancer c. Brain cancer d. Colon and rectal
cancer
52. Antonio with lung cancer develops Horner's syndrome when the
tumor invades the ribs and affects the sympathetic nerve ganglia.
When assessing for signs and symptoms of this syndrome, the nurse
should note:
a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of
the face. b. chest pain, dyspnea, cough, weight loss, and fever. c.
arm and shoulder pain and atrophy of arm and hand muscles, both
on the affected side. d. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply that it
stands for:
a. prostate-specific antigen, which is used to screen for prostate
cancer. b. protein serum antigen, which is used to determine protein
levels. c. pneumococcal strep antigen, which is a bacteria that causes
pneumonia. d. Papanicolaou-specific antigen, which is used to
screen for cervical cancer.
54. What is the most important postoperative instruction that nurse
Kate must give a client who has just returned from the operating
room after receiving a subarachnoid block?
a. "Avoid drinking liquids until the gag reflex returns." b. "Avoid
eating milk products for 24 hours." c. "Notify a nurse if you
experience blood in your urine." d. "Remain supine for the time
specified by the physician."
55. A male client suspected of having colorectal cancer will require
which diagnostic study to confirm the diagnosis?
a. Stool Hematest b. Carcinoembryonic antigen (CEA) c.
Sigmoidoscopy d. Abdominal computed tomography (CT) scan
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56. During a breast examination, which finding most strongly
suggests that the Luz has breast cancer?
a. Slight asymmetry of the breasts. b. A fixed nodular mass with
dimpling of the overlying skin c. Bloody discharge from the nipple d.
Multiple firm, round, freely movable masses that change with the
menstrual cycle
57. A female client with cancer is being evaluated for possible
metastasis. Which of the following is one of the most common
metastasis sites for cancer cells?
a. Liver b. Colon c. Reproductive tract d. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic resonance
imaging (MRI) to confirm or rule out a spinal cord lesion. During the
MRI scan, which of the following would pose a threat to the client?
a. The client lies still. b. The client asks questions. c. The client hears
thumping sounds. d. The client wears a watch and wedding band.
59. Nurse Cecile is teaching a female client about preventing
osteoporosis. Which of the following teaching points is correct?
a. Obtaining an X-ray of the bones every 3 years is recommended to
detect bone loss. b. To avoid fractures, the client should avoid
strenuous exercise. c. The recommended daily allowance of calcium
may be found in a wide variety of foods. d. Obtaining the
recommended daily allowance of calcium requires taking a calcium
supplement.
60. Before Jacob undergoes arthroscopy, the nurse reviews the
assessment findings for contraindications for this procedure. Which
finding is a contraindication?
a. Joint pain b. Joint deformity c. Joint flexion of less than 50% d.
Joint stiffness
Nursing Crib – Student Nurses’ Community 59
61. Mr. Rodriguez is admitted with severe pain in the knees. Which
form of arthritis is characterized by urate deposits and joint pain,
usually in the feet and legs, and occurs primarily in men over age 30?
a. Septic arthritis b. Traumatic arthritis c. Intermittent arthritis d.
Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old
client with stroke in evolution. The infusion contains 25,000 units of
heparin in 500 ml of saline solution. How many milliliters per hour
should be given?
a. 15 ml/hour b. 30 ml/hour c. 45 ml/hour d. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his
left arm is swollen. Which of the following conditions may cause
swelling after a stroke?
a. Elbow contracture secondary to spasticity b. Loss of muscle
contraction decreasing venous return c. Deep vein thrombosis (DVT)
due to immobility of the ipsilateral side d. Hypoalbuminemia due to
protein escaping from an inflamed glomerulus
64. Heberden’s nodes are a common sign of osteoarthritis. Which of
the following statement is correct about this deformity?
a. It appears only in men b. It appears on the distal interphalangeal
joint c. It appears on the proximal interphalangeal joint d. It appears
on the dorsolateral aspect of the interphalangeal joint.
65. Which of the following statements explains the main difference
between rheumatoid arthritis and osteoarthritis?
a. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t b.
Osteoarthritis is a localized disease rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease, rheumatoid arthritis is
localized d. Osteoarthritis has dislocations and subluxations,
rheumatoid arthritis doesn’t
66. Mrs. Cruz uses a cane for assistance in walking. Which of the
following statements is true about a cane or other assistive devices?
Nursing Crib – Student Nurses’ Community 60
a. A walker is a better choice than a cane. b. The cane should be
used on the affected side c. The cane should be used on the
unaffected side d. A client with osteoarthritis should be encouraged
to ambulate without the cane
67. A male client with type 1 diabetes is scheduled to receive 30 U of
70/30 insulin. There is no 70/30 insulin available. As a substitution,
the nurse may give the client: a. 9 U regular insulin and 21 U neutral
protamine Hagedorn (NPH). b. 21 U regular insulin and 9 U NPH. c.
10 U regular insulin and 20 U NPH. d. 20 U regular insulin and 10 U
NPH.
68. Nurse Len should expect to administer which medication to a
client with gout?
a. aspirin b. furosemide (Lasix) c. colchicines d. calcium gluconate
(Kalcinate)
69. Mr. Domingo with a history of hypertension is diagnosed with
primary hyperaldosteronism. This diagnosis indicates that the
client's hypertension is caused by excessive hormone secretion from
which of the following glands?
a. Adrenal cortex b. Pancreas c. Adrenal medulla d. Parathyroid
70. For a diabetic male client with a foot ulcer, the doctor orders bed
rest, a wetto-dry dressing change every shift, and blood glucose
monitoring before meals and bedtime. Why are wet-to-dry dressings
used for this client?
a. They contain exudate and provide a moist wound environment. b.
They protect the wound from mechanical trauma and promote
healing. c. They debride the wound and promote healing by
secondary intention. d. They prevent the entrance of
microorganisms and minimize wound discomfort.
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which
laboratory data would the nurse expect to find?
a. Hyperkalemia
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b. Reduced blood urea nitrogen (BUN) c. Hypernatremia d.
Hyperglycemia
72. A client is admitted for treatment of the syndrome of
inappropriate antidiuretic hormone (SIADH). Which nursing
intervention is appropriate?
a. Infusing I.V. fluids rapidly as ordered b. Encouraging increased oral
intake c. Restricting fluids d. Administering glucose-containing I.V.
fluids as ordered
73. A female client tells nurse Nikki that she has been working hard
for the last 3 months to control her type 2 diabetes mellitus with
diet and exercise. To determine the effectiveness of the client's
efforts, the nurse should check:
a. urine glucose level. b. fasting blood glucose level. c. serum
fructosamine level. d. glycosylated hemoglobin level.
74. Nurse Trinity administered neutral protamine Hagedorn (NPH)
insulin to a diabetic client at 7 a.m. At what time would the nurse
expect the client to be most at risk for a hypoglycemic reaction?
a. 10:00 am b. Noon c. 4:00 pm d. 10:00 pm
75. The adrenal cortex is responsible for producing which
substances?
a. Glucocorticoids and androgens b. Catecholamines and
epinephrine c. Mineralocorticoids and catecholamines d.
Norepinephrine and epinephrine
76. On the third day after a partial thyroidectomy, Proserfina
exhibits muscle twitching and hyperirritability of the nervous
system. When questioned, the client reports numbness and tingling
of the mouth and fingertips. Suspecting a lifethreatening electrolyte
disturbance, the nurse notifies the surgeon immediately. Which
electrolyte disturbance most commonly follows thyroid surgery?
a. Hypocalcemia b. Hyponatremia c. Hyperkalemia
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d. Hypermagnesemia
77. Which laboratory test value is elevated in clients who smoke and
can't be used as a general indicator of cancer?
a. Acid phosphatase level b. Serum calcitonin level c. Alkaline
phosphatase level d. Carcinoembryonic antigen level
78. Francis with anemia has been admitted to the medical-surgical
unit. Which assessment findings are characteristic of iron-deficiency
anemia?
a. Nights sweats, weight loss, and diarrhea b. Dyspnea, tachycardia,
and pallor c. Nausea, vomiting, and anorexia d. Itching, rash, and
jaundice
79. In teaching a female client who is HIV-positive about pregnancy,
the nurse would know more teaching is necessary when the client
says:
a. The baby can get the virus from my placenta." b. "I'm planning on
starting on birth control pills." c. "Not everyone who has the virus
gives birth to a baby who has the virus." d. "I'll need to have a C-
section if I become pregnant and have a baby."
80. When preparing Judy with acquired immunodeficiency syndrome
(AIDS) for discharge to the home, the nurse should be sure to
include which instruction?
a. "Put on disposable gloves before bathing." b. "Sterilize all plates
and utensils in boiling water." c. "Avoid sharing such articles as
toothbrushes and razors." d. "Avoid eating foods from serving dishes
shared by other family members."
81. Nurse Marie is caring for a 32-year-old client admitted with
pernicious anemia. Which set of findings should the nurse expect
when assessing the client?
a. Pallor, bradycardia, and reduced pulse pressure b. Pallor,
tachycardia, and a sore tongue c. Sore tongue, dyspnea, and weight
gain d. Angina, double vision, and anorexia
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82. After receiving a dose of penicillin, a client develops dyspnea and
hypotension. Nurse Celestina suspects the client is experiencing
anaphylactic shock. What should the nurse do first?
a. Page an anesthesiologist immediately and prepare to intubate the
client. b. Administer epinephrine, as prescribed, and prepare to
intubate the client if necessary. c. Administer the antidote for
penicillin, as prescribed, and continue to monitor the client's vital
signs. d. Insert an indwelling urinary catheter and begin to infuse I.V.
fluids as ordered.
83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin
therapy to reduce inflammation. When teaching the client about
aspirin, the nurse discusses adverse reactions to prolonged aspirin
therapy. These include:
a. weight gain. b. fine motor tremors. c. respiratory acidosis. d.
bilateral hearing loss.
84. A 23-year-old client is diagnosed with human immunodeficiency
virus (HIV). After recovering from the initial shock of the diagnosis,
the client expresses a desire to learn as much as possible about HIV
and acquired immunodeficiency syndrome (AIDS). When teaching
the client about the immune system, the nurse states that adaptive
immunity is provided by which type of white blood cell?
a. Neutrophil b. Basophil c. Monocyte d. Lymphocyte
85. In an individual with Sjögren's syndrome, nursing care should
focus on:
a. moisture replacement. b. electrolyte balance. c. nutritional
supplementation. d. arrhythmia management.
86. During chemotherapy for lymphocytic leukemia, Mathew
develops abdominal pain, fever, and "horse barn" smelling diarrhea.
It would be most important for the nurse to advise the physician to
order:
a. enzyme-linked immunosuppressant assay (ELISA) test. b.
electrolyte panel and hemogram.
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c. stool for Clostridium difficile test. d. flat plate X-ray of the
abdomen.
87. A male client seeks medical evaluation for fatigue, night sweats,
and a 20-lb weight loss in 6 weeks. To confirm that the client has
been infected with the human immunodeficiency virus (HIV), the
nurse expects the physician to order:
a. E-rosette immunofluorescence. b. quantification of T-
lymphocytes. c. enzyme-linked immunosorbent assay (ELISA). d.
Western blot test with ELISA.
88. A complete blood count is commonly performed before a Joe
goes into surgery. What does this test seek to identify?
a. Potential hepatic dysfunction indicated by decreased blood urea
nitrogen (BUN) and creatinine levels b. Low levels of urine
constituents normally excreted in the urine c. Abnormally low
hematocrit (HCT) and hemoglobin (Hb) levels d. Electrolyte
imbalance that could affect the blood's ability to coagulate properly
89. While monitoring a client for the development of disseminated
intravascular coagulation (DIC), the nurse should take note of what
assessment parameters?
a. Platelet count, prothrombin time, and partial thromboplastin time
b. Platelet count, blood glucose levels, and white blood cell (WBC)
count c. Thrombin time, calcium levels, and potassium levels d.
Fibrinogen level, WBC, and platelet count
90. When taking a dietary history from a newly admitted female
client, Nurse Len should remember that which of the following foods
is a common allergen?
a. Bread b. Carrots c. Orange d. Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of
the following phone calls should the nurse return first?
a. A client with hepatitis A who states, “My arms and legs are
itching.” b. A client with cast on the right leg who states, “I have a
funny feeling in my right leg.” c. A client with osteomyelitis of the
spine who states, “I am so nauseous that I can’t eat.”
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d. A client with rheumatoid arthritis who states, “I am having trouble
sleeping.”
92. Nurse Sarah is caring for clients on the surgical floor and has just
received report from the previous shift. Which of the following
clients should the nurse see first?
a. A 35-year-old admitted three hours ago with a gunshot wound;
1.5 cm area of dark drainage noted on the dressing. b. A 43-year-old
who had a mastectomy two days ago; 23 ml of serosanguinous fluid
noted in the Jackson-Pratt drain. c. A 59-year-old with a collapsed
lung due to an accident; no drainage noted in the previous eight
hours. d. A 62-year-old who had an abdominal-perineal resection
three days ago; client complaints of chills.
93. Nurse Eve is caring for a client who had a thyroidectomy 12
hours ago for treatment of Grave’s disease. The nurse would be
most concerned if which of the following was observed?
a. Blood pressure 138/82, respirations 16, oral temperature 99
degrees Fahrenheit. b. The client supports his head and neck when
turning his head to the right. c. The client spontaneously flexes his
wrist when the blood pressure is obtained. d. The client is drowsy
and complains of sore throat.
94. Julius is admitted with complaints of severe pain in the lower
right quadrant of the abdomen. To assist with pain relief, the nurse
should take which of the following actions?
a. Encourage the client to change positions frequently in bed. b.
Administer Demerol 50 mg IM q 4 hours and PRN. c. Apply warmth
to the abdomen with a heating pad. d. Use comfort measures and
pillows to position the client.
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the
following actions should the nurse take first?
a. Assess for a bruit and a thrill. b. Warm the dialysate solution. c.
Position the client on the left side. d. Insert a Foley catheter
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96. Nurse Jannah teaches an elderly client with right-sided weakness
how to use cane. Which of the following behaviors, if demonstrated
by the client to the nurse, indicates that the teaching was effective?
a. The client holds the cane with his right hand, moves the can
forward followed by the right leg, and then moves the left leg. b. The
client holds the cane with his right hand, moves the cane forward
followed by his left leg, and then moves the right leg. c. The client
holds the cane with his left hand, moves the cane forward followed
by the right leg, and then moves the left leg. d. The client holds the
cane with his left hand, moves the cane forward followed by his left
leg, and then moves the right leg.
97. An elderly client is admitted to the nursing home setting. The
client is occasionally confused and her gait is often unsteady. Which
of the following actions, if taken by the nurse, is most appropriate?
a. Ask the woman’s family to provide personal items such as photos
or mementos. b. Select a room with a bed by the door so the woman
can look down the hall. c. Suggest the woman eat her meals in the
room with her roommate. d. Encourage the woman to ambulate in
the halls twice a day.
98. Nurse Evangeline teaches an elderly client how to use a standard
aluminum walker. Which of the following behaviors, if demonstrated
by the client, indicates that the nurse’s teaching was effective?
a. The client slowly pushes the walker forward 12 inches, then takes
small steps forward while leaning on the walker. b. The client lifts
the walker, moves it forward 10 inches, and then takes several small
steps forward. c. The client supports his weight on the walker while
advancing it forward, then takes small steps while balancing on the
walker. d. The client slides the walker 18 inches forward, then takes
small steps while holding onto the walker for balance.
99. Nurse Deric is supervising a group of elderly clients in a
residential home setting. The nurse knows that the elderly are at
greater risk of developing sensory deprivation for what reason?
a. Increased sensitivity to the side effects of medications. b.
Decreased visual, auditory, and gustatory abilities. c. Isolation from
their families and familiar surroundings. d. Decrease musculoskeletal
function and mobility.
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100. A male client with emphysema becomes restless and confused.
What step should nurse Jasmine take next?
a. Encourage the client to perform pursed lip breathing. b. Check the
client’s temperature. c. Assess the client’s potassium level. d.
Increase the client’s oxygen flow rate.
NURSING PRACTICE IV
Care of Clients with Physiologic and Psychosocial Alterations
TEST IV - Care of Clients with Physiologic and Psychosocial
Alterations
1. Randy has undergone kidney transplant, what assessment would
prompt Nurse Katrina to suspect organ rejection?
a. Sudden weight loss b. Polyuria c. Hypertension d. Shock
2. The immediate objective of nursing care for an overweight, mildly
hypertensive male client with ureteral colic and hematuria is to
decrease:
a. Pain b. Weight c. Hematuria d. Hypertension
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution
before a subtotal thyroidectomy is performed. The nurse is aware
that this medication is given to:
a. Decrease the total basal metabolic rate. b. Maintain the function
of the parathyroid glands. c. Block the formation of thyroxine by the
thyroid gland. d. Decrease the size and vascularity of the thyroid
gland.
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware
that acute hypoglycemia also can develop in the client who is
diagnosed with:
a. Liver disease b. Hypertension c. Type 2 diabetes d.
Hyperthyroidism
5. Tracy is receiving combination chemotherapy for treatment of
metastatic carcinoma. Nurse Ruby should monitor the client for the
systemic side effect of:
a. Ascites b. Nystagmus c. Leukopenia d. Polycythemia
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6. Norma, with recent colostomy expresses concern about the
inability to control the passage of gas. Nurse Oliver should suggest
that the client plan to:
a. Eliminate foods high in cellulose. b. Decrease fluid intake at meal
times. c. Avoid foods that in the past caused flatus. d. Adhere to a
bland diet prior to social events.
7. Nurse Ron begins to teach a male client how to perform
colostomy irrigations. The nurse would evaluate that the instructions
were understood when the client states, “I should:
a. Lie on my left side while instilling the irrigating solution.” b. Keep
the irrigating container less than 18 inches above the stoma.” c.
Instill a minimum of 1200 ml of irrigating solution to stimulate
evacuation of the bowel.” d. Insert the irrigating catheter deeper
into the stoma if cramping occurs during the procedure.”
8. Patrick is in the oliguric phase of acute tubular necrosis and is
experiencing fluid and electrolyte imbalances. The client is
somewhat confused and complains of nausea and muscle weakness.
As part of the prescribed therapy to correct this electrolyte
imbalance, the nurse would expect to:
a. Administer Kayexalate b. Restrict foods high in protein c. Increase
oral intake of cheese and milk. d. Administer large amounts of
normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders
for Mario 2 liters of IV fluid to be administered q12 h. The drop
factor of the tubing is 10 gtt/ml. The nurse should set the flow to
provide:
a. 18 gtt/min b. 28 gtt/min c. 32 gtt/min d. 36 gtt/min
10.Terence suffered form burn injury. Using the rule of nines, which
has the largest percent of burns?
a. Face and neck b. Right upper arm and penis
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c. Right thigh and penis d. Upper trunk
11.Herbert, a 45 year old construction engineer is brought to the
hospital unconscious after falling from a 2-story building. When
assessing the client, the nurse would be most concerned if the
assessment revealed:
a. Reactive pupils b. A depressed fontanel c. Bleeding from
ears d. An elevated temperature
12.Nurse Sherry is teaching male client regarding his permanent
artificial pacemaker. Which information given by the nurse shows
her knowledge deficit about the artificial cardiac pacemaker?
a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances c. Have regular
follow up care d. May engage in contact sports
13.The nurse is ware that the most relevant knowledge about
oxygen administration to a male client with COPD is
a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for
breathing. b. Hypoxia stimulates the central chemoreceptors in the
medulla that makes the client breath. c. Oxygen is administered best
using a non-rebreathing mask d. Blood gases are monitored using a
pulse oximeter.
14.Tonny has undergoes a left thoracotomy and a partial
pneumonectomy. Chest tubes are inserted, and one-bottle water-
seal drainage is instituted in the operating room. In the
postanesthesia care unit Tonny is placed in Fowler's position on
either his right side or on his back. The nurse is aware that this
position:
a. Reduce incisional pain. b. Facilitate ventilation of the left lung. c.
Equalize pressure in the pleural space. d. Increase venous return
15.Kristine is scheduled for a bronchoscopy. When teaching Kristine
what to expect afterward, the nurse's highest priority of information
would be:
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a. Food and fluids will be withheld for at least 2 hours. b. Warm
saline gargles will be done q 2h. c. Coughing and deep-breathing
exercises will be done q2h. d. Only ice chips and cold liquids will be
allowed initially.
16.Nurse Tristan is caring for a male client in acute renal failure. The
nurse should expect hypertonic glucose, insulin infusions, and
sodium bicarbonate to be used to treat:
a. hypernatremia. b. hypokalemia. c. hyperkalemia. d.
hypercalcemia.
17.Ms. X has just been diagnosed with condylomata acuminata
(genital warts). What information is appropriate to tell this client?
a. This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) smear annually. b.
The most common treatment is metronidazole (Flagyl), which should
eradicate the problem within 7 to 10 days. c. The potential for
transmission to her sexual partner will be eliminated if condoms are
used every time they have sexual intercourse. d. The human
papillomavirus (HPV), which causes condylomata acuminata, can't
be transmitted during oral sex.
18.Maritess was recently diagnosed with a genitourinary problem
and is being examined in the emergency department. When
palpating the her kidneys, the nurse should keep which anatomical
fact in mind?
a. The left kidney usually is slightly higher than the right one. b. The
kidneys are situated just above the adrenal glands. c. The average
kidney is approximately 5 cm (2") long and 2 to 3 cm (¾" to 1-1/8")
wide. d. The kidneys lie between the 10th and 12th thoracic
vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the urology
unit. The nurse is aware that the diagnostic test are consistent with
CRF if the result is:
a. Increased pH with decreased hydrogen ions. b. Increased serum
levels of potassium, magnesium, and calcium. c. Blood urea nitrogen
(BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
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d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP)
excretion 75%. 20.Katrina has an abnormal result on a Papanicolaou
test. After admitting that she read her chart while the nurse was out
of the room, Katrina asks what dysplasia means. Which definition
should the nurse provide?
a. Presence of completely undifferentiated tumor cells that don't
resemble cells of the tissues of their origin. b. Increase in the
number of normal cells in a normal arrangement in a tissue or an
organ. c. Replacement of one type of fully differentiated cell by
another in tissues where the second type normally isn't found. d.
Alteration in the size, shape, and organization of differentiated cells.
21.During a routine checkup, Nurse Mariane assesses a male client
with acquired immunodeficiency syndrome (AIDS) for signs and
symptoms of cancer. What is the most common AIDS-related
cancer?
a. Squamous cell carcinoma b. Multiple myeloma c. Leukemia d.
Kaposi's sarcoma
22.Ricardo is scheduled for a prostatectomy, and the
anesthesiologist plans to use a spinal (subarachnoid) block during
surgery. In the operating room, the nurse positions the client
according to the anesthesiologist's instructions. Why does the client
require special positioning for this type of anesthesia?
a. To prevent confusion b. To prevent seizures c. To prevent
cerebrospinal fluid (CSF) leakage d. To prevent cardiac arrhythmias
23.A male client had a nephrectomy 2 days ago and is now
complaining of abdominal pressure and nausea. The first nursing
action should be to:
a. Auscultate bowel sounds. b. Palpate the abdomen. c. Change the
client's position. d. Insert a rectal tube.
24.Wilfredo with a recent history of rectal bleeding is being
prepared for a colonoscopy. How should the nurse Patricia position
the client for this test initially?
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a. Lying on the right side with legs straight b. Lying on the left side
with knees bent c. Prone with the torso elevated d. Bent over with
hands touching the floor
25.A male client with inflammatory bowel disease undergoes an
ileostomy. On the first day after surgery, Nurse Oliver notes that the
client's stoma appears dusky. How should the nurse interpret this
finding?
a. Blood supply to the stoma has been interrupted. b. This is a
normal finding 1 day after surgery. c. The ostomy bag should be
adjusted. d. An intestinal obstruction has occurred.
26.Anthony suffers burns on the legs, which nursing intervention
helps prevent contractures?
a. Applying knee splints b. Elevating the foot of the bed c.
Hyperextending the client's palms d. Performing shoulder range-of-
motion exercises
27.Nurse Ron is assessing a client admitted with second- and third-
degree burns on the face, arms, and chest. Which finding indicates a
potential problem?
a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg. b.
Urine output of 20 ml/hour. c. White pulmonary secretions. d. Rectal
temperature of 100.6° F (38° C).
28.Mr. Mendoza who has suffered a cerebrovascular accident (CVA)
is too weak to move on his own. To help the client avoid pressure
ulcers, Nurse Celia should:
a. Turn him frequently. b. Perform passive range-of-motion (ROM)
exercises. c. Reduce the client's fluid intake. d. Encourage the client
to use a footboard.
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29.Nurse Maria plans to administer dexamethasone cream to a
female client who has dermatitis over the anterior chest. How
should the nurse apply this topical agent?
a. With a circular motion, to enhance absorption. b. With an upward
motion, to increase blood supply to the affected area c. In long,
even, outward, and downward strokes in the direction of hair
growth d. In long, even, outward, and upward strokes in the
direction opposite hair growth
30.Nurse Kate is aware that one of the following classes of
medication protect the ischemic myocardium by blocking
catecholamines and sympathetic nerve stimulation is:
a. Beta -adrenergic blockers b. Calcium channel blocker c. Narcotics
d. Nitrates
31.A male client has jugular distention. On what position should the
nurse place the head of the bed to obtain the most accurate reading
of jugular vein distention?
a. High Fowler’s b. Raised 10 degrees c. Raised 30 degrees d. Supine
position
32.The nurse is aware that one of the following classes of
medications maximizes cardiac performance in clients with heart
failure by increasing ventricular contractility?
a. Beta-adrenergic blockers b. Calcium channel blocker c. Diuretics d.
Inotropic agents
33.A male client has a reduced serum high-density lipoprotein (HDL)
level and an elevated low-density lipoprotein (LDL) level. Which of
the following dietary modifications is not appropriate for this client?
a. Fiber intake of 25 to 30 g daily
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b. Less than 30% of calories form fat c. Cholesterol intake of less
than 300 mg daily d. Less than 10% of calories from saturated fat 34.
A 37-year-old male client was admitted to the coronary care unit
(CCU) 2 days ago with an acute myocardial infarction. Which of the
following actions would breach the client confidentiality?
a. The CCU nurse gives a verbal report to the nurse on the telemetry
unit before transferring the client to that unit b. The CCU nurse
notifies the on-call physician about a change in the client’s condition
c. The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress. d. At the
client’s request, the CCU nurse updates the client’s wife on his
condition
35. A male client arriving in the emergency department is receiving
cardiopulmonary resuscitation from paramedics who are giving
ventilations through an endotracheal (ET) tube that they placed in
the client’s home. During a pause in compressions, the cardiac
monitor shows narrow QRS complexes and a heart rate of
beats/minute with a palpable pulse. Which of the following actions
should the nurse take first?
a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg
L.V. over 10 minutes. b. Check endotracheal tube placement. c.
Obtain an arterial blood gas (ABG) sample. d. Administer atropine, 1
mg L.V.
36. After cardiac surgery, a client’s blood pressure measures 126/80
mm Hg. Nurse Katrina determines that mean arterial pressure (MAP)
is which of the following?
a. 46 mm Hg b. 80 mm Hg c. 95 mm Hg d. 90 mm Hg
37. A female client arrives at the emergency department with chest
and stomach pain and a report of black tarry stool for several
months. Which of the following order should the nurse Oliver
anticipate?
a. Cardiac monitor, oxygen, creatine kinase and lactate
dehydrogenase levels b. Prothrombin time, partial thromboplastin
time, fibrinogen and fibrin split product values.
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c. Electrocardiogram, complete blood count, testing for occult blood,
comprehensive serum metabolic panel. d. Electroencephalogram,
alkaline phosphatase and aspartate aminotransferase levels, basic
serum metabolic panel
38. Macario had coronary artery bypass graft (CABG) surgery 3 days
ago. Which of the following conditions is suspected by the nurse
when a decrease in platelet count from 230,000 ul to 5,000 ul is
noted?
a. Pancytopenia b. Idiopathic thrombocytopemic purpura (ITP) c.
Disseminated intravascular coagulation (DIC) d. Heparin-associated
thrombosis and thrombocytopenia (HATT)
39. Which of the following drugs would be ordered by the physician
to improve the platelet count in a male client with idiopathic
thrombocytopenic purpura (ITP)?
a. Acetylsalicylic acid (ASA) b. Corticosteroids c. Methotrezate d.
Vitamin K
40. A female client is scheduled to receive a heart valve replacement
with a porcine valve. Which of the following types of transplant is
this?
a. Allogeneic b. Autologous c. Syngeneic d. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the
following actions shows the initial response to the injury in the
extrinsic pathway?
a. Release of Calcium b. Release of tissue thromboplastin c.
Conversion of factors XII to factor XIIa d. Conversion of factor VIII to
factor VIIIa
42. Instructions for a client with systemic lupus erythematosus (SLE)
would include information about which of the following blood
dyscrasias?
a. Dressler’s syndrome b. Polycythemia c. Essential
thrombocytopenia
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d. Von Willebrand’s disease
43. The nurse is aware that the following symptoms is most
commonly an early indication of stage 1 Hodgkin’s disease?
a. Pericarditis b. Night sweat c. Splenomegaly d. Persistent
hypothermia
44. Francis with leukemia has neutropenia. Which of the following
functions must frequently assessed?
a. Blood pressure b. Bowel sounds c. Heart sounds d. Breath sounds
45. The nurse knows that neurologic complications of multiple
myeloma (MM) usually involve which of the following body system?
a. Brain b. Muscle spasm c. Renal dysfunction d. Myocardial
irritability
46. Nurse Patricia is aware that the average length of time from
human immunodeficiency virus (HIV) infection to the development
of acquired immunodeficiency syndrome (AIDS)?
a. Less than 5 years b. 5 to 7 years c. 10 years d. More than 10 years
47. An 18-year-old male client admitted with heat stroke begins to
show signs of disseminated intravascular coagulation (DIC). Which of
the following laboratory findings is most consistent with DIC?
a. Low platelet count b. Elevated fibrinogen levels c. Low levels of
fibrin degradation products d. Reduced prothrombin time
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48. Mario comes to the clinic complaining of fever, drenching night
sweats, and unexplained weight loss over the past 3 months.
Physical examination reveals a single enlarged supraclavicular lymph
node. Which of the following is the most probable diagnosis?
a. Influenza b. Sickle cell anemia c. Leukemia d. Hodgkin’s disease
49. A male client with a gunshot wound requires an emergency
blood transfusion. His blood type is AB negative. Which blood type
would be the safest for him to receive?
a. AB Rh-positive b. A Rh-positive c. A Rh-negative d. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and
beginning chemotherapy. 50. Stacy is discharged from the hospital
following her chemotherapy treatments. Which statement of Stacy’s
mother indicated that she understands when she will contact the
physician?
a. “I should contact the physician if Stacy has difficulty in sleeping”.
b. “I will call my doctor if Stacy has persistent vomiting and
diarrhea”. c. “My physician should be called if Stacy is irritable and
unhappy”. d. “Should Stacy have continued hair loss, I need to call
the doctor”.
51. Stacy’s mother states to the nurse that it is hard to see Stacy
with no hair. The best response for the nurse is:
a. “Stacy looks very nice wearing a hat”. b. “You should not worry
about her hair, just be glad that she is alive”. c. “Yes it is upsetting.
But try to cover up your feelings when you are with her or else she
may be upset”. d. “This is only temporary; Stacy will re-grow new
hair in 3-6 months, but may be different in texture”.
52. Stacy has beginning stomatitis. To promote oral hygiene and
comfort, the nurse in-charge should:
a. Provide frequent mouthwash with normal saline.
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b. Apply viscous Lidocaine to oral ulcers as needed. c. Use lemon
glycerine swabs every 2 hours. d. Rinse mouth with Hydrogen
Peroxide.
53. During the administration of chemotherapy agents, Nurse Oliver
observed that the IV site is red and swollen, when the IV is touched
Stacy shouts in pain. The first nursing action to take is:
a. Notify the physician b. Flush the IV line with saline solution c.
Immediately discontinue the infusion d. Apply an ice pack to the site,
followed by warm compress.
54. The term “blue bloater” refers to a male client which of the
following conditions?
a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic
obstructive bronchitis d. Emphysema
55. The term “pink puffer” refers to the female client with which of
the following conditions?
a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic
obstructive bronchitis d. Emphysema
56. Jose is in danger of respiratory arrest following the
administration of a narcotic analgesic. An arterial blood gas value is
obtained. Nurse Oliver would expect the paco2 to be which of the
following values?
a. 15 mm Hg b. 30 mm Hg c. 40 mm Hg d. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH
7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%.
This ABG result represents which of the following conditions?
a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis
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d. Respirator y alkalosis
58. Norma has started a new drug for hypertension. Thirty minutes
after she takes the drug, she develops chest tightness and becomes
short of breath and tachypneic. She has a decreased level of
consciousness. These signs indicate which of the following
conditions?
a. Asthma attack b. Pulmonary embolism c. Respiratory failure d.
Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites
and jaundice. To rule out cirrhosis of the liver: 59. Which laboratory
test indicates liver cirrhosis?
a. Decreased red blood cell count b. Decreased serum acid
phosphate level c. Elevated white blood cell count d. Elevated serum
aminotransferase
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis.
Mr. Gonzales is at increased risk for excessive bleeding primarily
because of:
a. Impaired clotting mechanism b. Varix formation c. Inadequate
nutrition d. Trauma of invasive procedure
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical
manifestation is most common with this condition?
a. Increased urine output b. Altered level of consciousness c.
Decreased tendon reflex d. Hypotension
62. When Mr. Gonzales regained consciousness, the physician orders
50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea.
The nurse best action would be:
a. “I’ll see if your physician is in the hospital”. b. “Maybe your
reacting to the drug; I will withhold the next dose”.
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c. “I’ll lower the dosage as ordered so the drug causes only 2 to 4
stools a day”. d. “Frequently, bowel movements are needed to
reduce sodium level”.
63. Which of the following groups of symptoms indicates a ruptured
abdominal aortic aneurysm?
a. Lower back pain, increased blood pressure, decreased re blood
cell (RBC) count, increased white blood (WBC) count. b. Severe lower
back pain, decreased blood pressure, decreased RBC count,
increased WBC count. c. Severe lower back pain, decreased blood
pressure, decreased RBC count, decreased RBC count, decreased
WBC count. d. Intermitted lower back pain, decreased blood
pressure, decreased RBC count, increased WBC count.
64. After undergoing a cardiac catheterization, Tracy has a large
puddle of blood under his buttocks. Which of the following steps
should the nurse take first?
a. Call for help. b. Obtain vital signs c. Ask the client to “lift up” d.
Apply gloves and assess the groin site
65. Which of the following treatment is a suitable surgical
intervention for a client with unstable angina?
a. Cardiac catheterization b. Echocardiogram c. Nitroglycerin d.
Percutaneous transluminal coronary angioplasty (PTCA)
66. The nurse is aware that the following terms used to describe
reduced cardiac output and perfusion impairment due to ineffective
pumping of the heart is:
a. Anaphylactic shock b. Cardiogenic shock c. Distributive shock d.
Myocardial infarction (MI)
67. A client with hypertension ask the nurse which factors can cause
blood pressure to drop to normal levels?
a. Kidneys’ excretion to sodium only. b. Kidneys’ retention of sodium
and water c. Kidneys’ excretion of sodium and water
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d. Kidneys’ retention of sodium and excretion of water
68. Nurse Rose is aware that the statement that best explains why
furosemide (Lasix) is administered to treat hypertension is:
a. It dilates peripheral blood vessels. b. It decreases sympathetic
cardioacceleration. c. It inhibits the angiotensin-coverting enzymes
d. It inhibits reabsorption of sodium and water in the loop of Henle.
69. Nurse Nikki knows that laboratory results supports the diagnosis
of systemic lupus erythematosus (SLE) is:
a. Elavated serum complement level b. Thrombocytosis, elevated
sedimentation rate c. Pancytopenia, elevated antinuclear antibody
(ANA) titer d. Leukocysis, elevated blood urea nitrogen (BUN) and
creatinine levels
70. Arnold, a 19-year-old client with a mild concussion is discharged
from the emergency department. Before discharge, he complains of
a headache. When offered acetaminophen, his mother tells the
nurse the headache is severe and she would like her son to have
something stronger. Which of the following responses by the nurse
is appropriate?
a. “Your son had a mild concussion, acetaminophen is strong
enough.” b. “Aspirin is avoided because of the danger of Reye’s
syndrome in children or young adults.” c. “Narcotics are avoided
after a head injury because they may hide a worsening condition.” d.
Stronger medications may lead to vomiting, which increases the
intracarnial pressure (ICP).”
71. When evaluating an arterial blood gas from a male client with a
subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which
of the following responses best describes the result?
a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP) b. Emergent; the client is poorly oxygenated c. Normal
d. Significant; the client has alveolar hypoventilation
72. When prioritizing care, which of the following clients should the
nurse Olivia assess first?
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a. A 17-year-old clients 24-hours postappendectomy b. A 33-year-old
client with a recent diagnosis of Guillain-Barre syndrome c. A 50-
year-old client 3 days postmyocardial infarction d. A 50-year-old
client with diverticulitis
73. JP has been diagnosed with gout and wants to know why
colchicine is used in the treatment of gout. Which of the following
actions of colchicines explains why it’s effective for gout?
a. Replaces estrogen b. Decreases infection c. Decreases
inflammation d. Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the
following statements about osteoarthritis is correct?
a. Osteoarthritis is rarely debilitating b. Osteoarthritis is a rare form
of arthritis c. Osteoarthritis is the most common form of arthritis d.
Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy develops the flu
and forgets to take her thyroid replacement medicine. The nurse
understands that skipping this medication will put the client at risk
for developing which of the following lifethreatening complications?
a. Exophthalmos b. Thyroid storm c. Myxedema coma d. Tibial
myxedema
76. Nurse Sugar is assessing a client with Cushing's syndrome. Which
observation should the nurse report to the physician immediately?
a. Pitting edema of the legs b. An irregular apical pulse c. Dry
mucous membranes d. Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is
admitted to the intensive care unit. Thirty-six hours later, the client's
urine output suddenly rises above 200 ml/hour, leading the nurse to
suspect diabetes insipidus. Which laboratory findings support the
nurse's suspicion of diabetes insipidus?
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a. Above-normal urine and serum osmolality levels b. Below-normal
urine and serum osmolality levels c. Above-normal urine osmolality
level, below-normal serum osmolality level d. Below-normal urine
osmolality level, above-normal serum osmolality level
78. Jomari is diagnosed with hyperosmolar hyperglycemic
nonketotic syndrome (HHNS) is stabilized and prepared for
discharge. When preparing the client for discharge and home
management, which of the following statements indicates that the
client understands her condition and how to control it?
a. "I can avoid getting sick by not becoming dehydrated and by
paying attention to my need to urinate, drink, or eat more than
usual." b. "If I experience trembling, weakness, and headache, I
should drink a glass of soda that contains sugar." c. "I will have to
monitor my blood glucose level closely and notify the physician if it's
constantly elevated." d. "If I begin to feel especially hungry and
thirsty, I'll eat a snack high in carbohydrates."
79. A 66-year-old client has been complaining of sleeping more,
increased urination, anorexia, weakness, irritability, depression, and
bone pain that interferes with her going outdoors. Based on these
assessment findings, the nurse would suspect which of the following
disorders?
a. Diabetes mellitus b. Diabetes insipidus c. Hypoparathyroidism d.
Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian
crisis about the need to take fludrocortisone acetate and
hydrocortisone at home. Which statement by the client indicates an
understanding of the instructions?
a. "I'll take my hydrocortisone in the late afternoon, before dinner."
b. "I'll take all of my hydrocortisone in the morning, right after I
wake up." c. "I'll take two-thirds of the dose when I wake up and
one-third in the late afternoon." d. "I'll take the entire dose at
bedtime." 81..Which of the following laboratory test results would
suggest to the nurse Len that a client has a corticotropin-secreting
pituitary adenoma?
a. High corticotropin and low cortisol levels
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b. Low corticotropin and high cortisol levels c. High corticotropin and
high cortisol levels d. Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal
hypophysectomy to remove a pituitary tumor. Preoperatively, the
nurse should assess for potential complications by doing which of
the following?
a. Testing for ketones in the urine b. Testing urine specific gravity c.
Checking temperature every 4 hours d. Performing capillary glucose
testing every 4 hours
83. Capillary glucose monitoring is being performed every 4 hours
for a client diagnosed with diabetic ketoacidosis. Insulin is
administered using a scale of regular insulin according to glucose
results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl
for which he receives 8 U of regular insulin. Nurse Mariner should
expect the dose's:
a. onset to be at 2 p.m. and its peak to be at 3 p.m. b. onset to be at
2:15 p.m. and its peak to be at 3 p.m. c. onset to be at 2:30 p.m. and
its peak to be at 4 p.m. d. onset to be at 4 p.m. and its peak to be at
6 p.m.
84. The physician orders laboratory tests to confirm hyperthyroidism
in a female client with classic signs and symptoms of this disorder.
Which test result would confirm the diagnosis?
a. No increase in the thyroid-stimulating hormone (TSH) level after
30 minutes during the TSH stimulation test b. A decreased TSH level
c. An increase in the TSH level after 30 minutes during the TSH
stimulation test d. Below-normal levels of serum triiodothyronine
(T3) and serum thyroxine (T4) as detected by radioimmunoassay
85. Rico with diabetes mellitus must learn how to self-administer
insulin. The physician has prescribed 10 U of U-100 regular insulin
and 35 U of U-100 isophane insulin suspension (NPH) to be taken
before breakfast. When teaching the client how to select and rotate
insulin injection sites, the nurse should provide which instruction?
a. "Inject insulin into healthy tissue with large blood vessels and
nerves." b. "Rotate injection sites within the same anatomic region,
not among different regions."
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c. "Administer insulin into areas of scar tissue or hypotrophy
whenever possible." d. "Administer insulin into sites above muscles
that you plan to exercise heavily later that day."
86. Nurse Sarah expects to note an elevated serum glucose level in a
client with hyperosmolar hyperglycemic nonketotic syndrome
(HHNS). Which other laboratory finding should the nurse anticipate?
a. Elevated serum acetone level b. Serum ketone bodies c. Serum
alkalosis d. Below-normal serum potassium level
87. For a client with Graves' disease, which nursing intervention
promotes comfort?
a. Restricting intake of oral fluids b. Placing extra blankets on the
client's bed c. Limiting intake of high-carbohydrate foods d.
Maintaining room temperature in the low-normal range
88. Patrick is treated in the emergency department for a Colles'
fracture sustained during a fall. What is a Colles' fracture?
a. Fracture of the distal radius b. Fracture of the olecranon c.
Fracture of the humerus d. Fracture of the carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which electrolytes are
involved in the development of this disorder?
a. Calcium and sodium b. Calcium and phosphorous c. Phosphorous
and potassium d. Potassium and sodium
90. Johnny a firefighter was involved in extinguishing a house fire
and is being treated to smoke inhalation. He develops severe
hypoxia 48 hours after the incident, requiring intubation and
mechanical ventilation. He most likely has developed which of the
following conditions?
a. Adult respiratory distress syndrome (ARDS) b. Atelectasis c.
Bronchitis
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d. Pneumonia
91. A 67-year-old client develops acute shortness of breath and
progressive hypoxia requiring right femur. The hypoxia was probably
caused by which of the following conditions?
a. Asthma attack b. Atelectasis c. Bronchitis d. Fat embolism
92. A client with shortness of breath has decreased to absent breath
sounds on the right side, from the apex to the base. Which of the
following conditions would best explain this?
a. Acute asthma b. Chronic bronchitis c. Pneumonia d. Spontaneous
pneumothorax
93. A 62-year-old male client was in a motor vehicle accident as an
unrestrained driver. He’s now in the emergency department
complaining of difficulty of breathing and chest pain. On
auscultation of his lung field, no breath sounds are present in the
upper lobe. This client may have which of the following conditions?
a. Bronchitis b. Pneumonia c. Pneumothorax d. Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the
thoracic cavity?
a. The space remains filled with air only b. The surgeon fills the space
with a gel c. Serous fluids fills the space and consolidates the region
d. The tissue from the other lung grows over to the other side
95. Hemoptysis may be present in the client with a pulmonary
embolism because of which of the following reasons?
a. Alveolar damage in the infracted area b. Involvement of major
blood vessels in the occluded area c. Loss of lung parenchyma
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d. Loss of lung tissue
96. Aldo with a massive pulmonary embolism will have an arterial
blood gas analysis performed to determine the extent of hypoxia.
The acid-base disorder that may be present is?
a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d.
Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is
admitted with a pneumothorax. The surgeon inserts a chest tube
and attaches it to a chest drainage system. Bubbling soon appears in
the water seal chamber. Which of the following is the most likely
cause of the bubbling?
a. Air leak b. Adequate suction c. Inadequate suction d. Kinked chest
tube
98. Nurse Michelle calculates the IV flow rate for a postoperative
client. The client receives 3,000 ml of Ringer’s lactate solution IV to
run over 24 hours. The IV infusion set has a drop factor of 10 drops
per milliliter. The nurse should regulate the client’s IV to deliver how
many drops per minute?
a. 18 b. 21 c. 35 d. 40
99. Mickey, a 6-year-old child with a congenital heart disorder is
admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is
ordered for the child. The bottle of Lanoxin contains .05 mg of
Lanoxin in 1 ml of solution. What amount should the nurse
administer to the child?
a. 1.2 ml b. 2.4 ml c. 3.5 ml d. 4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which
of the following statements, if made by the client, indicates to the
nurse that the teaching was successful?
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a. “I will wear the stockings until the physician tells me to remove
them.” b. “I should wear the stockings even when I am sleep.” c.
“Every four hours I should remove the stockings for a half hour.” d.
“I should put on the stockings before getting out of bed in the
morning.”
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NURSING PRACTICE V
Care of Clients with Physiologic and Psychosocial Alterations
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TEST V - Care of Clients with Physiologic and Psychosocial Alterations
1. Mr. Marquez reports of losing his job, not being able to sleep at
night, and feeling upset with his wife. Nurse John responds to the
client, “You may want to talk about your employment situation in
group today.” The Nurse is using which therapeutic technique?
a. Observations b. Restating c. Exploring d. Focusing
2. Tony refuses his evening dose of Haloperidol (Haldol), then
becomes extremely agitated in the dayroom while other clients are
watching television. He begins cursing and throwing furniture. Nurse
Oliver first action is to:
a. Check the client’s medical record for an order for an as-needed
I.M. dose of medication for agitation. b. Place the client in full
leather restraints. c. Call the attending physician and report the
behavior. d. Remove all other clients from the dayroom.
3. Tina who is manic, but not yet on medication, comes to the drug
treatment center. The nurse would not let this client join the group
session because:
a. The client is disruptive. b. The client is harmful to self. c. The client
is harmful to others. d. The client needs to be on medication first.
4. Dervid, an adolescent boy was admitted for substance abuse and
hallucinations. The client’s mother asks Nurse Armando to talk with
his husband when he arrives at the hospital. The mother says that
she is afraid of what the father might say to the boy. The most
appropriate nursing intervention would be to:
a. Inform the mother that she and the father can work through this
problem themselves. b. Refer the mother to the hospital social
worker. c. Agree to talk with the mother and the father together. d.
Suggest that the father and son work things out.
5. What is Nurse John likely to note in a male client being admitted
for alcohol withdrawal?
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a. Perceptual disorders. b. Impending coma. c. Recent alcohol intake.
d. Depression with mutism.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now
complains that it “doesn’t help” and refuses to take it. What should
the nurse say or do?
a. Withhold the drug. b. Record the client’s response. c. Encourage
the client to tell the doctor. d. Suggest that it takes awhile before
seeing the results.
7. Dervid, an adolescent has a history of truancy from school,
running away from home and “barrowing” other people’s things
without their permission. The adolescent denies stealing,
rationalizing instead that as long as no one was using the items, it
was all right to borrow them. It is important for the nurse to
understand the psychodynamically, this behavior may be largely
attributed to a developmental defect related to the:
a. Id b. Ego c. Superego d. Oedipal complex
8. In preparing a female client for electroconvulsive therapy (ECT),
Nurse Michelle knows that succinylcoline (Anectine) will be
administered for which therapeutic effect?
a. Short-acting anesthesia b. Decreased oral and respiratory
secretions. c. Skeletal muscle paralysis. d. Analgesia.
9. Nurse Gina is aware that the dietary implications for a client in
manic phase of bipolar disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple
slices. b. Increase calories, decrease fat, and decrease protein. c.
Give the client pieces of cut-up steak, carrots, and an apple. d.
Increase calories, carbohydrates, and protein.
10.What parental behavior toward a child during an admission
procedure should cause Nurse Ron to suspect child abuse?
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a. Flat affect b. Expressing guilt c. Acting overly solicitous toward the
child. d. Ignoring the child.
11.Nurse Lynnette notices that a female client with obsessive-
compulsive disorder washes her hands for long periods each day.
How should the nurse respond to this compulsive behavior?
a. By designating times during which the client can focus on the
behavior. b. By urging the client to reduce the frequency of the
behavior as rapidly as possible. c. By calling attention to or
attempting to prevent the behavior. d. By discouraging the client
from verbalizing anxieties.
12.After seeking help at an outpatient mental health clinic, Ruby
who was raped while walking her dog is diagnosed with
posttraumatic stress disorder (PTSD). Three months later, Ruby
returns to the clinic, complaining of fear, loss of control, and helpless
feelings. Which nursing intervention is most appropriate for Ruby?
a. Recommending a high-protein, low-fat diet. b. Giving sleep
medication, as prescribed, to restore a normal sleepwake cycle. c.
Allowing the client time to heal. d. Exploring the meaning of the
traumatic event with the client.
13.Meryl, age 19, is highly dependent on her parents and fears
leaving home to go away to college. Shortly before the semester
starts, she complains that her legs are paralyzed and is rushed to the
emergency department. When physical examination rules out a
physical cause for her paralysis, the physician admits her to the
psychiatric unit where she is diagnosed with conversion disorder.
Meryl asks the nurse, "Why has this happened to me?" What is the
nurse's best response?
a. "You've developed this paralysis so you can stay with your
parents. You must deal with this conflict if you want to walk again."
b. "It must be awful not to be able to move your legs. You may feel
better if you realize the problem is psychological, not physical." c.
"Your problem is real but there is no physical basis for it. We'll work
on what is going on in your life to find out why it's happened." d. "It
isn't uncommon for someone with your personality to develop a
conversion disorder during times of stress."
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14.Nurse Krina knows that the following drugs have been known to
be effective in treating obsessive-compulsive disorder (OCD):
a. benztropine (Cogentin) and diphenhydramine (Benadryl). b.
chlordiazepoxide (Librium) and diazepam (Valium) c. fluvoxamine
(Luvox) and clomipramine (Anafranil) d. divalproex (Depakote) and
lithium (Lithobid)
15.Alfred was newly diagnosed with anxiety disorder. The physician
prescribed buspirone (BuSpar). The nurse is aware that the teaching
instructions for newly prescribed buspirone should include which of
the following?
a. A warning about the drugs delayed therapeutic effect, which is
from 14 to 30 days. b. A warning about the incidence of neuroleptic
malignant syndrome (NMS). c. A reminder of the need to schedule
blood work in 1 week to check blood levels of the drug. d. A warning
that immediate sedation can occur with a resultant drop in pulse.
16.Richard with agoraphobia has been symptom-free for 4 months.
Classic signs and symptoms of phobias include:
a. Insomnia and an inability to concentrate. b. Severe anxiety and
fear. c. Depression and weight loss. d. Withdrawal and failure to
distinguish reality from fantasy.
17.Which medications have been found to help reduce or eliminate
panic attacks?
a. Antidepressants b. Anticholinergics c. Antipsychotics d. Mood
stabilizers
18.A client seeks care because she feels depressed and has gained
weight. To treat her atypical depression, the physician prescribes
tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day.
When this drug is used to treat atypical depression, what is its onset
of action?
a. 1 to 2 days b. 3 to 5 days c. 6 to 8 days
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d. 10 to 14 days
19.A 65 years old client is in the first stage of Alzheimer's disease.
Nurse Patricia should plan to focus this client's care on:
a. Offering nourishing finger foods to help maintain the client's
nutritional status. b. Providing emotional support and individual
counseling. c. Monitoring the client to prevent minor illnesses from
turning into major problems. d. Suggesting new activities for the
client and family to do together.
20.The nurse is assessing a client who has just been admitted to the
emergency department. Which signs would suggest an overdose of
an antianxiety agent?
a. Combativeness, sweating, and confusion b. Agitation,
hyperactivity, and grandiose ideation c. Emotional lability, euphoria,
and impaired memory d. Suspiciousness, dilated pupils, and
increased blood pressure
21.The nurse is caring for a client diagnosed with antisocial
personality disorder. The client has a history of fighting, cruelty to
animals, and stealing. Which of the following traits would the nurse
be most likely to uncover during assessment?
a. History of gainful employment b. Frequent expression of guilt
regarding antisocial behavior c. Demonstrated ability to maintain
close, stable relationships d. A low tolerance for frustration
22.Nurse Amy is providing care for a male client undergoing opiate
withdrawal. Opiate withdrawal causes severe physical discomfort
and can be life-threatening. To minimize these effects, opiate users
are commonly detoxified with:
a. Barbiturates b. Amphetamines c. Methadone d. Benzodiazepines
23.Nurse Cristina is caring for a client who experiences false sensory
perceptions with no basis in reality. These perceptions are known as:
a. Delusions b. Hallucinations
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c. Loose associations d. Neologisms
24.Nurse Marco is developing a plan of care for a client with
anorexia nervosa. Which action should the nurse include in the plan?
a. Restricts visits with the family and friends until the client begins to
eat. b. Provide privacy during meals. c. Set up a strict eating plan for
the client. d. Encourage the client to exercise, which will reduce her
anxiety.
25.Tim is admitted with a diagnosis of delusions of grandeur. The
nurse is aware that this diagnosis reflects a belief that one is:
a. Highly important or famous. b. Being persecuted c. Connected to
events unrelated to oneself d. Responsible for the evil in the world.
26.Nurse Jen is caring for a male client with manic depression. The
plan of care for a client in a manic state would include:
a. Offering a high-calorie meals and strongly encouraging the client
to finish all food. b. Insisting that the client remain active through
the day so that he’ll sleep at night. c. Allowing the client to exhibit
hyperactive, demanding, manipulative behavior without setting
limits. d. Listening attentively with a neutral attitude and avoiding
power struggles.
27.Ramon is admitted for detoxification after a cocaine overdose.
The client tells the nurse that he frequently uses cocaine but that he
can control his use if he chooses. Which coping mechanism is he
using?
a. Withdrawal b. Logical thinking c. Repression d. Denial
28.Richard is admitted with a diagnosis of schizotypal personality
disorder. Which signs would this client exhibit during social
situations?
a. Aggressive behavior b. Paranoid thoughts
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c. Emotional affect d. Independence needs
29.Nurse Mickey is caring for a client diagnosed with bulimia. The
most appropriate initial goal for a client diagnosed with bulimia is to:
a. Avoid shopping for large amounts of food. b. Control eating
impulses. c. Identify anxiety-causing situations d. Eat only three
meals per day.
30.Rudolf is admitted for an overdose of amphetamines. When
assessing the client, the nurse should expect to see:
a. Tension and irritability b. Slow pulse c. Hypotension d.
Constipation
31.Nicolas is experiencing hallucinations tells the nurse, “The voices
are telling me I’m no good.” The client asks if the nurse hears the
voices. The most appropriate response by the nurse would be:
a. “It is the voice of your conscience, which only you can control.” b.
“No, I do not hear your voices, but I believe you can hear them”. c.
“The voices are coming from within you and only you can hear
them.” d. “Oh, the voices are a symptom of your illness; don’t pay
any attention to them.”
32.The nurse is aware that the side effect of electroconvulsive
therapy that a client may experience:
a. Loss of appetite b. Postural hypotension c. Confusion for a time
after treatment d. Complete loss of memory for a time
33.A dying male client gradually moves toward resolution of feelings
regarding impending death. Basing care on the theory of Kubler-
Ross, Nurse Trish plans to use nonverbal interventions when
assessment reveals that the client is in the:
a. Anger stage b. Denial stage c. Bargaining stage
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d. Acceptance stage
34.The outcome that is unrelated to a crisis state is:
a. Learning more constructive coping skills b. Decompensation to a
lower level of functioning. c. Adaptation and a return to a prior level
of functioning. d. A higher level of anxiety continuing for more than
3 months.
35.Miranda a psychiatric client is to be discharged with orders for
haloperidol (haldol) therapy. When developing a teaching plan for
discharge, the nurse should include cautioning the client against:
a. Driving at night b. Staying in the sun c. Ingesting wines and
cheeses d. Taking medications containing aspirin
36.Jen a nursing student is anxious about the upcoming board
examination but is able to study intently and does not become
distracted by a roommate’s talking and loud music. The student’s
ability to ignore distractions and to focus on studying demonstrates:
a. Mild-level anxiety b. Panic-level anxiety c. Severe-level anxiety d.
Moderate-level anxiety
37.When assessing a premorbid personality characteristics of a client
with a major depression, it would be unusual for the nurse to find
that this client demonstrated:
a. Rigidity b. Stubbornness c. Diverse interest d. Over meticulousness
38.Nurse Krina recognizes that the suicidal risk for depressed client
is greatest:
a. As their depression begins to improve b. When their depression is
most severe c. Before nay type of treatment is started d. As they
lose interest in the environment
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39.Nurse Kate would expect that a client with vascular dementis
would experience:
a. Loss of remote memory related to anoxia b. Loss of abstract
thinking related to emotional state c. Inability to concentrate related
to decreased stimuli d. Disturbance in recalling recent events related
to cerebral hypoxia.
40.Josefina is to be discharged on a regimen of lithium carbonate. In
the teaching plan for discharge the nurse should include:
a. Advising the client to watch the diet carefully b. Suggesting that
the client take the pills with milk c. Reminding the client that a CBC
must be done once a month. d. Encouraging the client to have blood
levels checked as ordered.
41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a
female client. Nurse Katrina would be aware that the teaching about
the side effects of this drug were understood when the client state,
“I will call my doctor immediately if I notice any:
a. Sensitivity to bright light or sun b. Fine hand tremors or slurred
speech c. Sexual dysfunction or breast enlargement d. Inability to
urinate or difficulty when urinating
42.Nurse Mylene recognizes that the most important factor
necessary for the establishment of trust in a critical care area is:
a. Privacy b. Respect c. Empathy d. Presence
43.When establishing an initial nurse-client relationship, Nurse Hazel
should explore with the client the:
a. Client’s perception of the presenting problem. b. Occurrence of
fantasies the client may experience. c. Details of any ritualistic acts
carried out by the client d. Client’s feelings when external; controls
are instituted.
44.Tranylcypromine sulfate (Parnate) is prescribed for a depressed
client who has not responded to the tricyclic antidepressants. After
teaching the client about the medication, Nurse Marian evaluates
that learning has occurred when the client states, “I will avoid:
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a. Citrus fruit, tuna, and yellow vegetables.” b. Chocolate milk, aged
cheese, and yogurt’” c. Green leafy vegetables, chicken, and milk.” d.
Whole grains, red meats, and carbonated soda.”
45.Nurse John is a aware that most crisis situations should resolve in
about:
a. 1 to 2 weeks b. 4 to 6 weeks c. 4 to 6 months d. 6 to 12 months
46. Nurse Judy knows that statistics show that in adolescent suicide
behavior:
a. Females use more dramatic methods than males b. Males account
for more attempts than do females c. Females talk more about
suicide before attempting it d. Males are more likely to use lethal
methods than are females
47.Dervid with paranoid schizophrenia repeatedly uses profanity
during an activity therapy session. Which response by the nurse
would be most appropriate?
a. "Your behavior won't be tolerated. Go to your room
immediately." b. "You're just doing this to get back at me for making
you come to therapy." c. "Your cursing is interrupting the activity.
Take time out in your room for 10 minutes." d. "I'm disappointed in
you. You can't control yourself even for a few minutes."
48.Nurse Maureen knows that the nonantipsychotic medication
used to treat some clients with schizoaffective disorder is:
a. phenelzine (Nardil) b. chlordiazepoxide (Librium) c. lithium
carbonate (Lithane) d. imipramine (Tofranil)
49.Which information is most important for the nurse Trinity to
include in a teaching plan for a male schizophrenic client taking
clozapine (Clozaril)?
a. Monthly blood tests will be necessary. b. Report a sore throat or
fever to the physician immediately.
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c. Blood pressure must be monitored for hypertension. d. Stop the
medication when symptoms subside.
50.Ricky with chronic schizophrenia takes neuroleptic medication is
admitted to the psychiatric unit. Nursing assessment reveals rigidity,
fever, hypertension, and diaphoresis. These findings suggest which
lifethreatening reaction:
a. Tardive dyskinesia. b. Dystonia. c. Neuroleptic malignant
syndrome. d. Akathisia.
51.Which nursing intervention would be most appropriate if a male
client develop orthostatic hypotension while taking amitriptyline
(Elavil)?
a. Consulting with the physician about substituting a different type
of antidepressant. b. Advising the client to sit up for 1 minute before
getting out of bed. c. Instructing the client to double the dosage until
the problem resolves. d. Informing the client that this adverse
reaction should disappear within 1 week.
52.Mr. Cruz visits the physician's office to seek treatment for
depression, feelings of hopelessness, poor appetite, insomnia,
fatigue, low selfesteem, poor concentration, and difficulty making
decisions. The client states that these symptoms began at least 2
years ago. Based on this report, the nurse Tyfany suspects:
a. Cyclothymic disorder. b. Atypical affective disorder. c. Major
depression. d. Dysthymic disorder.
53.After taking an overdose of phenobarbital (Barbita), Mario is
admitted to the emergency department. Dr. Trinidad prescribes
activated charcoal (Charcocaps) to be administered by mouth
immediately. Before administering the dose, the nurse verifies the
dosage ordered. What is the usual minimum dose of activated
charcoal?
a. 5 g mixed in 250 ml of water b. 15 g mixed in 500 ml of water c. 30
g mixed in 250 ml of water d. 60 g mixed in 500 ml of water
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54.What herbal medication for depression, widely used in Europe, is
now being prescribed in the United States?
a. Ginkgo biloba b. Echinacea c. St. John's wort d. Ephedra
55.Cely with manic episodes is taking lithium. Which electrolyte level
should the nurse check before administering this medication?
a. Calcium b. Sodium c. Chloride d. Potassium
56.Nurse Josefina is caring for a client who has been diagnosed with
delirium. Which statement about delirium is true?
a. It's characterized by an acute onset and lasts about 1 month. b.
It's characterized by a slowly evolving onset and lasts about 1 week.
c. It's characterized by a slowly evolving onset and lasts about 1
month. d. It's characterized by an acute onset and lasts hours to a
number of days.
57.Edward, a 66 year old client with slight memory impairment and
poor concentration is diagnosed with primary degenerative
dementia of the Alzheimer's type. Early signs of this dementia
include subtle personality changes and withdrawal from social
interactions. To assess for progression to the middle stage of
Alzheimer's disease, the nurse should observe the client for:
a. Occasional irritable outbursts. b. Impaired communication. c. Lack
of spontaneity. d. Inability to perform self-care activities.
58.Isabel with a diagnosis of depression is started on imipramine
(Tofranil), 75 mg by mouth at bedtime. The nurse should tell the
client that:
a. This medication may be habit forming and will be discontinued as
soon as the client feels better. b. This medication has no serious
adverse effects.
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c. The client should avoid eating such foods as aged cheeses, yogurt,
and chicken livers while taking the medication. d. This medication
may initially cause tiredness, which should become less bothersome
over time.
59.Kathleen is admitted to the psychiatric clinic for treatment of
anorexia nervosa. To promote the client's physical health, the nurse
should plan to: a. Severely restrict the client's physical activities. b.
Weigh the client daily, after the evening meal. c. Monitor vital signs,
serum electrolyte levels, and acid-base balance. d. Instruct the client
to keep an accurate record of food and fluid intake.
60.Celia with a history of polysubstance abuse is admitted to the
facility. She complains of nausea and vomiting 24 hours after
admission. The nurse assesses the client and notes piloerection,
pupillary dilation, and lacrimation. The nurse suspects that the client
is going through which of the following withdrawals?
a. Alcohol withdrawal b. Cannibis withdrawal c. Cocaine withdrawal
d. Opioid withdrawal
61.Mr. Garcia, an attorney who throws books and furniture around
the office after losing a case is referred to the psychiatric nurse in
the law firm's employee assistance program. Nurse Beatriz knows
that the client's behavior most likely represents the use of which
defense mechanism?
a. Regression b. Projection c. Reaction-formation d.
Intellectualization
62.Nurse Anne is caring for a client who has been treated long term
with antipsychotic medication. During the assessment, Nurse Anne
checks the client for tardive dyskinesia. If tardive dyskinesia is
present, Nurse Anne would most likely observe:
a. Abnormal movements and involuntary movements of the mouth,
tongue, and face. b. Abnormal breathing through the nostrils
accompanied by a “thrill.” c. Severe headache, flushing, tremors, and
ataxia. d. Severe hypertension, migraine headache,
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63.Dennis has a lithium level of 2.4 mEq/L. The nurse immediately
would assess the client for which of the following signs or
symptoms?
a. Weakness b. Diarrhea c. Blurred vision d. Fecal incontinence
64.Nurse Jannah is monitoring a male client who has been placed
inrestraints because of violent behavior. Nurse determines that it
will be safe to remove the restraints when:
a. The client verbalizes the reasons for the violent behavior. b. The
client apologizes and tells the nurse that it will never happen again.
c. No acts of aggression have been observed within 1 hour after the
release of two of the extremity restraints. d. The administered
medication has taken effect.
65.Nurse Irish is aware that Ritalin is the drug of choice for a child
with ADHD. The side effects of the following may be noted by the
nurse:
a. Increased attention span and concentration b. Increase in appetite
c. Sleepiness and lethargy d. Bradycardia and diarrhea
66.Kitty, a 9 year old child has very limited vocabulary and
interaction skills. She has an I.Q. of 45. She is diagnosed to have
Mental retardation of this classification:
a. Profound b. Mild c. Moderate d. Severe
67.The therapeutic approach in the care of Armand an autistic child
include the following EXCEPT:
a. Engage in diversionary activities when acting -out b. Provide an
atmosphere of acceptance c. Provide safety measures d. Rearrange
the environment to activate the child
68.Jeremy is brought to the emergency room by friends who state
that he took something an hour ago. He is actively hallucinating,
agitated, with
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irritated nasal septum.
a. Heroin b. Cocaine c. LSD d. Marijuana
69.Nurse Pauline is aware that Dementia unlike delirium is
characterized by:
a. Slurred speech b. Insidious onset c. Clouding of consciousness d.
Sensory perceptual change
70.A 35 year old female has intense fear of riding an elevator. She
claims “ As if I will die inside.” The client is suffering from: a.
Agoraphobia b. Social phobia c. Claustrophobia d. Xenophobia
71.Nurse Myrna develops a counter-transference reaction. This is
evidenced by:
a. Revealing personal information to the client b. Focusing on the
feelings of the client. c. Confronting the client about discrepancies in
verbal or non-verbal behavior d. The client feels angry towards the
nurse who resembles his mother.
72.Tristan is on Lithium has suffered from diarrhea and vomiting.
What should the nurse in-charge do first:
a. Recognize this as a drug interaction b. Give the client Cogentin c.
Reassure the client that these are common side effects of lithium
therapy d. Hold the next dose and obtain an order for a stat serum
lithium level
73.Nurse Sarah ensures a therapeutic environment for all the client.
Which of the following best describes a therapeutic milieu?
a. A therapy that rewards adaptive behavior b. A cognitive approach
to change behavior c. A living, learning or working environment.
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d. A permissive and congenial environment
74.Anthony is very hostile toward one of the staff for no apparent
reason. He is manifesting:
a. Splitting b. Transference c. Countertransference d. Resistance
75.Marielle, 17 years old was sexually attacked while on her way
home from school. She is brought to the hospital by her mother.
Rape is an example of which type of crisis:
a. Situational b. Adventitious c. Developmental d. Internal
76.Nurse Greta is aware that the following is classified as an Axis I
disorder by the Diagnosis and Statistical Manual of Mental
Disorders, Text Revision (DSM-IV-TR) is:
a. Obesity b. Borderline personality disorder c. Major depression d.
Hypertension
77.Katrina, a newly admitted is extremely hostile toward a staff
member she has just met, without apparent reason. According to
Freudian theory, the nurse should suspect that the client is
experiencing which of the following phenomena?
a. Intellectualization b. Transference c. Triangulation d. Splitting
78.An 83year-old male client is in extended care facility is anxious
most of the time and frequently complains of a number of vague
symptoms that interfere with his ability to eat. These symptoms
indicate which of the following disorders?
a. Conversion disorder b. Hypochondriasis c. Severe anxiety
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d. Sublimation
79. Charina, a college student who frequently visited the health
center during the past year with multiple vague complaints of GI
symptoms before course examinations. Although physical causes
have been eliminated, the student continues to express her belief
that she has a serious illness. These symptoms are typically of which
of the following disorders?
a. Conversion disorder b. Depersonalization c. Hypochondriasis d.
Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents
are sedativehypnotic medication is used to induce sleep for a client
experiencing a sleep disorder is:
a. Triazolam (Halcion) b. Paroxetine (Paxil)\ c. Fluoxetine (Prozac) d.
Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may obtain secondary
gain. Which of the following statement refers to a secondary gain?
a. It brings some stability to the family b. It decreases the
preoccupation with the physical illness c. It enables the client to
avoid some unpleasant activity d. It promotes emotional support or
attention for the client
82. Dervid is diagnosed with panic disorder with agoraphobia is
talking with the nurse in-charge about the progress made in
treatment. Which of the following statements indicates a positive
client response?
a. “I went to the mall with my friends last Saturday” b. “I’m
hyperventilating only when I have a panic attack” c. “Today I decided
that I can stop taking my medication” d. “Last night I decided to eat
more than a bowl of cereal”
83. The effectiveness of monoamine oxidase (MAO) inhibitor drug
therapy in a client with posttraumatic stress disorder can be
demonstrated by which of the following client self –reports?
a. “I’m sleeping better and don’t have nightmares” b. “I’m not losing
my temper as much” c. “I’ve lost my craving for alcohol”
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d. I’ve lost my phobia for water”
84. Mark, with a diagnosis of generalized anxiety disorder wants to
stop taking his lorazepam (Ativan). Which of the following important
facts should nurse Betty discuss with the client about discontinuing
the medication?
a. Stopping the drug may cause depression b. Stopping the drug
increases cognitive abilities c. Stopping the drug decreases sleeping
difficulties d. Stopping the drug can cause withdrawal symptoms
85. Jennifer, an adolescent who is depressed and reported by his
parents as having difficulty in school is brought to the community
mental health center to be evaluated. Which of the following other
health problems would the nurse suspect?
a. Anxiety disorder b. Behavioral difficulties c. Cognitive impairment
d. Labile moods
86. Ricardo, an outpatient in psychiatric facility is diagnosed with
dysthymic disorder. Which of the following statement about
dysthymic disorder is true?
a. It involves a mood range from moderate depression to hypomania
b. It involves a single manic depression c. It’s a form of depression
that occurs in the fall and winter d. It’s a mood disorder similar to
major depression but of mild to moderate severity
87. The nurse is aware that the following ways in vascular dementia
different from Alzheimer’s disease is:
a. Vascular dementia has more abrupt onset b. The duration of
vascular dementia is usually brief c. Personality change is common
in vascular dementia d. The inability to perform motor activities
occurs in vascular dementia
88. Loretta, a newly admitted client was diagnosed with delirium
and has history of hypertension and anxiety. She had been taking
digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This
client’s impairment may be related to which of the following
conditions?
a. Infection b. Metabolic acidosis
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c. Drug intoxication d. Hepatic encephalopathy
89. Nurse Ron enters a client’s room, the client says, “They’re
crawling on my sheets! Get them off my bed!” Which of the
following assessment is the most accurate?
a. The client is experiencing aphasia b. The client is experiencing
dysarthria c. The client is experiencing a flight of ideas d. The client is
experiencing visual hallucination
90. Which of the following descriptions of a client’s experience and
behavior can be assessed as an illusion?
a. The client tries to hit the nurse when vital signs must be taken b.
The client says, “I keep hearing a voice telling me to run away” c. The
client becomes anxious whenever the nurse leaves the bedside d.
The client looks at the shadow on a wall and tells the nurse she sees
frightening faces on the wall.
91. During conversation of Nurse John with a client, he observes that
the client shift from one topic to the next on a regular basis. Which
of the following terms describes this disorder?
a. Flight of ideas b. Concrete thinking c. Ideas of reference d. Loose
association
92. Francis tells the nurse that her coworkers are sabotaging the
computer. When the nurse asks questions, the client becomes
argumentative. This behavior shows personality traits associated
with which of the following personality disorder?
a. Antisocial b. Histrionic c. Paranoid d. Schizotypal
93. Which of the following interventions is important for a Cely
experiencing with paranoid personality disorder taking olanzapine
(Zyprexa)?
a. Explain effects of serotonin syndrome b. Teach the client to watch
for extrapyramidal adverse reaction
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c. Explain that the drug is less affective if the client smokes d. Discuss
the need to report paradoxical effects such as euphoria
94. Nurse Alexandra notices other clients on the unit avoiding a
client diagnosed with antisocial personality disorder. When
discussing appropriate behavior in group therapy, which of the
following comments is expected about this client by his peers?
a. Lack of honesty b. Belief in superstition c. Show of temper
tantrums d. Constant need for attention
95. Tommy, with dependent personality disorder is working to
increase his selfesteem. Which of the following statements by the
Tommy shows teaching was successful?
a. “I’m not going to look just at the negative things about myself” b.
“I’m most concerned about my level of competence and progress” c.
“I’m not as envious of the things other people have as I used to be”
d. “I find I can’t stop myself from taking over things other should be
doing”
96. Norma, a 42-year-old client with a diagnosis of chronic
undifferentiated schizophrenia lives in a rooming house that has a
weekly nursing clinic. She scratches while she tells the nurse she
feels creatures eating away at her skin. Which of the following
interventions should be done first?
a. Talk about his hallucinations and fears b. Refer him for
anticholinergic adverse reactions c. Assess for possible physical
problems such as rash d. Call his physician to get his medication
increased to control his psychosis
97. Ivy, who is on the psychiatric unit is copying and imitating the
movements of her primary nurse. During recovery, she says, “I
thought the nurse was my mirror. I felt connected only when I saw
my nurse.” This behavior is known by which of the following terms?
a. Modeling b. Echopraxia c. Ego-syntonicity d. Ritualism
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98. Jun approaches the nurse and tells that he hears a voice telling
him that he’s evil and deserves to die. Which of the following terms
describes the client’s perception?
a. Delusion b. Disorganized speech c. Hallucination d. Idea of
reference
99. Mike is admitted to a psychiatric unit with a diagnosis of
undifferentiated schizophrenia. Which of the following defense
mechanisms is probably used by mike?
a. Projection b. Rationalization c. Regression d. Repression
100. Rocky has started taking haloperidol (Haldol). Which of the
following instructions is most appropriate for Ricky before taking
haloperidol?
a. Should report feelings of restlessness or agitation at once b. Use a
sunscreen outdoors on a year-round basis c. Be aware you’ll feel
increased energy taking this drug d. This drug will indirectly control
essential hypertension