Sei sulla pagina 1di 29

Community Health Nursing Comprehesive

Thread Started on Aug 18, 2010, 1:01pm

1. The nurse learned that the health of individuals and communities are, to a large extent, affected by a combination of many factors. She understands that these are the determinants of health listed by the World Health Organization, EXCEPT: a. Greater support from families, friends and communities are linked to better health. b. Access and use of services that prevent and treat disease influence health. c. Research, development and implementation of innovative public health solutions is also part d. Customs and tradition, and the beliefs of the family and community is also part Ans. C. Is not part of the determinants of health rather it is one of the functions of public health A. Social support system is part of the determinants of health; B. Health services is also part of the determinants of health; C. Is not part of the determinants of health rather it is one of the functions of public health; D. Culture is part of the determinants of health. ( 2. The classic definition of public health is the science and the art of preventing disease, prolonging life, promoting health and efficiency through organizing community effort for the sanitation of the environment, control of CD, education of personal hygiene, organization of medical and nursing services for the early diagnostic and treatment of disease and the development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organize to enable every citizen to realize his birthright of health and longevity. This definition was coined form: a. WHO Expert Committee on Nursing c. Ruth Freeman b. Dr. C.E. Winslow d. Public Health Nurse Lilian Wald Ans. B. Dr. C.E. Winslow A. WHO defined public health as the art of applying science in the context of politics so as to reduce inequities in health while ensuring the best health for the greatest number; B. Public health defined by Dr. Winslow exactly as mentioned above; C. Freeman defined community health nursing not public health as a service rendered by a professional nurse with communities, groups, familiesfor the promotion of health, prevention of illness, care of the sick at home and rehabilitation; D. Lilian Wald defined public health nursing not public health as service to all the people. (Cuevas, Frances Prescilla. Public Health Nursing in the Philippines. 10th ed. Philippines: Publication Committee of NLPGN,Inc., 2007 p. 4-7) 3. The Health Care Delivery System involves two major players; the first is financed through a tax-based budgeting system and the other is largely market-oriented. They are known to be as? a. National and Local Government Agencies b. For-profit and Non-profit health providers c. Public sector and LGU d. Department of Health and Non-profit health providers Ans. D. Department of Health and Non-profit health providers (Public and Private Sector) A. The National and Local Government Agencies are part of the public sector; B. For-profit and Non-profit health providers are both part of the private sector; C. The public sector and LGU are the same that took part in the public sector. D. The department of health is a public sector while the Non-profit health provider is part of the private sector. The 2 major players in the Health Care Delivery System are the Public and Private sectors. (Cuevas, Frances Prescilla. Public Health Nursing in the Philippines. 10th ed. Philippines: Publication Committee of NLPGN,Inc., 2007 p. 19-20)

4. What is the vision of the Department of Health? a. FOURmula ONE for health b. Health Sector Reform Agenda c. Health for all in the Philippines d. Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health Ans. C. Health for all in the Philippines A. FOURmula One for health is the framework for implementation of Health Sector Reform Agenda (HSRA); B. Health Sector Reform Agenda is the goal of the DOH; C. Health for all in the Philippines is the vision of the Department of Health; D. This is the Mission of the DOH. (Cuevas, Frances Prescilla. Public Health Nursing in the Philippines. 10th ed. Philippines: Publication Committee of NLPGN,Inc., 2007 p. 25-26) 5. The framework for the implementation of health sector reform agenda of the department of health is: a. FOURmula ONE for health b. Health Sector Reform Agenda c. Health for all in the Philippines d. Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health Ans. A. FOURmula ONE for health A. FOURmula One for health is the framework for implementation of Health Sector Reform Agenda (HSRA); B. Health Sector Reform Agenda is the goal of the DOH; C. Health for all in the Philippines is the vision of the Department of Health; D. Guarantee . is the Mission of the DOH. (Cuevas, Frances Prescilla. Public Health Nursing in the Philippines. 10th ed. Philippines: Publication Committee of NLPGN,Inc., 2007 p. 25-26) 6. The overriding goals of the Department of Health: a. FOURmula ONE for health b. Health Sector Reform Agenda c. Health for all in the Philippines d. Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health Ans. B. Health Sector Reform Agenda A. FOURmula One for health is the framework for implementation of Health Sector Reform Agenda (HSRA); B. Health Sector Reform Agenda is the goal of the DOH; C. Health for all in the Philippines is the vision of the Department of Health; D. Guarantee . is the Mission of the DOH. (Cuevas, Frances Prescilla. Public Health Nursing in the Philippines. 10th ed. Philippines: Publication Committee of NLPGN,Inc., 2007 p. 25-26) 7. The goal of this element in FOURmula ONE is to ensure the quality and affordability of health goods and services. a. Health financing c. Health regulation b. Health service delivery d. Good governance Ans. C. Health regulation A. Health financings goal of this health reform area is to foster greater, better and sustained investments in health; B. Health service deliverys goal is to improve and ensure the accessibility and availability of the basic and essential health care in both public and private facilities and services; C. Health regulation ensure the quality and affordability of health goods and services; D. Good governance help enhance the health system performance at the national and local levels. Cuevas, Frances Prescilla. Public Health Nursing in the Philippines. 10th ed. Philippines: Publication

Committee of NLPGN,Inc., 2007 p. 26) 8. The first international conference of Primary Health Care was held in Alma Ata, USSR on September 6-12, 1978 by WHO. The goal was adopted in the Philipppines on October 19, 1979. What is its underlying theme? a. Health in the Hands of the People by 2020 b. Health for All by the year 2000 c. Health for all in the Philippines d. Health Sector Reform Agenda Ans. A. Health in the Hands of the People by 2020 A. Health in the Hands of the People by 2020 is the underlying theme in the Philippines; B. Health for All by the year 2000 is the goal during the conference; C. Health for all in the Philippines is the vision of the Department of Health; D. Health Sector Reform Agenda is the goal of the DOH 9. The primary components of the PHC include: a. Immunization and Control Communicable Diseases b. Health Education c. Environmental Sanitation d. All of the above Ans. D. All of the above The elements or components of PHC include: Environmental Sanitation; Control of Communicable diseases; Immunizations; Health Education; Maternal and Child Health and Family Planning; Adequate Food and Proper Nutrition; Provision of Medical Care and Emergency Treatment; Treatment of Locally Endemic Diseases and Provision of Essential Drugs. 10. Mark is a trained community worker in the community. He is identified at what level of primary health care worker? a. BHWs b. Volunteer c. Intermediate level health care d. Trained Hilot Ans. A. There are two levels of primary health care workers in the community. They are: 1. Village or Barangay Health Workers who are the trained community health workers, health auxiliary volunteers, TBSs and trained healers and 2. Intermediate Level Health Workers such as the general medical practitioner, PHN, midwife, rural sanitary inspector and midwife. 11. 10. There are 4 cornerstones/pillars in PHC. Of the following which is NOT included? a. Government Funds b. Intra and intersectoral linkages c. Use of appropriate technology d. Active community participation Ans. A. Government Funds A. Government Funds is not part of the pillars of PHC; B. Intra and Intersecoral linkages is part of the 4 pillars; C. The use of appropriate technology is also part; D. Active community participation is also part of the PHC cornerstone. The missing pillar is Support Mechanism. 12. The intention of this level of prevention is to halt the disease or injury process and assist the person in obtaining an optimal status according to his present capabilities: a. Secondary Level b. Tertiary Level

c. Primary Level d. Quaternary Level Ans. B. Tertiary Level A. Secondary level: Early diagnosis, detection, screening, case finding, and prompt treatment. Examples are Sputum exam, cataract screening, ORESOL , etc.; B. Tertiary level: Rehabilitation. Services provided after a disease or disability has occurred and the recovery process has begun. Ex. Community based rehabilitation program; C. Primary level: Health promotion and specific protection, seeks to prevent a disease or condition before the person gets sick. To encourage optimal health and to increase the persons resistance to illness examples are prenatal care; D. There is no such thing as quaternary level. 13. The PHN understands that this function is the most inherent function. Her practice as a nurse is based on the science and art of caring, in whatever setting she maybe or role she may presume. a. Collaborating and coordinating function b. Supervisory function c. Health promotion and Education function d. Nursing care function Ans. D. Nursing Care function A. Collaborating and coordinating function bring the PHN its activities systematically into proper relation or harmony with each other; B. Supervisory function supervises the midwives and other auxiliary health workers in the catchment area. C. Health Promotion and Education function tells that her activities go beyond health teachings and health information campaign; D. Nursing care function is the inherent function, as such PHNs are expected to provide nursing care. 14. The nursing process is systematic, scientific, and dynamic, on going interpersonal process in which the nurse and the clients are viewed as system with each affecting the other and both being affected by the factors within the behavior. The following are part of the Planning Nursing Action, EXCEPT: a. Develop evaluation parameters b. Identify needed alterations c. Prioritize needs d. Construct action and Operational plan Ans. B. Identify needed alterations A. Developing evaluation parameter is part of planning nursing action; B. Identifying needed alterations is part of Evaluation of care and services rendered; C. Prioritize needs is in planning nursing action; D. Constructing action and Operational plan is also part of the planning nursing action phase. 15. Maita a student nurse when asked by her clinical instructor the basic principles of health education responded INCORRECTLY when she mentioned that health education is: a. a creative process b. achieved by doing c. recognized as a basic function of the people d. helping people attain their health through their efforts Ans. C. Recognize as a basic function of the people A. a creative process is part of the basic principles of health education as well as B. achieved by doing; C. is wrong because it should be the primary function of the public health workers not the people; D. is correct also because it emphasizes the own effort of the people. 16. The primary focus of community health nursing is health promotion. What is its ultimate goal? a. worth and dignity of man b. making the community health nurses as generalist

c. raise the level of health of the citizenry d. provide quality nursing services to individuals, families and communities utilizing as basis the standards set community health nursing practice. Ans. C. raise the level of health of the citizenry A. worth and dignity of man is the philosophy of CHN; B. making the community health nurses as generalist in the nursing profession; C. raising the level of health of citizenry is the ultimate goal; D. Provide quality nursing. Is one of the objectives. 17. These are the following principles of Community health nursing, EXCEPT: a. In CHN, the family is the unit service b. The CHNurse is responsible for her own professional growth. c. The CHNurse utilizes the already-existing active organized groups in the community. d. Opportunities for continuing staff education programs for nurses are the CHNurses responsibility. Ans. D. Opportunities for continuing staff education programs for nurses are the CHNurses responsibility A,B and C are part of the principles of Community Health Nursing.

18. The primary group focus of community health nursing practice especially in terms of maintaining the peoples optimum level of functioning is: a. Health Promotion b. Rehabilitation c. Reduction of lifestyle diseases d. Prevention of communicable disease Ans. A. Health Promotion Although letters b, c and d are also functions of community health nursing, health promotion is the primary group focus of community health nursing practice especially in terms of maintaining the peoples OLOF. 19. These are the steps in conducting home visit. Arrange in order of priority: I. Put the bag in a convenient place then proceed to perform the bag technique II. Record all important data, observation and care rendered III. State the purpose of the visit IV. Perform the nursing care needed and give health teachings V. Greet the patient and introduce yourself a. III,V,I,II, and V b. V,III,I,IV and II c. III,V,IV,I and II d. V,I,III,IV and II Ans. B. V,III,I,IV and II. Steps in conducting home visits: 1. Greet the patient and introduce self; 2. State the purpose of the visit; 3. Observe the patient and determine the health needs; 4. Put the bag in a convenient place then proceed to perform the bag technique; 5 Perform the nursing care needed and give health teachings; 6. Record all important data, observation and care rendered and 7. Make appointment for a return visit. 20. In the Philippine Health Care Delivery System, the secondary level of health service is provided by the: a. Regional Medical Center c. Provincial hospitals b. Puericulture Centers d. Rural Health Units Ans. C. Provincial hospitals The RHCDS provides three levels of health services: a. Primary Level: BHS, RHU, Community Hospitals, Lying in centers, puericulture centers, clinics of private practitioner b. Secondary Level: Emergency hospitals, District Hospitals, Provincials and City Hospitals

c. Tertiary Level: Regional Hospitals, National Medical Centers and Training Hospitals 21. The devolution of health services to the local government unit was mandated by: a. R.A. 7160 b. E.O. 851 c. R.A. 6713 d. R.A. 8749 Ans. A. RA 7160 is the local autonomy code, which transferred local health services under the authority of the local governments. EO 851 is the law of the Reorganization of DOH. RA 6713 is the code of conduct and ethical standards of public officials and employees. AR 8749 is the Clean Air Act, Approved in 2000 and took effect in 2001. 22. Nurse Cara learned that bag technique is a tool by which the nurse, during her visit enabled her to perform a nursing procedure with ease and deftness, to save time and effort in rendering nursing care to clients. Which of the following equipments are carried separately? a. Spirit of ammonia, Zephiran solution and 70% alcoohol b. Sphygmomanometer, Thermometer and Stethoscope c. Sphygmomanometer only d. Stethoscope and sphygmomanometer Ans. D. Stethoscope and sphygmomanometer A. Spirit of ammonia et als. Are carried in the bag; B. Thermometer is carried in the bag; C. Lacking stethoscope; D. Both are carried separately 23. The basic qualification of a CH Nurse is: a. Masters of Public Health b. Bachelor of Science in Nursing b. Licensed Practical Nurse d. b only Ans. D. b only 24. A process of analyzing and determining the community health status is community diagnosis. These are the following demographic variables needed in the diagnosis, EXCEPT: a. age and sex composition c. pattern of migration b. educational level d. total population Ans. B. Educational level A, C and D are all demographic variables; B. educational level is part of socio-economic and cultural variable.

25. The nurse gathered data that will be used in community diagnosis. She assessed the physical/geographical characteristics. In what factor does this belong? a. Socioeconomic and cultural variable b. Environmental Indicator c. Demographic data d. both B and D Ans. B. Environmental Indicator

26. What level of water source where a system with a source is observed, there is reservoir and piped distribution network up to the household. a. Level I b. Level II c. Level III d. Level IV Ans. C. Level III

A. Level I- a protected well or developed spring with outlet but without distribution; B. Level II a system composed of source, a reservoir and piped distribution network and communal faucet located not more than 2 meter from the nearest household; C. there is piped distribution network up to the household; D. no Level IV 27. Water system and deep well construction require the approval of: a. Mayors permit b. Secretary of health c. Rural sanitary inspector d. City health engineer Ans. B. The certification of the potability of an existing water source is also issued by the secretary of the DOH. 28. Which of the following is level 1 approved type of toilet facility? a. Water sealed b. Flushed type c. Pit latrines d. Water carriage type Ans. C. Level 1: non water carriage such as pit latrines, reed odorless earth closet; Level II water carriage type such as water sealed and flushed type septic tank; Level III water carriage type connected to septic tanks and sewerage system. 29. Vital Statistics refers to the systematic study of vital events such as births, illnesses, marriages, divorce, separation and deaths. It is the measure of the risk of dying from the cause related pregnancy, child birth and puerperium. a. Infant Mortality Rate b. Maternal Mortality Rate c. Maternal Morbidity rate d. Specific Death Rate Ans. B. Maternal Mortality Rate 30. In vital statistics, this measures the frequency of occurrence of the phenomenon during a given period of time. a. Prevalence Rate b. Incidence Rate c. Specific Rate d. except c Ans. B. Incidence Rate A. Prevalence Rate measures the proportion of the population which exhibits particular disease at a particular time; B. is the correct answer; C. Specific Rate the relationship is for a specific population class or group. It limits the occurrence of the event to the portion of the population definitely exposed to it; D. only Incidence Rate or letter B 31. This is the phase of COPAR where nurse do an ocular survey of short listed community. a. Pre-entry c. Organization Building b. Entry d. Sustenance and Strengthening Ans. A. Pre-entry

32. What part of the pre-entry phase where the nurse pay courtesy call to the community leaders, sensitize community leaders and conduct baseline survey? a. Community preparation selection c. Coordination

b. Final preparation d. Community preparation survey Ans. B. Final Preparation 33. When the Core group is selected the phase of COPAR is said to be: a. Phase I c. Phase II b. Phase III d. Phase IV Ans. C. Phase II 34. These are ways of partnership in COPAR, EXCEPT: a. Networking c. Collaboration b. Competition d. Cooperation Ans. B. Competition 35. The fundamental unit of any society, composed of father, mother and children related by blood or marriage is the family. When the authority inside the family is 50-50 basis or there is sharing of decision. This is said to be: a. Matriarchal c. Egalitarian b. Patriarchal d. Equalitarian Ans. C. Egalitarian A. Matriarchal mother is the dominant figure of authority; B. Patriarchal father is the dominant figure of authority; C. Egalitarian 50-50 basis, sharing of decision making; D. There is no such thing as Equalitarian 36. When the health status of the family is measured by nutritional status weight, height, mid-upper arm circumference. It is called: a. Nutritional assessment c. Dietary History b. Arthropometric assessment d. Eating/feeding habits, practices Ans. B. Arthropometric assessment A. Nutritional assessment especially for vulnerable or at risk members; B. Arthropometric assessment is the correct answer; C. Dietary history specifying the quality and quantity of food/nutrient intake per day; 37. It is the term used for intermittent occurrence of disease in a few and unrelated cases within a given locality. a. Endemic occurrence c. Epidemic occurrence b. Sporadic occurrence d. Pandemic occurrence Ans. B. Sporadic occurrence 38. Mortality and morbidity are categorized as community health nursing problems on: a. health resources c. health-related b. health status d. health indicators Ans. B. Vital Statistics is the collection of data of significant events that occur over a period of time within a population. Morbidity and mortality are among of the significant data needed to determine the health status of the community. 39. What is the leading cause of mortality in the Philippines as of 2003 statistics? a. Malignant Neoplasm c. Heart Diseases b. Vascular System Diseases d. Tuberculosis, all forms Ans. C. Heart Disease Mortality Statistics (2003) 1. Heart Diseases 2. Vascular System Diseases 3. Malignant Neoplasm

4. Accidents 5. Pneumonia 6. Tuberculosis, all forms 40. The nurse is well versed in environmental health and sanitation. She understands that the components and factors in the prevention of illness lie in the following, EXCEPT: a. environment b. disease agent c. food safety practices d. man Ans. C. Food safety practices is not part 41. What would you include in your health teaching in iodine deficiency? a. Eat sea foods and vegetables b. Eat beans c. Eat meats and vegetables d. Eat sweet potatoes Ans. A. Good source of iodine include sea foods and iodized salt( 42. A traditional plant used to lower the uric acid. a. Pansit pansitan b. Lagundi c. Bayabas d. Sambong Ans. A Pansit pansitan , also known as ulasimang bato (Peperonia pellucida) is a herbal medicine which is known to lower uric acid and beneficial in persons with rheumatism and gout. Its leaves 1 cups leaves to two glassful of water are boiled and the decoction is taken three times a day. Fresh leaves can also be eaten as a salad three times a day. 43. A traditional plant use to treat diarrhea: a. Lagundi b. Bayabas c. Pansit pansitan d. Sambong Ans. B. Bayabas or guava (Psidium guajava) is a fruit bearing tree. Its leaves are boiled for 15 minutes at low fire and decoction. It can be used for the following medicinal purposes: washing, diarrhea, mouth gargle and relief of tooth ache. 44. An alternative for mefenamic acid for toothache is: a. Tsaang gubat b. Lagundi c. Sambong d. Bawang Ans. D. Bawang or ajos is pounded and applied to the aching tooth. To lower cholesterol and for hypertension, 2 pcs. Bawang may be fried, roasted, soaked in vinegar or boiled and taken three times a day. 45. Used to relieve muscle and joint pain: a. Lagundi b. Akapulko c. Yerba Buena d. Sambong Ans. C Yerba Buena is indicative for the following ailments: Headache, stomachache, cough and colds, arthritis

causing joint pains, swollen gums, toothache, etc. 46. In the principle of from cleanest to the dirtiest care. Which of the following is arranged correctly? a. measles case, pregnant woman, newborn b. post-partum, newborn, measles case c. tuberculosis, hypertension, measles d. post-partum, measles case, newborn Ans. B. Post-partum, newborn, measles care 47. To disseminate information, the BEST type of nurse-family contact is: a. home visit b. clinic visit c. community assembly d. except b&c Ans. C. community assembly 48. The type of public health nursing that focuses on the promotion of health and wellness of pupils, teaching and non teaching personnel of the school. a. Occupational Health Nursing b. School Nursing c. Mental Health Nursing d. All of the above Ans. B. School Nursing 49. This type of vaccines are the most sensitive to heat. They are in the form of live attenuated and freeze dried: a. DPT, Hep B b. BCG, Tetanus Toxoid c. Measles, Oral Polio d. BCG, Measles Ans. C. Oral Polio Vaccine and Measles were the most sensitive to heat with storage temperature of -15 to -25 degree C at the freezer. 50. In DPT the Diptheria and Tetanus are in the form of weakened toxin, what is the form of Pertussis? a. Freeze dried bacteria b. Live attenuated c. Weakened toxoid d. Killed bacteria Ans. D. Killed bacteria. Oral Polio is live attenuated. Measles and BCG are freeze dried bacteria. Diptheria and Tetanus are weakened toxin. 51. It helps the nurse to explain the probable cause of health conditions that occur in the community: a. Vital Statistics b. Demography c. Epidemiology d. Multiple causation theory Ans. C. Epidemiology. Vital Statistics are indices of health and illness status of the community; Demography describes the characteristics of the population in terms of size, composition and distribution in space. Multiple causation theory explains disease as caused not by single condition but by several conditions. 52. It is the intrinsic property of microorganism to survive and multiply in the environment to produce disease. a. Agent c. Causative Agent b. Host d. Environment

Ans. A. Agent A. is the correct answer; B. Host influences exposure, susceptibility or response to agents; C. Causative agent is the infectious agent or its toxic component that is transmitted from the source of infection; D. Environment is the sum total of all external condition 53. The following are the components of the environment, EXCEPT: a. Physical c. Spiritual b. Biological d. Socio-economic Ans. C. Spiritual A. Physical environment is composed of the inanimate surroundings such as the geophysical conditions of the climate; B. Biological environment makes up the living things around us such as plants and animal life; C. There is no such thing as spiritual environment; D. Socio-economic environment which may be in the form of level of economic development of the community, presence of social disruptions and the like. 54. Marco was bitten by a dog. You interviewed Marco and his father to take the history before seeing a doctor. You told Marcos father not to kill the dog because the dog will be: a. Given a vaccine b. Confined c. Observed for 10 days d. Be examined Ans. C. When a person is bitten by a dog, the animal should be observed for 10 to 14 days. 1. The person bitten is immunized with rabies immunoglobulin and tetanus toxoid right after the incident to provide immediate protection; 2. If the dog dies before the the observation period is completed, the bitten person should be immunized with rabies vaccine; and 3. If the dog shows signs of rabies, the person should be immunized with rabies vaccineand the dog should be killed immediately and its brain be examined for the presence of Negri bodies, the diagnostic sign of the disease. 55. In patient with dengue fever, which of the following will you give to the patient as part of your intervention? a. Water and salt solution b. Oresol c. Saline solution d. IV fluids Ans. B. H-Fever is characterized by internal bleeding that could result in hypovolemia so rapid fluid replacement is the most important part of the treatment. ORESOL at 75ml/kg in 4-6 hours. Up to 2-3 liters can be given in adult clients. 56. What is the test that confirms the diagnosis of Dengue Fever? a. Torniquet Test b. Capillary Fragility Test c. Platelet Count d. Rumpel Lead Test Ans. C. 57. In doing a tourniquet test, how would petechiae be considered positive? a. 10 b, 20 c. 30 d. 5 Ans. B. The tourniquet test for H-Fever is also known as Rumpel Leads Test. The procedure in taking the test is:

1. Take BP 2. Inflate the BP cuff midway between the systolic and diastolic pressure and leave for 5 minutes 3. Release cuff 4. Count then umber of petechiae below the cuff at the atecubital fossa that would fit inside a 2.5cm square of 1 inch square. The test is positive if thepatient develops 20 or more petechiae with in the area

58. The communicable disease that causes infertility in both male and female? a. Gonorrhea c. Herpes b. Syphilis d. Chlamydia Ans. A 59. Which of the following is the most common and highly contagious STD? a. Gonorrhea c. Herpes b. Syphilis d. Chlamydia Ans. D 60. Which STD causes oral thrush? a. Trichomoniasis c. Chlamydia b. Candidiasis d. Gonorrhea Ans. B Community Health Nursing Pre-test 1
Thread Started on Aug 18, 2010, 12:53pm

1. This STD is characterized by greenish yellow, frothy musty odorous vaginal discharge accompanied with vaginal itchiness and painful urination? a. Trichomoniasis b. Chancroid c. Moniliasis d. Chlamydia Ans. A. Trichomoniasis 2. DOTS is a comprehensive strategy to detect and cure TB. The primary element of DOTS is a. Health workers counsel and observe their patients swallow each anti-TB medication and monitor progress until cures b. Regular drug supply c. Political will in terms of manpower and funding d. Sputum microscopy services Ans. A. The main strategy of the NTP is Directly Observed Treatment, short course (DOTS). This is a comprehensive strategy to control TB which primary health services around the world are using in the detection and cure TB 3. What is the mode of transmission of Pulmonary Tuberculosis? a. Fecal-oral c. Airborne, droplet b. Direct contact d. Blood borne Ans. C. (Martinez, D. Intensive Final Coaching Primary Health Care, Legazpi City: A1 Review Center, 06, question 36) 4. Standard examination in detecting PTb: a. X-ray c. Ultrasound b. Sputum Exam d. Tuberculin Test

Ans. B.

5. In Catergory II of the TB treatment regimen all are prescribed BUT one: a. Relapse case b. New pulmonary smear (+) cases c. Failure cases d. Other (smear +) Ans. B. Category I: Prescribed for a) new pulmonary smear (+) cases, b) new seriously ill pulmonary smear(-) cases with extensive parenchymal involvement and c.) new severely ill extrapulmonary TB cases; Category II: Prescribed for a.) failure cases, b) relapse cases; c) RAD (smear +), and OTHER (smear+); Category III Prescribed for a.) new smear (-) but with minimal pulmonary TB on radiography as confirmed by medical officer and b) new extrapulmonary TB (not serious). ( 6. Malaria can be prevented by the following EXCEPT: a. Avoiding outdoor night time activities b. Use of mosquito repellants c. Planting of herbal plants which can be mosquito repellants d. Spending leisure time in the forest Ans. D. Preventive activities against malaria include all but not limited to the following: 1. Avoid going outdoor between 9pm to 3 am , the peak biting hours of female anopheles mosquitoes 2. Prophylaxis: taking chloroquine every week starting one to two weeks before traveling 3. Using mosquito net or curtain treatment by soaking the mosquito net in insecticidal solution and allow to dry before using 4. House spraying of insecticide inside the house 5. Wearing clothes that cover arms and legs at night

7. During this stage the H fever is said to cause severe abdominal pain, vomiting and frequent bleeding from GI tract: a. Invasive Stage c. Convalescent Stage b. Toxic stage d. Febrile Stage Ans. B. Toxic Stage A. Invasive stage or febrile stage starts abruptly as high fever, abdominal pain and headache; later flushing which maybe accompanied by vomiting and epistaxis; B. Toxic or hemorrhagic stage is the time where severe abdominal pain, vomiting and frequent bleeding from the GI is observed; C. Convalescent or recovery stage most of the vital signs are stable.

8. What is the etiologic agent of Diptheria? a. Klebs-Loffler bacillus b. Bordet Gengou Bacillus c. Vibrio El Tor d. Filterable virus Ans. A. Klebs-Loffler bacillus

9. An example of this route of transmission is the dust particles with infectious agent and residue of evaporated droplets that remain suspended in the air: a. Vectorborne transmission c. Contact transmission b. Airborne transmission d. Droplet transmission Ans. Ans. B. Airborne transmission A. Vectorborne transmission examples are flies, ticks, mosquitoes and flies; B. Airborne transmission includes droplet nuclei, dust particles with infectious agent and organisms shed into the environment from the skin, hair or perineal area; C. Contact transmission includes direct contact, indirect contact and droplet contact; D. theres no such thing as droplet transmission only droplet contact.

10. This chain of infection allows the microorganisms to move from reservoir to host: a. Portal of Exit c. Portal of entry b. infectious agent d. susceptible host Ans. A. Portal of exit A. Some examples of movement from reservoir to host are excretions, secretions and skin droplets; B. The common site for the portal of entry is mucous membranes, GI tract and non-intact skin; C. Examples of infectious agents are bacteria and virus; D. susceptible host are the immunosuppressed patient, fatigued, elderly and other hospitalized patient.

11. Inflammatory processes provided by the WBC (leukocytes), whose main purpose is to limit the effect of harmful bacteria or injury by destroying or neutralizing the organism, and by limiting its spread throughout the body: a. First line of defense b. Second line of defense c. Third line of defense d. Fourth line of defense Ans. B. Second line of defense A. First line of defense include the skin and mucus membrane; B. Second line of defense involves leukocytes; C. Third line of defense include the antibodies

12. The immune response is considered to be: a. First line of defense b. Second line of defense c. Third line of defense d. Fourth line of defense Ans. C. Third line of defense A. First line of defense include the skin and mucus membrane; B. Second line of defense involves leukocytes; C. Third line of defense includes the antibodies.

13. Nurse Angelika believed that the complete destruction of all microorganisms, including the spores is: a. Disinfection c. Cleaning b. Sterilization d. all of these Ans. B. Sterilization 14. When asked about the risk of transmitting agents through large particles (5 micrometer or more) Crizelda refer this type of precaution to her clients as: a. Airborne precaution b. Contact precaution c. Standard precaution d. Droplet precaution Ans. D. Droplet precaution 15. It is an upper respiratory condition characterized by escalating fever (peaks 3-5 days), conjunctivitis and coryza: a. Measles b. German Measles c. chicken pox d. Varicella Ans. Measles 16. A day biting female mosquito that breeds in household or standing clean water: a. Female anopheles b. Male anopheles c. Aedes aegypti d. None of these Ans. C. Aedes aegypti

17. The following are the major causes of intestinal parasitic infections in the Philippines, EXCEPT: a. Trichuris trichiura c. Hookworm b. Ascaris lumbricoides d. none of these Ans. D. All of them are the three major causes of intestinal parasitic infections 18. What is the period of communicability of the epidemic parotitis? a. Begins before the glands are swollen and presumed to last as long as localized glandular swelling remains b. Begins after the glands are swollen especially when the localized glandular swelling remains c. Begins before the glands are swollen and after the glands are swollen even when the glandular swelling is not observed. d. except c Ans. A. Begins before the glands are swollen and presumed to last as long as localized glandular swelling remains 19. Which his TRUE regarding Filariasis? a. Microfilarie rate increases with age and then levels off during the acute stage b. Men have higher micronlariae rate than women c. During the chronic stage the disease develops 2-5 years from the onset of attack d. Hydrocoele is evident in men during the acute stage A. It is not during the acute stage but during the asymptomatic stage: B True that men have higher micronlariae rate than women; C. The disease develops from 10-15 years from the onset of attack; D. It is during the chronic stage when hydrocoele will be noted. 20. Which is FALSE about Tuberculosis? a. The most hazardous period for development of clinical disease is the first 6-12 months after infection b. The risk of developing the disease is highest in children under 3 years old. c. The degree of communicability depends on the virulence of the bacilli, adequacy of ventilation with no direct exposure of bacilli to the sun or UV light d. Susceptibility of the disease is markedly increased in those with HIV infection and other forms of immunosuppression Ans. C. All are true except C because the degree of communicability always involves exposure of the bacilli to the sun or UV light. 21. Which of the following tetanus immunization is given to a mother to prevent from a neonatal tetanus and provide 10 years protection for the mother? a. TT1 b.TT2 c. TT3 d. TT4 Ans. C. Schedule of TT immunization: VACCINATION SCHEDULE PROTECTION DURATION OF PROTECTION TT1 As early as possible during pregnancy 80% TT2 4 weeks after TT1 80% Infants protected from neonatal tetanus. Provides 3 year protection to the mother TT3 6 months after TT2 90% Infants protected from neonatal tetanus. Provides 5 year protection to the mother TT4 1 year after TT3 99% Infants protected from neonatal tetanus. Provides 10 year protection to the mother TT5 1 year after TT4 99% Infants protected from neonatal tetanus. Provides lifetime protection to the mother.

22. Which of the following vaccines is not recommended by IM injection? a. Measles vaccine c. Hepa B vaccine b. Tetanus toxoid d. DPT Ans. A. Measles vaccine 23. The following are vaccines which are less sensitive to heat: a. oral polio, DPT

b. Measles, Hep B c. BCG, TT d. BCG, oral polio Ans. C. BCG and TT Most sensitive to heat: oral polio and measles; least sensitive to heat: DPT, Hep B, BCG, TT

24. OPV should be stored in a freezer with a temperature of: a. 2-8 degrees C b. -15 to -25 degrees C c. -2 to -8 degrees C d. none of these Ans. B. -15 to -25 degrees C 25. Hepa B is given at birth with 6 weeks interval from the 1st dose to 2nd dose, 8 weeks interval from the 2nd to 3rd dose. It is given intramuscularly in the: a. outer part of upper arm b. gluteus maximus c. vastus lateralis d. deltoid region Ans. C. vastus lateralis 26. It is the principle practiced in order to assure that all vaccines are utilized before its due date: a. First expiry and first out b. First used and first contained c. First expiry and last out d. First used and last contained Ans. A. First expiry and First out

27. When reconstituting the freeze dried BCG vaccine the nurse must always keep the diluents in the room temperature by sustaining with the BCG vaccine ampules in the clinic table: a. TRUE b. FALSE c. TRUE in Hep B and DPT d. except A Ans. A. FALSE The BCG vaccine must always be kept in cold temperature and sustaining it in the refrigerator or vaccine carrier. 28. What is the classification of disease when the level of management is urgent referral in hospital? a. mild b. moderate c. severe d. most severe Ans. C. Severe. 29. What is the color presentation to children whose level of management is home care. a. yellow b. red c. green d. pink Ans. C. Green. ( 30. The following BUT one is part of the danger signs that needs to be checked in assessing the child using the integrated case management process? a. vomits everything b. convulsions c. unable to drink/breastfeed

d. difficulty breathing Ans. D. Difficulty of breathing is part of the main symptoms that needs to be assessed not the danger signs. The missing danger sign is abnormality sleepy or difficult to awaken. Fundamentals Pre-Test 1
Thread Started on Aug 18, 2010, 12:44pm

Analysis Health Promotion and Maintenance Nursing Process/Analysis Adult Health/Cardiovascular

1. A nurse is assessing the extent of pitting edema in a client with congestive heart failure. The nurse gently presses a finger on the client's ankle and notes a barely perceptible pit. The nurse interprets this finding as which measurement of pitting edema? a. 1+ b. 2+ c. 3+ d. 4+ A. The level of pitting edema is rated on a scale of 1+ to 4+. A barely perceptible pit is rated as 1+. A deeper pit that rebounds in a few seconds is rated as 2+. A deep pit that rebounds in 10 to 20 seconds is rated as 3+. A deeper pit that rebounds in greater than 30 seconds is rated as 4+. 2. The nurse notes documentation that a client's peripheral pulses are +3. The nurse determines that the pulses are a. Full and brisk b. Absent c. Normal or average d. Palpable, but diminished A. Pulses are rated on a scale of 0 to +4 as follows: 0 = absent; +1 = palpable, but diminished; +2 = normal or average; +3 = full and brisk; and +4 = full and bounding, often visible. 3. A nurse is reviewing a clients record and notes that the results of the clients vision test using a Snellen chart is 20/50. The nurse interprets this to mean that the client a. Has normal vision b. Has minimal visual c. Can read at a distance of 20 feet what a client with normal vision can read at 50 feet d. Can read at a distance of 50 feet what a client with normal vision can read at 20 feet C. When recording the results of visual acuity using the Snellen chart, the nurse would record the result using the numeric fraction noted at the end of the last successful line read on the Snellen chart. The top number (numerator) indicates the distance the client is standing from the chart, whereas the bottom number (denominator) gives the distance at which a person with normal vision could have read that particular line. Thus, 20/50 means that the client can read at a distance of 20 feet what a client with normal vision can read at 50 feet. Normal visual acuity is 20/20. Minimal vision is a vague description of a clients visual acuity. 4. A prenatal client tells the nurse that she is really worried about knowing how to care for her first-born child. The nurse formulates which nursing diagnosis for this client? a. Ineffective Coping

b. Dysfunctional Grieving c. Situational Low Self-esteem d. Deficient Knowledge D. Deficient Knowledge indicates a lack of information or psychomotor skills concerning a skill, condition, or treatment. This nursing diagnosis best describes the situation presented in the question. Situational Low Self-esteem represents temporary negative feelings about self in response to an event. Ineffective Coping implies that the person is unable to manage stressors adequately. Dysfunctional Grieving implies prolonged unresolved grief leading to detrimental activities. 5. The nurse notes documentation that a client has the presence of cherry angiomas located on the abdomen. On assessment of the client, the nurse would expect to note which characteristic of this skin lesion? a. Ruby red papules b. Thickened skin areas c. Pinpoint-sized red or purple spots d. Areas of redness warm to touch A. Cherry angiomas are noted as ruby red papules. Areas of skin thickening are noted as senile keratosis. Pinpointsized red or purple spots are known as petechiae. Areas of redness that are warm to touch are noted as erythema. 6. A nurse is assessing the risk factors for acquiring pneumonia during hospitalization for a group of clients. The nurse determines that which of the following clients is at lowest risk? a. An older client with diabetes mellitus b. A client with human immunodeficiency virus (HIV) c. A client with a spinal cord injury who is immobile d. A postoperative client who is ambulating D. The postoperative client who is ambulating is at lowest risk. This client has had no direct insult to the respiratory tract. Clients with HIV, an upper respiratory infection, or a chronic disease (e.g., heart, lung, or kidney disease; diabetes mellitus; or cancer) are at greater risk for development of pneumonia. Clients who are on bed rest and are immobilized also are at risk for development of pneumonia. 7. A nurse working in a prenatal clinic is reviewing the records of clients scheduled for prenatal visits. The nurse interprets that the client at greatest risk for abruptio placenta is the one who a. Is 26 years old and is a primipara b. Rides an exercise bike for 30 minutes 3 times weekly c. Has maternal hypertension d. Takes folic acid supplements daily C. Risk factors for abruptio placenta include maternal hypertension, smoking, and alcohol and/or cocaine use during pregnancy. Other risk factors include blunt external abdominal trauma, poor nutrition, and history of placental abruption. 8. The nurse teaches a client with gastroesophageal reflux disease (GERD) about the measures to prevent reflux while sleeping. The nurse determines that the client needs additional instructions if the client states a. "I shouldn't eat anything at bedtime." b. "I should take an antacid at bedtime." c. "I should sleep flat on my right side." d. "Losing weight will decrease some of the stomach pressure." C. Elevation of the head of the bed 6 to 8 inches will prevent nocturnal reflux. The client is instructed to avoid eating within 3 hours to bedtime to prevent nocturnal reflux. Antacids and histamine receptor antagonists may be prescribed for the client. Losing weight (if overweight) will decrease the gastroesophageal pressure gradient. 9. A nurse provides instructions to a client about the measures to treat gout. The nurse determines that the client

needs additional instructions if the client states that a. The intake of red meats needs to be limited. b. Weight loss can help prevent an attack. c. Medication can help keep the uric acid level down. d. Fluid intake needs to be limited. D. Medication therapy is a component of management for clients with gout, and the physician normally prescribes a medication that will promote uric acid excretion or will reduce its production for clients with chronic gout. Fluid intake is important to promote uric acid excretion. Weight loss can reduce the incidence of attacks and reduce uric acid levels. A decrease in the intake of red meats and organ meats will assist in controlling uric acid levels. 10. A nurse provides instructions to a client who is being discharged 24 hours after undergoing a percutaneous renal biopsy. Which statement by the client indicates a need to reinforce the instructions? a. "I need to avoid any strenuous lifting for about two weeks." b. "I shouldn't work out at the gym for about two weeks." c. "I will call the physician if my urine becomes bloody." d. "A fever is normal after this procedure." D. After percutaneous renal biopsy, the client is instructed to report immediately fever, increasing pain levels (back, flank, or shoulder), bleeding from the puncture site, weakness, dizziness, grossly bloody urine, or dysuria. Activity should be restricted if blood is seen in the urine. The client also is instructed to avoid strenuous lifting, physical exertion, or trauma to the biopsy site for up to 2 weeks after discharge. 11. A clinic nurse has provided instructions to the mother of a child with a urinary tract infection. Which statement by the mother indicates a need for further instructions? a. "I should wipe my child from front to back after urination or a bowel movement." b. "I should increase my child's fluid intake." c. "I should encourage my child to hold the urine and to urinate at least four times a day." d. "I should avoid the use of bubble baths with my child." C. The parents should be taught to wipe the child from front to back after urination or a bowel movement to avoid moving bacteria from the anus to the urethra. Fluid intake including water should be encouraged. The child should be encouraged to avoid holding urine and to urinate at least four times a day; also, the bladder should be emptied with each void to prevent residual urine. Bubble baths are avoided secondary to possible urethral irritation. 12. A nurse provides dietary instructions to a client with hypertension. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which of the following food items? a. Hot dogs b. Turkey c. Salad with blue cheese dressing d. Corned beef hash B. A client with hypertension needs to avoid foods that are high in sodium, such as bacon, hot dogs, luncheon meat, chipped or corned beef, kosher meat, smoked or salted meat or fish, peanut butter, and a variety of shellfish. Processed foods, canned foods, cheese, and many salad dressings also are high in sodium.

13. The nurse is providing dietary instructions to a client with ascites who will be discharged to home from the hospital. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which food item? a. Canned green beans b. Fresh plums

c. Cooked ham d. Bologna B. The client with ascites is generally encouraged to avoid foods that are high in sodium, which could aggravate fluid retention. The diet should be high in protein (unless specifically advised otherwise) and high in calories. Canned foods, ham, and cold cuts are high in sodium. 14. A nurse has provided instructions to a client with chronic obstructive pulmonary disease about the procedure for performing pursed lip breathing. The nurse observes the client perform the procedure and determines that he or she is performing it correctly if the client a. Takes a deep breath and exhales quickly b. Monitors inspiration time and ensures that expiration time is less than inspiration time c. Lies on the side in a supine position to perform the procedure d. Sits in an upright position, takes a deep breath, and exhales slowly D. Pursed lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, the client is instructed to take a deep breath and to exhale slowly through pursed lips. Therefore, options 1, 2, and 3 are incorrect. 15. A nurse has completed discharge teaching with the family of a client who requires dressing changes at home. Which method of evaluation would the nurse use to best determine the familys competence in performing the dressing changes? a. Asking a family member to perform the dressing change and observing the procedure b. Asking a family member to identify the supplies needed to perform the dressing change c. Asking a family member to list the steps of the procedure for performing the dressing change d. Asking a family member to verbalize the procedure for performing the dressing change A. Return demonstration is the most reliable evaluation of procedure performance. Selection of equipment is included in a return demonstration. Asking a family member to list the steps for the procedure or to verbalize the procedure does not allow the nurse to observe the psychomotor skill needed to perform the procedure. 16. A nurse is teaching a client diagnosed with iron deficiency anemia about the foods that are high in iron. The nurse tells the client to consume which high-iron food? a. Refined white bread b. Egg whites c. Mushrooms d. Spinach D. The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat; liver and other organ meats; blackstrap molasses; and oysters. Other good sources of iron are kidney beans, whole wheat bread, egg yolk, spinach, kale, beets, carrots, raisins, and apricots. 17. A clinic nurse provides instructions to a woman in the second trimester of pregnancy regarding measures to relieve backache. Which statement by the client indicates an understanding of these measures? a. "I will sleep on a soft mattress." b. "I will avoid doing those pelvic tilt exercises." c. "I will avoid getting tired, and I should work at maintaining a good posture." d. "I will wear shoes with a heel of at least 2 inches." C. Backache can occur because of the exaggerated lumbar and cervicothoracic curves caused by the change in the center of gravity from the enlarging abdomen. The client should be instructed to sleep on a firm mattress, to avoid fatigue, and to maintain good posture and body mechanics. Pelvic tilt exercises decrease strain to muscles of the abdomen and lower back caused by the added weight of the abdomen and the shift in the center of gravity. Wearing high-heeled shoes will add to the strain on the muscles and will exaggerate the shift in the center of gravity.

18. A prenatal client reports heartburn, and the nurse provides instructions to the client regarding measures to alleviate the discomfort. Which statement by the client indicates a need for further instructions? a. "I need to eat small, frequent meals." b. "I need to avoid fatty or spicy foods." c. "I need to lie down after eating." d. "I need to drink approximately 2000 mL fluid per day." C. Heartburn is associated with regurgitation of gastric acid contents into the esophagus. Self-care measures for heartburn include eating small, frequent meals; avoiding fatty or spicy foods; remaining upright for 30 minutes after eating; and drinking approximately 2000 mL fluid per day. 19. During the administration of a blood transfusion to a client, the nurse notes the presence of crackles in the clients lung bases. On further assessment, the nurse notes that the client has distended neck veins and an increase in central venous pressure. The nurse suspects that the client is experiencing what complication of the blood transfusion? a. Transfusion reaction b. Allergic reaction c. Sepsis d. Circulatory overload D. Chest or lumbar pain, cyanosis, dyspnea, moist productive cough, crackles in the lung bases, distended neck veins, and an increase in central venous pressure are clinical indications of circulatory overload caused from excessive infusion amounts or too rapid of an infusion rate. Clinical manifestations of sepsis include fever, abdominal cramps, nausea, vomiting, and diarrhea. A transfusion reaction and an allergic reaction are similar and can include manifestations such as flushing, itching, urticaria, tachycardia, and low back pain. 20. A client with type 1 diabetes mellitus has a blood glucose level of 554 mg/dL. The nurse calls the physician to report the level and monitors the client closely for which acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis C. Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level increases. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. 21. A client is scheduled for a liver biopsy, and the nurse reviews the results of the laboratory tests prescribed for the client. The nurse would contact the physician if which laboratory result is noted? a. Platelets: 210,000/mm<sup>3</sup> b. Thrombin time: 20 seconds c. Hematocrit: 40% d. Hemoglobin: 14 g/dL B. The normal thrombin time is 10 to 15 seconds. A prolonged time indicates that the client is at risk for bleeding. Coagulation profile tests are performed before a liver biopsy to ensure that the client is not at risk for bleeding as a result of the procedure. The laboratory results in options A,C, and D are within reference range. 22. A client who sustained an inhalation burn injury arrives in the emergency department. On assessment of the client, the nurse notes that the client is confused and combative. The nurse determines that the client is experiencing a. Anxiety

b. Fear c. Hypoxia d. Pain C. After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. Options A, B, and D are not associated with the data in the question. 23. A nurse is reviewing the assessment data in the record of a client assigned to her care and notes documentation that the client has pallor. The nurse determines that this skin color variation is most likely caused by a. An increased amount of bilirubin deposits in the tissues b. An increased amount of deoxygenated hemoglobin associated with hypoxia c. A reduced amount of oxyhemoglobin from decreased blood flow d. An increased amount of melanin in the tissues C. Pallor, a decrease in skin color, is caused by a decreased amount of oxyhemoglobin resulting from decreased blood flow. Some causes of pallor include anemia or shock. Pallor can best be assessed in the face, conjunctivae, nail beds, palms of the hands, or lips. A bluish discoloration (cyanosis) is caused by an increased amount of deoxygenated hemoglobin associated with hypoxia. A yellow-orange skin discoloration (jaundice) is caused by an increased amount of bilirubin deposits in the tissues. A tan-brown skin color is caused by an increased amount of melanin in the tissues. 24. A nurse notes that a client's serum potassium level is 5.8 mEq/L. The nurse interprets that this is an expected finding in the client with which problem? a. Diarrhea b. Diabetes insipidus c. Burn injury d. Pulmonary edema being treated with loop diuretics C.A serum potassium level greater than 5.1 mEq/L indicates hyperkalemia, and the nurse would report the result to the physician. Burn injuries are a cause of hyperkalemia. Other common causes of hyperkalemia include adrenal insufficiency (Addison disease), renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or diabetes insipidus or the client being treated with loop diuretics is at risk for hypokalemia. 25. The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg and notes the presence of edema in the foot below the cast. The nurse would interpret that this finding indicates a. Impaired arterial circulation b. The presence of an infection c. Impaired venous return d. Arterial insufficiency C. Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast, or the presence of hot spots, which are areas of the cast that are warmer than other areas. 26. A nurse reviews the assessment data on a client with a head injury and notes that the client's intracranial pressure reading is 10 mm Hg. On the basis of this finding, the nurse determines that the client's intracranial pressure reading a. Is increased b. Is normal c. Needs to be reduced with aggressive treatment measures d. Requires physician notification B. The normal intracranial pressure readings are between 0 and 15 mm Hg, and pressures greater than 20 mm Hg are

considered to be increased. Therefore, options A, C, and D are incorrect. 27. A nurse is reviewing the laboratory results of a client with cancer and notes that the calcium level is 14 mg/dL. The nurse determines that this calcium level is consistent with which oncological emergency? a. Syndrome of inappropriate antidiuretic hormone (SIADH) b. Spinal cord compression c. Superior vena cava syndrome d. Hypercalcemia D. One potentially life-threatening complication of cancer is hypercalcemia, which is characterized by calcium levels greater than 11 mg/dL. Although spinal cord compression and superior vena cava syndrome also are oncological emergencies, they are not characterized by high calcium levels. SIADH also is an oncological emergency, but it is characterized by hyponatremia. 28. A nurse reviews a client's urinalysis report. The nurse determines that which finding is abnormal? a. Opacity is clear. b. Specific gravity is 1.018. c. Ketones are negative. d. Protein is positive. D. The urine has a normal pH range of 4.5 to 8, and a specific gravity ranging from 1.002 to 1.035. Urine typically is screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, all of which should be negative. 29. A client with chronic renal failure returns to the nursing unit after receiving his second hemodialysis treatment, and the nurse monitors the client closely for signs of disequilibrium syndrome. The nurse monitors for which sign of this syndrome? a. Irritability b. Mental confusion c. Tachycardia d. Hypothermia B. Disequilibrium syndrome most often occurs in clients who are new to hemodialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from rapid removal of solutes from the body during hemodialysis and a greater residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates. The signs in options 1, 3, and 4 are not associated with disequilibrium syndrome. 30. A home care nurse is assessing a client who has begun using peritoneal dialysis 1 week ago. The nurse would suspect the onset of peritonitis if which of the following is noted on assessment? a. Oral temperature of 99.0 F b. Anorexia c. Cloudy dialysate output d. Mild abdominal discomfort C. Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. The slight temperature increase in option 1 is not the clearest indicator of infection. The complaint of anorexia is too vague to indicate peritonitis. Some mild abdominal discomfort may occur initially with peritoneal dialysis. 1. A nurse is reviewing the diagnostic tests prescribed for a client. The nurse notes that a lupus cell preparation (LE cell prep) has been ordered. The nurse determines that this test is used to screen primarily for which of following

disorders? a. Histoplasmosis b. Systemic lupus erythematosus (SLE) c. Human immunodeficiency virus (HIV) d. Progressive systemic sclerosis B. The LE cell prep may be performed on a client suspected of having SLE, or to screen for progressive systemic sclerosis. However, it is primarily used to screen for SLE. The other options are not associated with this diagnostic test. 2. The nurse is caring for a hospitalized client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse contacts the physician if which laboratory result is noted that may be an indication of potential pancreatitis? a. Increased potassium b. Increased serum triglycerides c. Increased blood urea nitrogen d. Increased creatinine B. An increased triglyceride or amylase level may indicate pancreatitis from the medication, which can be potentially fatal. If this occurs, the medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure. Options 3 and 4 relate to renal function and are not associated with this medication. This medication may decrease potassium. 3. A client seeks treatment for a fractured radius. There is an open wound on the arm through which jagged bone edges protrude. The nurse determines that the client has a a. Greenstick fracture b. Comminuted fracture c. Open fracture d. Simple fracture C. An open fracture (compound fracture) is one in which the skin has been broken and the wound extends to the depth of the fractured bone. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone; one side of the bone is fractured, and the other side is bent. A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft, with some possible displacement but without breaking the skin. 4. The client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle accident. The nurse monitors for complications and assesses the client most closely for which of the following complications in the early post-trauma period? a. Bradycardia b. Pain c. Hematuria d. Fever C. One complication of a pelvic fracture is damage to the kidneys and lower urinary tract. Therefore, the nurse would monitor for signs of this complication, which would include bloody urine. This client is also at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh area. Signs of hypovolemic shock include tachycardia and hypotension. Although infection is also a complication (indicated by a fever), it is not generally noted in the early post-trauma period. 5. The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. Which finding indicates an early sign of increased intracranial pressure? a. Increase in systolic blood pressure b. Decreasing level of consciousness c. Shallow, slow respirations d. Decrease in pulse rate B. Decreasing level of consciousness is the earliest and most sensitive sign of increased intracranial pressure. Other early signs include headache that increases in intensity with coughing or straining; pupillary changes such as dilation with slowed constriction, visual disturbances such as diplopia, and ptosis; and contralateral motor or sensory losses. Options 1, 3, and 4 indicate late signs of increasing intracranial pressure. 6. The nurse is performing an assessment on a client with a diagnosis of Bells palsy. The nurse would expect to observe which of the following symptoms in the client? a. Twitching on the affected side of the face b. Ptosis of the eyelid and closure of the eye

c. Facial drooping d. Periorbital edema C. Bells palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. Options 1, 2, and 4 are not associated findings in Bells palsy. 7. A client with a diagnosis of multiple myeloma is admitted to the hospital. On assessment, the nurse asks the client which question that specifically relates to a clinical manifestation of this disorder? a. "Are you having any bone pain?" b. "Do you have diarrhea?" c. "Have you noticed an increase in appetite?" d. "Do you have feelings of anxiety and nervousness, together with difficulty sleeping?" A. Multiple myeloma is characterized by an abnormal proliferation of plasma B cells. These cells infiltrate the bone marrow and produce abnormal and excessive amounts of immunoglobulin. The most common presenting symptom is bone pain. Hypercalcemia occurs as a result of release of calcium from the deteriorating bone tissue; subsequently, the client experiences confusion, somnolence, constipation, nausea, and thirst. 8. The nurse is preparing to care for a client with a diagnosis of metastatic cancer and notes documentation in the clients chart that the client is experiencing cachexia. Which of the following would the nurse expect to note on assessment of the client? a. Sunken eyes and a hollow cheek appearance b. Periorbital edema and swelling around the ears c. Generalized edema and the presence of weight gain d. Increased blood pressure and ascites A. A cachexia condition indicates a chronic wasting of the body. Cachexia accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Assessment findings in a client with cachexia include sunken eyes, hollow cheeks, and an exhausted, defeated expression. Options B, C, and D are not characteristics of a cachexia appearance. 9. A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous fistula. The nurse expects to note which finding if the fistula is patent? a. White fibrin specks noted in the fistula b. Palpation of a thrill over the site of the fistula c. Lack of a bruit at the site of the fistula d. Warmth and redness at the site of the fistula B. An internal arteriovenous fistula is created through a surgical procedure in which an artery in the arm is anastomosed to a vein. The fistula is internal. To determine patency, the nurse palpates over the fistula for a thrill and auscultates for a bruit. The nurse would not note white fibrin specks in the fistula, because the fistula is internal. Warmth and redness may indicate a potential inflammatory process. 10. A physician's office nurse is assessing a client who recently had a renal transplant. The nurse monitors for which signs of acute graft rejection? a. Hypotension, graft tenderness, and anemia b. Hypertension, oliguria, thirst, and hypothermia c. Fever, vomiting, hypotension, and copious amounts of dilute urine d. Fever, hypertension, graft tenderness, and malaise D. Acute rejection usually occurs within the first 3 months after transplantation, although it can occur for up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Options A, B, and C do not completely identify signs of acute rejection. 11. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when a. Suctioning is required frequently b. Excessive secretions are suctioned from a tracheostomy c. The clients skin and mucous membranes are light pink d. Aspiration of gastric contents occurs during suctioning D. Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distension. It also causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this complication. 12. A nurse is performing a cardiovascular assessment on a client with heart failure. Which of the following items would the nurse assess to gain the best information about the clients left-sided heart function?

a. Breath sounds b. Peripheral edema c. Jugular vein distention d. Hepatojugular reflux A. The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all indicators of rightsided heart function. Breath sounds are an accurate indicator of left-sided heart function. 13. A nurse suctioning a client through an endotracheal tube monitors the client for complications associated with the procedure. Which of the following indicates a complication? a. A blood pressure of 138/88 mm Hg b. An irregular heart rate c. A reddish coloration in the client's face d. A pulse oximetry level of 95% B. The client should be monitored closely for complications related to suctioning, including hypoxemia, cardiac irregularities resulting from vagal stimulation, mucosal trauma, and paroxysmal coughing. If complications occur during the procedure, especially cardiac irregularities, the procedure is stopped, and the client is reoxygenated. 14. An emergency department nurse is assessing a client who sustained a blunt chest injury and suspects the presence of flail chest. Which specific characteristic finding would the nurse note in this condition? a. Slow deep respirations b. Asymmetric chest movement c. Loss of consciousness d. Anxiety B. Flail chest is a thoracic injury resulting in paradoxical (asymmetric) motion of the chest wall segments. The client also exhibits severe chest pain; oscillation of the mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; decreased breath sounds on auscultation; and cyanosis. Although the client may exhibit anxiety related to difficulty breathing, anxiety can occur in any respiratory disorder in which dyspnea is a problem. Loss of consciousness can occur with a head injury, or if the respiratory condition deteriorated significantly. 15. A nurse is caring for a client with a tracheostomy tube and is monitoring the client for subcutaneous emphysema. The nurse identifies this complication by noting which of the following? a. Crackling sounds heard in the upper lobes bilaterally b. A puffy and crackling sensation on palpation of the tissues surrounding the tracheostomy site c. Signs of respiratory distress d. Dyspnea B. Subcutaneous emphysema occurs when air escapes from the tracheostomy incision into the tissues, dissects fascial planes under the skin, and accumulates around the face, neck, and upper chest. These areas appear puffy, and slight finger pressure produces a crackling sound and sensation. Generally, this is not a serious condition, because the air eventually will be absorbed. Options 1, 3, and 4 are not signs of subcutaneous emphysema, but they could be signs of other complications. 16. A nurse is monitoring a client with a tracheostomy tube for complications related to the tube. The nurse suspects tracheoesophageal fistula if which of the following is noted? a. Abdominal distention b. Excess mucus production c. Abnormal skin and mucous membrane color d. Use of accessory muscles to assist with breathing A. Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 2, 3, and 4 are not findings associated with this complication. 17. A nurse is assessing a client who was treated for an asthma attack. The nurse determines that the client's respiratory status has worsened if which of the following is noted? a. Loud wheezing b. Wheezing during inspiration and expiration c. Wheezing on expiration only d. Diminished breath sounds D. Diminished breath sounds are an indication of obstruction and possible impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must

be able to move sufficient air to produce breath sounds. The client with a severe asthma attack may have no audible wheezing because of the decrease of airflow. Clients may experience loud wheezes with minor attacks, whereas others may not wheeze with severe attacks. Wheezing usually occurs first on expiration. The client may wheeze during both inspiration and expiration as the asthma attack progresses. 18. A nurse is reviewing the assessment findings and laboratory results of a child diagnosed with new-onset glomerulonephritis. Which of the following findings would the nurse most likely expect to note? a. Increased creatinine levels b. Hypotension c. Low serum potassium d. Tea-colored urine D. Gross hematuria resulting in dark brown or smoky, tea-colored urine is a classic symptom of glomerulonephritis. Hypertension also is a common finding in glomerulonephritis. Blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration. 19. A nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the physician has documented bladder exstrophy. On assessment of the infant, the nurse expects to note which of the following? a. Undescended or hidden testes b. The opening of the urethral meatus below the normal placement on the glans penis c. The opening of the urethral meatus on the ventral side of the glans penis d. The urinary bladder on the outside of the body D. Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. Option 1 describes cryptorchidism. Option 2 describes hypospadias. Option 3 describes epispadias. 20. A newborn infant with a diagnosis of subdural hematoma is admitted to the newborn nursery. The nurse does which of the following to assess for the major symptom associated with subdural hematoma? a. Checks for contractures of the extremities b. Tests for equality of extremities when stimulating reflexes c. Monitors the urinary output pattern d. Monitors the urine for blood B. A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can, especially if the infant is actively bleeding, cause changes in the stimuli responses in the extremities on the opposite side of the body. Option A is incorrect because contractures would not occur this soon after delivery. Options C and D are incorrect. An infant, after delivery, would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. 21. A nurse notes documentation in a client's medical record that the client is experiencing anuria. On the basis of this notation, the nurse determines that the client a. Is unable to produce urine b. Has a diminished capacity to form urine c. Has difficulty having a bowel movement d. Has episodes of alternating constipation and diarrhea A. Anuria is the term used to describe an inability to produce urine. Oliguria is a diminished capacity to form urine and is most likely the result of a decrease in renal perfusion. Options C and D do not relate to urinary tract dysfunction. 22. A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's intake and output and expects that a. The client's output will be decreased. b. The client's urine will be dilute. c. The client's urine production will be increased. d. The majority of the client's fluid will be excreted through the skin. A. Febrile conditions affect urine production. The client who is diaphoretic loses fluids through insensible water loss, which decreases urine production. However, the increased body temperature associated with fever increases accumulation of body wastes. Although urine volume may be reduced, it is highly concentrated. Options B, C, and D are incorrect. 23. A nurse is monitoring a client for signs and symptoms of hypocalcemia. Which of the following symptoms is an indication of this electrolyte imbalance? a. Lethargy

b. Depressed sensorium c. Confusion d. Irritability B. Most of the clinical manifestations of hypocalcemia are related to neuromuscular hyperexcitability. These can include numbness and tingling of the hands, toes, and lips and emotional lability such as irritability and anxiety. Positive Trousseaus or Chvosteks sign also are present. Options A, B, and C are signs of hypercalcemia. 24. A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection? a. Do you have any blood in your urine? b. Have you noticed any swelling in your feet? c. Have you had any flank pain or headaches? d. Have you had any vaginal discharge? D. Clinical manifestations of a Candida infection include vaginal pain, itching, and a thick, white vaginal discharge. Hematuria, flank pain, and headache are clinical manifestations associated with urinary tract infections. Edema is not associated with a vaginal infection. 25. A client with sickle cell disease is admitted to the hospital with vaso-occlusive crisis. The nurse assesses the client for which most frequent manifestation of the disorder? a. Low-grade fever b. Pain c. Leukopenia d. Blurred vision B. A vaso-occlusive crisis has a sudden onset and results in severe pain in the long bones, joints, chest, back, and abdomen. The face may also be involved. Fever and leukocytosis are also manifestations. Blurred vision is not specifically associated with this condition. 26. The nurse monitors for which acid-base disorder that can most likely occur in a client with an ileostomy? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis A. Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for development of the acid-base disorders identified in options B, C, and D. 27. A hospitalized client with a peripheral intravenous (IV) line calls the nurse and reports that the IV site is painful. The nurse assesses the IV site and notes that it is cool and pale, and that the IV has stopped flowing. The nurse determines that which of the following effects has probably occurred? a. Infiltration b. Phlebitis c. Thrombosis d. Infection A. An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and insert a new IV line. The other three options are likely to be accompanied by warmth, not coolness, at the site. 28. A client in the second trimester of pregnancy is admitted to the maternity unit with a diagnosis of abruptio placentae. The nurse expects to note which clinical manifestation associated with this disorder? a. Painless vaginal bleeding b. Soft, relaxed uterus with normal tone c. Uterine hypertonicity d. Nontender uterus C. In abruptio placentae, abdominal pain, uterine tenderness, and uterine hypertonicity are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Observation of the fetal monitoring often reveals loss of variability and late decelerations, uterine hyperstimulation,

and increased resting tone. Painless, bright red vaginal bleeding; a soft, relaxed uterus with normal tone; and a nontender uterus are signs of placenta previa. 29. An antepartum client is diagnosed with bacterial vaginosis. The nurse expects to note which of the following on assessment of the client? a. Hematuria and hypertension b. Itching and vaginal discharge c. Proteinuria and hematuria d. Costovertebral angle pain B. Clinical manifestations of bacterial vaginosis include pain, itching, and a thick, white vaginal discharge. Proteinuria, hematuria, hypertension, and costovertebral angle pain are clinical manifestations associated with urinary tract infections. 30. A nurse receives a report at the beginning of the shift about a client with an intrauterine fetal demise. On assessment of the client, the nurse expects to note which of the following? a. Increased blood pressure, proteinuria, and edema b. Regression of pregnancy symptoms and absence of fetal heart tones c. Uterine size greater than expected for gestational age d. Intractable vomiting and dehydration B. Symptoms of a fetal demise include a decrease in fetal movement, no change or a decrease in fundal height, and absent fetal heart tones. In addition, many symptoms of the pregnancy may diminish, such as breast size and tenderness. Option A is associated with preeclampsia. Option D is associated with hyperemesis gravidarum.

Potrebbero piacerti anche