Medical Surgical Nursing Practice Test Part 1 (EASY) 1. Mrs.

Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to clients lungs indicative of chronic heart failure would be a. !tridor b. Crac"les c. #hee$es d. %riction rubs &. 'atric" who is hospitali$ed following a myocardial infarction as"s the nurse why he is ta"ing morphine. The nurse explains that morphine a. (ecrease anxiety and restlessness b. 'revents shoc" and relieves pain c. (ilates coronary blood vessels d. )elps prevent fibrillation of the heart *. #hich of the following should the nurse teach the client about the signs of digitalis toxicity+ a. ,ncreased appetite b. -levated blood pressure c. !"in rash over the chest and bac" d. .isual disturbances such as seeing yellow spots /. 0urse Trisha teaches a client with heart failure to ta"e oral %urosemide in the morning. The reason for this is to help1 a. 2etard rapid drug absorption b. -xcrete excessive fluids accumulated at night c. 'revents sleep disturbances during night d. 'revention of electrolyte imbalance 3. #hat would be the primary goal of therapy for a client with pulmonary edema and heart failure+ a. -nhance comfort b. ,ncrease cardiac output c. ,mprove respiratory status d. 'eripheral edema decreased 4. 0urse 5inda is caring for a client with head in6ury and monitoring the client with decerebrate posturing. #hich of the following is a characteristic of this type of posturing+

a. 7pper extremity flexion with lower extremity flexion b. 7pper extremity flexion with lower extremity extension c. -xtension of the extremities after a stimulus d. %lexion of the extremities after stimulus 7. 8 female client is ta"ing Cascara !agrada. 0urse 9etty informs the client that the following maybe experienced as side effects of this medication a. :, bleeding b. 'eptic ulcer disease c. 8bdominal cramps d. 'artial bowel obstruction 8. (r. Mar;ue$ orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. #hich of the following is the most essential nursing action+ a. Monitoring urine output fre;uently b. Monitoring blood pressure every / hours c. <btaining serum potassium levels daily d. <btaining infusion pump for the medication =. (uring the second day of hospitali$ation of the client after a Myocardial ,nfarction. #hich of the following is an expected outcome+ a. 8ble to perform self>care activities without pain b. !evere chest pain c. Can recogni$e the ris" factors of Myocardial ,nfarction d. Can 'articipate in cardiac rehabilitation wal"ing program 1?. 8 48 year old client is diagnosed with a right>sided brain attac" and is admitted to the hospital. ,n caring for this client@ the nurse should plan to a. 8pplication of elastic stoc"ings to prevent flaccid by muscle b. 7se hand roll and extend the left upper extremity on a pillow to prevent contractions c. 7se a bed cradle to prevent dorsiflexion of feet d. (o passive range of motion exercise 11. 0urse 5i$a is assigned to care for a client who has returned to the nursing unit after left nephrectomy. 0urse 5i$as highest priority would be1 a. )ourly urine output b. Temperature c. 8ble to turn side to side d. 8ble to sips clear li;uid

1&. 8 4/ year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheteri$ation. (uring pre cardiac catheteri$ation teaching@ 0urse Cherry should inform the client that the primary purpose of the procedure is1.. a. To determine the existence of C)( b. To visuali$e the disease process in the coronary arteries c. To obtain the heart chambers pressure d. To measure oxygen content of different heart chambers 1*. (uring the first several hours after a cardiac catheteri$ation@ it would be most essential for nurse Cherry to1 a. -levate clients bed at /3A b. ,nstruct the client to cough and deep breathe every & hours c. %re;uently monitor clients apical pulse and blood pressure d. Monitor clients temperature every hour 1/. Bate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. #hich of the following pharmaceutical agents should 0urse 8i$a prepare to administer to Bate+ a. 'rotamine !ulfate b. Cuinidine !ulfate c. .itamin C d. Coumadin 13. ,n reducing the ris" of endocarditis@ good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of1 a. (ental floss b. -lectric toothbrush c. Manual toothbrush d. ,rrigation device 14. 8mong the following signs and symptoms@ which would most li"ely be present in a client with mitral gurgitation+ a. 8ltered level of consciousness b. -xceptional (yspnea c. ,ncrease creatine phospholinase concentration d. Chest pain 17. Bris with a history of chronic infection of the urinary system complains of urinary fre;uency and burning sensation. To figure out whether the current problem is in

renal origin@ the nurse should assess whether the client has discomfort or pain in the1 a. 7rinary meatus b. 'ain in the 5abium c. !uprapubic area d. 2ight or left costovertebral angle 18. 0urse 'erry is evaluating the renal function of a male client. 8fter documenting urine volume and characteristics@ 0urse 'erry assesses which signs as the best indicator of renal function. a. 9lood pressure b. Consciousness c. (istension of the bladder d. 'ulse rate 1=. Dohn suddenly experiences a sei$ure@ and 0urse :ina notice that Dohn exhibits uncontrollable 6er"ing movements. 0urse :ina documents that Dohn experienced which type of sei$ure+ a. Tonic sei$ure b. 8bsence sei$ure c. Myoclonic sei$ure d. Clonic sei$ure &?. !mo"ing cessation is critical strategy for the client with 9urghers disease@ 0urse Dasmin anticipates that the male client will go home with a prescription for which medication+ a. 'aracetamol b. ,buprofen c. 0itroglycerin d. 0icotine E0icotrolF &1. 0urse 5illy has been assigned to a client with 2aynauds disease. 0urse 5illy reali$es that the etiology of the disease is un"nown but it is characteri$ed by a. -pisodic vasospastic disorder of capillaries b. -pisodic vasospastic disorder of small veins c. -pisodic vasospastic disorder of the aorta d. -pisodic vasospastic disorder of the small arteries &&. 0urse Damie should explain to male client with diabetes that self>monitoring of blood glucose is preferred to urine glucose testing because1

a. More accurate b. Can be done by the client c. ,t is easy to perform d. ,t is not influenced by drugs &*. Dessie weighed &1? pounds on admission to the hospital. 8fter & days of diuretic therapy@ Dessie weighs &?3.3 pounds. The nurse could estimate the amount of fluid Dessie has lost1 a. ?.* 5 b. 1.3 5 c. &.? 5 d. *.3 5 &/. 0urse (onna is aware that the shift of body fluids associated with ,ntravenous administration of albumin occurs in the process of a. <smosis b. (iffusion c. 8ctive transport d. %iltration &3. Myrna a 3& year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. 0urse Doy assesses for which sign and symptom that indicates complication associated with crutch wal"ing+ a. 5eft leg discomfort b. #ea" biceps brachii c. Triceps muscle spasm d. %orearm wea"ness &4. #hich of the following statements should the nurse teach the neutropenic client and his family to avoid+ a. 'erforming oral hygiene after every meal b. 7sing suppositories or enemas c. 'erforming perineal hygiene after each bowel movement d. 7sing a filter mas" &7. 8 female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. 8 surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in a. !ims position b. !upine position c. !emi>fowlers position

d. (orsal recumbent position &8. #hich nursing intervention ensures ade;uate ventilating exchange after surgery+ a. 2emove the airway only when client is fully conscious b. 8ssess for hypoventilation by auscultating the lungs c. 'osition client laterally with the nec" extended d. Maintain humidified oxygen via nasal canula &=. :eorge who has undergone thoracic surgery has chest tube connected to a water>seal drainage system attached to suction. 'resence of excessive bubbling is identified in water>seal chamber@ the nurse should1 a. G!tripH the chest tube catheter b. Chec" the system for air lea"s c. 2ecogni$e the system is functioning correctly d. (ecrease the amount of suction pressure *?. 8 client who has been diagnosed of hypertension is being taught to restrict inta"e of sodium. The nurse would "now that the teachings are effective if the client states that1 a. , can eat celery stic"s and carrots b. , can eat broiled scallops c. , can eat shredded wheat cereal d. , can eat spaghetti on rye bread *1. 8 male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most li"ely the result of increased1 a. 'ressure in the portal vein b. 'roduction of serum albumin c. !ecretion of bile salts d. ,nterstitial osmotic pressure *&. 8 newly admitted client is diagnosed with )odg"ins disease undergoes an excisional cervical lymph node biopsy under local anesthesia. #hat does the nurse assess first after the procedure+ a. .ital signs b. ,ncision site c. 8irway d. 5evel of consciousness

**. 8 client has 13I blood loss. #hich of the following nursing assessment findings indicates hypovolemic shoc"+ a. !ystolic blood pressure less than =?mm )g b. 'upils une;ually dilated c. 2espiratory rate of / breathJmin d. 'ulse rate less than 4?bpm */. 0urse 5ucy is planning to give pre operative teaching to a client who will be undergoing rhinoplasty. #hich of the following should be included+ a. 2esults of the surgery will be immediately noticeable postoperatively b. 0ormal saline nose drops will need to be administered preoperatively c. 8fter surgery@ nasal pac"ing will be in place 8 to 1? days d. 8spirin containing medications should not be ta"en 1/ days before surgery *3. 'aul is admitted to the hospital due to metabolic acidosis caused by (iabetic "etoacidosis E(B8F. The nurse prepares which of the following medications as an initial treatment for this problem+ a. 2egular insulin b. 'otassium c. !odium bicarbonate d. Calcium gluconate *4. (r. Mar;ue$ tells a client that an increase inta"e of foods that are rich in .itamin and beta>carotene are important for healthier s"in. The nurse teaches the client that excellent food sources of both of these substances are a. %ish and fruit 6am b. <ranges and grapefruit c. Carrots and potatoes d. !pinach and mangoes *7. 8 client has :astroesophageal 2eflux (isease E:-2(F. The nurse should teach the client that after every meals@ the client should1 a. 2est in sitting position b. Ta"e a short wal" c. (rin" plenty of water d. 5ie down at least *? minutes *8. 8fter gastroscopy@ an adaptation that indicates ma6or complication would be a. 0ausea and vomiting b. 8bdominal distention

c. ,ncreased :, motility d. (ifficulty in swallowing *=. 8 client who has undergone a cholecystectomy as"s the nurse whether there are any dietary restrictions that must be followed. 0urse )ilary would recogni$e that the dietary teaching was well understood when the client tells a family member that a. GMost people need to eat a high protein diet for 1& months after surgeryH b. G, should not eat those foods that upset me before the surgeryH c. G, should avoid fatty foods as long as , liveH d. GMost people can tolerate regular diet after this type of surgeryH /?. 0urse 2achel teaches a client who has been recently diagnosed with hepatitis 8 about untoward signs and symptoms related to )epatitis that may develop. The one that should be reported immediately to the physician is a. 2estlessness b. Kellow urine c. 0ausea d. Clay> colored stools /1. #hich of the following antituberculosis drugs can damage the 8th cranial nerve+ a. ,sonia$id E,0)F b. 'araoaminosalicylic acid E'8!F c. -thambutol hydrochloride EmyambutolF d. !treptomycin /&. The client as"s 0urse 8nnie the causes of peptic ulcer. 0urse 8nnie responds that recent research indicates that peptic ulcers are the result of which of the following a. :enetic defect in gastric mucosa b. !tress c. (iet high in fat d. )elicobacter pylori infection /*. 2yan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 1& to &/ hours after surgery+ a. 9ile green b. 9right red c. Cloudy white d. (ar" brown

//. 0urse Doan is assigned to come for client who has 6ust undergone eye surgery. 0urse Doan plans to teach the client activities that are permitted during the post operative period. #hich of the following is best recommended for the client+ a. #atching circus b. 9ending over c. #atching T. d. 5ifting ob6ects /3. 8 client suffered from a lower leg in6ury and see"s treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg@ and the in6ured leg appears shorter that the other leg. The affected leg is painful@ swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing a. %racture b. !train c. !prain d. Contusion /4. 0urse Denny is instilling an otic solution into an adult male client left ear. 0urse Denny avoids doing which of the following as part of the procedure a. 'ulling the auricle bac"ward and upward b. #arming the solution to room temperature c. 'acing the tip of the dropper on the edge of ear canal d. 'lacing client in side lying position /7. 0urse 9ea should instruct the male client with an ileostomy to report immediately which of the following symptom+ a. 8bsence of drainage from the ileostomy for 4 or more hours b. 'assage of li;uid stool in the stoma c. <ccasional presence of undigested food d. 8 temperature of *7.4 AC /8. Derry has diagnosed with appendicitis. )e develops a fever@ hypotension and tachycardia. The nurse suspects which of the following complications+ a. ,ntestinal obstruction b. 'eritonitis c. 9owel ischemia d. (eficient fluid volume /=. #hich of the following compilations should the nurse carefully monitors a client with acute pancreatitis.

a. Myocardial ,nfarction b. Cirrhosis c. 'eptic ulcer d. 'neumonia 3?. #hich of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit+ a. #atery stool b. Kellow sclera c. Tarry stool d. !hortness of breath

1. B. 5eft sided heart failure causes fluid accumulation in the capillary networ" of the lung. %luid eventually enters alveolar spaces and causes crac"ling sounds at the end of inspiration. &. B. Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction@ it also decreases apprehension and prevents cardiogenic shoc". *. D. !eeing yellow spots and colored vision are common symptoms of digitalis toxicity /. C. #hen diuretics are ta"en in the morning@ client will void fre;uently during daytime and will not need to void fre;uently at night. 3. B. The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. 'ulmonary edema is an acute medical emergency re;uiring immediate intervention. 4. C. (ecerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem in6ury. 7. C. The most fre;uent side effects of Cascara !agrada E5axativeF is abdominal cramps and nausea. 8. D. 8dministration of ,ntravenous 0itroglycerin infusion re;uires pump for accurate control of medication. =. A. 9y the &nd day of hospitali$ation after suffering a Myocardial ,nfarction@ Clients are able to perform care without chest pain 1?. B. The left side of the body will be affected in a right>sided brain attac". 11. A. 8fter nephrectomy@ it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining "idney also to detect renal failure early. 1&. B. The lumen of the arteries can be assessed by cardiac catheteri$ation. 8ngina is usually caused by narrowing of the coronary arteries. 1*. C. 9lood pressure is monitored to detect hypotension which may indicate shoc" or hemorrhage. 8pical pulse is ta"en to detect dysrhythmias related to cardiac irritability.

1/. A. 'rotamine !ulfate is used to prevent continuous bleeding in client who has undergone open heart surgery. 13. C. The use of electronic toothbrush@ irrigation device or dental floss may cause bleeding of gums@ allowing bacteria to enter and increasing the ris" of endocarditis. 14. B. #eight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation. 17. D. (iscomfort or pain is a problem that originates in the "idney. ,t is felt at the costovertebral angle on the affected side. 18. A. 'erfusion can be best estimated by blood pressure@ which is an indirect reflection of the ade;uacy of cardiac output. 1=. C. Myoclonic sei$ure is characteri$ed by sudden uncontrollable 6er"ing movements of a single or multiple muscle group. &?. D. 0icotine E0icotrolF is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome. &1. D. 2aynauds disease is characteri$ed by vasospasms of the small cutaneous arteries that involves fingers and toes. &&. A. 7rine testing provides an indirect measure that maybe influenced by "idney function while blood glucose testing is a more direct and accurate measure. &*. C. <ne liter of fluid approximately weighs &.& pounds. 8 /.3 pound weight loss e;uals to approximately &5. &/. A. <smosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration. &3. D. %orearm muscle wea"ness is a probable sign of radial nerve in6ury caused by crutch pressure on the axillae. &4. B. 0eutropenic client is at ris" for infection especially bacterial infection of the gastrointestinal and respiratory tract. &7. C. !emi>fowlers position will locali$e the spilled stomach contents in the lower part of the abdominal cavity. &8. C. 'ositioning the client laterally with the nec" extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur. &=. B. -xcessive bubbling indicates an air lea" which must be eliminated to permit lung expansion. *?. C. #heat cereal has a low sodium content. *1. A. -nlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites. *&. C. 8ssessing for an open airway is the priority. The procedure involves the nec"@ the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange. **. A. Typical signs and symptoms of hypovolemic shoc" includes systolic blood pressure of less than =? mm )g. */. D. 8spirin containing medications should not be ta"en 1/ days before surgery to decrease the ris" of bleeding. *3. A. Metabolic acidosis is anaerobic metabolism caused by lac" of ability of the body to use circulating glucose. 8dministration of insulin corrects this problem.

*4. D. 9eta>carotene and .itamin - are antioxidants which help to inhibit oxidation. .itamin - is found in the following foods wheat germ@ corn@ nuts@ seeds@ olives@ spinach@ asparagus and other green leafy vegetables. %ood sources of beta> carotene include dar" green vegetables@ carrots@ mangoes and tomatoes. *7. A. :ravity speeds up digestion and prevents reflux of stomach contents into the esophagus. *8. B. 8bdominal distension may be associated with pain@ may indicate perforation@ a complication that could lead to peritonitis. *=. D. ,t may ta"e / to 4 months to eat anything@ but most people can eat anything they want. /?. D. Clay colored stools are indicative of hepatic obstruction /1. D. !treptomycin is an aminoglycoside and damage on the 8th cranial nerve EototoxicityF is a common side effect of aminoglycosides. /&. D. Most peptic ulcer is caused by )elicopter pylori which is a gram negative bacterium. /*. D. 1& to &/ hours after subtotal gastrectomy gastric drainage is normally brown@ which indicates digested food. //. C. #atching T. is permissible because the eye does not need to move rapidly with this activity@ and it does not increase intraocular pressure. /3. A. Common signs and symptoms of fracture include pain@ deformity@ shortening of the extremity@ crepitus and swelling. /4. C. The dropper should not touch any ob6ect or any part of the clients ear. /7. A. !udden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed. /8. B. Complications of acute appendicitis are peritonitis@ perforation and abscess development. /=. D. 8 client with acute pancreatitis is prone to complications associated with respiratory system. 3?. B. 5iver inflammation and obstruction bloc" the normal flow of bile. -xcess bilirubin turns the s"in and sclera yellow and the urine dar" and frothy. Medical Surgical Nursing Practice Test Part (Moderate)

1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. ,n preventing the development of cerebral edema after surgery@ the nurse should expect the use of a. (iuretics b. 8ntihypertensive c. !teroids d. 8nticonvulsants &. )alfway through the administration of blood@ the female client complains of lumbar pain. 8fter stopping the infusion 0urse )a$el should

a. ,ncrease the flow of normal saline b. 8ssess the pain further c. 0otify the blood ban" d. <btain vital signs. *. 0urse Maureen "nows that the positive diagnosis for ),. infection is made based on which of the following a. 8 history of high ris" sexual behaviors. b. 'ositive -5,!8 and western blot tests c. ,dentification of an associated opportunistic infection d. -vidence of extreme weight loss and high fever /. 0urse Maureen is aware that a client who has been diagnosed with chronic renal failure recogni$es an ade;uate amount of high>biologic>value protein when the food the client selected from the menu was a. 2aw carrots b. 8pple 6uice c. #hole wheat bread d. Cottage cheese 3. Benneth who has diagnosed with uremic syndrome has the potential to develop complications. #hich among the following complications should the nurse anticipates a. %lapping hand tremors b. 8n elevated hematocrit level c. )ypotension d. )ypo"alemia 4. 8 client is admitted to the hospital with benign prostatic hyperplasia@ the nurse most relevant assessment would be a. %lan" pain radiating in the groin b. (istention of the lower abdomen c. 'erineal edema d. 7rethral discharge 7. 8 client has undergone with penile implant. 8fter &/ hrs of surgery@ the clients scrotum was edematous and painful. The nurse should a. 8ssist the client with sit$ bath b. 8pply war soa"s in the scrotum c. -levate the scrotum using a soft support d. 'repare for a possible incision and drainage.

8. 0urse ha$el receives emergency laboratory results for a client with chest pain and immediately informs the physician. 8n increased myoglobin level suggests which of the following+ a. 5iver disease b. Myocardial damage c. )ypertension d. Cancer =. 0urse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the a. 2ight atrium b. !uperior vena cava c. 8orta d. 'ulmonary 1?. 8 client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be a. ,neffective health maintenance b. ,mpaired s"in integrity c. (eficient fluid volume d. 'ain 11. 0urse )a$el teaches the client with angina about common expected side effects of nitroglycerin including a. high blood pressure b. stomach cramps c. headache d. shortness of breath 1&. The following are lipid abnormalities. #hich of the following is a ris" factor for the development of atherosclerosis and '.(+ a. )igh levels of low density lipid E5(5F cholesterol b. )igh levels of high density lipid E)(5F cholesterol c. 5ow concentration triglycerides d. 5ow levels of 5(5 cholesterol. 1*. #hich of the following represents a significant ris" immediately after surgery for repair of aortic aneurysm+ a. 'otential wound infection b. 'otential ineffective coping

c. 'otential electrolyte balance d. 'otential alteration in renal perfusion 1/. 0urse Dosie should instruct the client to eat which of the following foods to obtain the best supply of .itamin 91&+ a. dairy products b. vegetables c. :rains d. 9roccoli 13. Baren has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions+ a. 9owel function b. 'eripheral sensation c. 9leeding tendencies d. ,nta"e and out put 14. 5ydia is scheduled for elective splenectomy. 9efore the clients goes to surgery@ the nurse in charge final assessment would be a. signed consent b. vital signs c. name band d. empty bladder 17. #hat is the pea" age range in ac;uiring acute lymphocytic leu"emia E855F+ a. / to 1& years. b. &? to *? years c. /? to 3? years d. 4? 4? 7? years 18. Marie with acute lymphocytic leu"emia suffers from nausea and headache. These clinical manifestations may indicate all of the following except a. effects of radiation b. chemotherapy side effects c. meningeal irritation d. gastric distension 1=. 8 client has been diagnosed with (isseminated ,ntravascular Coagulation E(,CF. #hich of the following is contraindicated with the client+ a. 8dministering )eparin

b. 8dministering Coumadin c. Treating the underlying cause d. 2eplacing depleted blood products &?. #hich of the following findings is the best indication that fluid replacement for the client with hypovolemic shoc" is ade;uate+ a. 7rine output greater than *?mlJhr b. 2espiratory rate of &1 breathsJminute c. (iastolic blood pressure greater than =? mmhg d. !ystolic blood pressure greater than 11? mmhg &1. #hich of the following signs and symptoms would 0urse Maureen include in teaching plan as an early manifestation of laryngeal cancer+ a. !tomatitis b. 8irway obstruction c. )oarseness d. (ysphagia &&. Barina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it a. 'romotes the removal of antibodies that impair the transmission of impulses b. !timulates the production of acetylcholine at the neuromuscular 6unction. c. (ecreases the production of autoantibodies that attac" the acetylcholine receptors. d. ,nhibits the brea"down of acetylcholine at the neuromuscular 6unction. &*. 8 female client is receiving ,. Mannitol. 8n assessment specific to safe administration of the said drug is a. .ital signs ;/h b. #eighing daily c. 7rine output hourly d. 5evel of consciousness ;/h &/. 'atricia a &? year old college student with diabetes mellitus re;uests additional information about the advantages of using a pen li"e insulin delivery devices. The nurse explains that the advantages of these devices over syringes includes a. 8ccurate dose delivery b. !horter in6ection time c. 5ower cost with reusable insulin cartridges d. 7se of smaller gauge needle.

&3. 8 male clients left tibia was fractured in an automobile accident@ and a cast is applied. To assess for damage to ma6or blood vessels from the fracture tibia@ the nurse in charge should monitor the client for a. !welling of the left thigh b. ,ncreased s"in temperature of the foot c. 'rolonged reperfusion of the toes after blanching d. ,ncreased blood pressure &4. 8fter a long leg cast is removed@ the male client should a. Cleanse the leg by scrubbing with a bris" motion b. 'ut leg through full range of motion twice daily c. 2eport any discomfort or stiffness to the physician d. -levate the leg when sitting for long periods of time. &7. #hile performing a physical assessment of a male client with gout of the great toe@ 0urse .ivian should assess for additional tophi Eurate depositsF on the a. 9uttoc"s b. -ars c. %ace d. 8bdomen &8. 0urse Batrina would recogni$e that the demonstration of crutch wal"ing with tripod gait was understood when the client places weight on the a. 'alms of the hands and axillary regions b. 'alms of the hand c. 8xillary regions d. %eet@ which are set apart &=. Mang Dose with rheumatoid arthritis states@ Gthe only time , am without pain is when , lie in bed perfectly stillH. (uring the convalescent stage@ the nurse in charge with Mang Dose should encourage a. 8ctive 6oint flexion and extension b. Continued immobility until pain subsides c. 2ange of motion exercises twice daily d. %lexion exercises three times daily *?. 8 male client has undergone spinal surgery@ the nurse should a. <bserve the clients bowel movement and voiding patterns b. 5og>roll the client to prone position c. 8ssess the clients feet for sensation and circulation

d. -ncourage client to drin" plenty of fluids *1. Marina with acute renal failure moves into the diuretic phase after one wee" of therapy. (uring this phase the client must be assessed for signs of developing a. )ypovolemia b. renal failure c. metabolic acidosis d. hyper"alemia *&. 0urse Dudith obtains a specimen of clear nasal drainage from a client with a head in6ury. #hich of the following tests differentiates mucus from cerebrospinal fluid EC!%F+ a. 'rotein b. !pecific gravity c. :lucose d. Microorganism **. 8 && year old client suffered from his first tonic>clonic sei$ure. 7pon awa"ening the client as"s the nurse@ G#hat caused me to have a sei$ure+ #hich of the following would the nurse include in the primary cause of tonic clonic sei$ures in adults more the &? years+ a. -lectrolyte imbalance b. )ead trauma c. -pilepsy d. Congenital defect */. #hat is the priority nursing assessment in the first &/ hours after admission of the client with thrombotic C.8+ a. 'upil si$e and papillary response b. cholesterol level c. -chocardiogram d. 9owel sounds *3. 0urse 5inda is preparing a client with multiple sclerosis for discharge from the hospital to home. #hich of the following instruction is most appropriate+ a. G'ractice using the mechanical aids that you will need when future disabilities ariseH. b. G%ollow good health habits to change the course of the diseaseH. c. GBeep active@ use stress reduction strategies@ and avoid fatigue. d. GKou will need to accept the necessity for a ;uiet and inactive lifestyleH.

*4. The nurse is aware the early indicator of hypoxia in the unconscious client is a. Cyanosis b. ,ncreased respirations c. )ypertension d. 2estlessness *7. 8 client is experiencing spinal shoc". 0urse Myrna should expect the function of the bladder to be which of the following+ a. 0ormal b. 8tonic c. !pastic d. 7ncontrolled *8. #hich of the following stage the carcinogen is irreversible+ a. 'rogression stage b. ,nitiation stage c. 2egression stage d. 'romotion stage *=. 8mong the following components thorough pain assessment@ which is the most significant+ a. -ffect b. Cause c. Causing factors d. ,ntensity /?. 8 43 year old female is experiencing flare up of pruritus. #hich of the clients action could aggravate the cause of flare ups+ a. !leeping in cool and humidified environment b. (aily baths with fragrant soap c. 7sing clothes made from 1??I cotton d. ,ncreasing fluid inta"e /1. 8tropine sulfate E8tropineF is contraindicated in all but one of the following client+ a. 8 client with high blood b. 8 client with bowel obstruction c. 8 client with glaucoma d. 8 client with 7.T.,

/&. 8mong the following clients@ which among them is high ris" for potential ha$ards from the surgical experience+ a. 47>year>old client b. /=>year>old client c. **>year>old client d. 13>year>old client /*. 0urse Don assesses vital signs on a client undergone epidural anesthesia. #hich of the following would the nurse assess next+ a. )eadache b. 9ladder distension c. (i$$iness d. 8bility to move legs //. 0urse Batrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Menieres disease except a. 8ntiemetics b. (iuretics c. 8ntihistamines d. :lucocorticoids /3. #hich of the following complications associated with tracheostomy tube+ a. ,ncreased cardiac output b. 8cute respiratory distress syndrome E82(!F c. ,ncreased blood pressure d. (amage to laryngeal nerves /4. 0urse %aith should recogni$e that fluid shift in an client with burn in6ury results from increase in the a. Total volume of circulating whole blood b. Total volume of intravascular plasma c. 'ermeability of capillary walls d. 'ermeability of "idney tubules /7. 8n 8*>year>old woman has several ecchymotic areas on her right arm. The bruises are probably caused by a. increased capillary fragility and permeability b. increased blood supply to the s"in c. self inflicted in6ury d. elder abuse

/8. 0urse 8nna is aware that early adaptation of client with renal carcinoma is a. 0ausea and vomiting b. flan" pain c. weight gain d. intermittent hematuria /=. 8 male client with tuberculosis as"s 0urse 9rian how long the chemotherapy must be continued. 0urse 9rians accurate reply would be a. 1 to * wee"s b. 4 to 1& months c. * to 3 months d. * years and more 3?. 8 client has undergone laryngectomy. The immediate nursing priority would be a. Beep trachea free of secretions b. Monitor for signs of infection c. 'rovide emotional support d. 'romote means of communication Ans!ers and "ationale Medical Surgical Nursing Practice Test Part 1. &. *. /. C. :lucocorticoids EsteroidsF are used for their anti>inflammatory action@ which decreases the development of edema. A. The blood must be stopped at once@ and then normal saline should be infused to "eep the line patent and maintain blood volume. B. These tests confirm the presence of ),. antibodies that occur in response to the presence of the human immunodeficiency virus E),.F. D. <ne cup of cottage cheese contains approximately &&3 calories@ &7 g of protein@ = g of fat@ *? mg cholesterol@ and 4 g of carbohydrate. 'roteins of high biologic value E)9.F contain optimal levels of amino acids essential for life. A. -levation of uremic waste products causes irritation of the nerves@ resulting in flapping hand tremors. B. This indicates that the bladder is distended with urine@ therefore palpable. C. -levation increases lymphatic drainage@ reducing edema and pain. B. (etection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.

3. 4. 7. 8.

=.

D. #hen mitral stenosis is present@ the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent bac" ward flow into the pulmonary vein@ the pulmonary circulation is under pressure.

1?. A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension fre;uently do not experience pain@ deficient volume@ or impaired s"in integrity. ,t is the asymptomatic nature of hypertension that ma"es it so difficult to treat. 11. C. 9ecause of its widespread vasodilating effects@ nitroglycerin often produces side effects such as headache@ hypotension and di$$iness. 1&. A. 8n increased in 5(5 cholesterol concentration has been documented at ris" factor for the development of atherosclerosis. 5(5 cholesterol is not bro"en down into the liver but is deposited into the wall of the blood vessels. 1*. D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism@ prolonged hypotension@ or prolonged aortic cross>clamping during the surgery. 1/. A. :ood source of vitamin 91& are dairy products and meats. 13. C. 8plastic anemia decreases the bone marrow production of 29Cs@ white blood cells@ and platelets. The client is at ris" for bruising and bleeding tendencies. 14. B# 8n elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final chec" that must be completed before the client leaves the room so that continuity of care and assessment is provided for. 17. A. The pea" incidence of 8cute 5ymphocytic 5eu"emia E855F is / years of age. ,t is uncommon after 13 years of age. 18. D. 8cute 5ymphocytic 5eu"emia E855F does not cause gastric distention. ,t does invade the central nervous system@ and clients experience headaches and vomiting from meningeal irritation. 1=. B. (isseminated ,ntravascular Coagulation E(,CF has not been found to respond to oral anticoagulants such as Coumadin. &?. A. 7rine output provides the most sensitive indication of the clients response to therapy for hypovolemic shoc". 7rine output should be consistently greater than *? to *3 m5Jhr.

&1. C. -arly warning signs of laryngeal cancer can vary depending on tumor location. )oarseness lasting & wee"s should be evaluated because it is one of the most common warning signs. &&. C. !teroids decrease the bodys immune response thus decreasing the production of antibodies that attac" the acetylcholine receptors at the neuromuscular 6unction &*. C. The osmotic diuretic mannitol is contraindicated in the presence of inade;uate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the "idney. &/. A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly. &3. C. (amage to blood vessels may decrease the circulatory perfusion of the toes@ this would indicate the lac" of blood supply to the extremity. &4. D# -levation will help control the edema that usually occurs. &7. B# 7ric acid has a low solubility@ it tends to precipitate and form deposits at various sites where blood flow is least active@ including cartilaginous tissue such as the ears. &8. B. The palms should bear the clients weight to avoid damage to the nerves in the axilla. &=. A. 8ctive exercises@ alternating extension@ flexion@ abduction@ and adduction@ mobili$e exudates in the 6oints relieves stiffness and pain. *?. C# 8lteration in sensation and circulation indicates damage to the spinal cord@ if these occurs notify physician immediately. *1. A. ,n the diuretic phase fluid retained during the oliguric phase is excreted and may reach * to 3 liters daily@ hypovolemia may occur and fluids should be replaced. *&. C. The constituents of C!% are similar to those of blood plasma. 8n examination for glucose content is done to determine whether a body fluid is a mucus or a C!%. 8 C!% normally contains glucose. **. B. Trauma is one of the primary cause of brain damage and sei$ure activity in adults. <ther common causes of sei$ure activity in adults include neoplasms@ withdrawal from drugs and alcohol@ and vascular disease. */. A. ,t is crucial to monitor the pupil si$e and papillary response to indicate changes around the cranial nerves.

*3. C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active@ use stress reduction techni;ues and avoid fatigue because it is important to support the immune system while remaining active. *4. D. 2estlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless. *7. B. ,n spinal shoc"@ the bladder becomes completely atonic and will continue to fill unless the client is catheteri$ed. *8. A. 'rogression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed. *=. D. ,ntensity is the ma6or indicative of severity of pain and it is important for the evaluation of the treatment. /?. B# The use of fragrant soap is very drying to s"in hence causing the pruritus. /1. C# 8tropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure. /&. A. 8 47 year old client is greater ris" because the older adult client is more li"ely to have a less>effective immune system. /*. B. The last area to return sensation is in the perineal area@ and the nurse in charge should monitor the client for distended bladder. //. D. :lucocorticoids play no significant role in disease treatment. /3. D. Tracheostomy tube has several potential complications including bleeding@ infection and laryngeal nerve damage. /4. C. ,n burn@ the capillaries and small vessels dilate@ and cell damage cause the release of a histamine>li"e substance. The substance causes the capillary walls to become more permeable and significant ;uantities of fluid are lost. /7. A. 8ging process involves increased capillary fragility and permeability. <lder adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise li"e lesions caused by collection of extravascular blood in loosely structured dermis. /8. D. ,ntermittent pain is the classic sign of renal carcinoma. ,t is primarily due to capillary erosion by the cancerous growth.

/=. B# Tubercle bacillus is a drug resistant organism and ta"es a long time to be eradicated. 7sually a combination of three drugs is used for minimum of 4 months and at least six months beyond culture conversion. 3?. A# 'atent airway is the most priorityL therefore removal of secretions is necessary.

Medical Surgical Nursing Practice Test Part $ (%A"D) 1. 8 client is scheduled for insertion of an inferior vena cava E,.CF filter. 0urse 'atricia consults the physician about withholding which regularly scheduled medication on the day before the surgery+ a. 'otassium Chloride b. #arfarin !odium c. %urosemide d. (ocusate &. 8 nurse is planning to assess the corneal reflex on unconscious client. #hich of the following is the safest stimulus to touch the clients cornea+ a. Cotton buds b. !terile glove c. !terile tongue depressor d. #isp of cotton *. 8 female client develops an infection at the catheter insertion site. The nurse in charge uses the term GiatrogenicH when describing the infection because it resulted from a. Clients developmental level b. Therapeutic procedure c. 'oor hygiene d. ,nade;uate dietary patterns /. 0urse Carol is assessing a client with 'ar"insons disease. The nurse recogni$e brady"inesia when the client exhibits a. ,ntentional tremor b. 'aralysis of limbs c. Muscle spasm d. 5ac" of spontaneous movement 3. 8 client who suffered from automobile accident complains of seeing fre;uent flashes of light. The nurse should expect a. Myopia

b. (etached retina c. :laucoma d. !cleroderma 4. Bate with severe head in6ury is being monitored by the nurse for increasing intracranial pressure E,C'F. #hich finding should be most indicative sign of increasing intracranial pressure+ a. ,ntermittent tachycardia b. 'olydipsia c. Tachypnea d. ,ncreased restlessness 7. 8 hospitali$ed client had a tonic>clonic sei$ure while wal"ing in the hall. (uring the sei$ure the nurse priority should be a. )old the clients arms and leg firmly b. 'lace the client immediately to soft surface c. 'rotects the clients head from in6ury d. 8ttempt to insert a tongue depressor between the clients teeth 8. 8 client has undergone right pneumonectomy. #hen turning the client@ the nurse should plan to position the client either a. 2ight side>lying position or supine b. )igh fowlers c. 2ight or left side lying position d. 5ow fowlers position =. 0urse Denny should caution a female client who is sexually active in ta"ing ,sonia$id E,0)F because the drug has which of the following side effects+ a. 'revents ovulation b. )as a mutagenic effect on ova c. (ecreases the effectiveness of oral contraceptives d. ,ncreases the ris" of vaginal infection 1?. 8 client has undergone gastrectomy. 0urse Dovy is aware that the best position for the client is a. 5eft side lying b. 5ow fowlers c. 'rone d. !upine 11. (uring the initial postoperative period of the clients stoma. The nurse evaluates which of the following observations should be reported immediately to the physician+ a. !toma is dar" red to purple

b. !toma is oo$es a small amount of blood c. !toma is lightly edematous d. !toma does not expel stool 1&. Bate which has diagnosed with ulcerative colitis is following physicians order for bed rest with bathroom privileges. #hat is the rationale for this activity restriction+ a. 'revent in6ury b. 'romote rest and comfort c. 2educe intestinal peristalsis d. Conserve energy 1*. 0urse BC should regularly assess the clients ability to metaboli$e the total parenteral nutrition ET'0F solution ade;uately by monitoring the client for which of the following signs a. )yperglycemia b. )ypoglycemia c. )ypertension d. -levate blood urea nitrogen concentration 1/. 8 female client has an acute pancreatitis. #hich of the following signs and symptoms the nurse would expect to see+ a. Constipation b. )ypertension c. 8scites d. Daundice 13. 8 client is suspected to develop tetany after a subtotal thyroidectomy. #hich of the following symptoms might indicate tetany+ a. Tingling in the fingers b. 'ain in hands and feet c. Tension on the suture lines d. 9leeding on the bac" of the dressing 14. 8 38 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of hypothyroidism include a. (iarrhea b. .omiting c. Tachycardia d. #eight gain

17. 8 client has undergone for an ileal conduit@ the nurse in charge should closely monitor the client for occurrence of which of the following complications related to pelvic surgery+ a. 8scites b. Thrombophlebitis c. ,nguinal hernia d. 'eritonitis 18. (r. Mar;ue$ is about to defibrillate a client in ventricular fibrillation and says in a loud voice GclearH. #hat should be the action of the nurse+ a. 'laces conductive gel pads for defibrillation on the clients chest b. Turn off the mechanical ventilator c. !huts off the clients ,. infusion d. !teps away from the bed and ma"e sure all others have done the same 1=. 8 client has been diagnosed with glomerulonephritis complains of thirst. The nurse should offer a. Duice b. :inger ale c. Mil" sha"e d. )ard candy &?. 8 client with acute renal failure is aware that the most serious complication of this condition is a. Constipation b. 8nemia c. ,nfection d. 'latelet dysfunction &1. 0urse Baren is caring for clients in the <2. The nurse is aware that the last physiologic function that the client loss during the induction of anesthesia is a. Consciousness b. :ag reflex c. 2espiratory movement d. Corneal reflex &&. The nurse is assessing a client with pleural effusion. The nurse expect to find a. (eviation of the trachea towards the involved side b. 2educed or absent of breath sounds at the base of the lung c. Moist crac"les at the posterior of the lungs

d. ,ncreased resonance with percussion of the involved area &*. 8 client admitted with newly diagnosed with )odg"ins disease. #hich of the following would the nurse expect the client to report+ a. 5ymph node pain b. #eight gain c. 0ight sweats d. )eadache &/. 8 client has suffered from fall and sustained a leg in6ury. #hich appropriate ;uestion would the nurse as" the client to help determine if the in6ury caused fracture+ a. G,s the pain sharp and continuous+H b. G,s the pain dull ache+H c. G(oes the discomfort feel li"e a cramp+H d. G(oes the pain feel li"e the muscle was stretched+H &3. The 0urse is assessing the clients casted extremity for signs of infection. #hich of the following findings is indicative of infection+ a. -dema b. #ea" distal pulse c. Coolness of the s"in d. 'resence of Ghot spotH on the cast &4. 0urse 2hia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. 0urse 2hia would expect to note which of the following if this disorder is present+ a. Transparent tympanic membrane b. Thic" and immobile tympanic membrane c. 'early colored tympanic membrane d. Mobile tympanic membrane &7. 0urse Docelyn is caring for a client with nasogastric tube that is attached to low suction. 0urse Docelyn assesses the client for symptoms of which acid>base disorder+ a. 2espiratory al"alosis b. 2espiratory acidosis c. Metabolic acidosis d. Metabolic al"alosis &8. 8 male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid EC!%F for analysis. #hich of the following values should be negative if the C!% is normal+

a. 2ed blood cells b. #hite blood cells c. ,nsulin d. 'rotein &=. 8 client is suspected of developing diabetes insipidus. #hich of the following is the most effective assessment+ a. Ta"ing vital signs every / hours b. Monitoring blood glucose c. 8ssessing 89: values every other day d. Measuring urine output hourly *?. 8 38 year old client is suffering from acute phase of rheumatoid arthritis. #hich of the following would the nurse in charge identify as the lowest priority of the plan of care+ a. 'revent 6oint deformity b. Maintaining usual ways of accomplishing tas" c. 2elieving pain d. 'reserving 6oint function *1. 8mong the following@ which client is autotransfusion possible+ a. Client with 8,(! b. Client with ruptured bowel c. Client who is in danger of cardiac arrest d. Client with wound infection *&. #hich of the following is not a sign of thromboembolism+ a. -dema b. !welling c. 2edness d. Coolness **. 0urse 9ec"y is caring for client who begins to experience sei$ure while in bed. #hich action should the nurse implement to prevent aspiration+ a. 'osition the client on the side with head flexed forward b. -levate the head c. 7se tongue depressor between teeth d. 5oosen restrictive clothing */. 8 client has undergone bone biopsy. #hich nursing action should the nurse provide after the procedure+

a. 8dminister analgesics via ,M b. Monitor vital signs c. Monitor the site for bleeding@ swelling and hematoma formation d. Beep area in neutral position *3. 8 client is suffering from low bac" pain. #hich of the following exercises will strengthen the lower bac" muscle of the client+ a. Tennis b. 9as"etball c. (iving d. !wimming *4. 8 client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for a. EMF guaiac stool test b. !low@ strong pulse c. !udden@ severe abdominal pain d. ,ncreased bowel sounds *7. 8 client has undergone surgery for retinal detachment. #hich of the following goal should be prioriti$ed+ a. 'revent an increase intraocular pressure b. 8lleviate pain c. Maintain dar"ened room d. 'romote low>sodium diet *8. 8 Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is for a. Constricting pupil b. 2elaxing ciliary muscle c. Constricting intraocular vessel d. 'araly$ing ciliary muscle *=. #hen suctioning an unconscious client@ which nursing intervention should the nurse prioriti$e in maintaining cerebral perfusion+ a. 8dminister diuretics b. 8dminister analgesics c. 'rovide hygiene d. )yperoxygenate before and after suctioning

/?. #hen discussing breathing exercises with a postoperative client@ 0urse )a$el should include which of the following teaching+ a. !hort fre;uent breaths b. -xhale with mouth open c. -xercise twice a day d. 'lace hand on the abdomen and feel it rise /1. 5ouie@ with burns over *3I of the body@ complains of chilling. ,n promoting the clients comfort@ the nurse should a. Maintain room humidity below /?I b. 'lace top sheet on the client c. 5imit the occurrence of drafts d. Beep room temperature at 8? degrees /&. 0urse Trish is aware that temporary heterograft Epig s"inF is used to treat burns because this graft will a. 2elieve pain and promote rapid epitheliali$ation b. 9e sutured in place for better adherence c. (ebride necrotic epithelium d. Concurrently used with topical antimicrobials /*. Mar" has multiple abrasions and a laceration to the trun" and all four extremities says@ G, cant eat all this foodH. The food that the nurse should suggest to be eaten first should be a. Meat loaf and coffee b. Meat loaf and strawberries c. Tomato soup and apple pie d. Tomato soup and buttered bread //. Tony returns form surgery with permanent colostomy. (uring the first &/ hours the colostomy does not drain. The nurse should be aware that a. 'roper functioning of nasogastric suction b. 'resurgical decrease in fluid inta"e c. 8bsence of gastrointestinal motility d. ,ntestinal edema following surgery /3. #hen teaching a client about the signs of colorectal cancer@ 0urse Trish stresses that the most common complaint of persons with colorectal cancer is a. 8bdominal pain b. )emorrhoids c. Change in caliber of stools

d. Change in bowel habits /4. 5ouis develops peritonitis and sepsis after surgical repair of ruptures diverticulum. The nurse in charge should expect an assessment of the client to reveal a. Tachycardia b. 8bdominal rigidity c. 9radycardia d. ,ncreased bowel sounds /7. ,mmediately after liver biopsy@ the client is placed on the right side@ the nurse is aware that that this position should be maintained because it will a. )elp stop bleeding if any occurs b. 2educe the fluid trapped in the biliary ducts c. 'osition with greatest comfort d. 'romote circulating blood volume /8. Tony has diagnosed with hepatitis 8. The information from the health history that is most li"ely lin"ed to hepatitis 8 is a. -xposed with arsenic compounds at wor" b. #or"ing as local plumber c. #or"ing at hemodialysis clinic d. (ish washer in restaurants /=. 0urse Trish is aware that the laboratory test result that most li"ely would indicate acute pancreatitis is an elevated a. !erum bilirubin level b. !erum amylase level c. 'otassium level d. !odium level 3?. (r. Mar;ue$ orders serum electrolytes. To determine the effect of persistent vomiting@ 0urse Trish should be most concerned with monitoring the a. Chloride and sodium levels b. 'hosphate and calcium levels c. 'rotein and magnesium levels d. !ulfate and bicarbonate levels 1. C. :lucocorticoids EsteroidsF are used for their anti>inflammatory action@ which decreases the development of edema.

&. *. /.

A. The blood must be stopped at once@ and then normal saline should be infused to "eep the line patent and maintain blood volume. B. These tests confirm the presence of ),. antibodies that occur in response to the presence of the human immunodeficiency virus E),.F. D. <ne cup of cottage cheese contains approximately &&3 calories@ &7 g of protein@ = g of fat@ *? mg cholesterol@ and 4 g of carbohydrate. 'roteins of high biologic value E)9.F contain optimal levels of amino acids essential for life. A. -levation of uremic waste products causes irritation of the nerves@ resulting in flapping hand tremors. B. This indicates that the bladder is distended with urine@ therefore palpable. C. -levation increases lymphatic drainage@ reducing edema and pain. B. (etection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred. D. #hen mitral stenosis is present@ the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent bac" ward flow into the pulmonary vein@ the pulmonary circulation is under pressure.

3. 4. 7. 8. =.

1?. A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension fre;uently do not experience pain@ deficient volume@ or impaired s"in integrity. ,t is the asymptomatic nature of hypertension that ma"es it so difficult to treat. 11. C. 9ecause of its widespread vasodilating effects@ nitroglycerin often produces side effects such as headache@ hypotension and di$$iness. 1&. A. 8n increased in 5(5 cholesterol concentration has been documented at ris" factor for the development of atherosclerosis. 5(5 cholesterol is not bro"en down into the liver but is deposited into the wall of the blood vessels. 1*. D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism@ prolonged hypotension@ or prolonged aortic cross>clamping during the surgery. 1/. A. :ood source of vitamin 91& are dairy products and meats. 13. C. 8plastic anemia decreases the bone marrow production of 29Cs@ white blood cells@ and platelets. The client is at ris" for bruising and bleeding tendencies.

14. B# 8n elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final chec" that must be completed before the client leaves the room so that continuity of care and assessment is provided for. 17. A. The pea" incidence of 8cute 5ymphocytic 5eu"emia E855F is / years of age. ,t is uncommon after 13 years of age. 18. D. 8cute 5ymphocytic 5eu"emia E855F does not cause gastric distention. ,t does invade the central nervous system@ and clients experience headaches and vomiting from meningeal irritation. 1=. B. (isseminated ,ntravascular Coagulation E(,CF has not been found to respond to oral anticoagulants such as Coumadin. &?. A. 7rine output provides the most sensitive indication of the clients response to therapy for hypovolemic shoc". 7rine output should be consistently greater than *? to *3 m5Jhr. &1. C. -arly warning signs of laryngeal cancer can vary depending on tumor location. )oarseness lasting & wee"s should be evaluated because it is one of the most common warning signs. &&. C. !teroids decrease the bodys immune response thus decreasing the production of antibodies that attac" the acetylcholine receptors at the neuromuscular 6unction &*. C. The osmotic diuretic mannitol is contraindicated in the presence of inade;uate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the "idney. &/. A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly. &3. C. (amage to blood vessels may decrease the circulatory perfusion of the toes@ this would indicate the lac" of blood supply to the extremity. &4. D# -levation will help control the edema that usually occurs. &7. B# 7ric acid has a low solubility@ it tends to precipitate and form deposits at various sites where blood flow is least active@ including cartilaginous tissue such as the ears. &8. B. The palms should bear the clients weight to avoid damage to the nerves in the axilla.

&=. A. 8ctive exercises@ alternating extension@ flexion@ abduction@ and adduction@ mobili$e exudates in the 6oints relieves stiffness and pain. *?. C# 8lteration in sensation and circulation indicates damage to the spinal cord@ if these occurs notify physician immediately. *1. A. ,n the diuretic phase fluid retained during the oliguric phase is excreted and may reach * to 3 liters daily@ hypovolemia may occur and fluids should be replaced. *&. C. The constituents of C!% are similar to those of blood plasma. 8n examination for glucose content is done to determine whether a body fluid is a mucus or a C!%. 8 C!% normally contains glucose. **. B. Trauma is one of the primary cause of brain damage and sei$ure activity in adults. <ther common causes of sei$ure activity in adults include neoplasms@ withdrawal from drugs and alcohol@ and vascular disease. */. A. ,t is crucial to monitor the pupil si$e and papillary response to indicate changes around the cranial nerves. *3. C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active@ use stress reduction techni;ues and avoid fatigue because it is important to support the immune system while remaining active. *4. D. 2estlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless. *7. B. ,n spinal shoc"@ the bladder becomes completely atonic and will continue to fill unless the client is catheteri$ed. *8. A. 'rogression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed. *=. D. ,ntensity is the ma6or indicative of severity of pain and it is important for the evaluation of the treatment. /?. B# The use of fragrant soap is very drying to s"in hence causing the pruritus. /1. C# 8tropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure. /&. A. 8 47 year old client is greater ris" because the older adult client is more li"ely to have a less>effective immune system. /*. B. The last area to return sensation is in the perineal area@ and the nurse in charge should monitor the client for distended bladder.

//. D. :lucocorticoids play no significant role in disease treatment. /3. D. Tracheostomy tube has several potential complications including bleeding@ infection and laryngeal nerve damage. /4. C. ,n burn@ the capillaries and small vessels dilate@ and cell damage cause the release of a histamine>li"e substance. The substance causes the capillary walls to become more permeable and significant ;uantities of fluid are lost. /7. A. 8ging process involves increased capillary fragility and permeability. <lder adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise li"e lesions caused by collection of extravascular blood in loosely structured dermis. /8. D. ,ntermittent pain is the classic sign of renal carcinoma. ,t is primarily due to capillary erosion by the cancerous growth. /=. B# Tubercle bacillus is a drug resistant organism and ta"es a long time to be eradicated. 7sually a combination of three drugs is used for minimum of 4 months and at least six months beyond culture conversion. 3?. A# 'atent airway is the most priorityL therefore removal of secretions is necessary.

Medical Surgical Nursing Practice Ans!er Part $

1. B. ,n preoperative period@ the nurse should consult with the physician about withholding #arfarin !odium to avoid occurrence of hemorrhage. &. D. 8 client who is unconscious is at greater ris" for corneal abrasion. %or this reason@ the safest way to test the cornel reflex is by touching the cornea lightly with a wisp of cotton. *. B. ,atrogenic infection is caused by the heath care provider or is induced inadvertently by medical treatment or procedures. /. D. 9rady"inesia is slowing down from the initiation and execution of movement. 3. B. This symptom is caused by stimulation of retinal cells by ocular movement.

4. D. 2estlessness indicates a lac" of oxygen to the brain stem which impairs the reticular activating system. 7. C. 2hythmic contraction and relaxation associated with tonic>clonic sei$ure can cause repeated banging of head. 8. A. 2ight side lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump. =. C. ,sonia$id E,0)F interferes in the effectiveness of oral contraceptives and clients of childbearing age should be counseled to use an alternative form of birth control while ta"ing this drug. 1?. B. 8 client who has had abdominal surgery is best placed in a low fowlers position. This relaxes abdominal muscles and provides maximum respiratory and cardiovascular function. 11. A. (ar" red to purple stoma indicates inade;uate blood supply. 1&. C. The rationale for activity restriction is to help reduce the hypermotility of the colon. 1*. A. (uring Total 'arenteral 0utrition ET'0F administration@ the client should be monitored regularly for hyperglycemia. 1/. D. Daundice may be present in acute pancreatitis owing to obstruction of the biliary duct. 13. A. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally in6ured or removed. 14. D. Typical signs of hypothyroidism includes weight gain@ fatigue@ decreased energy@ apathy@ brittle nails@ dry s"in@ cold intolerance@ constipation and numbness. 17. B. 8fter a pelvic surgery@ there is an increased chance of thrombophlebitits owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. 18. D. %or the safety of all personnel@ if the defibrillator paddles are being discharged@ all personnel must stand bac" and be clear of all the contact with the client or the clients bed. 1=. D. )ard candy will relieve thirst and increase carbohydrates but does not supply extra fluid. &?. C. ,nfection is responsible for one third of the traumatic or surgically induced death of clients with renal failure as well as medical induced acute renal failure E82%F

&1. C. There is no respiratory movement in stage / of anesthesia@ prior to this stage@ respiration is depressed but present. &&. B. Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange. &*. C. 8ssessment of a client with )odg"ins disease most often reveals enlarged@ painless lymph node@ fever@ malaise and night sweats. &/. A. %ractured pain is generally described as sharp@ continuous@ and increasing in fre;uency. &3. D. !igns and symptoms of infection under a casted area include odor or purulent drainage and the presence of Ghot spotH which are areas on the cast that are warmer than the others. &4. B. <toscopic examnation in a client with mastoiditis reveals a dull@ red@ thic" and immobile tymphanic membrane with or without perforation. &7. D. 5oss of gastric fluid via nasogastric suction or vomiting causes metabolic al"alosis because of the loss of hydrochloric acid which is a potent acid in the body. &8. A. The adult with normal cerebrospinal fluid has no red blood cells. &=. D. Measuring the urine output to detect excess amount and chec"ing the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus. *?. B. The nurse should focus more on developing less stressful ways of accomplishing routine tas". *1. C. 8utotransfusion is acceptable for the client who is in danger of cardiac arrest. *&. D. The client with thromboembolism does not have coolness. **. A. 'ositioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration. */. C. 0ursing care after bone biopsy includes close monitoring of the punctured site for bleeding@ swelling and hematoma formation. *3. D. #al"ing and swimming are very helpful in strengthening bac" muscles for the client suffering from lower bac" pain. *4. C. !udden@ severe abdominal pain is the most indicative sign of perforation. #hen perforation of an ulcer occurs@ the nurse maybe unable to hear bowel sounds at all.

*7. A. 8fter surgery to correct a detached retina@ prevention of increased intraocular pressure is the priority goal. *8. A. Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased out flow of a;ueous humor. *=. D. ,t is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion. /?. D. 8bdominal breathing improves lungs expansion /1. C. 8 Client with burns is very sensitive to temperature changes because heat is loss in the burn areas. /&. A. The graft covers the nerve endings@ which reduces pain and provides framewor" for granulation /*. B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing. //. C. This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics. /3. D. Constipation@ diarrhea@ andJor constipation alternating with diarrhea are the most common symptoms of colorectal cancer. /4. B. #ith increased intraabdominal pressure@ the abdominal wall will become tender and rigid. /7. A. 'ressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after liver biopsy. /8. B. )epatitis 8 is primarily spread via fecal>oral route. !ewage polluted water may harbor the virus. /=. B. 8mylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems. 3?. A. !odium@ which is concerned with the regulation of extracellular fluid volume@ it is lost with vomiting. Chloride@ which balances cations in the extracellular compartments@ is also lost with vomiting@ because sodium and chloride are parallel electrolytes@ hyponatremia will accompany.

Ps&chiatric Nursing Practice Test Part 1

1. Marco approached 0urse Trish as"ing for advice on how to deal with his alcohol addiction. 0urse Trish should tell the client that the only effective treatment for alcoholism is a. 'sychotherapy b. 8lcoholics anonymous E8.8.F c. Total abstinence d. 8version Therapy &. 0urse )a$el is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is "nown as a. )allucinations b. (elusions c. 5oose associations d. 0eologisms *. 0urse Monet is caring for a female client who has suicidal tendency. #hen accompanying the client to the restroom@ 0urse Monet should1 a. :ive her privacy b. 8llow her to urinate c. <pen the window and allow her to get some fresh air d. <bserve her /. 0urse Maureen is developing a plan of care for a female client with anorexia nervosa. #hich action should the nurse include in the plan+ a. 'rovide privacy during meals b. !et>up a strict eating plan for the client c. -ncourage client to exercise to reduce anxiety d. 2estrict visits with the family 3. 8 client is experiencing anxiety attac". The most appropriate nursing intervention should include+ a. Turning on the television b. 5eaving the client alone c. !taying with the client and spea"ing in short sentences

d. 8s" the client to play with other clients 4. 8 female client is admitted with a diagnosis of delusions of :280(-72. This diagnosis reflects a belief that one is a. 9eing Billed b. )ighly famous and important c. 2esponsible for evil world d. Connected to client unrelated to oneself 7. 8 &? year old client was diagnosed with dependent personality disorder. #hich behavior is not most li"ely to be evidence of ineffective individual coping+ a. 2ecurrent self>destructive behavior b. 8voiding relationship c. !howing interest in solitary activities d. ,nability to ma"e choices and decision without advise 8. 8 male client is diagnosed with schi$otypal personality disorder. #hich signs would this client exhibit during social situation+ a. 'aranoid thoughts b. -motional affect c. ,ndependence need d. 8ggressive behavior =. 0urse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is+ a. -ncourage to avoid foods b. ,dentify anxiety causing situations c. -at only three meals a day d. 8void shopping plenty of groceries 1?. 0urse Tony was caring for a /1 year old female client. #hich behavior by the client indicates adult cognitive development+ a. :enerates new levels of awareness b. 8ssumes responsibility for her actions c. )as maximum ability to solve problems and learn new s"ills d. )er perception are based on reality 11. 8 neuromuscular bloc"ing agent is administered to a client before -CT therapy. The 0urse should carefully observe the client for+ a. 2espiratory difficulties b. 0ausea and vomiting c. (i$$iness d. !ei$ures 1&. 8 73 year old client is admitted to the hospital with the diagnosis of dementia of the 8l$heimers type and depression. The symptom that is unrelated to depression would be+ a. 8pathetic response to the environment b. G, dont "nowH answer to ;uestions c. !hallow of labile effect d. 0eglect of personal hygiene 1*. 0urse Trish is wor"ing in a mental health facilityL the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to+

a. Teach client to measure , N < b. ,nvolve client in planning daily meal c. <bserve client during meals d. Monitor client continuously 1/. 0urse 'atricia is aware that the ma6or health complication associated with intractable anorexia nervosa would be+ a. Cardiac dysrhythmias resulting to cardiac arrest b. :lucose intolerance resulting in protracted hypoglycemia c. -ndocrine imbalance causing cold amenorrhea d. (ecreased metabolism causing cold intolerance 13. 0urse 8nna can minimi$e agitation in a disturbed client by+ a. ,ncreasing stimulation b. limiting unnecessary interaction c. increasing appropriate sensory perception d. ensuring constant client and staff contact 14. 8 *= year old mother with obsessive>compulsive disorder has become immobili$ed by her elaborate hand washing and wal"ing rituals. 0urse Trish recogni$es that the basis of <.C. disorder is often a. 'roblems with being too conscientious b. 'roblems with anger and remorse c. %eelings of guilt and inade;uacy d. %eeling of unworthiness and hopelessness 17. Mario is complaining to other clients about not being allowed by staff to "eep food in his room. #hich of the following interventions would be most appropriate+ a. 8llowing a snac" to be "ept in his room b. 2eprimanding the client c. ,gnoring the clients behavior d. !etting limits on the behavior 18. Conney with borderline personality disorder who is to be discharge soon threatens to Gdo somethingH to herself if discharged. #hich of the following actions by the nurse would be most important+ a. 8s" a family member to stay with the client at home temporarily b. (iscuss the meaning of the clients statement with her c. 2e;uest an immediate extension for the client d. ,gnore the clients statement because its a sign of manipulation 1=. Doey a client with antisocial personality disorder belches loudly. 8 staff member as"s Doey@ G(o you "now why people find you repulsive+H this statement most li"ely would elicit which of the following client reaction+ a. (epensiveness b. -mbarrassment c. !hame d. 2emorsefulness &?. #hich of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist+

a. 2ationali$ation b. !upportive confrontation c. 5imit setting d. Consistency &1. Cely is experiencing alcohol withdrawal exhibits tremors@ diaphoresis and hyperactivity. 9lood pressure is 1=?J87 mmhg and pulse is =& bpm. #hich of the medications would the nurse expect to administer+ a. 0aloxone E0arcanF b. 9en$lropine ECogentinF c. 5ora$epam E8tivanF d. )aloperidol E)aldolF &&. #hich of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal+ a. Mil" b. <range Duice c. !oda d. 2egular Coffee &*. #hich of the following would 0urse )a$el expect to assess for a client who is exhibiting late signs of heroin withdrawal+ a. Kawning N diaphoresis b. 2estlessness N ,rritability c. Constipation N steatorrhea d. .omiting and (iarrhea &/. To establish open and trusting relationship with a female client who has been hospitali$ed with severe anxiety@ the nurse in charge should+ a. -ncourage the staff to have fre;uent interaction with the client b. !hare an activity with the client c. :ive client feedbac" about behavior d. 2espect clients need for personal space &3. 0urse Monette recogni$es that the focus of environmental EM,5,-7F therapy is to a. Manipulate the environment to bring about positive changes in behavior b. 8llow the clients freedom to determine whether or not they will be involved in activities c. 2ole play life events to meet individual needs d. 7se natural remedies rather than drugs to control behavior &4. 0urse Trish would expect a child with a diagnosis of reactive attachment disorder to a. )ave more positive relation with the father than the mother b. Cling to mother N cry on separation c. 9e able to develop only superficial relation with the others d. )ave been physically abuse &7. #hen teaching parents about childhood depression 0urse Trina should say+ a. ,t may appear acting out behavior b. (oes not respond to conventional treatment c. ,s short in duration N resolves easily

d. 5oo"s almost identical to adult depression &8. 0urse 'erry is aware that language development in autistic child resembles a. !canning speech b. !peech lag c. !huttering d. -cholalia &=. 8 4? year old female client who lives alone tells the nurse at the community health center G, really dont need anyone to tal" toH. The T. is my best friend. The nurse recogni$es that the client is using the defense mechanism "nown as+ a. (isplacement b. 'ro6ection c. !ublimation d. (enial *?. #hen wor"ing with a male client suffering phobia about blac" cats@ 0urse Trish should anticipate that a problem for this client would be+ a. 8nxiety when discussing phobia b. 8nger toward the feared ob6ect c. (enying that the phobia exist d. (istortion of reality when completing daily routines *1. 5inda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate 5indas anxiety. The most therapeutic ;uestion by the nurse would be+ a. #ould you li"e to watch T.+ b. #ould you li"e me to tal" with you+ c. 8re you feeling upset now+ d. ,gnore the client *&. 0urse 'enny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be a. 8voidance of situation N certain activities that resemble the stress b. (epression and a blunted affect when discussing the traumatic situation c. 5ac" of interest in family N others d. 2e>experiencing the trauma in dreams or flashbac" **. 0urse 9en6ie is communicating with a male client with substance>induced persisting dementiaL the client cannot remember facts and fills in the gaps with imaginary information. 0urse 9en6ie is aware that this is typical of+ a. %light of ideas b. 8ssociative looseness c. Confabulation d. Concretism */. 0urse Doey is aware that the signs N symptoms that would be most specific for diagnosis anorexia are+ a. -xcessive weight loss@ amenorrhea N abdominal distension b. !low pulse@ 1?I weight loss N alopecia c. Compulsive behavior@ excessive fears N nausea d. -xcessive activity@ memory lapses N an increased pulse

*3. 8 characteristic that would suggest to 0urse 8nne that an adolescent may have bulimia would be a. %re;uent regurgitation N re>swallowing of food b. 'revious history of gastritis c. 9adly stained teeth d. 'ositive body image *4. 0urse Monette is aware that extremely depressed clients seem to do best in settings where they have a. Multiple stimuli b. 2outine 8ctivities c. Minimal decision ma"ing d. .aried 8ctivities *7. To further assess a clients suicidal potential. 0urse Batrina should be especially alert to the client expression of a. %rustration N fear of death b. 8nger N resentment c. 8nxiety N loneliness d. )elplessness N hopelessness *8. 8 nursing care plan for a male client with bipolar , disorder should include a. 'roviding a structured environment b. (esigning activities that will re;uire the client to maintain contact with reality c. -ngaging the client in conversing about current affairs d. Touching the client provide assurance *=. #hen planning care for a female client using ritualistic behavior@ 0urse :ina must recogni$e that the ritual a. )elps the client focus on the inability to deal with reality b. )elps the client control the anxiety c. ,s under the clients conscious control d. ,s used by the client primarily for secondary gains /?. 8 *& year old male graduate student@ who has become increasingly withdrawn and neglectful of his wor" and personal hygiene@ is brought to the psychiatric hospital by his parents. 8fter detailed assessment@ a diagnosis of schi$ophrenia is made. ,t is unli"ely that the client will demonstrate a. 5ow self esteem b. Concrete thin"ing c. -ffective self boundaries d. #ea" ego /1. 8 &* year old client has been admitted with a diagnosis of schi$ophrenia says to the nurse GKes@ its march@ March is little womanH. Thats literal you "nowH. These statement illustrate a. 0eologisms b. -cholalia c. %light of ideas d. 5oosening of association

/&. 8 long term goal for a paranoid male client who has un6ustifiably accused his wife of having many extramarital affairs would be to help the client develop a. ,nsight into his behavior b. 9etter self control c. %eeling of self worth d. %aith in his wife /*. 8 male client who is experiencing disordered thin"ing about food being poisoned is admitted to the mental health unit. The nurse uses which communication techni;ue to encourage the client to eat dinner+ a. %ocusing on self>disclosure of own food preference b. 7sing open ended ;uestion and silence c. <ffering opinion about the need to eat d. .erbali$ing reasons that the client may not choose to eat //. 0urse 0ina is assigned to care for a client diagnosed with Catatonic !tupor. #hen 0urse 0ina enters the clients room@ the client is found lying on the bed with a body pulled into a fetal position. 0urse 0ina should+ a. 8s" the client direct ;uestions to encourage tal"ing b. 2a"e the client into the dayroom to be with other clients c. !it beside the client in silence and occasionally as" open>ended ;uestion d. 5eave the client alone and continue with providing care to the other clients /3. 0urse Tina is caring for a client with delirium and states that Gloo" at the spiders on the wallH. #hat should the nurse respond to the client+ a. GKoure having hallucination@ there are no spiders in this room at allH b. G, can see the spiders on the wall@ but they are not going to hurt youH c. G#ould you li"e me to "ill the spidersH d. G, "now you are frightened@ but , do not see spiders on the wallH /4. 0urse Donel is providing information to a community group about violence in the family. #hich statement by a group member would indicate a need to provide additional information+ a. G8buse occurs more in low>income familiesH b. G8buser 8re often 6ealous or self>centeredH c. G8buser use fear and intimidationH d. G8buser usually have poor self>esteemH /7. (uring electroconvulsive therapy E-CTF the client receives oxygen by mas" via positive pressure ventilation. The nurse assisting with this procedure "nows that positive pressure ventilation is necessary because+ a. 8nesthesia is administered during the procedure b. (ecrease oxygen to the brain increases confusion and disorientation c. :rand mal sei$ure activity depresses respirations d. Muscle relaxations given to prevent in6ury during sei$ure activity depress respirations. /8. #hen planning the discharge of a client with chronic anxiety@ 0urse Chris evaluates achievement of the discharge maintenance goals. #hich goal would be most appropriately having been included in the plan of care re;uiring evaluation+ a. The client eliminates all anxiety from daily situations b. The client ignores feelings of anxiety

c. The client identifies anxiety producing situations d. The client maintains contact with a crisis counselor /=. 0urse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed+ a. 0euroleptic medication b. !hort term seclusion c. 'sychosurgery d. -lectroconvulsive therapy 3?. Mario is admitted to the emergency room with drug>included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the a. 5ength of time on the med. b. 0ame of the ingested medication N the amount ingested c. 2eason for the suicide attempt d. 0ame of the nearest relative N their phone number

Ans!ers and "ationale Ps&chiatric Nursing Practice Test Part 1 1. C. Total abstinence is the only effective treatment for alcoholism. &. A. )allucinations are visual@ auditory@ gustatory@ tactile or olfactory perceptions that have no basis in reality. *. D. The 0urse has a responsibility to observe continuously the acutely suicidal client. The 0urse should watch for clues@ such as communicating suicidal thoughts@ and messagesL hoarding medications and tal"ing about death. /. B# -stablishing a consistent eating plan and monitoring clients weight are important to this disorder. 3. C. 8ppropriate nursing interventions for an anxiety attac" include using short sentences@ staying with the client@ decreasing stimuli@ remaining calm and medicating as needed. 4. B. (elusion of grandeur is a false belief that one is highly famous and important. 7. D. ,ndividual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will ma"e decisions with them. 8. A. Clients with schi$otypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.

=. B. 9ulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. 1?. A. 8n adult age *1 to /3 generates new level of awareness. 11. A. 0euromuscular 9loc"er@ such as !7CC,0K5C)<5,0- E8nectineF produces respiratory depression because it inhibits contractions of respiratory muscles. 1&. C. #ith depression@ there is little or no emotional involvement therefore little alteration in affect. 1*. D. These clients often hide food or force vomitingL therefore they must be carefully monitored. 1/. A. These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure@ these electrolytes are necessary for cardiac functioning. 13. B. 5imiting unnecessary interaction will decrease stimulation and agitation. 14. C. 2itualistic behavior seen in this disorder is aimed at controlling guilt and inade;uacy by maintaining an absolute set pattern of behavior. 17. D. The nurse needs to set limits in the clients manipulative behavior to help the client control dysfunctional behavior. 8 consistent approach by the staff is necessary to decrease manipulation. 18. B. 8ny suicidal statement must be assessed by the nurse. The nurse should discuss the clients statement with her to determine its meaning in terms of suicide. 1=. A. #hen the staff member as" the client if he wonders why others find him repulsive@ the client is li"ely to feel defensive because the ;uestion is belittling. The natural tendency is to counterattac" the threat to self image. &?. B. The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self. &1. C. The nurse would most li"ely administer ben$odia$epine@ such as lora$epan EativanF to the client who is experiencing symptom The clients experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the C0! from alcohol begins to decrease.

&&. D. 2egular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. !erving coffee top the client may add to tremors or wa"efulness. &*. D. .omiting and diarrhea are usually the late signs of heroin withdrawal@ along with muscle spasm@ fever@ nausea@ repetitive@ abdominal cramps and bac"ache. &/. D. Moving to a clients personal space increases the feeling of threat@ which increases anxiety. &3. A. -nvironmental EM,5,-7F therapy aims at having everything in the clients surrounding area toward helping the client. &4. C. Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially &7. A. Children have difficulty verbally expressing their feelings@ acting out behavior@ such as temper tantrums@ may indicate underlying depression. &8. D. The autistic child repeat sounds or words spo"en by others. &=. D. The client statement is an example of the use of denial@ a defense that bloc"s problem by unconscious refusing to admit they exist. *?. A. (iscussion of the feared ob6ect triggers an emotional response to the ob6ect. *1. B. The nurse presence may provide the client with support N feeling of control. *&. D. -xperiencing the actual trauma in dreams or flashbac" is the ma6or symptom that distinguishes post traumatic stress disorder from other anxiety disorder. **. C. Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits. */. A. These are the ma6or signs of anorexia nervosa. #eight loss is excessive E13I of expected weightF. *3. C. (ental enamel erosion occurs from repeated self>induced vomiting. *4. B. (epression usually is both emotional N physical. 8 simple daily routine is the best@ least stressful and least anxiety producing. *7. D. The expression of these feeling may indicate that this client is unable to continue the struggle of life.

*8. A. !tructure tends to decrease agitation and anxiety and to increase the clients feeling of security. *=. B. The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action. /?. C. 8 person with this disorder would not have ade;uate self>boundaries. /1. D. 5oose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message. /&. C. )elping the client to develop feeling of self worth would reduce the clients need to use pathologic defenses. /*. B. <pen ended ;uestions and silence are strategies used to encourage clients to discuss their problem in descriptive manner. //. C. Clients who are withdrawn may be immobile and mute@ and re;uire consistent@ repeated interventions. Communication with withdrawn clients re;uires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence@ as"ing open>ended ;uestion and pausing to provide opportunities for the client to respond. /3. D. #hen hallucination is present@ the nurse should reinforce reality with the client. /4. A. 'ersonal characteristics of abuser include low self>esteem@ immaturity@ dependence@ insecurity and 6ealousy. /7. D. 8 short acting s"eletal muscle relaxant such as succinylcholine E8nectineF is administered during this procedure to prevent in6uries during sei$ure. /8. C. 2ecogni$ing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. /=. D. -lectroconvulsive therapy is an effective treatment for depression that has not responded to medication. 3?. B. ,n an emergency@ lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation. Ps&chiatric Nursing Practice Test Part 1. 0urse Tony should first discuss terminating the nurse>client relationship with a client during the

a. Termination phase when discharge plans are being made. b. #or"ing phase when the client shows some progress. c. <rientation phase when a contract is established. d. #or"ing phase when the client brings it up. &. Malou is diagnosed with ma6or depression spends ma6ority of the day lying in bed with the sheet pulled over his head. #hich of the following approaches by the nurse would be the most therapeutic+ a. Cuestion the client until he responds b. ,nitiate contact with the client fre;uently c. !it outside the clients room d. #ait for the client to begin the conversation *. Doe who is very depressed exhibits psychomotor retardation@ a flat affect and apathy. The nurse in charge observes Doe to be in need of grooming and hygiene. #hich of the following nursing actions would be most appropriate+ a. #aiting until the clients family can participate in the clients care b. 8s"ing the client if he is ready to ta"e shower c. -xplaining the importance of hygiene to the client d. !tating to the client that its time for him to ta"e a shower /. #hen teaching Mario with a typical depression about foods to avoid while ta"ing phenel$ineE0ardilF@ which of the following would the nurse in charge include+ a. 2oasted chic"en b. %resh fish c. !alami d. )amburger 3. #hen assessing a female client who is receiving tricyclic antidepressant therapy@ which of the following would alert the nurse to the possibility that the client is experiencing anticholinergic effects+ a. 7rine retention and blurred vision b. 2espiratory depression and convulsion c. (elirium and !edation d. Tremors and cardiac arrhythmias 4. %or a male client with dysthymic disorder@ which of the following approaches would the nurse expect to implement+ a. -CT b. 'sychotherapeutic approach c. 'sychoanalysis

d. 8ntidepressant therapy 7. (anny who is diagnosed with bipolar disorder and acute mania@ states the nurse@ G#here is my daughter+ , love 5ouis. 2ain@ rain go away. (ogs eat dirt.H The nurse interprets these statements as indicating which of the following+ a. -cholalia b. 0eologism c. Clang associations d. %light of ideas 8. Terry with mania is s"ipping up and down the hallway practically running into other clients. #hich of the following activities would the nurse in charge expect to include in Terrys plan of care+ a. #atching T. b. Cleaning dayroom tables c. 5eading group activity d. 2eading a boo" =. #hen assessing a male client for suicidal ris"@ which of the following methods of suicide would the nurse identify as most lethal+ a. #rist cutting b. )ead banging c. 7se of gun d. 8spirin overdose 1?. Dun has been hospitali$ed for ma6or depression and suicidal ideation. #hich of the following statements indicates to the nurse that the client is improving+ a. G,m of no use to anyone anymore.H b. G, "now my "ids dont need me anymore since theyre grown.H c. G, couldnt "ill myself because , dont want to go to hell.H d. G, dont thin" about "illing myself as much as , used to.H 11. #hich of the following activities would 0urse Trish recommend to the client who becomes very anxious when thoughts of suicide occur+ a. 7sing exercise bicycle b. Meditating c. #atching T. d. 2eading comics

1&. #hen developing the plan of care for a client receiving haloperidol@ which of the following medications would nurse Monet anticipate administering if the client developed extra pyramidal side effects+ a. <lan$apine EOyprexaF b. 'aroxetine E'axilF c. 9en$tropine mesylate ECogentinF d. 5ora$epam E8tivanF 1*. Don a suspicious client states that G, "now you nurses are spraying my food with poison as you ta"e it out of the cart.H #hich of the following would be the best response of the nurse+ a. :iving the client canned supplements until the delusion subsides b. 8s"ing what "ind of poison the client suspects is being used c. !erving foods that come in sealed pac"ages d. 8llowing the client to be the first to open the cart and get a tray 1/. 8 client is suffering from catatonic behaviors. #hich of the following would the nurse use to determine that the medication administered '20 have been most effective+ a. The client responds to verbal directions to eat b. The client initiates simple activities without direction c. The client wal"s with the nurse to her room d. The client is able to move all extremities occasionally 13. 0urse )a$el invites new clients parents to attend the psycho educational program for families of the chronically mentally ill. The program would be most li"ely to help the family with which of the following issues+ a. (eveloping a support networ" with other families b. %eeling more guilty about the clients illness c. 2ecogni$ing the clients wea"ness d. Managing their financial concern and problems 14. #hen planning care for (ory with schi$otypal personality disorder@ which of the following would help the client become involved with others+ a. 8ttending an activity with the nurse b. 5eading a sing a long in the afternoon c. 'articipating solely in group activities d. 9eing involved with primarily one to one activities 17. #hich statement about an individual with a personality disorder is true+

a. 'sychotic behavior is common during acute episodes b. 'rognosis for recovery is good with therapeutic intervention c. The individual typically remains in the mainstream of society@ although he has problems in social and occupational roles d. The individual usually see"s treatment willingly for symptoms that are personally distressful. 18. 0urse Dohn is tal"ing with a client who has been diagnosed with antisocial personality about how to sociali$e during activities without being seductive. 0urse Dohn would focus the discussion on which of the following areas+ a. (iscussing his relationship with his mother b. 8s"ing him to explain reasons for his seductive behavior c. !uggesting to apologi$e to others for his behavior d. -xplaining the negative reactions of others toward his behavior 1=. Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. 0urse Trish would recommend which of the following activities for Tina+ a. 9a"ing class b. 2ole playing c. !crap boo" ma"ing d. Music group &?. Doy has entered the chemical dependency unit for treatment of alcohol dependency. #hich of the following clients possession will the nurse most li"ely place in a loc"ed area+ a. Toothpaste b. !hampoo c. 8ntiseptic wash d. Moisturi$er &1. #hich of the following assessment would provide the best information about the clients physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal+ a. !leeping pattern b. Mental alertness c. 0utritional status d. .ital signs &&. 8fter administering naloxone E0arcanF@ an opioid antagonist@ 0urse 2onald should monitor the female client carefully for which of the following+

a. 2espiratory depression b. -pilepsy c. Bidney failure d. Cerebral edema &*. #hich of the following would nurse 2onald use as the best measure to determine a clients progress in rehabilitation+ a. The way he gets along with his parents b. The number of drug>free days he has c. The "inds of friends he ma"es d. The amount of responsibility his 6ob entails &/. 8 female client is brought by ambulance to the hospital emergency room after ta"ing an overdose of barbiturates is comatose. 0urse Trish would be especially alert for which of the following+ a. -pilepsy b. Myocardial ,nfarction c. 2enal failure d. 2espiratory failure &3. Doey who has a chronic user of cocaine reports that he feels li"e he has coc"roaches crawling under his s"in. )is arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following+ a. (elusion b. %ormication c. %lash bac" d. Confusion &4. Dose is diagnosed with amphetamine psychosis and was admitted in the emergency room. 0urse 2onald would most li"ely prepare to administer which of the following medication+ a. 5ibrium b. .alium c. 8tivan d. )aldol &7. #hich of the following li;uids would nurse 5eng administer to a female client who is intoxicated with phencyclidine E'C'F to hasten excretion of the chemical+ a. !ha"e b. Tea c. Cranberry Duice

d. :rape 6uice &8. #hen developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. #hich of the following would the nurse expect to initiate+ a. %acilitating progressive review of the accident and its conse;uences b. 'ostponing discussion of the accident until the client brings it up c. Telling the client to avoid details of the accident d. )elping the client to evaluate her sisters behavior &=. The nursing assistant tells nurse 2onald that the client is not in the dining room for lunch. 0urse 2onald would direct the nursing assistant to do which of the following+ a. Tell the client hell need to wait until supper to eat if he misses lunch b. ,nvite the client to lunch and accompany him to the dining room c. ,nform the client that he has 1? minutes to get to the dining room for lunch d. Ta"e the client a lunch tray and let the client eat in his room *?. The initial nursing intervention for the significant>others during shoc" phase of a grief reaction should be focused on a. 'resenting full reality of the loss of the individuals b. (irecting the individuals activities at this time c. !taying with the individuals involved d. Mobili$ing the individuals support system *1. Doys stream of consciousness is occupied exclusively with thoughts of her fathers death. 0urse 2onald should plan to help Doy through this stage of grieving@ which is "nown as a. !hoc" and disbelief b. (eveloping awareness c. 2esolving the loss d. 2estitution *&. #hen ta"ing a health history from a female client who has a moderate level of cognitive impairment due to dementia@ the nurse would expect to note the presence of a. 8ccentuated premorbid traits b. -nhance intelligence c. ,ncreased inhibitions d. )yper vigilance **. #hat is the priority care for a client with a dementia resulting from 8,(!+

a. 'lanning for remotivational therapy b. 8rranging for long term custodial care c. 'roviding basic intellectual stimulation d. 8ssessing pain fre;uently */. Derome who has eating disorder often exhibits similar symptoms. 0urse 5hey would expect an adolescent client with anorexia to exhibit a. 8ffective instability b. (ishered@ un"empt physical appearance c. (epersonali$ation and dereali$ation d. 2epetitive motor mechanisms *3. The primary nursing diagnosis for a female client with a medical diagnosis of ma6or depression would be a. !ituational low self>esteem related to altered role b. 'owerlessness related to the loss of ideali$ed self c. !piritual distress related to depression d. ,mpaired verbal communication related to depression *4. #hen developing an initial nursing care plan for a male client with a 9ipolar , disorder Emanic episodeF nurse 2on should plan to+ a. ,solate his gym time b. -ncourage his active participation in unit programs c. 'rovide foods@ fluids and rest d. -ncourage his participation in programs *7. :race is exhibiting withdrawn patterns of behavior. 0urse Dohnny is aware that this type of behavior eventually produces feeling of a. 2epression b. 5oneliness c. 8nger d. 'aranoia *8. <ne morning a female client on the inpatient psychiatric service complains to nurse )a$el that she has been waiting for over an hour for someone to accompany her to activities. 0urse )a$el replies to the client G#ere doing the best we can. There are a lot of other people on the unit who needs attention too.H This statement shows that the nurses use of a. (efensive behavior b. 2eality reinforcement c. 5imit>setting behavior

d. ,mpulse control *=. 8 nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self>esteem probably related to childhood abuse. The most appropriate short term client outcome would be a. .erbali$ing the need for anxiety medications b. 2ecogni$ing each existing personality c. -ngaging in ob6ect>oriented activities d. -liminating defense mechanisms and phobia /?. 8 &3 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices@ responding to imaginary companions and withdrawing to his room for several days at a time. 0urse Monette understands that the withdrawal is a defense against the clients fear of a. 'hobia b. 'owerlessness c. 'unishment d. 2e6ection /1. #hen as"ing the parents about the onset of problems in young client with the diagnosis of schi$ophrenia@ 0urse 5inda would expect that they would relate the clients difficulties began in a. -arly childhood b. 5ate childhood c. 8dolescence d. 'uberty /&. Dose who has been hospitali$ed with schi$ophrenia tells 0urse 2on@ GMy heart has stopped and my veins have turned to glassPH 0urse 2on is aware that this is an example of a. !omatic delusions b. (epersonali$ation c. )ypochondriasis d. -cholalia /*. ,n recogni$ing common behaviors exhibited by male client who has a diagnosis of schi$ophrenia@ nurse Dosie can anticipate a. !lumped posture@ pessimistic out loo" and flight of ideas b. :randiosity@ arrogance and distractibility c. #ithdrawal@ regressed behavior and lac" of social s"ills d. (isorientation@ forgetfulness and anxiety

//. <ne morning@ nurse (iane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is a. 'hysically ill and experiencing abdominal discomfort b. Tired and probably did not sleep well last night c. 8ttempting to hide from the nurse d. %eeling more anxious today /3. 0urse 9ea notices a female client sitting alone in the corner smiling and tal"ing to herself. 2eali$ing that the client is hallucinating. 0urse 9ea should a. ,nvite the client to help decorate the dayroom b. 5eave the client alone until he stops tal"ing c. 8s" the client why he is smiling and tal"ing d. Tell the client it is not good for him to tal" to himself /4. #hen being admitted to a mental health facility@ a young female adult tells 0urse Mylene that the voices she hears frighten her. 0urse Mylene understands that the client tends to hallucinate more vividly a. #hile watching T. b. (uring meal time c. (uring group activities d. 8fter going to bed /7. 0urse Dohn recogni$es that paranoid delusions usually are related to the defense mechanism of a. 'ro6ection b. ,dentification c. 2epression d. 2egression /8. #hen planning care for a male client using paranoid ideation@ nurse Dasmin should reali$e the importance of a. :iving the client difficult tas"s to provide stimulation b. 'roviding the client with activities in which success can be achieved c. 2emoving stress so that the client can relax d. 0ot placing any demands on the client /=. 0urse :erry is aware that the defense mechanism commonly used by clients who are alcoholics is a. (isplacement

b. (enial c. 'ro6ection d. Compensation 3?. #ithin a few hours of alcohol withdrawal@ nurse Dohn should assess the male client for the presence of a. (isorientation@ paranoia@ tachycardia b. Tremors@ fever@ profuse diaphoresis c. ,rritability@ heightened alertness@ 6er"y movements d. Kawning@ anxiety@ convulsions Ans!ers and "ationale Ps&chiatric Nursing Practice Test Part 1. C. #hen the nurse and client agree to wor" together@ a contract should be established@ the length of the relationship should be discussed in terms of its ultimate termination. &. B. The nurse should initiate brief@ fre;uent contacts throughout the day to let the client "now that he is important to the nurse. This will positively affect the clients self>esteem. *. D. The client with depression is preoccupied@ has decreased energy@ and is unable to ma"e decisions. The nurse presents the situation@ G,ts time for a showerH@ and assists the client with personal hygiene to preserve his dignity and self>esteem. /. C. %oods high in tyramine@ those that are fermented@ pic"led@ aged@ or smo"ed must be avoided because when they are ingested in combination with M8<,s a hypertensive crisis will occur. 3. A. 8nticholinergic effects@ which result from bloc"age of the parasympathetic EcraniosacralF nervous system including urine retention@ blurred vision@ dry mouth N constipation. 4. B. (ysthymia is a less severe@ chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least & years. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self image@ negative feelings about the future. 7. D. %light of ideas is speech pattern of rapid transition from topic to topic@ often without finishing one idea. ,t is common in mania. 8. B. The client with mania is very active N needs to have this energy channeled in a constructive tas" such as cleaning or tidying the room. =. C. 8 crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method N the delivery of the lethal impact of the method. 1?. D. The statement G, dont thin" about "illing myself as much as , used to.H ,ndicates a lessening of suicidal ideation and improvement in the clients condition. 11. A. 7sing exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur.

1&. C. The drug of choice for a client experiencing extra pyramidal side effects from haloperidol E)aldolF is ben$tropine mesylate EcogentinF because of its anti cholinergic properties. 1*. D. 8llowing the client to be the first to open the cart N ta"e a tray presents the client with the reality that the nurses are not touching the food N tray@ thereby dispelling the delusion. 1/. B. 8lthough all the actions indicate improvement@ the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors. 13. A. 'sychoeducational groups for families develop a support networ". They provide education about the biochemical etiology of psychiatric disease to reduce@ not increase family guilt. 14. C. 8ttending activity with the nurse assists the client to become involved with others slowly. The client with schi$otypal personality disorder needs support@ "indness N gentle suggestion to improve social s"ills N interpersonal relationship. 17. C. 8n individual with personality disorder usually is not hospitali$ed unless a coexisting 8xis , psychiatric disorder is present. :enerally@ these individuals ma"e marginal ad6ustments and remain in society@ although they typically experience relationship and occupational problems related to their inflexible behaviors. 'ersonality disorders are chronic lifelong patterns of behaviorL acute episodes do not occur. 'sychotic behavior is usually not common@ although it can occur in either schi$otypal personality disorder or borderline personality disorder. 9ecause these disorders are enduring and evasive and the individual is inflexible@ prognosis for recovery is unfavorable. :enerally@ the individual does not see" treatment because he does not perceive problems with his own behavior. (istress can occur based on other peoples reaction to the individuals behavior. 18. D. The nurse would explain the negative reactions of others towards the clients behaviors to ma"e the clients aware of the impact of his seductive behaviors on others. 1=. B. The nurse would use role>playing to teach the client appropriate responses to others and in various situations. This client dramati$es events@ drawn attention to self@ and is unaware of and does not deal with feelings. The nurse wor"s to help the client clarify true feelings N learn to express them appropriately. &?. C. 8ntiseptic mouthwash often contains alcohol N should be "ept in loc"ed area@ unless labeling clearly indicates that the product does not contain alcohol. &1. D. Monitoring of vital signs provides the best information about the clients overall physiologic status during alcohol withdrawal N the physiologic response to the medication used. &&. A. 8fter administering naloxone E0arcanF the nurse should monitor the clients respiratory status carefully@ because the drug is short acting N respiratory depression may recur after its effects wear off. &*. B. The best measure to determine a clients progress in rehabilitation is the number of drug> free days he has. The longer the client is free of drugs@ the better the prognosis is.

&/. D. 9arbiturates are C0! depressantsL the nurse would be especially alert for the possibility of respiratory failure. 2espiratory failure is the most li"ely cause of death from barbiturate over dose. &3. B. The feeling of bugs crawling under the s"in is termed as formication@ and is associated with cocaine use. &4. D. The nurse would prepare to administer an antipsychotic medication such as )aldol to a client experiencing amphetamine psychosis to decrease agitation N psychotic symptoms@ including delusions@ hallucinations N cognitive impairment. &7. C. 8n acid environment aids in the excretion of 'C'. The nurse will definitely give the client with 'C' intoxication cranberry 6uice to acidify the urine to a ph of 3.3 N accelerate excretion. &8. A. The nurse would facilitate progressive review of the accident and its conse;uence to help the client integrate feelings N memories and to begin the grieving process. &=. B. The nurse instructs the nursing assistant to invite the client to lunch N accompany him to the dinning room to decrease manipulation@ secondary gain@ dependency and reinforcement of negative behavior while maintaining the clients worth. *?. C. This provides support until the individuals coping mechanisms and personal support systems can be immobili$ed. *1. C. 2esolving a loss is a slow@ painful@ continuous process until a mental image of the dead person@ almost devoid of negative or undesirable features emerges. *&. A. 8 moderate level of cognitive impairment due to dementia is characteri$ed by increasing dependence on environment N social structure and by increasing psychologic rigidity with accentuated previous traits N behaviors. **. C. This action maintains for as long as possible@ the clients intellectual functions by providing an opportunity to use them. */. A. ,ndividuals with anorexia often display irritability@ hospitality@ and a depressed mood. *3. D. (epressed clients demonstrate decreased communication because of lac" of psychic or physical energy. *4. C. The client in a manic episode of the illness often neglects basic needs@ these needs are a priority to ensure ade;uate nutrition@ fluid@ and rest. *7. B. The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness. *8. A. The nurses response is not therapeutic because it does not recogni$e the clients needs but tries to ma"e the client feel guilty for being demanding. *=. B. The client must recogni$e the existence of the sub personalities so that interpretation can occur. /?. D. 8n aloof@ detached@ withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe@ emotional distance. /1. C. The usual age of onset of schi$ophrenia is adolescence or early childhood. /&. A. !omatic delusion is a fixed false belief about ones body. /*. C. These are the classic behaviors exhibited by clients with a diagnosis of schi$ophrenia.

//. D. The fetal position represents regressed behavior. 2egression is a way of responding to overwhelming anxiety. /3. B. This provides a stimulus that competes with and reduces hallucination. /4. D. 8uditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. /7. A. 'ro6ection is a mechanism in which inner thoughts and feelings are pro6ected onto the environment@ seeming to come from outside the self rather than from within. /8. B. This will help the client develop self>esteem and reduce the use of paranoid ideation. /=. B. (enial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence. 3?. C. 8lcohol is a central nervous system depressant. These symptoms are the bodys neurologic adaptation to the withdrawal of alcohol. Ps&chiatric Nursing Practice Test Part $ 1. %rancis who is addicted to cocaine withdraws from the drug. 0urse 2on should expect to observe a. )yperactivity b. (epression c. !uspicion d. (elirium &. 0urse Dohn is aware that a serious effect of inhaling cocaine is+ a. (eterioration of nasal septum b. 8cute fluid and electrolyte imbalances c. -xtra pyramidal tract symptoms d. -sophageal varices *. 8 tentative diagnosis of opiate addiction@ 0urse Candy should assess a recently hospitali$ed client for signs of opiate withdrawal. These signs would include a. 2hinorrhea@ convulsions@ subnormal temperature b. 0ausea@ dilated pupils@ constipation c. 5acrimation@ vomiting@ drowsiness d. Muscle aches@ papillary constriction@ yawning /. 8 /8 year old male client is brought to the psychiatric emergency room after attempting to 6ump off a bridge. The clients wife states that he lost his 6ob several months ago and has been unable to find another 6ob. The primary nursing intervention at this time would be to assess for a. 8 past history of depression

b. Current plans to commit suicide c. The presence of marital difficulties d. %eelings of excessive failure 3. 9efore helping a male client who has been sexually assaulted@ nurse Maureen should recogni$e that the rapist is motivated by feelings of a. )ostility b. ,nade;uacy c. ,ncompetence d. 'assion 4. #hen wor"ing with children who have been sexually abused by a family member it is important for the nurse to understand that these victims usually are overwhelmed with feelings of a. )umiliation b. Confusion c. !elf blame d. )atred 7. Doy who has 6ust experienced her second spontaneous abortion expresses anger towards her physician@ the hospital and the Grotten nursing careH. #hen assessing the situation@ the nurse recogni$es that the client may be using the coping mechanism of a. 'ro6ection b. (isplacement c. (enial d. 2eaction formation 8. The most critical factor for nurse 5inda to determine during crisis intervention would be the clients a. 8vailable situational supports b. #illingness to restructure the personality c. (evelopmental theory d. 7nderlying unconscious conflict =. 0urse Trish suggests a crisis intervention group to a client experiencing a developmental crisis. These groups are successful because the a. Crisis intervention wor"er is a psychologist and understands behavior patterns b. Crisis group supplies a wor"able solution to the clients problem c. Client is encouraged to tal" about personal problems d. Client is assisted to investigate alternative approaches to solving the identified problem

1?. 0urse 2onald could evaluate that the staffs approach to setting limits for a demanding@ angry client was effective if the client a. 8pologi$es for disrupting the units routine when something is needed b. 7nderstands the reason why fre;uent calls to the staff were made c. (iscuss concerns regarding the emotional condition that re;uired hospitali$ations d. 0o longer calls the nursing staff for assistance 11. 0urse Dohn is aware that the therapy that has the highest success rate for people with phobias would be a. 'sychotherapy aimed at rearranging maladaptive thought process b. 'sychoanalytical exploration of repressed conflicts of an earlier development phase c. !ystematic desensiti$ation using relaxation techni;ue d. ,nsight therapy to determine the origin of the anxiety and fear 1&. #hen nurse )a$el considers a clients placement on the continuum of anxiety@ a "ey in determining the degree of anxiety being experienced is the clients a. 'erceptual field b. (elusional system c. Memory state d. Creativity level 1*. ,n the diagnosis of a possible pervasive developmental autistic disorder. The nurse would find it most unusual for a * year old child to demonstrate a. 8n interest in music b. 8n attachment to odd ob6ects c. 2itualistic behavior d. 2esponsiveness to the parents 1/. Malou with schi$ophrenia tells 0urse Melinda@ GMy intestines are rotted from worms chewing on them.H This statement indicates a a. Dealous delusion b. !omatic delusion c. (elusion of grandeur d. (elusion of persecution 13. 8ndy is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. 0urse )ilary should expects the assessment to reveal a. Coldness@ detachment and lac" of tender feelings b. !omatic symptoms c. ,nability to function as responsible parent

d. 7npredictable behavior and intense interpersonal relationships 14. '2<'280<5<5 E,nderalF is used in the mental health setting to manage which of the following conditions+ a. 8ntipsychotic Q induced a"athisia and anxiety b. <bsessive Q compulsive disorder E<C(F to reduce ritualistic behavior c. (elusions for clients suffering from schi$ophrenia d. The manic phase of bipolar illness as a mood stabili$er 17. #hich medication can control the extra pyramidal effects associated with antipsychotic agents+ a. Clora$epate ETranxeneF b. 8mantadine E!ymmetrelF c. (oxepin E!ine;uanF d. 'erphena$ine ETrilafonF 18. #hich of the following statements should be included when teaching clients about monoamine oxidase inhibitor EM8<,F antidepressants+ a. (ont ta"e aspirin or nonsteroidal anti>inflammatory drugs E0!8,(sF b. )ave blood levels screened wee"ly for leucopenia c. 8void strenuous activity because of the cardiac effects of the drug d. (ont ta"e prescribed or over the counter medications without consulting the physician 1=. Bris periodically has acute panic attac"s. These attac"s are unpredictable and have no apparent association with a specific ob6ect or situation. (uring an acute panic attac"@ Bris may experience a. )eightened concentration b. (ecreased perceptual field c. (ecreased cardiac rate d. (ecreased respiratory rate &?. ,nitial interventions for Marco with acute anxiety include all except which of the following+ a. Touching the client in an attempt to comfort him b. 8pproaching the client in calm@ confident manner c. -ncouraging the client to verbali$e feelings and concerns d. 'roviding the client with a safe@ ;uiet and private place &1. 0urse Dessie is assessing a client suffering from stress and anxiety. 8 common physiological response to stress and anxiety is

a. 7ticaria b. .ertigo c. !edation d. (iarrhea &&. #hen performing a physical examination on a female anxious client@ nurse 0elli would expect to find which of the following effects produced by the parasympathetic system+ a. Muscle tension b. )yperactive bowel sounds c. (ecreased urine output d. Constipation &*. #hich of the following drugs have been "nown to be effective in treating obsessive> compulsive disorder E<C(F+ a. (ivalproex Edepa"oteF and 5ithium ElithobidF b. Chlordia$epoxide E5ibriumF and dia$epam EvaliumF c. %luvoxamine E5uvoxF and clomipramine EanafranilF d. 9en$tropine ECogentinF and diphenhydramine EbenadrylF &/. Tony with agoraphobia has been symptom>free for / months. Classic signs and symptoms of phobia include a. !evere anxiety and fear b. #ithdrawal and failure to distinguish reality from fantasy c. (epression and weight loss d. ,nsomnia and inability to concentrate &3. #hich nursing action is most appropriate when trying to diffuse a clients impending violent behavior+ a. 'lace the client in seclusion b. 5eaving the client alone until he can tal" about his feelings c. ,nvolving the client in a ;uiet activity to divert attention d. )elping the client identify and express feelings of anxiety and anger &4. 2osana is in the second stage of 8l$heimers disease who appears to be in pain. #hich ;uestion by 0urse Denny would best elicit information about the pain+ a. G#here is your pain located+H b. G(o you hurt+ EpauseF G(o you hurt+H c. GCan you describe your pain+H d. G#here do you hurt+H

&7. 0ursing preparation for a client undergoing electroconvulsive therapy E-CTF resemble those used for a. :eneral anesthesia b. Cardiac stress testing c. 0eurologic examination d. 'hysical therapy &8. Dose who is receiving monoamine oxidase inhibitor antidepressant should avoid tyramine@ a compound found in which of the following foods+ a. %igs and cream cheese b. %ruits and yellow vegetables c. 8ged cheese and Chianti wine d. :reen leafy vegetables &=. -rlinda@ age 83@ with ma6or depression undergoes a sixth electroconvulsive therapy E-CTF treatment. #hen assessing the client immediately after -CT@ the nurse expects to find a. 'ermanent short>term memory loss and hypertension b. 'ermanent long>term memory loss and hypomania c. Transitory short>term memory loss and permanent long>term memory loss d. Transitory short and long term memory loss and confusion *?. 9arbara with bipolar disorder is being treated with lithium for the first time. 0urse Clint should observe the client for which common adverse effect of lithium+ a. 'olyuria b. !ei$ures c. Constipation d. !exual dysfunction *1. 0urse %red is assessing a client who has 6ust been admitted to the -2 department. #hich signs would suggest an overdose of an antianxiety agent+ a. !uspiciousness@ dilated pupils and incomplete 9' b. 8gitation@ hyperactivity and grandiose ideation c. Combativeness@ sweating and confusion d. -motional lability@ euphoria and impaired memory *&. (ischarge instructions for a male client receiving tricyclic antidepressants include which of the following information+ a. 2estrict fluids and sodium inta"e b. (ont consume alcohol

c. (iscontinue if dry mouth and blurred vision occur d. 2estrict fluid and sodium inta"e **. ,mportant teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following+ a. ,ncreased incidence of dysmenorrhea while ta"ing the drug b. <ccurrence of incomplete libido due to medication adverse effects c. Continuing previous use of contraception during periods of amenorrhea d. ,nstruction that amenorrhea is irreversible */. 8 client refuses to remain on psychotropic medications after discharge from an inpatient psychiatric unit. #hich information should the community health nurse assess first during the initial follow>up with this client+ a. ,ncome level and living arrangements b. ,nvolvement of family and support systems c. 2eason for inpatient admission d. 2eason for refusal to ta"e medications *3. The nurse understands that the therapeutic effects of typical antipsychotic medications are associated with which neurotransmitter change+ a. (ecreased dopamine level b. ,ncreased acetylcholine level c. !tabili$ation of serotonin d. !timulation of :898 *4. #hich of the following best explains why tricyclic antidepressants are used with caution in elderly patients+ a. Central 0ervous !ystem effects b. Cardiovascular system effects c. :astrointestinal system effects d. !erotonin syndrome effects *7. 8 client with depressive symptoms is given prescribed medications and tal"s with his therapist about his belief that he is worthless and unable to cope with life. 'sychiatric care in this treatment plan is based on which framewor"+ a. 9ehavioral framewor" b. Cognitive framewor" c. ,nterpersonal framewor" d. 'sychodynamic framewor"

*8. 8 nurse who explains that a clients psychotic behavior is unconsciously motivated understands that the clients disordered behavior arises from which of the following+ a. 8bnormal thin"ing b. 8ltered neurotransmitters c. ,nternal needs d. 2esponse to stimuli *=. 8 client with depression has been hospitali$ed for treatment after ta"ing a leave of absence from wor". The clients employer expects the client to return to wor" following inpatient treatment. The client tells the nurse@ G,m no good. ,m a failureH. 8ccording to cognitive theory@ these statements reflect a. 5earned behavior b. 'unitive superego and decreased self>esteem c. %aulty thought processes that govern behavior d. -vidence of difficult relationships in the wor" environment /?. The nurse describes a client as anxious. #hich of the following statement about anxiety is true+ a. 8nxiety is usually pathological b. 8nxiety is directly observable c. 8nxiety is usually harmful d. 8nxiety is a response to a threat /1. 8 client with a phobic disorder is treated by systematic desensiti$ation. The nurse understands that this approach will do which of the following+ a. )elp the client execute actions that are feared b. )elp the client develop insight into irrational fears c. )elp the client substitutes one fear for another d. )elp the client decrease anxiety /&. #hich client outcome would best indicate successful treatment for a client with an antisocial personality disorder+ a. The client exhibits charming behavior when around authority figures b. The client has decreased episodes of impulsive behaviors c. The client ma"es statements of self>satisfaction d. The clients statements indicate no remorse for behaviors /*. The nurse is caring for a client with an autoimmune disorder at a medical clinic@ where alternative medicine is used as an ad6unct to traditional therapies. #hich information should the nurse teach the client to help foster a sense of control over his symptoms+

a. 'athophysiology of disease process b. 'rinciples of good nutrition c. !ide effects of medications d. !tress management techni;ues //. #hich of the following is the most distinguishing feature of a client with an antisocial personality disorder+ a. 8ttention to detail and order b. 9i$arre mannerisms and thoughts c. !ubmissive and dependent behavior d. (isregard for social and legal norms /3. #hich nursing diagnosis is most appropriate for a client with anorexia nervosa who expresses feelings of guilt about not meeting family expectations+ a. 8nxiety b. (isturbed body image c. (efensive coping d. 'owerlessness /4. 8 nurse is evaluating therapy with the family of a client with anorexia nervosa. #hich of the following would indicate that the therapy was successful+ a. The parents reinforced increased decision ma"ing by the client b. The parents clearly verbali$e their expectations for the client c. The client verbali$es that family meals are now en6oyable d. The client tells her parents about feelings of low>self esteem /7. 8 client with dysthymic disorder reports to a nurse that his life is hopeless and will never improve in the future. )ow can the nurse best respond using a cognitive approach+ a. 8gree with the clients painful feelings b. Challenge the accuracy of the clients belief c. (eny that the situation is hopeless d. 'resent a cheerful attitude /8. 8 client with ma6or depression has not verbali$ed problem areas to staff or peers since admission to a psychiatric unit. #hich activity should the nurse recommend to help this client express himself+ a. 8rt therapy in a small group b. 9as"etball game with peers on the unit c. 2eading a self>help boo" on depression d. #atching movie with the peer group

/=. The home health psychiatric nurse visits a client with chronic schi$ophrenia who was recently discharged after a prolong stay in a state hospital. The client lives in a boarding home@ reports no family involvement@ and has little social interaction. The nurse plan to refer the client to a day treatment program in order to help him with a. Managing his hallucinations b. Medication teaching c. !ocial s"ills training d. .ocational training 3?. #hich activity would be most appropriate for a severely withdrawn client+ a. 8rt activity with a staff member b. 9oard game with a small group of clients c. Team sport in the gym d. #atching T. in the dayroom

1. B. There is no set of symptoms associated with cocaine withdrawal@ only the depression that follows the high caused by the drug. &. A. Cocaine is a chemical that when inhaled@ causes destruction of the mucous membranes of the nose. *. D. These adaptations are associated with opiate withdrawal which occurs after cessation or reduction of prolonged moderate or heavy use of opiates. /. B. #hether there is a suicide plan is a criterion when assessing the clients determination to ma"e another attempt. 3. A. 2apists are believed to harbor and act out hostile feelings toward all women through the act of rape. 4. C. These children often have nonsexual needs met by individual and are powerless to refuse. 8mbivalence results in self>blame and also guilt. 7. B. The clients anger over the abortion is shifted to the staff and the hospital because she is unable to deal with the abortion at this time. 8. A. 'ersonal internal strength and supportive individuals are critical factors that can be employed to assist the individual to cope with a crisis. =. D. Crisis intervention group helps client reestablish psychologic e;uilibrium by assisting them to explore new alternatives for coping. ,t considers realistic situations using rational and flexible problem solving methods. 1?. C. This would document that the client feels comfortable enough to discuss the problems that have motivated the behavior. 11. C. The most successful therapy for people with phobias involves behavior modification techni;ues using desensiti$ation. 1&. A. 'erceptual field is a "ey indicator of anxiety level because the perceptual fields narrow as anxiety increases. 1*. D. <ne of the symptoms of autistic child displays a lac" of responsiveness to others. There is little or no extension to the external environment.

1/. B. !omatic delusions focus on bodily functions or systems and commonly include delusion about foul odor emissions@ insect manifestations@ internal parasites and misshapen parts. 13. D. 8 client with borderline personality displays a pervasive pattern of unpredictable behavior@ mood and self image. ,nterpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive. 14. A. 'ropranolol is a potent beta adrenergic bloc"er and producing a sedating effect@ therefore it is used to treat antipsychotic induced a"athisia and anxiety. 17. B. 8mantadine is an anticholinergic drug used to relive drug>induced extra pyramidal adverse effects such as muscle wea"ness@ involuntary muscle movements@ pseudopar"insonism and tar dive dys"inesia. 18. C. M8<, antidepressants when combined with a number of drugs can cause life> threatening hypertensive crisis. ,ts imperative that a client chec"s with his physician and pharmacist before ta"ing any other medications. 1=. B. 'anic is the most severe level of anxiety. (uring panic attac"@ the client experiences a decrease in the perceptual field@ becoming more focused on self@ less aware of surroundings and unable to process information from the environment. The decreased perceptual field contributes to impaired attention and inability to concentrate. &?. A. The emergency nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety. &1. D. (iarrhea is a common physiological response to stress and anxiety. &&. B. The parasympathetic nervous system would produce incomplete :.,. motility resulting in hyperactive bowel sounds@ possibly leading to diarrhea. &*. C. The antidepressants fluvoxamine and clomipramine have been effective in the treatment of <C(. &/. A. 'hobias cause severe anxiety Esuch as panic attac"F that is out of proportion to the threat of the feared ob6ect or situation. 'hysical signs and symptoms of phobias include profuse sweating@ poor motor control@ tachycardia and elevated 9.'. &3. D. ,n many instances@ the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. !uch statement as G#hat happened to get you this angry+H may help the client verbali$es feelings rather than act on them. &4. B. #hen spea"ing to a client with 8l$heimers disease@ the nurse should use close>ended ;uestions. Those that the client can answer with GyesH or GnoH whenever possible and avoid ;uestions that re;uire the client to ma"e choices. 2epeating the ;uestion aids comprehension. &7. A. The nurse should prepare a client for -CT in a manner similar to that for general anesthesia. &8. C. 8ged cheese and Chianti wine contain high concentrations of tyramine. &=. D. -CT commonly causes transitory short and long term memory loss and confusion@ especially in geriatric clients. ,t rarely results in permanent short and long term memory loss.

*?. A. 'olyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. *1. D. !igns of anxiety agent overdose include emotional lability@ euphoria and impaired memory. *&. B. (rin"ing alcohol can potentiate the sedating action of tricyclic antidepressants. (ry mouth and blurred vision are normal adverse effects of tricyclic antidepressants. **. C. #omen may experience amenorrhea@ which is reversible@ while ta"ing antipsychotics. 8menorrhea doesnt indicate cessation of ovulation thus@ the client can still be pregnant. */. D. The first are for assessment would be the clients reason for refusing medication. The client may not understand the purpose for the medication@ may be experiencing distressing side effects@ or may be concerned about the cost of medicine. ,n any case@ the nurse cannot provide appropriate intervention before assessing the clients problem with the medication. The patients income level@ living arrangements@ and involvement of family and support systems are relevant issues following determination of the clients reason for refusing medication. The nurse providing follow>up care would have access to the clients medical record and should already "now the reason for inpatient admission. *3. A. -xcess dopamine is thought to be the chemical cause for psychotic thin"ing. The typical antipsychotics act to bloc" dopamine receptors and therefore decrease the amount of neurotransmitter at the synapses. The typical antipsychotics do not increase acetylcholine@ stabili$e serotonin@ stimulate :898. *4. B. The TC8s affect norepinephrine as well as other neurotransmitters@ and thus have significant cardiovascular side effects. Therefore@ they are used with caution in elderly clients who may have increased ris" factors for cardiac problems because of their age and other medical conditions. The remaining side effects would apply to any client ta"ing a TC8 and are not particular to an elderly person. *7. B. Cognitive thin"ing therapy focuses on the clients misperceptions about self@ others and the world that impact functioning and contribute to symptoms. 7sing medications to alter neurotransmitter activity is a psychobiologic approach to treatment. The other answer choices are framewor"s for care@ but hey are not applicable to this situation. *8. C. The concept that behavior is motivated and has meaning comes from the psychodynamic framewor". 8ccording to this perspective@ behavior arises from internal wishes or needs. Much of what motivates behavior comes from the unconscious. The remaining responses do not address the internal forces thought to motivate behavior. *=. C. The client is demonstrating faulty thought processes that are negative and that govern his behavior in his wor" situation Q issues that are typically examined using a cognitive theory approach. ,ssues involving learned behavior are best explored through behavior theory@ not cognitive theory. ,ssues involving ego development are the focus of psychoanalytic theory. <ption / is incorrect because there is no evidence in this situation that the client has conflictual relationships in the wor" environment.

/?. D. 8nxiety is a response to a threat arising from internal or external stimuli. /1. A. !ystematic desensiti$ation is a behavioral therapy techni;ue that helps clients with irrational fears and avoidance behavior to face the thing they fear@ without experiencing anxiety. There is no attempt to promote insight with this procedure@ and the client will not be taught to substitute one fear for another. 8lthough the clients anxiety may decrease with successful confrontation of irrational fears@ the purpose of the procedure is specifically related to performing activities that typically are avoided as part of the phobic response. /&. B. 8 client with antisocial personality disorder typically has fre;uent episodes of acting impulsively with poor ability to delay self>gratification. Therefore@ decreased fre;uency of impulsive behaviors would be evidence of improvement. Charming behavior when around authority figures and statements indicating no remorse are examples of symptoms typical of someone with this disorder and would not indicate successful treatment. !elf>satisfaction would be viewed as a positive change if the client expresses low self>esteemL however this is not a characteristic of a client with antisocial personality disorder. /*. D. ,n autoimmune disorders@ stress and the response to stress can exacerbate symptoms. !tress management techni;ues can help the client reduce the psychological response to stress@ which in turn will help reduce the physiologic stress response. This will afford the client an increased sense of control over his symptoms. The nurse can address the remaining answer choices in her teaching about the clients disease and treatmentL however@ "nowledge alone will not help the client to manage his stress effectively enough to control symptoms. //. D. (isregard for established rules of society is the most common characteristic of a client with antisocial personality disorder. 8ttention to detail and order is characteristic of someone with obsessive compulsive disorder. 9i$arre mannerisms and thoughts are characteristics of a client with schi$oid or schi$otypal disorder. !ubmissive and dependent behaviors are characteristic of someone with a dependent personality. /3. D. The client with anorexia typically feels powerless@ with a sense of having little control over any aspect of life besides eating behavior. <ften@ parental expectations and standards are ;uite high and lead to the clients sense of guilt over not measuring up. /4. A. <ne of the core issues concerning the family of a client with anorexia is control. The familys acceptance of the clients ability to ma"e independent decisions is "ey to successful family intervention. 8lthough the remaining options may occur during the process of therapy@ they would not necessarily indicate a successful outcomeL the central family issues of dependence and independence are not addresses on these responses. /7. B. 7se of cognitive techni;ues allows the nurse to help the client recogni$e that this negative beliefs may be distortions and that@ by changing his thin"ing@ he can adopt more positive beliefs that are realistic and hopeful. 8greeing with the clients feelings and presenting a cheerful attitude are not consistent with a cognitive approach and would not be helpful in this situation. (enying the clients feelings is belittling and may convey that the nurse does not understand the depth of the clients distress.

/8. A# 8rt therapy provides a nonthreatening vehicle for the expression of feelings@ and use of a small group will help the client become comfortable with peers in a group setting. 9as"etball is a competitive game that re;uires energyL the client with ma6or depression is not li"ely to participate in this activity. 2ecommending that the client read a self>help boo" may increase@ not decrease his isolation. #atching movie with a peer group does not guarantee that interaction will occurL therefore@ the client may remain isolated. /=. C# (ay treatment programs provide clients with chronic@ persistent mental illness training in social s"ills@ such as meeting and greeting people@ as"ing ;uestions or directions@ placing an order in a restaurant@ ta"ing turns in a group setting activity. 8lthough management of hallucinations and medication teaching may also be part of the program offered in a day treatment@ the nurse is referring the client in this situation because of his need for sociali$ation s"ills. .ocational training generally ta"es place in a rehabilitation facilityL the client described in this situation would not be a candidate for this service. 3?. A# The best approach with a withdrawn client is to initiate brief@ nondemanding activities on a one>to>one basis. This approach gives the nurse an opportunity to establish a trusting relationship with the client. 8 board game with a group clients or playing a team sport in the gym may overwhelm a severely withdrawn client. #atching T. is a solitary activity that will reinforce the clients withdrawal from others.

Pre'(oard E)amination 1. 8 woman in a child bearing age receives a rubella vaccination. 0urse Doy would give her which of the following instructions+ a. 2efrain from eating eggs or egg products for &/ hours b. 8void having sexual intercourse c. (ont get pregnant at least * months d. 8void exposure to sun &. Donas who is diagnosed with encephalitis is under the treatment of Mannitol. #hich of the following patient outcomes indicate to 0urse 2onald that the treatment of Mannitol has been effective for a patient that has increased intracranial pressure+ a. ,ncreased urinary output b. (ecreased 22 c. !lowed papillary response

d. (ecreased level of consciousness *. Mary as"ed 0urse Maureen about the incubation period of rabies. #hich statement by the 0urse Maureen is appropriate+ a. ,ncubation period is 4 months b. ,ncubation period is 1 wee" c. ,ncubation period is 1 month d. ,ncubation period varies depending on the site of the bite /. #hich of the following should 0urse Cherry do first in ta"ing care of a male client with rabies+ a. -ncourage the patient to ta"e a bath b. Cover ,. bottle with brown paper bag c. 'lace the patient near the comfort room d. 'lace the patient near the door 3. #hich of the following is the screening test for dengue hemorrhagic fever+ a. Complete blood count b. -5,!8 c. 2umpel>leede test d. !edimentation rate 4. Mr. (ela 2osa is suspected to have malaria after a business trip in 'alawan. The most important diagnostic test in malaria is a. #9C count b. 7rinalysis c. -5,!8 d. 'eripheral blood smear 7. The 0urse supervisor is planning for patients assignment for the 8M shift. The nurse supervisor avoids assigning which of the following staff members to a client with herpes $oster+ a. 0urse who never had chic"en pox b. 0urse who never had roseola c. 0urse who never had german measles d. 0urse who never had mumps 8. Clarissa is 7 wee"s pregnant. %urther examination revealed that she is susceptible to rubella. #hen would be the most appropriate for her to receive rubella immuni$ation+ a. 8t once

b. (uring &nd trimester c. (uring *rd trimester d. 8fter the delivery of the baby =. 8 female child with rubella should be isolated from a a. &1 year old male cousin living in the same house b. 18 year old sister who recently got married c. 11 year old sister who had rubeola during childhood d. / year old girl who lives next door 1?. #hat is the primary prevention of leprosy+ a. 0utrition b. .itamins c. 9C: vaccination d. ('T vaccination 11. 8 bacteria which causes diphtheria is also "nown as+ a. 8moeba b. Cholera c. Blebs>loeffler bacillus d. !pirochete 1&. 0urse 2on performed mantoux s"in test today EMondayF to a male adult client. #hich statement by the client indicates that he understood the instruction well+ a. , will come bac" later b. , will come bac" next month c. , will come bac" on %riday d. , will come bac" on #ednesday@ same time@ to read the result 1*. 8 male client had undergone Mantoux s"in test. 0urse 2onald notes an 8mm area of indurations at the site of the s"in test. The nurse interprets the result as a. 0egative b. 7ncertain and needs to be repeated c. 'ositive d. ,nconclusive 1/. Tony will start a 4 month therapy with ,sonia$id E,0)F. 0urse Trish plans to teach the client to a. 7se alcohol moderately b. 8void vitamin supplements while o therapy

c. ,ncomplete inta"e of dairy products d. May be discontinued if symptoms subsides 13. #hich is the primary characteristic lesion of syphilis+ a. !ore eyes b. !ore throat c. Chancroid d. Chancre 14. #hat is the fast breathing of Dana who is * wee"s old+ a. 4? breaths per minute b. /? breaths per minute c. 1? breaths per minute d. &? breaths per minute 17. #hich of the following signs and symptoms indicate some dehydration+ a. (rin"s eagerly b. 2estless and irritable c. 7nconscious d. 8 and 9 18. #hat is the first line for dysentery+ a. 8moxicillin b. Tetracycline c. Cefalexin d. Cotrimoxa$ole 1=. ,n home made oresol@ what is the ratio of salt and sugar if you want to prepare with 1 liter of water+ a. 1 tbsp. salt and 8 tbsp. sugar b. 1 tbsp. salt and 8 tsp. sugar c. 1 tsp. salt and 8 tsp. sugar d. 8 tsp. salt and 8 tsp. sugar &?. :entian .iolet is used for a. #ound b. 7mbilical infections c. -ar infections d. 9urn &1. #hich of the following is a live attenuated bacterial vaccine+ a. 9C: b. <'. c. Measles d. 0one of the above

&&. -', is based on+ a. 9asic health services b. !cope of community affected c. -pidemiological situation d. 2esearch studies &*. TT+ provides how many percentage of protection against tetanus+ a. 1?? b. == c. 8? d. =? &/. Temperature of refrigerator to maintain potency of measles and <'. vaccine is a. >*c to >8c b. >13c to >&3c c. M13c to M&3c d. M*c to M8c &3. (iptheria is a a. 9acterial toxin b. Billed bacteria c. 5ive attenuated d. 'lasma derivatives &4. 9udgeting is under in which part of management process+ a. (irecting b. Controlling c. <rgani$ing d. 'lanning &7. Time table showing planned wor" days and shifts of nursing personnel is a. !taffing b. !chedule c. !cheduling d. 'lanning &8. 8 force within an individual that influences the strength of behavior+ a. Motivation b. -nvy c. 2eward d. !elf>esteem

&=. GTo be the leading hospital in the 'hilippinesH is best illustrate in a. Mission b. 'hilosophy c. .ision d. <b6ective *?. ,t is the professionally desired norms against which a staff performance will be compared+ a. Dob descriptions b. !urvey c. %low chart d. !tandards *1. 2eprimanding a staff nurse for wor" that is done incorrectly is an example of what type of reinforcement+ a. %eedbac" b. 'ositive reinforcement c. 'erformance appraisal d. 0egative reinforcement *&. Cuestions that are answerable only by choosing an option from a set of given alternatives are "nown as+ a. !urvey b. Close ended c. Cuestionnaire d. (emographic **. 8 researcher that ma"es a generali$ation based on observations of an individuals behavior is said to be which type of reasoning a. ,nductive b. 5ogical c. ,llogical d. (eductive */. The balance of a researchs benefit vs. its ris"s to the sub6ect is a. 8nalysis b. 2is">benefit ratio c. 'ercentile d. Maximum ris" *3. 8n individualJob6ect that belongs to a general population is aJan

a. -lement b. !ub6ect c. 2espondent d. 8uthor *4. 8n illustration that shows how the members of an organi$ation are connected a. %lowchart b. 9ar graph c. <rgani$ational chart d. 5ine graph *7. The first college of nursing that was established in the 'hilippines is a. %atima 7niversity b. %ar -astern 7niversity c. 7niversity of the -ast d. 7niversity of !to. Tomas *8. %lorence nightingale is born on a. %rance b. 9ritain c. 7.! d. ,taly *=. <b6ective data is also called a. Covert b. <vert c. ,nference d. -valuation /?. 8n example of sub6ective data is a. !i$e of wounds b. .! c. 5ethargy d. The statement of patient GMy hand is painfulH /1. #hat is the best position in palpating the breast+ a. Trendelenburg b. !ide lying c. !upine d. 5ithotomy /&. #hen is the best time in performing breast self examination+ a. 7 days after menstrual period

b. 7 days before menstrual period c. 3 days after menstrual period d. 3 days before menstrual period /*. #hich of the following should be given the highest priority before performing physical examination to a patient+ a. 'reparation of the room b. 'reparation of the patient c. 'reparation of the nurse d. 'reparation of environment //. ,t is a flip over card usually "ept in portable file at nursing station. a. 0ursing care plan b. Medicine and treatment record c. Bardex d. T'2 sheet /3. Dose has undergone thoracentesis. The nurse in charge is aware that the best position for Dose is a. !emi fowlers b. 5ow fowlers c. !ide lying@ unaffected side d. !ide lying@ affected side /4. The degree of patients abdominal distension may be determined by a. 8uscultation b. 'alpation c. ,nspection d. 'ercussion /7. 8 male client is addicted with hallucinogen. #hich physiologic effect should the nurse expect+ a. 9radyprea b. 9radycardia c. Constricted pupils d. (ilated pupils /8. Tristan a / year old boy has suffered from full thic"ness burns of the face@ chest and nec". #hat will be the priority nursing diagnosis+ a. ,neffective airway clearance related to edema b. ,mpaired mobility related to pain c. ,mpaired urinary elimination related to fluid loss d. 2is" for infection related to epidermal disruption

/=. ,n assessing a clients incision 1 day after the surgery@ 0urse 9etty expect to see which of the following as signs of a local inflammatory response+ a. :reenish discharge b. 9rown exudates at incision edges c. 'allor around sutures d. 2edness and warmth 3?. 0urse 2onald is aware that the amiotic fluid in the third trimester weighs approximately a. & "ilograms b. 1 "ilograms c. 1?? grams d. 1.3 "ilograms 31. 8fter delivery of a baby girl. 0urse :ina examines the umbilical cord and expects to find a cord to a. Two arteries and two veins b. <ne artery and one vein c. Two arteries and one vein d. <ne artery and two veins 3&. Myrna a pregnant client reports that her last menstrual cycle is Duly 11@ her expected date of birth is a. 0ovember / b. 0ovember 11 c. 8pril / d. 8pril 18 3*. #hich of the following is not a good source of iron+ a. 9utter b. 'echay c. :rains d. 9eef 3/. Maureen is admitted with a diagnosis of ectopic pregnancy. #hich of the following would you anticipate+ a. 0'< b. 9ed rest c. ,mmediate surgery

d. -nema 33. :ina a postpartum client is diagnosed with endometritis. #hich position would you expect to place her based on this diagnosis+ a. !upine b. 5eft side lying c. Trendelinburg d. !emi>fowlers 34. 0urse )a$el "nows that Myrna understands her condition well when she remar"s that urinary fre;uency is caused by a. 'ressure caused by the ascending uterus b. #ater inta"e of *5 a day c. -ffect of cold weather d. ,ncrease inta"e of fruits and vegetables 37. )ow many ml of blood is loss during the first &/ hours post delivery of Myrna+ a. 1?? b. 3?? c. &?? d. /?? 38. #hich of the following hormones stimulates the secretion of mil"+ a. 'rogesterone b. 'rolactin c. <xytocin d. -strogen 3=. 0urse Carla is aware that Mylas second stage of labor is beginning when the following assessment is noted a. 9ay of water is bro"en b. Contractions are regular c. Cervix is completely dilated d. 'resence of bloody show 4?. The lea"ing fluid is tested with nitra$ine paper. 0urse Belly confirms that the clients membrane have ruptures when the paper turns into a a. 'in" b. .iolet c. :reen

d. 9lue 41. 8fter amniotomy@ the priority nursing action is a. (ocument the color and consistency of amniotic fluid b. 5isten the fetal heart tone c. 'osition the mother in her left side d. 5et the mother rest 4&. #hich is the most fre;uent reason for postpartum hemorrhage+ a. 'erineal lacerations b. %re;uent internal examination E,-F c. C! d. 7terine atony 4*. <n &nd postpartum day@ which height would you expect to find the fundus in a woman who has had a caesarian birth+ a. 1 finger above umbilicus b. & fingers above umbilicus c. & fingers below umbilicus d. 1 finger below umbilicus 4/. #hich of the following criteria allows 0urse Bris to perform home deliveries+ a. 0ormal findings during assessment b. 'revious C! c. (iabetes history d. )ypertensive history 43. 0urse Carla is aware that one of the following vaccines is done by intramuscular E,MF in6ection+ a. Measles b. <'. c. 9C: d. Tetanus toxoid 44. 8sin law is on which legal basis a. 28 884? b. 28 &777 c. 2, 817& d. 22 441?

47. 0urse Dohn is aware that the herbal medicine appropriate for urolithiasis is a. 8"apulco b. !ambong c. Tsaang gubat d. 9ayabas 48. CommunityJ'ublic health bag is defined as a. 8n essential and indispensable e;uipment of the community health nurse during home visit b. ,t contains drugs and e;uipment used by the community health nurse c. ,s a re;uirement in the health center and for home visit d. ,t is a tool used by the community health nurse in rendering effective procedures during home visit 4=. TT/ provides how many percentage of protection against tetanus+ a. 7? b. 8? c. =? d. == 7?. Third postpartum visit must be done by public health nurse a. #ithin &/ hours after delivery b. 8fter &>/ wee"s c. #ithin 1 wee" d. 8fter & months 71. 0urse Candy is aware that the family planning method that may give =8I protection to another pregnancy to women a. 'ills b. Tubal ligation c. 5actational 8menorrhea method E58MF d. ,7( 7&. #hich of the following is not a part of ,MC, case management process a. Counsel the mother b. ,dentify the illness c. 8ssess the child d. Treat the child

7*. ,f a young child has pneumonia when should the mother bring him bac" for follow up+ a. 8fter & days b. ,n the afternoon c. 8fter / days d. 8fter 3 days 7/. ,t is the certification recognition program that develop and promotes standard for health facilities a. %ormula b. Tuto" gamutan c. !entrong program movement d. !entrong sigla movement 73. 9aby Marie was born May &*@ 1=8/. 0urse Dohn will expect finger thumb opposition on a. 8pril 1=83 b. %ebruary 1=83 c. March 1=83 d. Dune 1=83 74. 9aby 2eese is a 1& month old child. 0urse <liver would anticipate how many teeth+ a. = b. 7 c. 8 d. 4 77. #hich of the following is the primary antidote for Tylenol poisoning+ a. 0arcan b. (igoxin c. 8cetylcysteine d. %luma$enil 78. 8 male child has an intelligence ;uotient of approximately /?. #hich "ind of environment and interdisciplinary program most li"ely to benefit this child would be best described as a. )abit training b. !heltered wor"shop c. Custodial d. -ducational

7=. 0urse Dudy is aware that following condition would reflect presence of congenital :., anomaly+ a. Cord prolapse b. 'olyhydramios c. 'lacenta previa d. <ligohydramios 8?. 0urse Christine provides health teaching for the parents of a child diagnosed with celiac disease. 0urse Christine teaches the parents to include which of the following food items in the childs diet a. 2ye toast b. <atmeal c. #hite bread d. 2ice 81. 0urse 2andy is planning to administer oral medication to a * year old child. 0urse 2andy is aware that the best way to proceed is by a. G#ould you li"e to drin" your medicine+H b. G,f you ta"e your medicine now@ ,ll give you lollipopH c. G!ee the other boy too" his medicine+ 0ow its your turn.H d. G)eres your medicine. #ould you li"e a mango or orange 6uice+H 8&. 8t what age a child can brush her teeth without help+ a. 4 years b. 7 years c. 3 years d. 8 years 8*. 2ibivarin E.ira$oleF is prescribed for a female hospitali$ed child with 2!.. 0urse Dudy prepare this medication via which route+ a. ,ntra venous b. <ral c. <xygen tent d. !ubcutaneous 8/. The present chairman of the 9oard of 0ursing in the 'hilippines is a. Maria Doanna Cervantes b. Carmencita 8ba;uin c. 5eonor 2osero d. 'rimitiva 'a;uic

83. The obligation to maintain efficient ethical standards in the practice of nursing belong to this body a. 9<0 b. 80!8' c. '08 d. 20 84. 8 male nurse was found guilty of negligence. )is license was revo"ed. 2e>issuance of revo"ed certificates is after how many years+ a. 1 year b. & years c. * years d. / years 87. #hich of the following information cannot be seen in the '2C identification card+ a. 2egistration (ate b. 5icense 0umber c. (ate of 8pplication d. !ignature of '2C chairperson 88. 9reastfeeding is being enforced by mil" code or a. -< 31 b. 2.8. 74?? c. 2.8. 47?? d. '.(. ==4 8=. !elf governance@ ability to choose or carry out decision without undue pressure or coercion from anyone a. .eracity b. 8utonomy c. %idelity d. 9eneficence =?. 8 male patient complained because his scheduled surgery was cancelled because of earth;ua"e. The hospital personnel may be excused because of a. :overnance b. 2espondent superior c. %orce ma6eure d. 2es ipsa lo;uitor

=1. 9eing on time@ meeting deadlines and completing all scheduled duties is what virtue+ a. %idelity b. 8utonomy c. .eracity d. Confidentiality =&. This ;uality is being demonstrated by 0urse 2on who raises the side rails of a confused and disoriented patient+ a. 2esponsibility b. 2esourcefulness c. 8utonomy d. 'rudence =*. #hich of the following is formal continuing education+ a. Conference b. -nrollment in graduate school c. 2efresher course d. !eminar =/. The 9!0 curriculum prepares the graduates to become+ a. 0urse generalist b. 0urse specialist c. 'rimary health nurse d. Clinical instructor =3. (isposal of medical records in government hospitalJinstitutions must be done in close coordination with what agency+ a. (epartment of )ealth b. 2ecords Management 8rchives <ffice c. Metro Manila (evelopment 8uthority d. 9ureau of ,nternal 2evenue =4. 0urse Dolina must see to it that the written consent of mentally ill patients must be ta"en from a. 0urse b. 'riest c. %amily lawyer d. 'arentsJlegal guardians =7. #hen 0urse Clarence respects the clients self>disclosure@ this is a gauge for the nurses

a. 2espectfulness b. 5oyalty c. Trustworthiness d. 'rofessionalism =8. The 0urse is aware that the following tas"s can be safely delegated by the nurse to a non>nurse health wor"er except a. Ta"ing vital signs b. Change ,. infusions c. Transferring the client from bed to chair d. ,rrigation of 0:T ==. (uring the evening round 0urse Tina saw Mr. Toralba meditating and afterwards started singing prayerful hymns. #hat would be the best response of 0urse Tina+ a. Call the attention of the client and encourage to sleep b. 2eport the incidence to head nurse c. 2espect the clients action d. (ocument the situation 1??. ,n caring for a dying client@ you should perform which of the following activities a. (o not resuscitate b. 8ssist client to perform 8(5 c. -ncourage to exercise d. 8ssist client towards a peaceful death 1?1. The 0urse is aware that the ability to enter into the life of another person and perceive his current feelings and their meaning is "nown a. 9elongingness b. :enuineness c. -mpathy d. 2espect 1?&. The termination phase of the 0'2 is best described one of the following a. 2eview progress of therapy and attainment of goals b. -xploring the clients thoughts@ feelings and concerns c. ,dentifying and solving patients problem d. -stablishing rapport 1?*. (uring the process of cocaine withdrawal@ the physician orders which of the following

a. )aloperidol E)aldolF b. ,mipramine ETofranilF c. 9en$tropine ECogentinF d. (ia$epam E.aliumF 1?/. The nurse is aware that cocaine is classified as a. )allucinogen b. 'sycho stimulant c. 8nxiolytic d. 0arcotic 1?3. ,n community health nursing@ it is the most important ris" factor in the development of mental illness+ a. !eparation of parents b. 'olitical problems c. 'overty d. !exual abuse 1?4. 8ll of the following are characteristics of crisis except a. The client may become resistive and active in stopping the crisis b. ,t is self>limiting for />4 wee"s c. ,t is uni;ue in every individual d. ,t may also affect the family of the client 1?7. %reud states that temper tantrums is observed in which of the following a. <ral b. 8nal c. 'hallic d. 5atency 1?8. The nurse is aware that ego development begins during a. Toddler period b. 'reschool age c. !chool age d. ,nfancy 1?=. !ituation 8 1= year old nursing student has lost *4 lbs for / wee"s. )er parents brought her to the hospital for medical evaluation. The diagnosis was 80<2-R,8 0-2.<!8. The 'rimary gain of a client with anorexia nervosa is a. #eight loss

b. #eight gain c. 2educe anxiety d. 8ttractive appearance 11?. The nurse is aware that the primary nursing diagnosis for the client is a. 8ltered nutrition less than body re;uirement b. 8ltered nutrition more than body re;uirement c. ,mpaired tissue integrity d. 2is" for malnutrition 111. 8fter 1/ days in the hospital@ which finding indicates that her condition in improving+ a. !he tells the nurse that she had no idea that she is thin b. !he arrives earlier than scheduled time of group therapy c. !he tells the nurse that she eat * times or more in a day d. !he gained / lbs in two wee"s 11&. The nurse is aware that ataractics or psychic energi$ers are also "nown as a. 8nti manic b. 8nti depressants c. 8ntipsychotics d. 8nti anxiety 11*. Bnown as mood elevators a. 8nti depressants b. 8ntipsychotics c. 8nti manic d. 8nti anxiety 11/. The priority of care for a client with 8l$heimers disease is a. )elp client develop coping mechanism b. -ncourage to learn new hobbies and interest c. 'rovide him stimulating environment d. !implify the environment to eliminate the need to ma"e chores 113. 8utism is diagnosed at a. ,nfancy b. * years old c. 3 years old d. !chool age

114. The common characteristic of autism child is a. ,mpulsitivity b. !elf destructiveness c. )ostility d. #ithdrawal 117. The nurse is aware that the most common indication in using -CT is a. !chi$ophrenia b. 9ipolar c. 8norexia 0ervosa d. (epression 118. 8 therapy that focuses on here and now principle to promote self>acceptance+ a. :estalt therapy b. Cognitive therapy c. 9ehavior therapy d. 'ersonality therapy 11=. 8 client has many irrational thoughts. The goal of therapy is to change her a. 'ersonality b. Communication c. 9ehavior d. Cognition 1&?. The appropriate nutrition for 9ipolar , disorder@ in manic phase is a. 5ow fat@ low sodium b. 5ow calorie@ high fat c. %inger foods@ high in calorie d. !mall fre;uent feedings 1&1. #hich of the following activity would be best for a depressed client+ a. Chess b. 9as"etball c. !wimming d. %inger painting 1&&. The nurse is aware that clients with severe depression@ possess which defense mechanism a. ,ntro6ection b. !uppression c. 2epression d. 'ro6ection

1&*. 0urse Dohn is aware that self mutilation among 9ipolar disorder patients is a means of a. <vercoming fear of failure b. <vercoming feeling of insecurity c. 2elieving depression d. 2elieving anxiety 1&/. #hich of the following may cause an increase in the cystitis symptoms+ a. #ater b. <range 6uice c. Coffee d. Mango 6uice 1&3. ,n caring for clients with renal calculi@ which is the priority nursing intervention+ a. 2ecord vital signs b. !train urine c. 5imit fluids d. 8dminister analgesics as prescribed 1&4. ,n patient with renal failure@ the diet should be a. 5ow protein@ low sodium@ low potassium b. 5ow protein@ high potassium c. )igh carbohydrate@ low protein d. )igh calcium@ high protein 1&7. #hich of the following cannot be corrected by dialysis+ a. )ypernatremia b. )yper"alemia c. -levated creatinine d. (ecreased hemoglobin 1&8. Tony with infection is receiving antibiotic therapy. 5ater the client complaints of ringing in the ears. This ototoxicity is damage to a. /th C0 b. 8th C0 c. 7th C0 d. =th C0 1&=. 0urse -mma provides teaching to a patient with recurrent urinary tract infection includes the following a. ,ncrease inta"e of tea@ coffee and colas b. .oid every 4 hours per day c. .oid immediately after intercourse d. Ta"e tub bath everyday

1*?. #hich assessment finding indicates circulatory constriction in a male client with a newly applied long leg cast+ a. 9lanching or cyanosis of legs b. Complaints of pressure or tightness c. ,nability to move toes d. 0umbness of toes 1*1. (uring acute gout attac"@ the nurse administer which of the following drug a. 'rednisone E(eltasoneF b. Colchicines c. 8spirin d. 8llopurinol EOyloprimF 1*&. ,nformation in the patients chart is inadmissible in court as evidence when a. The client ob6ects to its use b. )andwriting is not legible c. ,t has too many unofficial abbreviations d. The clients parents refuses to use it 1**. 0urse Baren is revising a client plan of care. (uring which step of the nursing process does such revision ta"e place+ a. 'lanning b. ,mplementation c. (iagnosing d. -valuation 1*/. #hen examining a client with abdominal pain@ 0urse )a$el should assess a. !ymptomatic ;uadrant either second or first b. The symptomatic ;uadrant last c. The symptomatic ;uadrant first d. 8ny ;uadrant 1*3. )ow long will nurse Dohn obtain an accurate reading of temperature via oral route+ a. * minutes b. 1 minute c. 8 minutes d. 13 minutes 1*4. The one filing the criminal care against an accused party is said to be the+ a. :uilty b. 8ccused c. 'laintiff d. #itness 1*7. 8 male client has a standing (02 order. )e then suddenly stopped breathing and you are at his bedside. Kou would a. Call the physician

b. !tay with the client and do nothing c. Call another nurse d. Call the family 1*8. The 808 recogni$ed nursing informatics heralding its establishment as a new field in nursing during what year+ a. 1==/ b. 1==& c. &??? d. &??1 1*=. #hen is the first certification of nursing informatics given+ a. 1==?>1==* b. &??1>&??& c. 1==/>1==4 d. &??3>&??8 1/?. The nurse is assessing a female client with possible diagnosis of osteoarthritis. The most significant ris" factor for osteoarthritis is a. <besity b. 2ace c. Dob d. 8ge 1/1. 8 male client complains of vertigo. 0urse 9ea anticipates that the client may have a problem with which portion of the ear+ a. Tymphanic membranes b. ,nner ear c. 8uricle d. -xternal ear 1/&. #hen performing #ebers test@ 0urse 2osean expects that this client will hear a. <n unaffected side b. 5onger through bone than air conduction c. <n affected side by bone conduction d. 9y neither bone or air conduction 1/*. Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic ma"e up. Myasthenia gravis can confirmed by a. Bernigs sign b. 9rud$ins"is sign c. 8 positive sweat chloride test d. 8 positive edrophonium ETensilonF test 1//. 8 male client is hospitali$ed with :uillain>9arre !yndrome. #hich assessment finding is the most significant+

a. -ven@ unlabored respirations b. !oft@ non distended abdomen c. 7rine output of 3? mlJhr d. #arm s"in 1/3. %or a female client with suspected intracranial pressure E,C'F@ a most appropriate respiratory goal is a. Maintain partial pressure of arterial oxygen E'a <&F above 8?mm)g b. 'romote elimination of carbon dioxide c. 5ower the ') d. 'revent respiratory al"alosis 1/4. #hich nursing assessment would identify the earliest sign of ,C'+ a. Change in level of consciousness b. Temperature of over 1?*A% c. #idening pulse pressure d. 7ne;ual pupils 1/7. The greatest danger of an uncorrected atrial fibrillation for a male patient will be which of the following a. 'ulmonary embolism b. Cardiac arrest c. Thrombus formation d. Myocardial infarction 1/8. 5inda@ 8 *? year old post hysterectomy client has visited the health center. !he in;uired about 9!- and as"ed the nurse when 9!- should be performed. Kou answered that the 9!- is best performed a. 7 days after menstruation b. 8t the same day each month c. (uring menstruation d. 9efore menstruation 1/=. 8n infant is ordered to recive 3?? ml of (30!! for &/ hours. The ,ntravenous drip is running at 4? gttsJmin. )ow many drops per minute should the flow rate be+ a. 4? gttsJmin. b. &1 gttsJmin c. *? gttsJmin d. 13 gttsJmin 13?. Mr. :utierre$ is to receive 1 liter of (325 to run for 1& hours. The drop factor

of the ,. infusion set is 1? drops per minute. 8pproximately how many drops per minutes should the ,. be regulated+ a. 1*>1/ drops b. 17>18 drops c. 1?>1& drops d. 13>14 drops

Maternal and Child %ealth Practice Test Part 1 1. #hen assessing the ade;uacy of sperm for conception to occur@ which of the following is the most useful criterion+ a. !perm count b. !perm motility c. !perm maturity d. !emen volume &. 8 couple who wants to conceive but has been unsuccessful during the last & years has undergone many diagnostic procedures. #hen discussing the situation with the nurse@ one partner states@ G#e "now several friends in our age group and all of them have their own child already@ #hy cant we have one+H. #hich of the following would be the most pertinent nursing diagnosis for this couple+ a. %ear related to the un"nown b. 'ain related to numerous procedures. c. ,neffective family coping related to infertility. d. !elf>esteem disturbance related to infertility. *. #hich of the following urinary symptoms does the pregnant woman most fre;uently experience during the first trimester+ a. (ysuria b. %re;uency c. ,ncontinence d. 9urning /. )eartburn and flatulence@ common in the second trimester@ are most li"ely the result of which of the following+ a. ,ncreased plasma )C: levels b. (ecreased intestinal motility c. (ecreased gastric acidity d. -levated estrogen levels 3. <n which of the following areas would the nurse expect to observe chloasma+ a. 9reast@ areola@ and nipples b. Chest@ nec"@ arms@ and legs c. 8bdomen@ breast@ and thighs

d. Chee"s@ forehead@ and nose 4. 8 pregnant client states that she GwaddlesH when she wal"s. The nurses explanation is based on which of the following as the cause+ a. The large si$e of the newborn b. 'ressure on the pelvic muscles c. 2elaxation of the pelvic 6oints d. -xcessive weight gain 7. #hich of the following represents the average amount of weight gained during pregnancy+ a. 1& to && lb b. 13 to &3 lb c. &/ to *? lb d. &3 to /? lb 8. #hen tal"ing with a pregnant client who is experiencing aching swollen@ leg veins@ the nurse would explain that this is most probably the result of which of the following+ a. Thrombophlebitis b. 'regnancy>induced hypertension c. 'ressure on blood vessels from the enlarging uterus d. The force of gravity pulling down on the uterus =. Cervical softening and uterine souffle are classified as which of the following+ a. (iagnostic signs b. 'resumptive signs c. 'robable signs d. 'ositive signs 1?. #hich of the following would the nurse identify as a presumptive sign of pregnancy+ a. )egar sign b. 0ausea and vomiting c. !"in pigmentation changes d. 'ositive serum pregnancy test 11. #hich of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester+ a. ,ntroversion@ egocentrism@ narcissism b. 8w"wardness@ clumsiness@ and unattractiveness c. 8nxiety@ passivity@ extroversion d. 8mbivalence@ fear@ fantasies 1&. (uring which of the following would the focus of classes be mainly on physiologic changes@ fetal development@ sexuality@ during pregnancy@ and nutrition+ a. 'repregnant period b. %irst trimester c. !econd trimester d. Third trimester 1*. #hich of the following would be disadvantage of breast feeding+ a. ,nvolution occurs more rapidly

b. The incidence of allergies increases due to maternal antibodies c. The father may resent the infants demands on the mothers body d. There is a greater chance for error during preparation 1/. #hich of the following would cause a false>positive result on a pregnancy test+ a. The test was performed less than 1? days after an abortion b. The test was performed too early or too late in the pregnancy c. The urine sample was stored too long at room temperature d. 8 spontaneous abortion or a missed abortion is impending 13. %)2 can be auscultated with a fetoscope as early as which of the following+ a. 3 wee"s gestation b. 1? wee"s gestation c. 13 wee"s gestation d. &? wee"s gestation 14. 8 client 5M' began Duly 3. )er -(( should be which of the following+ a. Danuary & b. March &8 c. 8pril 1& d. <ctober 1& 17. #hich of the following fundal heights indicates less than 1& wee"s gestation when the date of the 5M' is un"nown+ a. 7terus in the pelvis b. 7terus at the xiphoid c. 7terus in the abdomen d. 7terus at the umbilicus 18. #hich of the following danger signs should be reported promptly during the antepartum period+ a. Constipation b. 9reast tenderness c. 0asal stuffiness d. 5ea"ing amniotic fluid 1=. #hich of the following prenatal laboratory test values would the nurse consider as significant+ a. )ematocrit **.3I b. 2ubella titer less than 1 8 c. #hite blood cells 8@???Jmm* d. <ne hour glucose challenge test 11? gJd5 &?. #hich of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor+ a. <ccurring at irregular intervals b. !tarting mainly in the abdomen c. :radually increasing intervals d. ,ncreasing intensity with wal"ing &1. (uring which of the following stages of labor would the nurse assess GcrowningH+ a. %irst stage b. !econd stage c. Third stage

d. %ourth stage &&. 9arbiturates are usually not given for pain relief during active labor for which of the following reasons+ a. The neonatal effects include hypotonia@ hypothermia@ generali$ed drowsiness@ and reluctance to feed for the first few days. b. These drugs readily cross the placental barrier@ causing depressive effects in the newborn & to * hours after intramuscular in6ection. c. They rapidly transfer across the placenta@ and lac" of an antagonist ma"e them generally inappropriate during labor. d. 8dverse reactions may include maternal hypotension@ allergic or toxic reaction or partial or total respiratory failure &*. #hich of the following nursing interventions would the nurse perform during the third stage of labor+ a. <btain a urine specimen and other laboratory tests. b. 8ssess uterine contractions every *? minutes. c. Coach for effective client pushing d. 'romote parent>newborn interaction. &/. #hich of the following actions demonstrates the nurses understanding about the newborns thermoregulatory ability+ a. 'lacing the newborn under a radiant warmer. b. !uctioning with a bulb syringe c. <btaining an 8pgar score d. ,nspecting the newborns umbilical cord &3. ,mmediately before expulsion@ which of the following cardinal movements occur+ a. (escent b. %lexion c. -xtension d. -xternal rotation &4. 9efore birth@ which of the following structures connects the right and left auricles of the heart+ a. 7mbilical vein b. %oramen ovale c. (uctus arteriosus d. (uctus venosus &7. #hich of the following when present in the urine may cause a reddish stain on the diaper of a newborn+ a. Mucus b. 7ric acid crystals c. 9ilirubin d. -xcess iron &8. #hen assessing the newborns heart rate@ which of the following ranges would be considered normal if the newborn were sleeping+ a. 8? beats per minute b. 1?? beats per minute c. 1&? beats per minute d. 1/? beats per minute

&=. #hich of the following is true regarding the fontanels of the newborn+ a. The anterior is triangular shapedL the posterior is diamond shaped. b. The posterior closes at 18 monthsL the anterior closes at 8 to 1& wee"s. c. The anterior is large in si$e when compared to the posterior fontanel. d. The anterior is bulgingL the posterior appears sun"en. *?. #hich of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood+ a. 9lin"@ cough@ rooting@ and gag b. 9lin"@ cough@ snee$e@ gag c. 2ooting@ snee$e@ swallowing@ and cough d. !tepping@ blin"@ cough@ and snee$e *1. #hich of the following describes the 9abins"i reflex+ a. The newborns toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stro"ed upward from the ball of the heel and across the ball of the foot. b. The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise. c. The newborn turns the head in the direction of stimulus@ opens the mouth@ and begins to suc" when chee"@ lip@ or corner of mouth is touched. d. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface *&. #hich of the following statements best describes hyperemesis gravidarum+ a. !evere anemia leading to electrolyte@ metabolic@ and nutritional imbalances in the absence of other medical problems. b. !evere nausea and vomiting leading to electrolyte@ metabolic@ and nutritional imbalances in the absence of other medical problems. c. 5oss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients d. !evere nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding **. #hich of the following would the nurse identify as a classic sign of ',)+ a. -dema of the feet and an"les b. -dema of the hands and face c. #eight gain of 1 lbJwee" d. -arly morning headache */. ,n which of the following types of spontaneous abortions would the nurse assess dar" brown vaginal discharge and a negative pregnancy tests+ a. Threatened b. ,mminent c. Missed d. ,ncomplete *3. #hich of the following factors would the nurse suspect as predisposing a client to placenta previa+ a. Multiple gestation b. 7terine anomalies c. 8bdominal trauma

d. 2enal or vascular disease *4. #hich of the following would the nurse assess in a client experiencing abruptio placenta+ a. 9right red@ painless vaginal bleeding b. Concealed or external dar" red bleeding c. 'alpable fetal outline d. !oft and nontender abdomen *7. #hich of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy@ usually with severe hemorrhage+ a. 'lacenta previa b. -ctopic pregnancy c. ,ncompetent cervix d. 8bruptio placentae *8. #hich of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor+ a. #ea" contraction prolonged to more than 7? seconds b. Tetanic contractions prolonged to more than =? seconds c. ,ncreased pain with bright red vaginal bleeding d. ,ncreased restlessness and anxiety *=. #hen preparing a client for cesarean delivery@ which of the following "ey concepts should be considered when implementing nursing care+ a. ,nstruct the mothers support person to remain in the family lounge until after the delivery b. 8rrange for a staff member of the anesthesia department to explain what to expect postoperatively c. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth d. -xplain the surgery@ expected outcome@ and "ind of anesthetics /?. #hich of the following best describes preterm labor+ a. 5abor that begins after &? wee"s gestation and before *7 wee"s gestation b. 5abor that begins after 13 wee"s gestation and before *7 wee"s gestation c. 5abor that begins after &/ wee"s gestation and before &8 wee"s gestation d. 5abor that begins after &8 wee"s gestation and before /? wee"s gestation /1. #hen '2<M occurs@ which of the following provides evidence of the nurses understanding of the clients immediate needs+ a. The chorion and amnion rupture / hours before the onset of labor. b. '2<M removes the fetus most effective defense against infection c. 0ursing care is based on fetal viability and gestational age. d. '2<M is associated with malpresentation and possibly incompetent cervix /&. #hich of the following factors is the underlying cause of dystocia+ a. 0urtional b. Mechanical c. -nvironmental d. Medical /*. #hen uterine rupture occurs@ which of the following would be the priority+

a. 5imiting hypovolemic shoc" b. <btaining blood specimens c. ,nstituting complete bed rest d. ,nserting a urinary catheter //. #hich of the following is the nurses initial action when umbilical cord prolapse occurs+ a. 9egin monitoring maternal vital signs and %)2 b. 'lace the client in a "nee>chest position in bed c. 0otify the physician and prepare the client for delivery d. 8pply a sterile warm saline dressing to the exposed cord /3. #hich of the following amounts of blood loss following birth mar"s the criterion for describing postpartum hemorrhage+ a. More than &?? ml b. More than *?? ml c. More than /?? ml d. More than 3?? ml /4. #hich of the following is the primary predisposing factor related to mastitis+ a. -pidemic infection from nosocomial sources locali$ing in the lactiferous glands and ducts b. -ndemic infection occurring randomly and locali$ing in the periglandular connective tissue c. Temporary urinary retention due to decreased perception of the urge to avoid d. 9reast in6ury caused by overdistention@ stasis@ and crac"ing of the nipples /7. #hich of the following best describes thrombophlebitis+ a. ,nflammation and clot formation that result when blood components combine to form an aggregate body b. ,nflammation and blood clots that eventually become lodged within the pulmonary blood vessels c. ,nflammation and blood clots that eventually become lodged within the femoral vein d. ,nflammation of the vascular endothelium with clot formation on the vessel wall /8. #hich of the following assessment findings would the nurse expect if the client develops (.T+ a. Midcalf pain@ tenderness and redness along the vein b. Chills@ fever@ malaise@ occurring & wee"s after delivery c. Muscle pain the presence of )omans sign@ and swelling in the affected limb d. Chills@ fever@ stiffness@ and pain occurring 1? to 1/ days after delivery /=. #hich of the following are the most commonly assessed findings in cystitis+ a. %re;uency@ urgency@ dehydration@ nausea@ chills@ and flan" pain b. 0octuria@ fre;uency@ urgency dysuria@ hematuria@ fever and suprapubic pain c. (ehydration@ hypertension@ dysuria@ suprapubic pain@ chills@ and fever d. )igh fever@ chills@ flan" pain nausea@ vomiting@ dysuria@ and fre;uency

3?. #hich of the following best reflects the fre;uency of reported postpartum GbluesH+ a. 9etween 1?I and /?I of all new mothers report some form of postpartum blues b. 9etween *?I and 3?I of all new mothers report some form of postpartum blues c. 9etween 3?I and 8?I of all new mothers report some form of postpartum blues d. 9etween &3I and 7?I of all new mothers report some form of postpartum blues Ans!ers and "ationale Maternal and Child %ealth Practice Test Part 1 1. B# 8lthough all of the factors listed are important@ sperm motility is the most significant criterion when assessing male infertility. !perm count@ sperm maturity@ and semen volume are all significant@ but they are not as significant sperm motility. &. D. 9ased on the partners statement@ the couple is verbali$ing feelings of inade;uacy and negative feelings about themselves and their capabilities. Thus@ the nursing diagnosis of self>esteem disturbance is most appropriate. %ear@ pain@ and ineffective family coping also may be present but as secondary nursing diagnoses. *. B. 'ressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary fre;uency. (ysuria@ incontinence@ and burning are symptoms associated with urinary tract infections. /. C. (uring the second trimester@ the reduction in gastric acidity in con6unction with pressure from the growing uterus and smooth muscle relaxation@ can cause heartburn and flatulence. )C: levels increase in the first@ not the second@ trimester. (ecrease intestinal motility would most li"ely be the cause of constipation and bloating. -strogen levels decrease in the second trimester. 3. D. Chloasma@ also called the mas" of pregnancy@ is an irregular hyperpigmented area found on the face. ,t is not seen on the breasts@ areola@ nipples@ chest@ nec"@ arms@ legs@ abdomen@ or thighs. 4. C. (uring pregnancy@ hormonal changes cause relaxation of the pelvic 6oints@ resulting in the typical GwaddlingH gait. Changes in posture are related to the growing fetus. 'ressure on the surrounding muscles causing discomfort is due to the growing uterus. #eight gain has no effect on gait. 7. C. The average amount of weight gained during pregnancy is &/ to *? lb. This weight gain consists of the following fetus Q 7.3 lbL placenta and membrane Q 1.3 lbL amniotic fluid Q & lbL uterus Q &.3 lbL breasts Q * lbL and increased blood volume Q & to / lbL extravascular fluid and fat Q / to = lb. 8 gain of 1& to && lb is insufficient@ whereas a weight gain of 13 to &3 lb is marginal. 8 weight gain of &3 to /? lb is considered excessive. 8. C# 'ressure of the growing uterus on blood vessels results in an increased ris" for venous stasis in the lower extremities. !ubse;uently@ edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to

thrombus formation. 'regnancy>induced hypertension is not associated with these symptoms. :ravity plays only a minor role with these symptoms. =. C# Cervical softening E:oodell signF and uterine soufflS are two probable signs of pregnancy. 'robable signs are ob6ective findings that strongly suggest pregnancy. <ther probable signs include )egar sign@ which is softening of the lower uterine segmentL 'is"ace" sign@ which is enlargement and softening of the uterusL serum laboratory testsL changes in s"in pigmentationL and ultrasonic evidence of a gestational sac. 'resumptive signs are sub6ective signs and include amenorrheaL nausea and vomitingL urinary fre;uencyL breast tenderness and changesL excessive fatigueL uterine enlargementL and ;uic"ening. 1?. B# 'resumptive signs of pregnancy are sub6ective signs. <f the signs listed@ only nausea and vomiting are presumptive signs. )egar sign@ s"in pigmentation changes@ and a positive serum pregnancy test are considered probably signs@ which are strongly suggestive of pregnancy. 11. D# (uring the first trimester@ common emotional reactions include ambivalence@ fear@ fantasies@ or anxiety. The second trimester is a period of well>being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism@ passivity@ or introversion. 8t times the woman may seem egocentric and self>centered. (uring the third trimester@ the woman typically feels aw"ward@ clumsy@ and unattractive@ often becoming more introverted or reflective of her own childhood. 1&. B. %irst>trimester classes commonly focus on such issues as early physiologic changes@ fetal development@ sexuality during pregnancy@ and nutrition. !ome early classes may include pregnant couples. !econd and third trimester classes may focus on preparation for birth@ parenting@ and newborn care. 1*. C. #ith breast feeding@ the fathers body is not capable of providing the mil" for the newborn@ which may interfere with feeding the newborn@ providing fewer chances for bonding@ or he may be 6ealous of the infants demands on his wifes time and body. 9reast feeding is advantageous because uterine involution occurs more rapidly@ thus minimi$ing blood loss. The presence of maternal antibodies in breast mil" helps decrease the incidence of allergies in the newborn. 8 greater chance for error is associated with bottle feeding. 0o preparation is re;uired for breast feeding. 1/. A. 8 false>positive reaction can occur if the pregnancy test is performed less than 1? days after an abortion. 'erforming the tests too early or too late in the pregnancy@ storing the urine sample too long at room temperature@ or having a spontaneous or missed abortion impending can all produce false>negative results. 13. D. The %)2 can be auscultated with a fetoscope at about &? wee"s gestation. %)2 usually is ausculatated at the midline suprapubic region with (oppler ultrasound transducer at 1? to 1& wee"s gestation. %)2@ cannot be heard any earlier than 1? wee"s gestation. 14. C# To determine the -(( when the date of the clients 5M' is "nown use 0agele rule. To the first day of the 5M'@ add 7 days@ subtract * months@ and add 1 year Eif applicableF to arrive at the -(( as follows 3 M 7 T 1& EDulyF minus * T / E8prilF. Therefore@ the clients -(( is 8pril 1&.

17. A# #hen the 5M' is un"nown@ the gestational age of the fetus is estimated by uterine si$e or position Efundal heightF. The presence of the uterus in the pelvis indicates less than 1& wee"s gestation. 8t approximately 1& to 1/ wee"s@ the fundus is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately &? wee"s gestation and reaches the xiphoid at term or /? wee"s. 18. D. (anger signs that re;uire prompt reporting lea"ing of amniotic fluid@ vaginal bleeding@ blurred vision@ rapid weight gain@ and elevated blood pressure. Constipation@ breast tenderness@ and nasal stuffiness are common discomforts associated with pregnancy. 1=. B. 8 rubella titer should be 1 8 or greater. Thurs@ a finding of a titer less than 1 8 is significant@ indicating that the client may not possess immunity to rubella. 8 hematocrit of **.3I a white blood cell count of 8@???Jmm*@ and a 1 hour glucose challenge test of 11? gJdl are with normal parameters. &?. D. #ith true labor@ contractions increase in intensity with wal"ing. ,n addition@ true labor contractions occur at regular intervals@ usually starting in the bac" and sweeping around to the abdomen. The interval of true labor contractions gradually shortens. &1. B. Crowing@ which occurs when the newborns head or presenting part appears at the vaginal opening@ occurs during the second stage of labor. (uring the first stage of labor@ cervical dilation and effacement occur. (uring the third stage of labor@ the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to / hours after birth@ during which time the mother and newborn recover from the physical process of birth and the mothers organs undergo the initial read6ustment to the nonpregnant state. &&. C. 9arbiturates are rapidly transferred across the placental barrier@ and lac" of an antagonist ma"es them generally inappropriate during active labor. 0eonatal side effects of barbiturates include central nervous system depression@ prolonged drowsiness@ delayed establishment of feeding Ee.g. due to poor suc"ing reflex or poor suc"ing pressureF. Tran;uili$ers are associated with neonatal effects such as hypotonia@ hypothermia@ generali$ed drowsiness@ and reluctance to feed for the first few days. 0arcotic analgesic readily cross the placental barrier@ causing depressive effects in the newborn & to * hours after intramuscular in6ection. 2egional anesthesia is associated with adverse reactions such as maternal hypotension@ allergic or toxic reaction@ or partial or total respiratory failure. &*. D. (uring the third stage of labor@ which begins with the delivery of the newborn@ the nurse would promote parent>newborn interaction by placing the newborn on the mothers abdomen and encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor. 8ssessing uterine contractions every *? minutes is performed during the latent phase of the first stage of labor. Coaching the client to push effectively is appropriate during the second stage of labor. &/. A# The newborns ability to regulate body temperature is poor. Therefore@ placing the newborn under a radiant warmer aids in maintaining his or her body temperature. !uctioning with a bulb syringe helps maintain a patent airway.

<btaining an 8pgar score measures the newborns immediate ad6ustment to extrauterine life. ,nspecting the umbilical cord aids in detecting cord anomalies. &3. D# ,mmediately before expulsion or birth of the rest of the body@ the cardinal movement of external rotation occurs. (escent flexion@ internal rotation@ extension@ and restitution Ein this orderF occur before external rotation. &4. B# The foramen ovale is an opening between the right and left auricles EatriaF that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. The umbilical vein@ ductus arteriosus@ and ductus venosus are obliterated at birth. &7. B# 7ric acid crystals in the urine may produce the reddish Gbric" dustH stain on the diaper. Mucus would not produce a stain. 9ilirubin and iron are from hepatic adaptation. &8. B. The normal heart rate for a newborn that is sleeping is approximately 1?? beats per minute. ,f the newborn was awa"e@ the normal heart rate would range from 1&? to 14? beats per minute. &=. C. The anterior fontanel is larger in si$e than the posterior fontanel. 8dditionally@ the anterior fontanel@ which is diamond shaped@ closes at 18 months@ whereas the posterior fontanel@ which is triangular shaped@ closes at 8 to 1& wee"s. 0either fontanel should appear bulging@ which may indicate increased intracranial pressure@ or sun"en@ which may indicate dehydration. *?. B. 9lin"@ cough@ snee$e@ swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. 2eflexes such as rooting and stepping subside within the first year. *1. A. #ith the babins"i reflex@ the newborns toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stro"ed upward form the heel and across the ball of the foot. #ith the startle reflex@ the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. #ith the rooting and suc"ing reflex@ the newborn turns his head in the direction of stimulus@ opens the mouth@ and begins to suc" when the chee"s@ lip@ or corner of mouth is touched. #ith the crawl reflex@ the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface. *&. B. The description of hyperemesis gravidarum includes severe nausea and vomiting@ leading to electrolyte@ metabolic@ and nutritional imbalances in the absence of other medical problems. )yperemesis is not a form of anemia. 5oss of appetite may occur secondary to the nausea and vomiting of hyperemesis@ which@ if it continues@ can deplete the nutrients transported to the fetus. (iarrhea does not occur with hyperemesis. **. B# -dema of the hands and face is a classic sign of ',). Many healthy pregnant woman experience foot and an"le edema. 8 weight gain of & lb or more per wee" indicates a problem. -arly morning headache is not a classic sign of ',). */. C# ,n a missed abortion@ there is early fetal intrauterine death@ and products of conception are not expelled. The cervix remains closedL there may be a dar" brown vaginal discharge@ negative pregnancy test@ and cessation of uterine growth and breast tenderness. 8 threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy@ with no cervical dilation. 8n incomplete

abortion presents with bleeding@ cramping@ and cervical dilation. 8n incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation. *3. A# Multiple gestation is one of the predisposing factors that may cause placenta previa. 7terine anomalies abdominal trauma@ and renal or vascular disease may predispose a client to abruptio placentae. *4. B# 8 client with abruptio placentae may exhibit concealed or dar" red bleeding@ possibly reporting sudden intense locali$ed uterine pain. The uterus is typically firm to boardli"e@ and the fetal presenting part may be engaged. 9right red@ painless vaginal bleeding@ a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa. *7. D# 8bruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy@ usually with severe hemorrhage. 'lacenta previa refers to implantation of the placenta in the lower uterine segment@ causing painless bleeding in the third trimester of pregnancy. -ctopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. ,ncompetent cervix is a conduction characteri$ed by painful dilation of the cervical os without uterine contractions. *8. B# )yperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than =?seconds@ which could lead to such complications as fetal distress@ abruptio placentae@ amniotic fluid embolism@ laceration of the cervix@ and uterine rupture. #ea" contractions would not occur. 'ain@ bright red vaginal bleeding@ and increased restlessness and anxiety are not associated with hyperstimulation. *=. C# 8 "ey point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth@ the depth and breadth of instruction will depend on circumstances and time available. 8llowing the mothers support person to remain with her as much as possible is an important concept@ although doing so depends on many variables. 8rranging for necessary explanations by various staff members to be involved with the clients care is a nursing responsibility. The nurse is responsible for reinforcing the explanations about the surgery@ expected outcome@ and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used. /?. A# 'reterm labor is best described as labor that begins after &? wee"s gestation and before *7 wee"s gestation. The other time periods are inaccurate. /1. B# '2<M can precipitate many potential and actual problemsL one of the most serious is the fetus loss of an effective defense against infection. This is the clients most immediate need at this time. Typically@ '2<M occurs about 1 hour@ not / hours@ before labor begins. %etal viability and gestational age are less immediate considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of '2<M. /&. B# (ystocia is difficult@ painful@ prolonged labor due to mechanical factors involving the fetus EpassengerF@ uterus EpowersF@ pelvis EpassageF@ or psyche.

0utritional@ environment@ and medical factors may contribute to the mechanical factors that cause dystocia. /*. A# #ith uterine rupture@ the client is at ris" for hypovolemic shoc". Therefore@ the priority is to prevent and limit hypovolemic shoc". ,mmediate steps should include giving oxygen@ replacing lost fluids@ providing drug therapy as needed@ evaluating fetal responses and preparing for surgery. <btaining blood specimens@ instituting complete bed rest@ and inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture. //. B# The immediate priority is to minimi$e pressure on the cord. Thus the nurses initial action involves placing the client on bed rest and then placing the client in a "nee>chest position or lowering the head of the bed@ and elevating the maternal hips on a pillow to minimi$e the pressure on the cord. Monitoring maternal vital signs and %)2@ notifying the physician and preparing the client for delivery@ and wrapping the cord with sterile saline soa"ed warm gau$e are important. 9ut these actions have no effect on minimi$ing the pressure on the cord. /3. D# 'ostpartum hemorrhage is defined as blood loss of more than 3?? ml following birth. 8ny amount less than this not considered postpartum hemorrhage. /4. D# #ith mastitis@ in6ury to the breast@ such as overdistention@ stasis@ and crac"ing of the nipples@ is the primary predisposing factor. -pidemic and endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection@ not mastitis. /7. D# Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. 9lood components combining to form an aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary embolismL in the femoral vein@ femoral thrombophlebitis. /8. C# Classic symptoms of (.T include muscle pain@ the presence of )omans sign@ and swelling of the affected limb. Midcalf pain@ tenderness@ and redness@ along the vein reflect superficial thrombophlebitis. Chills@ fever and malaise occurring & wee"s after delivery reflect pelvic thrombophlebitis. Chills@ fever@ stiffness and pain occurring 1? to 1/ days after delivery suggest femoral thrombophlebitis. /=. B# Manifestations of cystitis include@ fre;uency@ urgency@ dysuria@ hematuria nocturia@ fever@ and suprapubic pain. (ehydration@ hypertension@ and chills are not typically associated with cystitis. )igh fever chills@ flan" pain@ nausea@ vomiting@ dysuria@ and fre;uency are associated with pvelonephritis. 3?. C# 8ccording to statistical reports@ between 3?I and 8?I of all new mothers report some form of postpartum blues. The ranges of 1?I to /?I@ *?I to 3?I@ and &3I to 7?I are incorrect.

Maternal and Child %ealth Practice Test Part 1. %or the client who is using oral contraceptives@ the nurse informs the client about the need to ta"e the pill at the same time each day to accomplish which of the following+ a. (ecrease the incidence of nausea b. Maintain hormonal levels c. 2educe side effects d. 'revent drug interactions &. #hen teaching a client about contraception. #hich of the following would the nurse include as the most effective method for preventing sexually transmitted infections+ a. !permicides b. (iaphragm c. Condoms d. .asectomy *. #hen preparing a woman who is & days postpartum for discharge@ recommendations for which of the following contraceptive methods would be avoided+ a. (iaphragm b. %emale condom c. <ral contraceptives d. 2hythm method /. %or which of the following clients would the nurse expect that an intrauterine device would not be recommended+ a. #oman over age *3 b. 0ulliparous woman c. 'romiscuous young adult d. 'ostpartum client 3. 8 client in her third trimester tells the nurse@ G,m constipated all the timePH #hich of the following should the nurse recommend+ a. (aily enemas b. 5axatives c. ,ncreased fiber inta"e d. (ecreased fluid inta"e 4. #hich of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy+ a. 1? pounds per trimester b. 1 pound per wee" for /? wee"s c. U pound per wee" for /? wee"s d. 8 total gain of &3 to *? pounds 7. The client tells the nurse that her last menstrual period started on Danuary 1/ and ended on Danuary &?. 7sing 0ageles rule@ the nurse determines her -(( to be which of the following+ a. !eptember &7

b. <ctober &1 c. 0ovember 7 d. (ecember &7 8. #hen ta"ing an obstetrical history on a pregnant client who states@ G, had a son born at *8 wee"s gestation@ a daughter born at *? wee"s gestation and , lost a baby at about 8 wee"s@H the nurse should record her obstetrical history as which of the following+ a. :& T& '? 8? 5& b. :* T1 '1 8? 5& c. :* T& '? 8? 5& d. :/ T1 '1 81 5& =. #hen preparing to listen to the fetal heart rate at 1& wee"s gestation@ the nurse would use which of the following+ a. !tethoscope placed midline at the umbilicus b. (oppler placed midline at the suprapubic region c. %etoscope placed midway between the umbilicus and the xiphoid process d. -xternal electronic fetal monitor placed at the umbilicus 1?. #hen developing a plan of care for a client newly diagnosed with gestational diabetes@ which of the following instructions would be the priority+ a. (ietary inta"e b. Medication c. -xercise d. :lucose monitoring 11. 8 client at &/ wee"s gestation has gained 4 pounds in / wee"s. #hich of the following would be the priority when assessing the client+ a. :lucosuria b. (epression c. )andJface edema d. (ietary inta"e 1&. 8 client 1& wee"s pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. !peculum examination reveals & to * cms cervical dilation. The nurse would document these findings as which of the following+ a. Threatened abortion b. ,mminent abortion c. Complete abortion d. Missed abortion 1*. #hich of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy+ a. 2is" for infection b. 'ain c. Bnowledge (eficit d. 8nticipatory :rieving 1/. 9efore assessing the postpartum clients uterus for firmness and position in relation to the umbilicus and midline@ which of the following should the nurse do first+

a. 8ssess the vital signs b. 8dminister analgesia c. 8mbulate her in the hall d. 8ssist her to urinate 13. #hich of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples+ a. Tell her to breast feed more fre;uently b. 8dminister a narcotic before breast feeding c. -ncourage her to wear a nursing brassiere d. 7se soap and water to clean the nipples 14. The nurse assesses the vital signs of a client@ / hours postpartum that are as follows 9' =?J4?L temperature 1??./V%L pulse 1?? wea"@ threadyL 2 &? per minute. #hich of the following should the nurse do first+ a. 2eport the temperature to the physician b. 2echec" the blood pressure with another cuff c. 8ssess the uterus for firmness and position d. (etermine the amount of lochia 17. The nurse assesses the postpartum vaginal discharge ElochiaF on four clients. #hich of the following assessments would warrant notification of the physician+ a. 8 dar" red discharge on a &>day postpartum client b. 8 pin" to brownish discharge on a client who is 3 days postpartum c. 8lmost colorless to creamy discharge on a client & wee"s after delivery d. 8 bright red discharge 3 days after delivery 18. 8 postpartum client has a temperature of 1?1./V%@ with a uterus that is tender when palpated@ remains unusually large@ and not descending as normally expected. #hich of the following should the nurse assess next+ a. 5ochia b. 9reasts c. ,ncision d. 7rine 1=. #hich of the following is the priority focus of nursing practice with the current early postpartum discharge+ a. 'romoting comfort and restoration of health b. -xploring the emotional status of the family c. %acilitating safe and effective self>and newborn care d. Teaching about the importance of family planning &?. #hich of the following actions would be least effective in maintaining a neutral thermal environment for the newborn+ a. 'lacing infant under radiant warmer after bathing b. Covering the scale with a warmed blan"et prior to weighing c. 'lacing crib close to nursery window for family viewing d. Covering the infants head with a "nit stoc"inette &1. 8 newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following+ a. Talipes e;uinovarus b. %ractured clavicle

c. Congenital hypothyroidism d. ,ncreased intracranial pressure &&. (uring the first / hours after a male circumcision@ assessing for which of the following is the priority+ a. ,nfection b. )emorrhage c. (iscomfort d. (ehydration &*. The mother as"s the nurse. G#hats wrong with my sons breasts+ #hy are they so enlarged+H #hish of the following would be the best response by the nurse+ a. GThe breast tissue is inflamed from the trauma experienced with birthH b. G8 decrease in material hormones present before birth causes enlargement@H c. GKou should discuss this with your doctor. ,t could be a malignancyH d. GThe tissue has hypertrophied while the baby was in the uterusH &/. ,mmediately after birth the nurse notes the following on a male newborn respirations 78L apical hearth rate 14? 9'M@ nostril flaringL mild intercostal retractionsL and grunting at the end of expiration. #hich of the following should the nurse do+ a. Call the assessment data to the physicians attention b. !tart oxygen per nasal cannula at & 5Jmin. c. !uction the infants mouth and nares d. 2ecogni$e this as normal first period of reactivity &3. The nurse hears a mother telling a friend on the telephone about umbilical cord care. #hich of the following statements by the mother indicates effective teaching+ a. G(aily soap and water cleansing is bestH b. W8lcohol helps it dry and "ills germsH c. G8n antibiotic ointment applied daily prevents infectionH d. G)e can have a tub bath each dayH &4. 8 newborn weighing *??? grams and feeding every / hours needs 1&? caloriesJ"g of body weight every &/ hours for proper growth and development. )ow many ounces of &? calJo$ formula should this newborn receive at each feeding to meet nutritional needs+ a. & ounces b. * ounces c. / ounces d. 4 ounces &7. The postterm neonate with meconium>stained amniotic fluid needs care designed to especially monitor for which of the following+ a. 2espiratory problems b. :astrointestinal problems c. ,ntegumentary problems d. -limination problems &8. #hen measuring a clients fundal height@ which of the following techni;ues denotes the correct method of measurement used by the nurse+

a. %rom the xiphoid process to the umbilicus b. %rom the symphysis pubis to the xiphoid process c. %rom the symphysis pubis to the fundus d. %rom the fundus to the umbilicus &=. 8 client with severe preeclampsia is admitted with of 9' 14?J11?@ proteinuria@ and severe pitting edema. #hich of the following would be most important to include in the clients plan of care+ a. (aily weights b. !ei$ure precautions c. 2ight lateral positioning d. !tress reduction *?. 8 postpartum primipara as"s the nurse@ G#hen can we have sexual intercourse again+H #hich of the following would be the nurses best response+ a. G8nytime you both want to.H b. G8s soon as choose a contraceptive method.H c. G#hen the discharge has stopped and the incision is healed.H d. G8fter your 4 wee"s examination.H *1. #hen preparing to administer the vitamin B in6ection to a neonate@ the nurse would select which of the following sites as appropriate for the in6ection+ a. (eltoid muscle b. 8nterior femoris muscle c. .astus lateralis muscle d. :luteus maximus muscle *&. #hen performing a pelvic examination@ the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following+ a. Clitoris b. 'arotid gland c. !"enes gland d. 9artholins gland **. To differentiate as a female@ the hormonal stimulation of the embryo that must occur involves which of the following+ a. ,ncrease in maternal estrogen secretion b. (ecrease in maternal androgen secretion c. !ecretion of androgen by the fetal gonad d. !ecretion of estrogen by the fetal gonad */. 8 client at 8 wee"s gestation calls complaining of slight nausea in the morning hours. #hich of the following client interventions should the nurse ;uestion+ a. Ta"ing 1 teaspoon of bicarbonate of soda in an 8>ounce glass of water b. -ating a few low>sodium crac"ers before getting out of bed c. 8voiding the inta"e of li;uids in the morning hours d. -ating six small meals a day instead of thee large meals *3. The nurse documents positive ballottement in the clients prenatal record. The nurse understands that this indicates which of the following+ a. 'alpable contractions on the abdomen b. 'assive movement of the unengaged fetus

c. %etal "ic"ing felt by the client d. -nlargement and softening of the uterus *4. (uring a pelvic exam the nurse notes a purple>blue tinge of the cervix. The nurse documents this as which of the following+ a. 9raxton>)ic"s sign b. Chadwic"s sign c. :oodells sign d. Mc(onalds sign *7. (uring a prenatal class@ the nurse explains the rationale for breathing techni;ues during preparation for labor based on the understanding that breathing techni;ues are most important in achieving which of the following+ a. -liminate pain and give the expectant parents something to do b. 2educe the ris" of fetal distress by increasing uteroplacental perfusion c. %acilitate relaxation@ possibly reducing the perception of pain d. -liminate pain so that less analgesia and anesthesia are needed *8. 8fter / hours of active labor@ the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. #hich of the following would the nurse anticipate doing+ a. <btaining an order to begin ,. oxytocin infusion b. 8dministering a light sedative to allow the patient to rest for several hour c. 'reparing for a cesarean section for failure to progress d. ,ncreasing the encouragement to the patient when pushing begins *=. 8 multigravida at *8 wee"s gestation is admitted with painless@ bright red bleeding and mild contractions every 7 to 1? minutes. #hich of the following assessments should be avoided+ a. Maternal vital sign b. %etal heart rate c. Contraction monitoring d. Cervical dilation /?. #hich of the following would be the nurses most appropriate response to a client who as"s why she must have a cesarean delivery if she has a complete placenta previa+ a. GKou will have to as" your physician when he returns.H b. GKou need a cesarean to prevent hemorrhage.H c. GThe placenta is covering most of your cervix.H d. GThe placenta is covering the opening of the uterus and bloc"ing your baby.H /1. The nurse understands that the fetal head is in which of the following positions with a face presentation+ a. Completely flexed b. Completely extended c. 'artially extended d. 'artially flexed /&. #ith a fetus in the left>anterior breech presentation@ the nurse would expect the fetal heart rate would be most audible in which of the following areas+ a. 8bove the maternal umbilicus and to the right of midline

b. ,n the lower>left maternal abdominal ;uadrant c. ,n the lower>right maternal abdominal ;uadrant d. 8bove the maternal umbilicus and to the left of midline /*. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following+ a. 5anugo b. )ydramnio c. Meconium d. .ernix //. 8 patient is in labor and has 6ust been told she has a breech presentation. The nurse should be particularly alert for which of the following+ a. Cuic"ening b. <phthalmia neonatorum c. 'ica d. 'rolapsed umbilical cord /3. #hen describing di$ygotic twins to a couple@ on which of the following would the nurse base the explanation+ a. Two ova fertili$ed by separate sperm b. !haring of a common placenta c. -ach ova with the same genotype d. !haring of a common chorion /4. #hich of the following refers to the single cell that reproduces itself after conception+ a. Chromosome b. 9lastocyst c. Oygote d. Trophoblast /7. ,n the late 1=3?s@ consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. #hich of the following was an outgrowth of this concept+ a. 5abor@ delivery@ recovery@ postpartum E5(2'F b. 0urse>midwifery c. Clinical nurse specialist d. 'repared childbirth /8. 8 client has a midpelvic contracture from a previous pelvic in6ury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth+ a. !ymphysis pubis b. !acral promontory c. ,schial spines d. 'ubic arch /=. #hen teaching a group of adolescents about variations in the length of the menstrual cycle@ the nurse understands that the underlying mechanism is due to variations in which of the following phases+ a. Menstrual phase b. 'roliferative phase

c. !ecretory phase d. ,schemic phase 3?. #hen teaching a group of adolescents about male hormone production@ which of the following would the nurse include as being produced by the 5eydig cells+ a. %ollicle>stimulating hormone b. Testosterone c. 5euteini$ing hormone d. :onadotropin releasing hormone

Ans!ers and "ationale Maternal and Child %ealth Practice Test Part &. C. Condoms@ when used correctly and consistently@ are the most effective contraceptive method or barrier against bacterial and viral sexually transmitted infections. 8lthough spermicides "ill sperm@ they do not provide reliable protection against the spread of sexually transmitted infections@ especially intracellular organisms such as ),.. ,nsertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations@ which could place the client at ris" for infection transmission. Male sterili$ation eliminates spermato$oa from the e6aculate@ but it does not eliminate bacterial andJor viral microorganisms that can cause sexually transmitted infections. *. A. The diaphragm must be fitted individually to ensure effectiveness. 9ecause of the changes to the reproductive structures during pregnancy and following delivery@ the diaphragm must be refitted@ usually at the 4 wee"s examination following childbirth or after a weight loss of 13 lbs or more. ,n addition@ for maximum effectiveness@ spermicidal 6elly should be placed in the dome and around the rim. )owever@ spermicidal 6elly should not be inserted into the vagina until involution is completed at approximately 4 wee"s. 7se of a female condom protects the reproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth. <ral contraceptives may be started within the first postpartum wee" to ensure suppression of ovulation. %or the couple who has determined the females fertile period@ using the rhythm method@ avoidance of intercourse during this period@ is safe and effective. /. C. 8n ,7( may increase the ris" of pelvic inflammatory disease@ especially in women with more than one sexual partner@ because of the increased ris" of sexually transmitted infections. 8n 7,( should not be used if the woman has an active or chronic pelvic infection@ postpartum infection@ endometrial hyperplasia or carcinoma@ or uterine abnormalities. 8ge is not a factor in determining the ris"s associated with ,7( use. Most ,7( users are over the age of *?. 8lthough there is a slightly higher ris" for infertility in women who have never been pregnant@ the ,7( is an acceptable option as long as the ris">benefit ratio is discussed. ,7(s may be inserted immediately after delivery@ but this is not recommended because of the increased ris" and rate of expulsion at this time. 3. C. (uring the third trimester@ the enlarging uterus places pressure on the intestines. This coupled with the effect of hormones on smooth muscle relaxation

causes decreased intestinal motility EperistalsisF. ,ncreasing fiber in the diet will help fecal matter pass more ;uic"ly through the intestinal tract@ thus decreasing the amount of water that is absorbed. 8s a result@ stool is softer and easier to pass. -nemas could precipitate preterm labor andJor electrolyte loss and should be avoided. 5axatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. 7se for more than 1 wee" can also lead to laxative dependency. 5i;uid in the diet helps provide a semisolid@ soft consistency to the stool. -ight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation. 4. D. To ensure ade;uate fetal growth and development during the /? wee"s of a pregnancy@ a total weight gain &3 to *? pounds is recommended 1.3 pounds in the first 1? wee"sL = pounds by *? wee"sL and &7.3 pounds by /? wee"s. The pregnant woman should gain less weight in the first and second trimester than in the third. (uring the first trimester@ the client should only gain 1.3 pounds in the first 1? wee"s@ not 1 pound per wee". 8 weight gain of U pound per wee" would be &? pounds for the total pregnancy@ less than the recommended amount. 7. B. To calculate the -(( by 0ageles rule@ add 7 days to the first day of the last menstrual period and count bac" * months@ changing the year appropriately. To obtain a date of !eptember &7@ 7 days have been added to the last day of the 5M' Erather than the first day of the 5M'F@ plus / months Einstead of * monthsF were counted bac". To obtain the date of 0ovember 7@ 7 days have been subtracted Einstead of addedF from the first day of 5M' plus 0ovember indicates counting bac" & months Einstead of * monthsF from Danuary. To obtain the date of (ecember &7@ 7 days were added to the last day of the 5M' Erather than the first day of the 5M'F and (ecember indicates counting bac" only 1 month Einstead of * monthsF from Danuary. 8. D# The client has been pregnant four times@ including current pregnancy E:F. 9irth at *8 wee"s gestation is considered full term ETF@ while birth form &? wee"s to *8 wee"s is considered preterm E'F. 8 spontaneous abortion occurred at 8 wee"s E8F. !he has two living children E5F. =. B# 8t 1& wee"s gestation@ the uterus rises out of the pelvis and is palpable above the symphysis pubis. The (oppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. The fetal heart rate at this age is not audible with a stethoscope. The uterus at 1& wee"s is 6ust above the symphysis pubis in the abdominal cavity@ not midway between the umbilicus and the xiphoid process. 8t 1& wee"s the %)2 would be difficult to auscultate with a fetoscope. 8lthough the external electronic fetal monitor would pro6ect the %)2@ the uterus has not risen to the umbilicus at 1& wee"s. 1?. A# 8lthough all of the choices are important in the management of diabetes@ diet therapy is the mainstay of the treatment plan and should always be the priority. #omen diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels. -xercise@ is important for all pregnant women and especially for diabetic women@ because it burns up glucose@ thus decreasing blood sugar. )owever@ dietary inta"e@ not exercise@ is the priority. 8ll pregnant women with diabetes should have periodic monitoring of

serum glucose. )owever@ those with gestational diabetes generally do not need daily glucose monitoring. The standard of care recommends a fasting and &>hour postprandial blood sugar level every & wee"s. 11. C# 8fter &? wee"s gestation@ when there is a rapid weight gain@ preeclampsia should be suspected@ which may be caused by fluid retention manifested by edema@ especially of the hands and face. The three classic signs of preeclampsia are hypertension@ edema@ and proteinuria. 8lthough urine is chec"ed for glucose at each clinic visit@ this is not the priority. (epression may cause either anorexia or excessive food inta"e@ leading to excessive weight gain or loss. This is not@ however@ the priority consideration at this time. #eight gain thought to be caused by excessive food inta"e would re;uire a &/>hour diet recall. )owever@ excessive inta"e would not be the primary consideration for this client at this time. 1&. B# Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. Thus@ the nurse would document an imminent abortion. ,n a threatened abortion@ cramping and vaginal bleeding are present@ but there is no cervical dilation. The symptoms may subside or progress to abortion. ,n a complete abortion all the products of conception are expelled. 8 missed abortion is early fetal intrauterine death without expulsion of the products of conception. 1*. B# %or the client with an ectopic pregnancy@ lower abdominal pain@ usually unilateral@ is the primary symptom. Thus@ pain is the priority. 8lthough the potential for infection is always present@ the ris" is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. The client may have a limited "nowledge of the pathology and treatment of the condition and will most li"ely experience grieving@ but this is not the priority at this time. 1/. D# 9efore uterine assessment is performed@ it is essential that the woman empty her bladder. 8 full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. .ital sign assessment is not necessary unless an abnormality in uterine assessment is identified. 7terine assessment should not cause acute pain that re;uires administration of analgesia. 8mbulating the client is an essential component of postpartum care@ but is not necessary prior to assessment of the uterus. 13. A# %eeding more fre;uently@ about every & hours@ will decrease the infants frantic@ vigorous suc"ing from hunger and will decrease breast engorgement@ soften the breast@ and promote ease of correct latching>on for feeding. 0arcotics administered prior to breast feeding are passed through the breast mil" to the infant@ causing excessive sleepiness. 0ipple soreness is not severe enough to warrant narcotic analgesia. 8ll postpartum clients@ especially lactating mothers@ should wear a supportive brassiere with wide cotton straps. This does not@ however@ prevent or reduce nipple soreness. !oaps are drying to the s"in of the nipples and should not be used on the breasts of lactating mothers. (ry nipple s"in predisposes to crac"s and fissures@ which can become sore and painful. 14. D# 8 wea"@ thready pulse elevated to 1?? 9'M may indicate impending hemorrhagic shoc". 8n increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus@ the nurse should chec" the amount

of lochia present. Temperatures up to 1??./8% in the first &/ hours after birth are related to the dehydrating effects of labor and are considered normal. 8lthough rechec"ing the blood pressure may be a correct choice of action@ it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. 8ssessing the uterus for firmness and position in relation to the umbilicus and midline is important@ but the nurse should chec" the extent of vaginal bleeding first. Then it would be appropriate to chec" the uterus@ which may be a possible cause of the hemorrhage. 17. D# 8ny bright red vaginal discharge would be considered abnormal@ but especially 3 days after delivery@ when the lochia is typically pin" to brownish. 5ochia rubra@ a dar" red discharge@ is present for & to * days after delivery. 9right red vaginal bleeding at this time suggests late postpartum hemorrhage@ which occurs after the first &/ hours following delivery and is generally caused by retained placental fragments or bleeding disorders. 5ochia rubra is the normal dar" red discharge occurring in the first & to * days after delivery@ containing epithelial cells@ erythrocyes@ leu"ocytes and decidua. 5ochia serosa is a pin" to brownish serosanguineous discharge occurring from * to 1? days after delivery that contains decidua@ erythrocytes@ leu"ocytes@ cervical mucus@ and microorganisms. 5ochia alba is an almost colorless to yellowish discharge occurring from 1? days to * wee"s after delivery and containing leu"ocytes@ decidua@ epithelial cells@ fat@ cervical mucus@ cholesterol crystals@ and bacteria. 18. A# The data suggests an infection of the endometrial lining of the uterus. The lochia may be decreased or copious@ dar" brown in appearance@ and foul smelling@ providing further evidence of a possible infection. 8ll the clients data indicate a uterine problem@ not a breast problem. Typically@ transient fever@ usually 1?1V%@ may be present with breast engorgement. !ymptoms of mastitis include influen$a> li"e manifestations. 5ocali$ed infection of an episiotomy or C>section incision rarely causes systemic symptoms@ and uterine involution would not be affected. The client data do not include dysuria@ fre;uency@ or urgency@ symptoms of urinary tract infections@ which would necessitate assessing the clients urine. 1=. C# 9ecause of early postpartum discharge and limited time for teaching@ the nurses priority is to facilitate the safe and effective care of the client and newborn. 8lthough promoting comfort and restoration of health@ exploring the familys emotional status@ and teaching about family planning are important in postpartumJnewborn nursing care@ they are not the priority focus in the limited time presented by early post>partum discharge. &?. C# )eat loss by radiation occurs when the infants crib is placed too near cold walls or windows. Thus placing the newborns crib close to the viewing window would be least effective. 9ody heat is lost through evaporation during bathing. 'lacing the infant under the radiant warmer after bathing will assist the infant to be rewarmed. Covering the scale with a warmed blan"et prior to weighing prevents heat loss through conduction. 8 "nit cap prevents heat loss from the head a large head@ a large body surface area of the newborns body. &1. B# 8 fractured clavicle would prevent the normal Moro response of symmetrical se;uential extension and abduction of the arms followed by flexion and adduction. ,n talipes e;uinovarus EclubfootF the foot is turned medially@ and in

plantar flexion@ with the heel elevated. The feet are not involved with the Moro reflex. )ypothyroiddism has no effect on the primitive reflexes. 8bsence of the Moror reflex is the most significant single indicator of central nervous system status@ but it is not a sign of increased intracranial pressure. &&. B# )emorrhage is a potential ris" following any surgical procedure. 8lthough the infant has been given vitamin B to facilitate clotting@ the prophylactic dose is often not sufficient to prevent bleeding. 8lthough infection is a possibility@ signs will not appear within / hours after the surgical procedure. The primary discomfort of circumcision occurs during the surgical procedure@ not afterward. 8lthough feedings are withheld prior to the circumcision@ the chances of dehydration are minimal. &*. B# The presence of excessive estrogen and progesterone in the maternal>fetal blood followed by prompt withdrawal at birth precipitates breast engorgement@ which will spontaneously resolve in / to 3 days after birth. The trauma of the birth process does not cause inflammation of the newborns breast tissue. 0ewborns do not have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety. 9reast tissue does not hypertrophy in the fetus or newborns. &/. D# The first 13 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period. The infants assessment data reflect normal adaptation. Thus@ the physician does not need to be notified and oxygen is not needed. The data do not indicate the presence of cho"ing@ gagging or coughing@ which are signs of excessive secretions. !uctioning is not necessary. &3. B# 8pplication of 7?I isopropyl alcohol to the cord minimi$es microorganisms EgermicidalF and promotes drying. The cord should be "ept dry until it falls off and the stump has healed. 8ntibiotic ointment should only be used to treat an infection@ not as a prophylaxis. ,nfants should not be submerged in a tub of water until the cord falls off and the stump has completely healed. &4. B# To determine the amount of formula needed@ do the following mathematical calculation. * "g x 1&? calJ"g per day T *4? caloriesJday feeding ; / hours T 4 feedings per day T 4? calories per feeding 4? calories per feedingL 4? calories per feeding with formula &? calJo$ T * ounces per feeding. 9ased on the calculation. &@ / or 4 ounces are incorrect. &7. A# ,ntrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. 8t birth some of the meconium fluid may be aspirated@ causing mechanical obstruction or chemical pneumonitis. The infant is not at increased ris" for gastrointestinal problems. -ven though the s"in is stained with meconium@ it is noninfectious EsterileF and nonirritating. The postterm meconium>stained infant is not at additional ris" for bowel or urinary problems. &8. C# The nurse should use a nonelastic@ flexible@ paper measuring tape@ placing the $ero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. The xiphoid and umbilicus are not appropriate landmar"s to use when measuring the height of the fundus EMc(onalds measurementF.

&=. B# #omen hospitali$ed with severe preeclampsia need decreased C0! stimulation to prevent a sei$ure. !ei$ure precautions provide environmental safety should a sei$ure occur. 9ecause of edema@ daily weight is important but not the priority. 'reclampsia causes vasospasm and therefore can reduce utero>placental perfusion. The client should be placed on her left side to maximi$e blood flow@ reduce blood pressure@ and promote diuresis. ,nterventions to reduce stress and anxiety are very important to facilitate coping and a sense of control@ but sei$ure precautions are the priority. *?. C# Cessation of the lochial discharge signifies healing of the endometrium. 2is" of hemorrhage and infection are minimal * wee"s after a normal vaginal delivery. Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is re;uesting. Choice of a contraceptive method is important@ but not the specific criteria for safe resumption of sexual activity. Culturally@ the 4>wee"s examination has been used as the time frame for resuming sexual activity@ but it may be resumed earlier. *1. C. The middle third of the vastus lateralis is the preferred in6ection site for vitamin B administration because it is free of blood vessels and nerves and is large enough to absorb the medication. The deltoid muscle of a newborn is not large enough for a newborn ,M in6ection. ,n6ections into this muscle in a small child might cause damage to the radial nerve. The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest. 9ecause of the proximity of the sciatic nerve@ the gluteus maximus muscle should not be until the child has been wal"ing & years. *&. D. 9artholins glands are the glands on either side of the vaginal orifice. The clitoris is female erectile tissue found in the perineal area above the urethra. The parotid glands are open into the mouth. !"enes glands open into the posterior wall of the female urinary meatus. **. D. The fetal gonad must secrete estrogen for the embryo to differentiate as a female. 8n increase in maternal estrogen secretion does not effect differentiation of the embryo@ and maternal estrogen secretion occurs in every pregnancy. Maternal androgen secretion remains the same as before pregnancy and does not effect differentiation. !ecretion of androgen by the fetal gonad would produce a male fetus. */. A. 7sing bicarbonate would increase the amount of sodium ingested@ which can cause complications. -ating low>sodium crac"ers would be appropriate. !ince li;uids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate. -ating six small meals a day would "eep the stomach full@ which often decrease nausea. *3. B. 9allottement indicates passive movement of the unengaged fetus. 9allottement is not a contraction. %etal "ic"ing felt by the client represents ;uic"ening. -nlargement and softening of the uterus is "nown as 'is"ace"s sign. *4. B. Chadwic"s sign refers to the purple>blue tinge of the cervix. 9raxton )ic"s contractions are painless contractions beginning around the /th month. :oodells sign indicates softening of the cervix. %lexibility of the uterus against the cervix is "nown as Mc(onalds sign.

*7. C. 9reathing techni;ues can raise the pain threshold and reduce the perception of pain. They also promote relaxation. 9reathing techni;ues do not eliminate pain@ but they can reduce it. 'ositioning@ not breathing@ increases uteroplacental perfusion. *8. A. The clients labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin@ which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. 8dministering light sedative would be done for hypertonic uterine contractions. 'reparing for cesarean section is unnecessary at this time. <xytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. ,t is too early to anticipate client pushing with contractions. *=. D. The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. 8ssessing maternal vital signs can help determine maternal physiologic status. %etal heart rate is important to assess fetal well>being and should be done. Monitoring the contractions will help evaluate the progress of labor. /?. D. 8 complete placenta previa occurs when the placenta covers the opening of the uterus@ thus bloc"ing the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. Telling the client to as" the physician is a poor response and would increase the patients anxiety. 8lthough a cesarean would help to prevent hemorrhage@ the statement does not explain why the hemorrhage could occur. #ith a complete previa@ the placenta is covering all the cervix@ not 6ust most of it. /1. B. #ith a face presentation@ the head is completely extended. #ith a vertex presentation@ the head is completely or partially flexed. #ith a brow EforeheadF presentation@ the head would be partially extended. /&. D. #ith this presentation@ the fetal upper torso and bac" face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect. /*. C# The greenish tint is due to the presence of meconium. 5anugo is the soft@ downy hair on the shoulders and bac" of the fetus. )ydramnios represents excessive amniotic fluid. .ernix is the white@ cheesy substance covering the fetus. //. D# ,n a breech position@ because of the space between the presenting part and the cervix@ prolapse of the umbilical cord is common. Cuic"ening is the womans first perception of fetal movement. <phthalmia neonatorum usually results from maternal gonorrhea and is con6unctivitis. 'ica refers to the oral inta"e of nonfood substances. /3. A# (i$ygotic EfraternalF twins involve two ova fertili$ed by separate sperm. Mono$ygotic EidenticalF twins involve a common placenta@ same genotype@ and common chorion. /4. C# The $ygote is the single cell that reproduces itself after conception. The chromosome is the material that ma"es up the cell and is gained from each parent. 9lastocyst and trophoblast are later terms for the embryo after $ygote. /7. D# 'repared childbirth was the direct result of the 1=3?s challenging of the routine use of analgesic and anesthetics during childbirth. The 5(2' was a much

later concept and was not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth. 2oles for nurse midwives and clinical nurse specialists did not develop from this challenge. /8. C# The ischial spines are located in the mid>pelvic region and could be narrowed due to the previous pelvic in6ury. The symphysis pubis@ sacral promontory@ and pubic arch are not part of the mid>pelvis. /=. B# .ariations in the length of the menstrual cycle are due to variations in the proliferative phase. The menstrual@ secretory and ischemic phases do not contribute to this variation. 3?. B. Testosterone is produced by the 5eyding cells in the seminiferous tubules. %ollicle>stimulating hormone and leutein$ing hormone are released by the anterior pituitary gland. The hypothalamus is responsible for releasing gonadotropin> releasing hormone.

Maternal and Child %ealth Practice Test Part $ 1. #hile performing physical assessment of a 1& month>old@ the nurse notes that the infants anterior fontanelle is still slightly open. #hich of the following is the nurses most appropriate action+ a. 0otify the physician immediately because there is a problem. b. 'erform an intensive neurologic examination. c. 'erform an intensive developmental examination. d. (o nothing because this is a normal finding for the age. &. #hen teaching a mother about introducing solid foods to her child@ which of the following indicates the earliest age at which this should be done+ a. 1 month b. & months c. * months d. / months *. The infant of a substance>abusing mother is at ris" for developing a sense of which of the following+ a. Mistrust b. !hame c. :uilt d. ,nferiority /. #hich of the following toys should the nurse recommend for a 3>month>old+ a. 8 big red balloon b. 8 teddy bear with button eyes c. 8 push>pull wooden truc" d. 8 colorful busy box

3. The mother of a &>month>old is concerned that she may be spoiling her baby by pic"ing her up when she cries. #hich of the following would be the nurses best response+ a. G 5et her cry for a while before pic"ing her up@ so you dont spoil herH b. G9abies need to be held and cuddledL you wont spoil her this wayH c. GCrying at this age means the baby is hungryL give her a bottleH d. G,f you leave her alone she will learn how to cry herself to sleepH 4. #hen assessing an 18>month>old@ the nurse notes a characteristic protruding abdomen. #hich of the following would explain the rationale for this finding+ a. ,ncreased food inta"e owing to age b. 7nderdeveloped abdominal muscles c. 9owlegged posture d. 5inear growth curve 7. ,f parents "eep a toddler dependent in areas where he is capable of using s"ills@ the toddle will develop a sense of which of the following+ a. Mistrust b. !hame c. :uilt d. ,nferiority 8. #hich of the following is an appropriate toy for an 18>month>old+ a. Multiple>piece pu$$le b. Miniature cars c. %inger paints d. Comic boo" =. #hen teaching parents about the childs readiness for toilet training@ which of the following signs should the nurse instruct them to watch for in the toddler+ a. (emonstrates dryness for / hours b. (emonstrates ability to sit and wal" c. )as a new sibling for stimulation d. .erbali$es desire to go to the bathroom 1?. #hen teaching parents about typical toddler eating patterns@ which of the following should be included+ a. %ood G6agsH b. 'reference to eat alone c. Consistent table manners d. ,ncrease in appetite 11. #hich of the following suggestions should the nurse offer the parents of a />year> old boy who resists going to bed at night+ a. G8llow him to fall asleep in your room@ then move him to his own bed.H b. GTell him that you will loc" him in his room if he gets out of bed one more time.H c. G-ncourage active play at bedtime to tire him out so he will fall asleep faster.H d. G2ead him a story and allow him to play ;uietly in his bed until he falls asleep.H

1&. #hen providing therapeutic play@ which of the following toys would best promote imaginative play in a />year>old+ a. 5arge bloc"s b. (ress>up clothes c. #ooden pu$$le d. 9ig wheels 1*. #hich of the following activities@ when voiced by the parents following a teaching session about the characteristics of school>age cognitive development would indicate the need for additional teaching+ a. Collecting baseball cards and marbles b. <rdering dolls according to si$e c. Considering simple problem>solving options d. (eveloping plans for the future 1/. 8 hospitali$ed schoolager states G,m not afraid of this place@ ,m not afraid of anything.H This statement is most li"ely an example of which of the following+ a. 2egression b. 2epression c. 2eaction formation d. 2ationali$ation 13. 8fter teaching a group of parents about accident prevention for schoolagers@ which of the following statements by the group would indicate the need for more teaching+ a. G!choolagers are more active and adventurous than are younger children.H b. G!choolagers are more susceptible to home ha$ards than are younger children.H c. G!choolagers are unable to understand potential dangers around them.H d. G!choolargers are less sub6ect to parental control than are younger children.H 14. #hich of the following s"ills is the most significant one learned during the schoolage period+ a. Collecting b. <rdering c. 2eading d. !orting 17. 8 child age 7 was unable to receive the measles@ mumps@ and rubella EMM2F vaccine at the recommended scheduled time. #hen would the nurse expect to administer MM2 vaccine+ a. ,n a month from now b. ,n a year from now c. 8t age 1? d. 8t age 1* 18. The adolescents inability to develop a sense of who he is and what he can become results in a sense of which of the following+ a. !hame b. :uilt c. ,nferiority

d. 2ole diffusion 1=. #hich of the following would be most appropriate for a nurse to use when describing menarche to a 1*>year>old+ a. 8 females first menstruation or menstrual GperiodsH b. The first year of menstruation or GperiodH c. The entire menstrual cycle or from one GperiodH to another d. The onset of uterine maturation or pea" growth &?. 8 1/>year>old boy has acne and according to his parents@ dominates the bathroom by using the mirror all the time. #hich of the following remar"s by the nurse would be least helpful in tal"ing to the boy and his parents+ a. GThis is probably the only concern he has about his body. !o dont worry about it or the time he spends on it.H b. GTeenagers are anxious about how their peers perceive them. !o they spend a lot of time grooming.H c. G8 teen may develop a poor self>image when experiencing acne. (o you feel this way sometimes+H d. GKou appear to be "eeping your face well washed. #ould you feel comfortable discussing your cleansing method+H &1. #hich of the following should the nurse suspect when noting that a *>year>old is engaging in explicit sexual behavior during doll play+ a. The child is exhibiting normal pre>school curiosity b. The child is acting out personal experiences c. The child does not "now how to play with dolls d. The child is probably developmentally delayed. &&. #hich of the following statements by the parents of a child with school phobia would indicate the need for further teaching+ a. G#ell "eep him at home until phobia subsides.H b. G#ell wor" with his teachers and counselors at school.H c. G#ell try to encourage him to tal" about his problem.H d. G#ell discuss possible solutions with him and his counselor.H &*. #hen developing a teaching plan for a group of high school students about teenage pregnancy@ the nurse would "eep in mind which of the following+ a. The incidence of teenage pregnancies is increasing. b. Most teenage pregnancies are planned. c. (enial of the pregnancy is common early on. d. The ris" for complications during pregnancy is rare. &/. #hen assessing a child with a cleft palate@ the nurse is aware that the child is at ris" for more fre;uent episodes of otitis media due to which of the following+ a. 5owered resistance from malnutrition b. ,neffective functioning of the -ustachian tubes c. 'lugging of the -ustachian tubes with food particles d. 8ssociated congenital defects of the middle ear. &3. #hile performing a neurodevelopmental assessment on a *>month>old infant@ which of the following characteristics would be expected+ a. 8 strong Moro reflex b. 8 strong parachute reflex

c. 2olling from front to bac" d. 5ifting of head and chest when prone &4. 9y the end of which of the following would the nurse most commonly expect a childs birth weight to triple+ a. / months b. 7 months c. = months d. 1& months &7. #hich of the following best describes parallel play between two toddlers+ a. !haring crayons to color separate pictures b. 'laying a board game with a nurse c. !itting near each other while playing with separate dolls d. !haring their dolls with two different nurses &8. #hich of the following would the nurse identify as the initial priority for a child with acute lymphocytic leu"emia+ a. ,nstituting infection control precautions b. -ncouraging ade;uate inta"e of iron>rich foods c. 8ssisting with coping with chronic illness d. 8dministering medications via ,M in6ections &=. #hich of the following information@ when voiced by the mother@ would indicate to the nurse that she understands home care instructions following the administration of a diphtheria@ tetanus@ and pertussis in6ection+ a. Measures to reduce fever b. 0eed for dietary restrictions c. 2easons for subse;uent rash d. Measures to control subse;uent diarrhea *?. #hich of the following actions by a community health nurse is most appropriate when noting multiple bruises and burns on the posterior trun" of an 18>month>old child during a home visit+ a. 2eport the childs condition to 'rotective !ervices immediately. b. !chedule a follow>up visit to chec" for more bruises. c. 0otify the childs physician immediately. d. (on nothing because this is a normal finding in a toddler. *1. #hich of the following is being used when the mother of a hospitali$ed child calls the student nurse and states@ GKou idiot@ you have no idea how to care for my sic" childH+ a. (isplacement b. 'ro6ection c. 2epression d. 'sychosis *&. #hich of the following should the nurse expect to note as a fre;uent complication for a child with congenital heart disease+ a. !usceptibility to respiratory infection b. 9leeding tendencies c. %re;uent vomiting and diarrhea d. !ei$ure disorder

**. #hich of the following would the nurse do first for a *>year>old boy who arrives in the emergency room with a temperature of 1?3 degrees@ inspiratory stridor@ and restlessness@ who is learning forward and drooling+ a. 8uscultate his lungs and place him in a mist tent. b. )ave him lie down and rest after encouraging fluids. c. -xamine his throat and perform a throat culture d. 0otify the physician immediately and prepare for intubation. */. #hich of the following would the nurse need to "eep in mind as a predisposing factor when formulating a teaching plan for child with a urinary tract infection+ a. 8 shorter urethra in females b. %re;uent emptying of the bladder c. ,ncreased fluid inta"e d. ,ngestion of acidic 6uices *3. #hich of the following should the nurse do first for a 13>year>old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome+ a. Medicate him with acetaminophen. b. 0otify the physician immediately c. 2elease the traction d. Monitor him every 3 minutes *4. 8t which of the following ages would the nurse expect to administer the varicella $oster vaccine to child+ a. 8t birth b. & months c. 4 months d. 1& months *7. #hen discussing normal infant growth and development with parents@ which of the following toys would the nurse suggest as most appropriate for an 8>month> old+ a. 'ush>pull toys b. 2attle c. 5arge bloc"s d. Mobile *8. #hich of the following aspects of psychosocial development is necessary for the nurse to "eep in mind when providing care for the preschool child+ a. The child can use complex reasoning to thin" out situations. b. %ear of body mutilation is a common preschool fear c. The child engages in competitive types of play d. ,mmediate gratification is necessary to develop initiative. *=. #hich of the following is characteristic of a preschooler with mid mental retardation+ a. !low to feed self b. 5ac" of speech c. Mar"ed motor delays d. :ait disability

/?. #hich of the following assessment findings would lead the nurse to suspect (own syndrome in an infant+ a. !mall tongue b. Transverse palmar crease c. 5arge nose d. 2estricted 6oint movement /1. #hile assessing a newborn with cleft lip@ the nurse would be alert that which of the following will most li"ely be compromised+ a. !uc"ing ability b. 2espiratory status c. 5ocomotion d. :, function /&. #hen providing postoperative care for the child with a cleft palate@ the nurse should position the child in which of the following positions+ a. !upine b. 'rone c. ,n an infant seat d. <n the side /*. #hile assessing a child with pyloric stenosis@ the nurse is li"ely to note which of the following+ a. 2egurgitation b. !teatorrhea c. 'ro6ectile vomiting d. GCurrant 6ellyH stools //. #hich of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux E:-2F+ a. %luid volume deficit b. 2is" for aspiration c. 8ltered nutrition less than body re;uirements d. 8ltered oral mucous membranes /3. #hich of the following parameters would the nurse monitor to evaluate the effectiveness of thic"ened feedings for an infant with gastroesophageal reflux E:-2F+ a. .omiting b. !tools c. 7terine d. #eight /4. (ischarge teaching for a child with celiac disease would include instructions about avoiding which of the following+ a. 2ice b. Mil" c. #heat d. Chic"en /7. #hich of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection+ a. 2espiratory distress

b. 5ethargy c. #atery diarrhea d. #eight gain /8. #hich of the following should the nurse do first after noting that a child with )irschsprung disease has a fever and watery explosive diarrhea+ a. 0otify the physician immediately b. 8dminister antidiarrheal medications c. Monitor child ever *? minutes d. 0othing@ this is characteristic of )irschsprung disease /=. 8 newborns failure to pass meconium within the first &/ hours after birth may indicate which of the following+ a. )irschsprung disease b. Celiac disease c. ,ntussusception d. 8bdominal wall defect 3?. #hen assessing a child for possible intussusception@ which of the following would be least li"ely to provide valuable information+ a. !tool inspection b. 'ain pattern c. %amily history d. 8bdominal palpation

Ans!ers and "ationale Maternal and Child %ealth Practice Test Part $

1. D# The anterior fontanelle typically closes anywhere between 1& to 18 months of age. Thus@ assessing the anterior fontanelle as still being slightly open is a normal finding re;uiring no further action. 9ecause it is normal finding for this age@ notifying he physician or performing additional examinations are inappropriate. &. D# !olid foods are not recommended before age / to 4 months because of the suc"ing reflex and the immaturity of the gastrointestinal tract and immune system. Therefore@ the earliest age at which to introduce foods is / months. 8ny time earlier would be inappropriate. *. A# 8ccording to -ri"son@ infants need to have their needs met consistently and effectively to develop a sense of trust. 8n infant whose needs are consistently unmet or who experiences significant delays in having them met@ such as in the case of the infant of a substance>abusing mother@ will develop a sense of uncertainty@ leading to mistrust of caregivers and the environment. Toddlers develop a sense of shame when their autonomy needs are not met consistently. 'reschoolers develop a sense of guilt when their sense of initiative is thwarted. !choolagers develop a sense of inferiority when they do not develop a sense of industry.

/. D# 8 busy box facilitates the fine motor development that occurs between / and 4 months. 9alloons are contraindicated because small children may aspirate balloons. 9ecause the button eyes of a teddy bear may detach and be aspirated@ this toy is unsafe for children younger than * years. 8 3>month>old is too young to use a push> pull toy. 3. B# ,nfants need to have their security needs met by being held and cuddled. 8t & months of age@ they are unable to ma"e the connection between crying and attention. This association does not occur until late infancy or early toddlerhood. 5etting the infant cry for a time before pic"ing up the infant or leaving the infant alone to cry herself to sleep interferes with meeting the infants need for security at this very young age. ,nfants cry for many reasons. 8ssuming that the child s hungry may cause overfeeding problems such as obesity. 4. B# 7nderdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. (uring toddlerhood@ food inta"e decreases@ not increases. Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trun". Toddler growth patterns occur in a stepli"e@ not linear pattern. 7. B# 8ccording to -ri"son@ toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. ,nfants develop mistrust when their needs are not consistently gratified. 'reschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met. 8. C# Koung toddlers are still sensorimotor learners and they en6oy the experience of feeling different textures. Thus@ finger paints would be an appropriate toy choice. Multiple>piece toys@ such as pu$$le@ are too difficult to manipulate and may be ha$ardous if the pieces are small enough to be aspirated. Miniature cars also have a high potential for aspiration. Comic boo"s are on too high a level for toddlers. 8lthough they may en6oy loo"ing at some of the pictures@ toddlers are more li"ely to rip a comic boo" apart. =. D# The child must be able to sate the need to go to the bathroom to initiate toilet training. 7sually@ a child needs to be dry for only & hours@ not / hours. The child also must be able to sit@ wal"@ and s;uat. 8 new sibling would most li"ely hinder toilet training. 1?. A# Toddlers become pic"y eaters@ experiencing food 6ags and eating large amounts one day and very little the next. 8 toddlers food gags express a preference for the ritualism of eating one type of food for several days at a time. Toddlers typically en6oy sociali$ation and limiting others at meal time. Toddlers prefer to feed themselves and thus are too young to have table manners. 8 toddlers appetite and need for calories@ protein@ and fluid decrease due to the dramatic slowing of growth rate.

11. D# 'reschoolers commonly have fears of the dar"@ being left alone especially at bedtime@ and ghosts@ which may affect the childs going to bed at night. Cuiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about loc"ing him in his room will viewed by the child as a threat. 8dditionally@ a loc"ed door is frightening and potentially ha$ardous. .igorous activity at bedtime stirs up the child and ma"es more difficult to fall asleep. 1&. B# (ress>up clothes enhance imaginative play and imagination@ allowing preschoolers to engage in rich fantasy play. 9uilding bloc"s and wooden pu$$les are appropriate for encouraging fine motor development. 9ig wheels and tricycles encourage gross motor development. 1*. D# The school>aged child is in the stage of concrete operations@ mar"ed by inductive reasoning@ logical operations@ and reversible concrete thought. The ability to consider the future re;uires formal thought operations@ which are not developed until adolescence. Collecting baseball cards and marbles@ ordering dolls by si$e@ and simple problem>solving options are examples of the concrete operational thin"ing of the schoolager. 1/. C# 2eaction formation is the schoolagers typical defensive response when hospitali$ed. ,n reaction formation@ expression of unacceptable thoughts or behaviors is prevented Eor overriddenF by the exaggerated expression of opposite thoughts or types of behaviors. 2egression is seen in toddlers and preshcoolers when they retreat or return to an earlier level of development. 2epression refers to the involuntary bloc"ing of unpleasant feelings and experiences from ones awareness. 2ationali$ation is the attempt to ma"e excuses to 6ustify unacceptable feelings or behaviors. 13. C# The schoolagers cognitive level is sufficiently developed to enable good understanding of and adherence to rules. Thus@ schoolagers should be able to understand the potential dangers around them. #ith growth comes greater freedom and children become more adventurous and daring. The school>aged child is also still prone to accidents and home ha$ards@ especially because of increased motor abilities and independence. 'lus the home ha$ards differ from other age groups. These ha$ards@ which are potentially lethal but tempting@ may include firearms@ alcohol@ and medications. !chool>age children begin to internali$e their own controls and need less outside direction. 'lus the child is away from home more often. !ome parental or caregiver assistance is still needed to answer ;uestions and provide guidance for decisions and responsibilities. 14. C# The most significant s"ill learned during the school>age period is reading. (uring this time the child develops formal adult articulation patterns and learns that words can be arranged in structure. Collective@ ordering@ and sorting@ although important@ are not most significant s"ills learned.

17. C# 9ased on the recommendations of the 8merican 8cademy of %amily 'hysicians and the 8merican 8cademy of 'ediatrics@ the MM2 vaccine should be given at the age of 1? if the child did not receive it between the ages of / to 4 years as recommended. ,mmuni$ation for diphtheria and tetanus is re;uired at age 1*. 18. D# 8ccording to -ri"son@ role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame when they do not achieve autonomy. 'reschoolers develop a sense of guilt when they do not develop a sense of initiative. !chool>age children develop a sense of inferiority when they do not develop a sense of industry. 1=. A# Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. 7terine growth and broadening of the pelvic girdle occurs before menarche. &?. A# !tating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time her spends on it shuts off further investigation and is li"ely to ma"e the adolescent and his parents feel defensive. The statement about peer acceptance and time spent in front of the mirror for the development of self image provides information about the adolescents needs to the parents and may help to gain trust with the adolescent. 8s"ing the adolescent how he feels about the acne will encourage the adolescent to share his feelings. (iscussing the cleansing method shows interest and concern for the adolescent and also can help to identify any patient>teaching needs for the adolescent regarding cleansing. &1. B# 'reschoolers should be developmentally incapable of demonstrating explicit sexual behavior. ,f a child does so@ the child has been exposed to such behavior@ and sexual abuse should be suspected. -xplicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. #hether or nor the child "nows how to play with dolls is irrelevant. &&. A# The parents need more teaching if they state that they will "eep the child home until the phobia subsides. (oing so reinforces the childs feelings of worthlessness and dependency. The child should attend school even during resolution of the problem. 8llowing the child to verbali$e helps the child to ventilate feelings and may help to uncover causes and solutions. Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. The child should participate and play an active role in developing possible solutions. &*. C# The adolescent who becomes pregnant typically denies the pregnancy early on. -arly recognition by a parent or health care provider may be crucial to timely initiation of prenatal care. The incidence of adolescent pregnancy has declined since 1==1@ yet morbidity remains high. Most teenage pregnancies are unplanned and occur out of wedloc". The pregnant adolescent is at high ris" for physical complications including premature labor and low>birth>weight infants@ high neonatal mortality@ iron

deficiency anemia@ prolonged labor@ and fetopelvic disproportion as well as numerous psychological crises. &/. B# 9ecause of the structural defect@ children with cleft palate may have ineffective functioning of their -ustachian tubes creating fre;uent bouts of otitis media. Most children with cleft palate remain well>nourished and maintain ade;uate nutrition through the use of proper feeding techni;ues. %ood particles do not pass through the cleft and into the -ustachian tubes. There is no association between cleft palate and congenial ear deformities. &3. D# 8 *>month>old infant should be able to lift the head and chest when prone. The Moro reflex typically diminishes or subsides by * months. The parachute reflex appears at = months. 2olling from front to bac" usually is accomplished at about 3 months. &4. D# 8 childs birth weight usually triples by 1& months and doubles by / months. 0o specific birth weight parameters are established for 7 or = months. &7. C# Toddlers engaging in parallel play will play near each other@ but not with each other. Thus@ when two toddlers sit near each other but play with separate dolls@ they are exhibiting parallel play. !haring crayons@ playing a board game with a nurse@ or sharing dolls with two different nurses are all examples of cooperative play. &8. A# 8cute lymphocytic leu"emia E855F causes leu"openia@ resulting in immunosuppression and increasing the ris" of infection@ a leading cause of death in children with 855. Therefore@ the initial priority nursing intervention would be to institute infection control precautions to decrease the ris" of infection. ,ron>rich foods help with anemia@ but dietary iron is not an initial intervention. The prognosis of 855 usually is good. )owever@ later on@ the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion. ,n6ections should be discouraged@ owing to increased ris" from bleeding due to thrombocytopenia. &=. A# The pertusis component may result in fever and the tetanus component may result in in6ection soreness. Therefore@ the mothers verbali$ation of information about measures to reduce fever indicates understanding. 0o dietary restrictions are necessary after this in6ection is given. 8 subse;uent rash is more li"ely to be seen 3 to 1? days after receiving the MM2 vaccine@ not the diphtheria@ pertussis@ and tetanus vaccine. (iarrhea is not associated with this vaccine. *?. A# Multiple bruises and burns on a toddler are signs child abuse. Therefore@ the nurse is responsible for reporting the case to 'rotective !ervices immediately to protect the child from further harm. !cheduling a follow>up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data. 8lthough the nurse should notify the physician@ the goal is to initiate measures to protect the childs safety. 0otifying the physician immediately does not initiate the

removal of the child from harm nor does it absolve the nurse from responsibility. Multiple bruises and burns are not normal toddler in6uries. *1. B# The mother is using pro6ection@ the defense mechanism used when a person attributes his or her own undesirable traits to another. (isplacement is the transfer of emotion onto an unrelated ob6ect@ such as when the mother would "ic" a chair or bang the door shut. 2epression is the submerging of painful ideas into the unconscious. 'sychosis is a state of being out of touch with reality. *&. A# Children with congenital heart disease are more prone to respiratory infections. 9leeding tendencies@ fre;uent vomiting@ and diarrhea and sei$ure disorders are not associated with congenital heart disease. **. D# The child is exhibiting classic signs of epiglottitis@ always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. %urther assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life>threatening emergency. )aving the child lie down would cause additional distress and may result in respiratory arrest. Throat examination may result in laryngospasm that could be fatal. */. A# ,n females@ the urethra is shorter than in males. This decreases the distance for organisms to travel@ thereby increasing the chance of the child developing a urinary tract infection. %re;uent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress. ,ncreased fluid inta"e enables the bladder to be cleared more fre;uently@ thus helping to prevent urinary tract infections. The inta"e of acidic 6uices helps to "eep the urine p) acidic and thus decrease the chance of flora development. *3. B# Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation. 8cetaminophen ETylenolF will be ineffective since the pain is related to the increasing pressure and tissue ischemia. The cast@ not traction@ is being used in this situation for immobili$ation@ so releasing the traction would be inappropriate. ,n this situation@ specific action not continued monitoring is indicated. *4. D# The varicella $oster vaccine E.O.F is a live vaccine given after age 1& months. The first dose of hepatitis 9 vaccine is given at birth to & months@ then at 1 to / months@ and then again at 4 to 18 months. (ta' is routinely given at &@ /@ 4@ and 13 to 18 months and a booster at / to 4 years. *7. C# 9ecause the 8>month>old is refining his gross motor s"ills@ being able to sit unsupported and also improving his fine motor s"ills@ probably capable of ma"ing hand>to>hand transfers@ large bloc"s would be the most appropriate toy selection. 'ush>pull toys would be more appropriate for the 1? to 1&>month>old as he or she

begins to cruise the environment. 2attles and mobiles are more appropriate for infants in the 1 to * month age range. Mobiles pose a danger to older infants because of possible strangulation. *8. B# (uring the preschool period@ the child has mastered a sense of autonomy and goes on to master a sense of initiative. (uring this period@ the child commonly experiences more fears than at any other time. <ne common fear is fear of the body mutilation@ especially associated with painful experiences. The preschool child uses simple@ not complex@ reasoning@ engages in associative@ not competitive@ play Einteractive and cooperative play with sharingF@ and is able to tolerate longer periods of delayed gratification. *=. A# Mild mental retardation refers to development disability involving an ,C 3? to 7?. Typically@ the child is not noted as being retarded@ but exhibits slowness in performing tas"s@ such as self>feeding@ wal"ing@ and ta"ing. 5ittle or no speech@ mar"ed motor delays@ and gait disabilities would be seen in more severe forms mental retardation. /?. B. (own syndrome is characteri$ed by the following a transverse palmar crease Esimian creaseF@ separated sagittal suture@ obli;ue palpebral fissures@ small nose@ depressed nasal bridge@ high>arched palate@ excess and lax s"in@ wide spacing and plantar crease between the second and big toes@ hyperextensible and lax 6oints@ large protruding tongue@ and muscle wea"ness. /1. A# 9ecause of the defect@ the child will be unable to from the mouth ade;uately around nipple@ thereby re;uiring special devices to allow for feeding and suc"ing gratification. 2espiratory status may be compromised if the child is fed improperly or during postoperative period@ 5ocomotion would be a problem for the older infant because of the use of restraints. :, functioning is not compromised in the child with a cleft lip. /&. B# 'ostoperatively children with cleft palate should be placed on their abdomens to facilitate drainage. ,f the child is placed in the supine position@ he or she may aspirate. 7sing an infant seat does not facilitate drainage. !ide>lying does not facilitate drainage as well as the prone position. /*. C# 'ro6ectile vomiting is a "ey symptom of pyloric stenosis. 2egurgitation is seen more commonly with :-2. !teatorrhea occurs in malabsorption disorders such as celiac disease. GCurrant 6ellyH stools are characteristic of intussusception. //. D# :-2 is the bac"flow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal EcardiacF sphincter. 0o alteration in the oral mucous membranes occurs with this disorder. %luid volume deficit@ ris" for aspiration@ and altered nutrition are appropriate nursing diagnoses.

/3. A# Thic"ened feedings are used with :-2 to stop the vomiting. Therefore@ the nurse would monitor the childs vomiting to evaluate the effectiveness of using the thic"ened feedings. 0o relationship exists between feedings and characteristics of stools and uterine. ,f feedings are ineffective@ this should be noted before there is any change in the childs weight. /4. C# Children with celiac disease cannot tolerate or digest gluten. Therefore@ because of its gluten content@ wheat and wheat>containing products must be avoided. 2ice@ mil"@ and chic"en do not contain gluten and need not be avoided. /7. C# -pisodes of celiac crises are precipitated by infections@ ingestion of gluten@ prolonged fasting@ or exposure to anticholinergic drugs. Celiac crisis is typically characteri$ed by severe watery diarrhea. 2espiratory distress is unli"ely in a routine upper respiratory infection. ,rritability@ rather than lethargy@ is more li"ely. 9ecause of the fluid loss associated with the severe watery diarrhea@ the childs weight is more li"ely to be decreased. /8. A# %or the child with )irschsprung disease@ fever and explosive diarrhea indicate enterocolitis@ a life>threatening situation. Therefore@ the physician should be notified immediately. :enerally@ because of the intestinal obstruction and inade;uate propulsive intestinal movement@ antidiarrheals are not used to treat )irschsprung disease. The child is acutely ill and re;uires intervention@ with monitoring more fre;uently than every *? minutes. )irschsprung disease typically presents with chronic constipation. /=. A. %ailure to pass meconium within the first &/ hours after birth may be an indication of )irschsprung disease@ a congenital anomaly resulting in mechanical obstruction due to inade;uate motility in an intestinal segment. %ailure to pass meconium is not associated with celiac disease@ intussusception@ or abdominal wall defect. 3?. C. 9ecause intussusception is not believed to have a familial tendency@ obtaining a family history would provide the least amount of information. !tool inspection@ pain pattern@ and abdominal palpation would reveal possible indicators of intussusception. Current@ 6elly>li"e stools containing blood and mucus are an indication of intussusception. 8cute@ episodic abdominal pain is characteristics of intussusception. 8 sausage>shaped mass may be palpated in the right upper ;uadrant.

*oundation o+ Nursing ' Comprehensi,e Test Part 1

1. 7sing the principles of standard precautions@ the nurse would wear gloves in what nursing interventions+ a. 'roviding a bac" massage

&.

*.

/.

3.

4.

7.

8.

b. %eeding a client c. 'roviding hair care d. 'roviding oral hygiene The nurse is preparing to ta"e vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. #hat is the best method used to assess the clients temperature+ a. <ral b. 8xillary c. 2adial d. )eat sensitive tape 8 nurse obtained a clients pulse and found the rate to be above normal. The nurse document this findings as a. Tachypnea b. )yper pyrexia c. 8rrythmia d. Tachycardia #hich of the following actions should the nurse ta"e to use a wide base support when assisting a client to get up in a chair+ a. 9end at the waist and place arms under the clients arms and lift b. %ace the client@ bend "nees and place hands on clients forearm and lift c. !pread his or her feet apart d. Tighten his or her pelvic muscles 8 client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the s"in flushed and warm. #hich of the following would be the best method to ta"e the clients body temperature+ a. <ral b. 8xillary c. 8rterial line d. 2ectal 8 client who is unconscious needs fre;uent mouth care. #hen performing a mouth care@ the best position of a client is a. %owlers position b. !ide lying c. !upine d. Trendelenburg 8 client is hospitali$ed for the first time@ which of the following actions ensure the safety of the client+ a. Beep unnecessary furniture out of the way b. Beep the lights on at all time c. Beep side rails up at all time d. Beep all e;uipment out of view 8 wal">in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse ta"es the clients vital sign hereafter. #hat phrase of nursing process is being implemented here by the nurse+ a. 8ssessment b. (iagnosis

c. 'lanning d. ,mplementation =. ,t is best describe as a systematic@ rational method of planning and providing nursing care for individual@ families@ group and community a. 8ssessment b. 0ursing 'rocess c. (iagnosis d. ,mplementation 1?. -xchange of gases ta"es place in which of the following organ+ a. Bidney b. 5ungs c. 5iver d. )eart 11. The Chamber of the heart that receives oxygenated blood from the lungs is the+ a. 5eft atrium b. 2ight atrium c. 5eft ventricle d. 2ight ventricle 1&. 8 muscular enlarge pouch or sac that lies slightly to the left which is used for temporary storage of food1 a. :allbladder b. 7rinary bladder c. !tomach d. 5ungs 1*. The ability of the body to defend itself against scientific invading agent such as baceria@ toxin@ viruses and foreign body a. )ormones b. !ecretion c. ,mmunity d. :lands 1/. )ormones secreted by ,slets of 5angerhans a. 'rogesterone b. Testosterone c. ,nsulin d. )emoglobin 13. ,t is a transparent membrane that focuses the light that enters the eyes to the retina. a. 5ens b. !clera c. Cornea d. 'upils 14. #hich of the following is included in <rems theory+ a. Maintenance of a sufficient inta"e of air b. !elf perception c. 5ove and belonging d. 'hysiologic needs

17. #hich of the following cluster of data belong to Maslows hierarchy of needs a. 5ove and belonging b. 'hysiologic needs c. !elf actuali$ation d. 8ll of the above 18. This is characteri$ed by severe symptoms relatively of short duration. a. Chronic ,llness b. 8cute ,llness c. 'ain d. !yndrome 1=. #hich of the following is the nurses role in the health promotion a. )ealth ris" appraisal b. Teach client to be effective health consumer c. #or"site wellness d. 0one of the above &?. ,t is describe as a collection of people who share some attributes of their lives. a. %amily b. ,llness c. Community d. 0ursing &1. %ive teaspoon is e;uivalent to how many milliliters EmlF+ a. *? ml b. &3 ml c. 1& ml d. && ml &&. 18?? ml is e;ual to how many liters+ a. 1.8 b. 18??? c. 18? d. &8?? &*. #hich of the following is the abbreviation of drops+ a. :tt. b. :tts. c. (p. d. (r. &/. The abbreviation for micro drop is1 a. Xgtt b. gtt c. mdr d. mgts &3. #hich of the following is the meaning of '20+ a. #hen advice b. ,mmediately c. #hen necessary d. 0ow &4. #hich of the following is the appropriate meaning of C92+

a. Cardiac 9oard 2oom b. Complete 9athroom c. Complete 9ed 2est d. Complete 9oard 2oom &7. 1 tsp is e;uals to how many drops+ a. 13 b. 4? c. 1? d. *? &8. &? cc is e;ual to how many ml+ a. & b. &? c. &??? d. &???? &=. 1 cup is e;uals to how many ounces+ a. 8 b. 8? c. 8?? d. 8??? *?. The nurse must verify the clients identity before administration of medication. #hich of the following is the safest way to identify the client+ a. 8s" the client his name b. Chec" the clients identification band c. !tate the clients name aloud and have the client repeat it d. Chec" the room number *1. The nurse prepares to administer buccal medication. The medicine should be placed1 a. <n the clients s"in b. 9etween the clients chee"s and gums c. 7nder the clients tongue d. <n the clients con6uctiva *&. The nurse administers cleansing enema. The common position for this procedure is1 a. !ims left lateral b. (orsal 2ecumbent c. !upine d. 'rone **. 8 client complains of difficulty of swallowing@ when the nurse try to administer capsule medication. #hich of the following measures the nurse should do+ a. (issolve the capsule in a glass of water b. 9rea" the capsule and give the content with an applesauce c. Chec" the availability of a li;uid preparation d. Crash the capsule and place it under the tongue */. #hich of the following is the appropriate route of administration for insulin+ a. ,ntramuscular b. ,ntradermal

c. !ubcutaneous d. ,ntravenous *3. The nurse is ordered to administer ampicillin capsule T,' p.o. The nurse shoud give the medication1 a. Three times a day orally b. Three times a day after meals c. Two time a day by mouth d. Two times a day before meals *4. 9ac" Care is best describe as a. Caring for the bac" by means of massage b. #ashing of the bac" c. 8pplication of cold compress at the bac" d. 8pplication of hot compress at the bac" *7. ,t refers to the preparation of the bed with a new set of linens a. 9ed bath b. 9ed ma"ing c. 9ed shampoo d. 9ed lining *8. #hich of the following is the most important purpose of handwashing a. To promote hand circulation b. To prevent the transfer of microorganism c. To avoid touching the client with a dirty hand d. To provide comfort *=. #hat should be done in order to prevent contaminating of the environment in bed ma"ing+ a. 8void funning soiled linens b. !trip all linens at the same time c. %inished both sides at the time d. -mbrace soiled linen /?. The most important purpose of cleansing bed bath is a. To cleanse@ refresh and give comfort to the client who must remain in bed b. To expose the necessary parts of the body c. To develop s"ills in bed bath d. To chec" the body temperature of the client in bed /1. #hich of the following techni;ue involves the sense of sight+ a. ,nspection b. 'alpation c. 'ercussion d. 8uscultation /&. The first techni;ues used examining the abdomen of a client is a. 'alpation b. 8uscultation c. 'ercussion d. ,nspection /*. 8 techni;ue in physical examination that is use to assess the movement of air through the tracheobronchial tree

a. 'alpation b. 8uscultation c. ,nspection d. 'ercussion //. 8n instrument used for auscultation is a. 'ercussion>hammer b. 8udiometer c. !tethoscope d. !phygmomanometer /3. 2esonance is best describe as a. !ounds created by air filled lungs b. !hort@ high pitch and thudding c. Moderately loud with musical ;uality d. (rum>li"e /4. The best position for examining the rectum is a. 'rone b. !ims c. Bnee>chest d. 5ithotomy /7. ,t refers to the manner of wal"ing a. :ait b. 2ange of motion c. %lexion and extension d. )opping /8. The nurse as"ed the client to read the !nellen chart. #hich of the following is tested a. <ptic b. <lfactory c. <culomotor d. Troclear /=. 8nother name for "nee>chest position is a. :enu>dorsal b. :enu>pectoral c. 5ithotomy d. !ims 3?. The nurse prepare ,M in6ection that is irritating to the subcutaneous tissue. #hich of the following is the best action in order to prevent trac"ing of the medication a. 7se a small gauge needle b. 8pply ice on the in6ection site c. 8dminister at a /3A angle d. 7se the O>trac" techni;ue 'art 1

1.d &.b *.d /b 3.b 4.b 7.c 8.a =.b 1?.b

11.a 1&.c 1*.c 1/.c 13.c 14.a 17.d 18.b 1=.b &?.c

&1.b &&.a &*.b &/.a &3.c &4.c &7.b &8.b &=.a *?.a

*1.b *&.a **.c */.c *3.a *4.a *7.b *8.b *=.a /?.a

/1.a /&.d /*.b //.c /3.a /4.vc /7.a /8.a /=.b 3?.d

*oundation o+ Nursing ' Comprehensi,e Test Part

1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be1 a. Maintain the patient on strict bed rest at all times b. Maintain the patient in an orthopneic position as needed c. 8dminister oxygen by .enturi mas" at &/I@ as needed d. 8llow a 1 hour rest period between activities &. The nurse observes that Mr. 8dams begins to have increased difficulty breathing. !he elevates the head of the bed to the high %owler position@ which decreases his respiratory distress. The nurse documents this breathing as a. Tachypnea b. -upnca c. <rthopnea d. )yperventilation *. The physician orders a platelet count to be performed on Mrs. !mith after brea"fast. The nurse is responsible for a. ,nstructing the patient about this diagnostic test b. #riting the order for this test c. :iving the patient brea"fast d. 8ll of the above /. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 3??>mg low sodium diet. These include a. 8 ham and !wiss cheese sandwich on whole wheat bread b. Mashed potatoes and broiled chic"en c. 8 tossed salad with oil and vinegar and olives

d. Chic"en bouillon 3. The physician orders a maintenance dose of 3@??? units of subcutaneous heparin Ean anticoagulantF daily. 0ursing responsibilities for Mrs. Mitchell now include a. 2eviewing daily activated partial thromboplastin time E8'TTF and prothrombin time. b. 2eporting an 8'TT above /3 seconds to the physician c. 8ssessing the patient for signs and symptoms of fran" and occult bleeding d. 8ll of the above 4. The four main concepts common to nursing that appear in each of the current conceptual models are a. 'erson@ nursing@ environment@ medicine b. 'erson@ health@ nursing@ support systems c. 'erson@ health@ psychology@ nursing d. 'erson@ environment@ health@ nursing 7. ,n Maslows hierarchy of physiologic needs@ the human need of greatest priority is a. 5ove b. -limination c. 0utrition d. <xygen 8. The family of an accident victim who has been declared brain>dead seems amenable to organ donation. #hat should the nurse do+ a. (iscourage them from ma"ing a decision until their grief has eased b. 5isten to their concerns and answer their ;uestions honestly c. -ncourage them to sign the consent form right away d. Tell them the body will not be available for a wa"e or funeral =. 8 new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. #hat should she do+ a. Complain to her fellow nurses b. #ait until she "nows more about the unit c. (iscuss the problem with her supervisor d. ,nform the staff that they must volunteer to rotate 1?. #hich of the following principles of primary nursing has proven the most satisfying to the patient and nurse+ a. Continuity of patient care promotes efficient@ cost>effective nursing care b. 8utonomy and authority for planning are best delegated to a nurse who "nows the patient well c. 8ccountability is clearest when one nurse is responsible for the overall plan and its implementation. d. The holistic approach provides for a therapeutic relationship@ continuity@ and efficient nursing care. 11. ,f nurse administers an in6ection to a patient who refuses that in6ection@ she has committed a. 8ssault and battery b. 0egligence c. Malpractice

d. 0one of the above 1&. ,f patient as"s the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent@ the nurse could be held liable for a. !lander b. 5ibel c. 8ssault d. 2espondent superior 1*. 8 registered nurse reaches to answer the telephone on a busy pediatric unit@ momentarily turning away from a * month>old infant she has been weighing. The infant falls off the scale@ suffering a s"ull fracture. The nurse could be charged with a. (efamation b. 8ssault c. 9attery d. Malpractice 1/. #hich of the following is an example of nursing malpractice+ a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. c. The nurse assists a patient out of bed with the bed loc"ed in positionL the patient slips and fractures his right humerus. d. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor. 13. #hich of the following signs and symptoms would the nurse expect to find when assessing an 8sian patient for postoperative pain following abdominal surgery+ a. (ecreased blood pressure and heart rate and shallow respirations b. Cuiet crying c. ,mmobility@ diaphoresis@ and avoidance of deep breathing or coughing d. Changing position every & hours 14. 8 patient is admitted to the hospital with complaints of nausea@ vomiting@ diarrhea@ and severe abdominal pain. #hich of the following would immediately alert the nurse that the patient has bleeding from the :, tract+ a. Complete blood count b. :uaiac test c. .ital signs d. 8bdominal girth 17. The correct se;uence for assessing the abdomen is a. Tympanic percussion@ measurement of abdominal girth@ and inspection b. 8ssessment for distention@ tenderness@ and discoloration around the umbilicus. c. 'ercussions@ palpation@ and auscultation d. 8uscultation@ percussion@ and palpation 18. )igh>pitched gurgles head over the right lower ;uadrant are

a. 8 sign of increased bowel motility b. 8 sign of decreased bowel motility c. 0ormal bowel sounds d. 8 sign of abdominal cramping 1=. 8 patient about to undergo abdominal inspection is best placed in which of the following positions+ a. 'rone b. Trendelenburg c. !upine d. !ide>lying &?. %or a rectal examination@ the patient can be directed to assume which of the following positions+ a. :enupecterol b. !ims c. )ori$ontal recumbent d. 8ll of the above &1. (uring a 2omberg test@ the nurse as"s the patient to assume which position+ a. !itting b. !tanding c. :enupectoral d. Trendelenburg &&. ,f a patients blood pressure is 13?J=4@ his pulse pressure is a. 3/ b. =4 c. 13? d. &/4 &*. 8 patient is "ept off food and fluids for 1? hours before surgery. )is oral temperature at 8 a.m. is ==.8 % E*7.7 CF This temperature reading probably indicates a. ,nfection b. )ypothermia c. 8nxiety d. (ehydration &/. #hich of the following parameters should be chec"ed when assessing respirations+ a. 2ate b. 2hythm c. !ymmetry d. 8ll of the above &3. 8 *8>year old patients vital signs at 8 a.m. are axillary temperature ==.4 % E*7.4 CFL pulse rate@ 88L respiratory rate@ *?. #hich findings should be reported+ a. 2espiratory rate only b. Temperature only c. 'ulse rate and temperature d. Temperature and respiratory rate &4. 8ll of the following can cause tachycardia except

a. %ever b. -xercise c. !ympathetic nervous system stimulation d. 'arasympathetic nervous system stimulation &7. 'alpating the midclavicular line is the correct techni;ue for assessing a. 9aseline vital signs b. !ystolic blood pressure c. 2espiratory rate d. 8pical pulse &8. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital+ a. 8pical b. 2adial c. 'edal d. %emoral &=. #hich of the following patients is at greatest ris" for developing pressure ulcers+ a. 8n alert@ chronic arthritic patient treated with steroids and aspirin b. 8n 88>year old incontinent patient with gastric cancer who is confined to his bed at home c. 8n apathetic 4*>year old C<'( patient receiving nasal oxygen via cannula d. 8 confused 78>year old patient with congestive heart failure EC)%F who re;uires assistance to get out of bed. *?. The physician orders the administration of high>humidity oxygen by face mas" and placement of the patient in a high %owlers position. 8fter assessing Mrs. 'aul@ the nurse writes the following nursing diagnosis ,mpaired gas exchange related to increased secretions. #hich of the following nursing interventions has the greatest potential for improving this situation+ a. -ncourage the patient to increase her fluid inta"e to &?? ml every & hours b. 'lace a humidifier in the patients room. c. Continue administering oxygen by high humidity face mas" d. 'erform chest physiotheraphy on a regular schedule *1. The most common deficiency seen in alcoholics is a. Thiamine b. 2iboflavin c. 'yridoxine d. 'antothenic acid *&. #hich of the following statement is incorrect about a patient with dysphagia+ a. The patient will find pureed or soft foods@ such as custards@ easier to swallow than water b. %owlers or semi %owlers position reduces the ris" of aspiration during swallowing c. The patient should always feed himself d. The nurse should perform oral hygiene before assisting with feeding.

**. To assess the "idney function of a patient with an indwelling urinary E%oleyF catheter@ the nurse measures his hourly urine output. !he should notify the physician if the urine output is a. 5ess than *? mlJhour b. 4/ ml in & hours c. =? ml in * hours d. 1&3 ml in / hours */. Certain substances increase the amount of urine produced. These include a. Caffeine>containing drin"s@ such as coffee and cola. b. 9eets c. 7rinary analgesics d. Baolin with pectin EBaopectateF *3. 8 male patient who had surgery & days ago for head and nec" cancer is about to ma"e his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. #hich of the following nursing interventions would be appropriate+ a. -ncourage the patient to wal" in the hall alone b. (iscourage the patient from wal"ing in the hall for a few more days c. 8ccompany the patient for his wal". d. Consuit a physical therapist before allowing the patient to ambulate *4. 8 patient has exacerbation of chronic obstructive pulmonary disease EC<'(F manifested by shortness of breathL orthopnea thic"@ tenacious secretionsL and a dry hac"ing cough. 8n appropriate nursing diagnosis would be a. ,neffective airway clearance related to thic"@ tenacious secretions. b. ,neffective airway clearance related to dry@ hac"ing cough. c. ,neffective individual coping to C<'(. d. 'ain related to immobili$ation of affected leg. *7. Mrs. 5im begins to cry as the nurse discusses hair loss. The best response would be a. G(ont worry. ,ts only temporaryH b. G#hy are you crying+ , didnt get to the bad news yetH c. GKour hair is really prettyH d. G, "now this will be difficult for you@ but your hair will grow bac" after the completion of chemotheraphyH *8. 8n additional .itamin C is re;uired during all of the following periods except a. ,nfancy b. Koung adulthood c. Childhood d. 'regnancy *=. 8 prescribed amount of oxygen s needed for a patient with C<'( to prevent a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood E'aC<&F b. Circulatory overload due to hypervolemia c. 2espiratory excitement d. ,nhibition of the respiratory hypoxic stimulus

/?. 8fter 1 wee" of hospitali$ation@ Mr. :ray develops hypo"alemia. #hich of the following is the most significant symptom of his disorder+ a. 5ethargy b. ,ncreased pulse rate and blood pressure c. Muscle wea"ness d. Muscle irritability /1. #hich of the following nursing interventions promotes patient safety+ a. 8sses the patients ability to ambulate and transfer from a bed to a chair b. (emonstrate the signal system to the patient c. Chec" to see that the patient is wearing his identification band d. 8ll of the above /&. !tudies have shown that about /?I of patients fall out of bed despite the use of side railsL this has led to which of the following conclusions+ a. !ide rails are ineffective b. !ide rails should not be used c. !ide rails are a deterrent that prevent a patient from falling out of bed. d. !ide rails are a reminder to a patient not to get out of bed /*. -xamples of patients suffering from impaired awareness include all of the following except a. 8 semiconscious or over fatigued patient b. 8 disoriented or confused patient c. 8 patient who cannot care for himself at home d. 8 patient demonstrating symptoms of drugs or alcohol withdrawal //. The most common in6ury among elderly persons is a. 8theroscleotic changes in the blood vessels b. ,ncreased incidence of gallbladder disease c. 7rinary Tract ,nfection d. )ip fracture /3. The most common psychogenic disorder among elderly person is a. (epression b. !leep disturbances Esuch as bi$arre dreamsF c. ,nability to concentrate d. (ecreased appetite /4. #hich of the following vascular system changes results from aging+ a. ,ncreased peripheral resistance of the blood vessels b. (ecreased blood flow c. ,ncreased wor" load of the left ventricle d. 8ll of the above /7. #hich of the following is the most common cause of dementia among elderly persons+ a. 'ar"insons disease b. Multiple sclerosis c. 8myotrophic lateral sclerosis E5ou :erhigs diseaseF d. 8l$heimers disease /8. The nurses most important legal responsibility after a patients death in a hospital is

a. <btaining a consent of an autopsy b. 0otifying the coroner or medical examiner c. 5abeling the corpse appropriately d. -nsuring that the attending physician issues the death certification /=. 9efore rigor mortis occurs@ the nurse is responsible for a. 'roviding a complete bath and dressing change b. 'lacing one pillow under the bodys head and shoulders c. 2emoving the bodys clothing and wrapping the body in a shroud d. 8llowing the body to relax normally 3?. #hen a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness@ a ma6or nursing priority is to a. 'rotect the patient from in6ury b. ,nsert an airway c. -levate the head of the bed d. #ithdraw all pain medications

*oundation o+ Nursing ' Comprehensi,e Test Part Ans!ers and "ationale 1. B# #hen a patient develops dyspnea and shortness of breath@ the orthopneic position encourages maximum chest expansion and "eeps the abdominal organs from pressing against the diaphragm@ thus improving ventilation. 9ed rest and oxygen by .enturi mas" at &/I would improve oxygenation of the tissues and cells but must be ordered by a physician. 8llowing for rest periods decreases the possibility of hypoxia. &. C# <rthopnea is difficulty of breathing except in the upright position. Tachypnea is rapid respiration characteri$ed by ;uic"@ shallow breaths. -upnea is normal respiration Q ;uiet@ rhythmic@ and without effort. *. C# 8 platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient brea"fast at the scheduled time. The physician is responsible for instructing the patient about the test and for writing the order for the test. /. B# Mashed potatoes and broiled chic"en are low in natural sodium chloride. )am@ olives@ and chic"en bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. 3. D# 8ll of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The normal activated partial thromboplastin time is 14 to &3 seconds and the normal prothrombin time is 1& to 13 secondsL these levels must remain within two to two and one half the normal levels. 8ll patients receiving anticoagulant therapy must be observed for signs and symptoms of fran" and occult bleeding Eincluding hemorrhage@ hypotension@ tachycardia@ tachypnea@ restlessness@ pallor@ cold and clammy s"in@ thirst and confusionFL blood pressure should be measured every / hours and the patient should be instructed to report

promptly any bleeding that occurs with tooth brushing@ bowel movements@ urination or heavy prolonged menstruation. 4. D# The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of %lorence 0ightingale include the person receiving nursing care@ his environment@ his health on the health illness continuum@ and the nursing actions necessary to meet his needs. 7. D# Maslow@ who defined a need as a satisfaction whose absence causes illness@ considered oxygen to be the most important physiologic needL without it@ human life could not exist. 8ccording to this theory@ other physiologic needs Eincluding food@ water@ elimination@ shelter@ rest and sleep@ activity and temperature regulationF must be met before proceeding to the next hierarchical levels on psychosocial needs. 8. B# The brain>dead patients family needs support and reassurance in ma"ing a decision about organ donation. 9ecause transplants are done within hours of death@ decisions about organ donation must be made as soon as possible. )owever@ the familys concerns must be addressed before members are as"ed to sign a consent form. The body of an organ donor is available for burial. =. C# 8lthough a new head nurse should initially spend time observing the unit for its strengths and wea"ness@ she should ta"e action if a problem threatens patient safety. ,n this case@ the supervisor is the resource person to approach. 1?. D# !tudies have shown that patients and nurses both respond well to primary nursing care units. 'atients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. 0urses feel personal satisfaction@ much of it related to positive feedbac" from the patients. They also seem to gain a greater sense of achievement and esprit de corps. 11. A# 8ssault is the un6ustifiable attempt or threat to touch or in6ure another person. 9attery is the unlawful touching of another person or the carrying out of threatened physical harm. Thus@ any act that a nurse performs on the patient against his will is considered assault and battery. 1&. A# <ral communication that in6ures an individuals reputation is considered slander. #ritten communication that does the same is considered libel. 1*. D# Malpractice is defined as in6urious or unprofessional actions that harm another. ,t involves professional misconduct@ such as omission or commission of an act that a reasonable and prudent nurse would or would not do. ,n this example@ the standard of care was breachedL a *>month>old infant should never be left unattended on a scale. 1/. A# The three elements necessary to establish a nursing malpractice are nursing error Eadministering penicillin to a patient with a documented allergy to the drugF@ in6ury Ecerebral damageF@ and proximal cause Eadministering the penicillin caused the cerebral damageF. 8pplying a hot water bottle or heating pad to a patient without a physicians order does not include the three re;uired components. 8ssisting a patient out of bed with the bed loc"ed in position is the correct nursing practiceL therefore@ the fracture was not the result of malpractice. 8dministering an incorrect medication is a nursing errorL however@ if such action resulted in a serious illness or chronic problem@ the nurse could be sued for malpractice.

13. C# 8n 8sian patient is li"ely to hide his pain. Conse;uently@ the nurse must observe for ob6ective signs. ,n an abdominal surgery patient@ these might include immobility@ diaphoresis@ and avoidance of deep breathing or coughing@ as well as increased heart rate@ shallow respirations Estemming from pain upon moving the diaphragm and respiratory musclesF@ and guarding or rigidity of the abdominal wall. !uch a patient is unli"ely to display emotion@ such as crying. 14. B# To assess for :, tract bleeding when fran" blood is absent@ the nurse has two options !he can test for occult blood in vomitus@ if present@ or in stool Q through guaiac E)emoccultF test. 8 complete blood count does not provide immediate results and does not always immediately reflect blood loss. Changes in vital signs may be cause by factors other than blood loss. 8bdominal girth is unrelated to blood loss. 17. D# 9ecause percussion and palpation can affect bowel motility and thus bowel sounds@ they should follow auscultation in abdominal assessment. Tympanic percussion@ measurement of abdominal girth@ and inspection are methods of assessing the abdomen. 8ssessing for distention@ tenderness and discoloration around the umbilicus can indicate various bowel>related conditions@ such as cholecystitis@ appendicitis and peritonitis. 18. C# )yperactive sounds indicate increased bowel motilityL two or three sounds per minute indicate decreased bowel motility. 8bdominal cramping with hyperactive@ high pitched tin"ling bowel sounds can indicate a bowel obstruction. 1=. C# The supine position Ealso called the dorsal positionF@ in which the patient lies on his bac" with his face upward@ allows for easy access to the abdomen. ,n the prone position@ the patient lies on his abdomen with his face turned to the side. ,n the Trendelenburg position@ the head of the bed is tilted downward to *? to /? degrees so that the upper body is lower than the legs. ,n the lateral position@ the patient lies on his side. &?. D# 8ll of these positions are appropriate for a rectal examination. ,n the genupectoral E"nee>chestF position@ the patient "neels and rests his chest on the table@ forming a =? degree angle between the torso and upper legs. ,n !ims position@ the patient lies on his left side with the left arm behind the body and his right leg flexed. ,n the hori$ontal recumbent position@ the patient lies on his bac" with legs extended and hips rotated outward. &1. B# (uring a 2omberg test@ which evaluates for sensory or cerebellar ataxia@ the patient must stand with feet together and arms resting at the sidesYfirst with eyes open@ then with eyes closed. The need to move the feet apart to maintain this stance is an abnormal finding. &&. A# The pulse pressure is the difference between the systolic and diastolic blood pressure readings Q in this case@ 3/. &*. D# 8 slightly elevated temperature in the immediate preoperative or post operative period may result from the lac" of fluids before surgery rather than from infection. 8nxiety will not cause an elevated temperature. )ypothermia is an abnormally low body temperature. &/. D# The ;uality and efficiency of the respiratory process can be determined by appraising the rate@ rhythm@ depth@ ease@ sound@ and symmetry of respirations.

&3. D# 7nder normal conditions@ a healthy adult breathes in a smooth uninterrupted pattern 1& to &? times a minute. Thus@ a respiratory rate of *? would be abnormal. 8 normal adult body temperature@ as measured on an oral thermometer@ ranges between =7A and 1??A% E*4.1A and *7.8ACFL an axillary temperature is approximately one degree lower and a rectal temperature@ one degree higher. Thus@ an axillary temperature of ==.4A% E*7.4ACF would be considered abnormal. The resting pulse rate in an adult ranges from 4? to 1?? beatsJminute@ so a rate of 88 is normal. &4. D# 'arasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction@ rate of impulse conduction and blood flow through the coronary vessels. %ever@ exercise@ and sympathetic stimulation all increase the heart rate. &7. D# The apical pulse Ethe pulse at the apex of the heartF is located on the midclavicular line at the fourth@ fifth@ or sixth intercostal space. 9ase line vital signs include pulse rate@ temperature@ respiratory rate@ and blood pressure. 9lood pressure is typically assessed at the antecubital fossa@ and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. &8. C# 9ecause the pedal pulse cannot be detected in 1?I to &?I of the population@ its absence is not necessarily a significant finding. )owever@ the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. 8bsence of the apical@ radial@ or femoral pulse is abnormal and should be investigated. &=. B# 'ressure ulcers are most li"ely to develop in patients with impaired mental status@ mobility@ activity level@ nutrition@ circulation and bladder or bowel control. 8ge is also a factor. Thus@ the 88>year old incontinent patient who has impaired nutrition Efrom gastric cancerF and is confined to bed is at greater ris". *?. A# 8de;uate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature@ diaphoresis@ dehydration and dyspnea. )igh> humidity air and chest physiotherapy help li;uefy and mobili$e secretions. *1. A# Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. *&. C# 8 patient with dysphagia Edifficulty swallowingF re;uires assistance with feeding. %eeding himself is a long>range expected outcome. !oft foods@ %owlers or semi>%owlers position@ and oral hygiene before eating should be part of the feeding regimen. **. A# 8 urine output of less than *?mlJhour indicates hypovolemia or oliguria@ which is related to "idney function and inade;uate fluid inta"e. */. A# %luids containing caffeine have a diuretic effect. 9eets and urinary analgesics@ such as pyridium@ can color urine red. Baopectate is an anti diarrheal medication. *3. C# 8 hospitali$ed surgical patient leaving his room for the first time fears re6ection and others staring at him@ so he should not wal" alone. 8ccompanying him will offer moral support@ enabling him to face the rest of the world. 'atients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. #aiting to consult a physical therapist is unnecessary.

*4. A# Thic"@ tenacious secretions@ a dry@ hac"ing cough@ orthopnea@ and shortness of breath are signs of ineffective airway clearance. ,neffective airway clearance related to dry@ hac"ing cough is incorrect because the cough is not the reason for the ineffective airway clearance. ,neffective individual coping related to C<'( is wrong because the etiology for a nursing diagnosis should not be a medical diagnosis EC<'(F and because no data indicate that the patient is coping ineffectively. 'ain related to immobili$ation of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. *7. D# G, "now this will be difficultH ac"nowledges the problem and suggests a resolution to it. G(ont worry..H offers some relief but doesnt recogni$e the patients feelings. G.., didnt get to the bad news yetH would be inappropriate at any time. GKour hair is really prettyH offers no consolation or alternatives to the patient. *8. B# 8dditional .itamin C is needed in growth periods@ such as infancy and childhood@ and during pregnancy to supply demands for fetal growth and maternal tissues. <ther conditions re;uiring extra vitamin C include wound healing@ fever@ infection and stress. *=. D# (elivery of more than & liters of oxygen per minute to a patient with chronic obstructive pulmonary disease EC<'(F@ who is usually in a state of compensated respiratory acidosis Eretaining carbon dioxide EC<&FF@ can inhibit the hypoxic stimulus for respiration. 8n increased partial pressure of carbon dioxide in arterial blood E'8C<&F would not initially result in cardiac arrest. Circulatory overload and respiratory excitement have no relevance to the ;uestion. /?. C# 'resenting symptoms of hypo"alemia E a serum potassium level below *.3 m-;JliterF include muscle wea"ness@ chronic fatigue@ and cardiac dysrhythmias. The combined effects of inade;uate food inta"e and prolonged diarrhea can deplete the potassium stores of a patient with :, problems. /1. D# 8ssisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patients ability to carry out these functions safely. (emonstrating the signal system and providing an opportunity for a return demonstration ensures that the patient "nows how to operate the e;uipment and encourages him to call for assistance when needed. Chec"ing the patients identification band verifies the patients identity and prevents identification mista"es in drug administration. /&. D# !ince about /?I of patients fall out of bed despite the use of side rails@ side rails cannot be said to prevent fallsL however@ they do serve as a reminder that the patient should not get out of bed. The other answers are incorrect interpretations of the statistical data. /*. C# 8 patient who cannot care for himself at home does not necessarily have impaired awarenessL he may simply have some degree of immobility. //. D# )ip fracture@ the most common in6ury among elderly persons@ usually results from osteoporosis. The other answers are diseases that can occur in the elderly from physiologic changes. /3. A# !leep disturbances@ inability to concentrate and decreased appetite are symptoms of depression@ the most common psychogenic disorder among elderly persons. <ther symptoms include diminished memory@ apathy@ disinterest in

appearance@ withdrawal@ and irritability. (epression typically begins before the onset of old age and usually is caused by psychosocial@ genetic@ or biochemical factors /4. D# 8ging decreases elasticity of the blood vessels@ which leads to increased peripheral resistance and decreased blood flow. These changes@ in turn@ increase the wor" load of the left ventricle. /7. D# 8l$heimerLs disease@ sometimes "nown as senile dementia of the Alzheimers type or primary degenerative dementia@ is an insidiousL progressive@ irreversible@ and degenerative disease of the brain whose etiology is still un"nown. Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors@ muscle rigidity@ hypo"inesis@ dysphagia@ and dysphonia. Multiple sclerosis, a progressive@ degenerative disease involving demyelination of the nerve fibers@ usually begins in young adulthood and is mar"ed by periods of remission and exacerbation. Amyotrophic lateral sclerosis@ a disease mar"ed by progressive degeneration of the neurons@ eventually results in atrophy of all the musclesL including those necessary for respiration. /8. C# The nurse is legally responsible for labeling the corpse when death occurs in the hospital. !he may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patients deathL however@ she is not legally responsible for performing these functions. The attending physician may need information from the nurse to complete the death certificate@ but he is responsible for issuing it. /=. B# The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. !he is re;uired to bathe only soiled areas of the body since the mortician will wash the entire body. 9efore wrapping the body in a shroud@ the nurse places a clean gown on the body and closes the eyes and mouth. 3?. A# -nsuring the patients safety is the most essential action at this time. The other nursing actions may be necessary but are not a ma6or priority.

*oundation o+ Nursing ' Comprehensi,e Test Part $ 1. #hich element in the circular chain of infection can be eliminated by preserving s"in integrity+ a. )ost b. 2eservoir c. Mode of transmission d. 'ortal of entry &. #hich of the following will probably result in a brea" in sterile techni;ue for respiratory isolation+ a. <pening the patients window to the outside environment b. Turning on the patients room ventilator c. <pening the door of the patients room leading into the hospital corridor

d. %ailing to wear gloves when administering a bed bath *. #hich of the following patients is at greater ris" for contracting an infection+ a. 8 patient with leu"openia b. 8 patient receiving broad>spectrum antibiotics c. 8 postoperative patient who has undergone orthopedic surgery d. 8 newly diagnosed diabetic patient /. -ffective hand washing re;uires the use of a. !oap or detergent to promote emulsification b. )ot water to destroy bacteria c. 8 disinfectant to increase surface tension d. 8ll of the above 3. 8fter routine patient contact@ hand washing should last at least a. *? seconds b. 1 minute c. & minute d. * minutes 4. #hich of the following procedures always re;uires surgical asepsis+ a. .aginal instillation of con6ugated estrogen b. 7rinary catheteri$ation c. 0asogastric tube insertion d. Colostomy irrigation 7. !terile techni;ue is used whenever a. !trict isolation is re;uired b. Terminal disinfection is performed c. ,nvasive procedures are performed d. 'rotective isolation is necessary 8. #hich of the following constitutes a brea" in sterile techni;ue while preparing a sterile field for a dressing change+ a. 7sing sterile forceps@ rather than sterile gloves@ to handle a sterile item b. Touching the outside wrapper of sterili$ed material without sterile gloves c. 'lacing a sterile ob6ect on the edge of the sterile field d. 'ouring out a small amount of solution E13 to *? mlF before pouring the solution into a sterile container =. 8 natural body defense that plays an active role in preventing infection is a. Kawning b. 9ody hair c. )iccupping d. 2apid eye movements 1?. 8ll of the following statement are true about donning sterile gloves except a. The first glove should be pic"ed up by grasping the inside of the cuff. b. The second glove should be pic"ed up by inserting the gloved fingers under the cuff outside the glove. c. The gloves should be ad6usted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist d. The inside of the glove is considered sterile

11. #hen removing a contaminated gown@ the nurse should be careful that the first thing she touches is the a. #aist tie and nec" tie at the bac" of the gown b. #aist tie in front of the gown c. Cuffs of the gown d. ,nside of the gown 1&. #hich of the following nursing interventions is considered the most effective form or universal precautions+ a. Cap all used needles before removing them from their syringes b. (iscard all used uncapped needles and syringes in an impenetrable protective container c. #ear gloves when administering ,M in6ections d. %ollow enteric precautions 1*. 8ll of the following measures are recommended to prevent pressure ulcers except a. Massaging the reddened are with lotion b. 7sing a water or air mattress c. 8dhering to a schedule for positioning and turning d. 'roviding meticulous s"in care 1/. #hich of the following blood tests should be performed before a blood transfusion+ a. 'rothrombin and coagulation time b. 9lood typing and cross>matching c. 9leeding and clotting time d. Complete blood count EC9CF and electrolyte levels. 13. The primary purpose of a platelet count is to evaluate the a. 'otential for clot formation b. 'otential for bleeding c. 'resence of an antigen>antibody response d. 'resence of cardiac en$ymes 14. #hich of the following white blood cell E#9CF counts clearly indicates leu"ocytosis+ a. /@3??JmmZ b. 7@???JmmZ c. 1?@???JmmZ d. &3@???JmmZ 17. 8fter 3 days of diuretic therapy with &?mg of furosemide E5asixF daily@ a patient begins to exhibit fatigue@ muscle cramping and muscle wea"ness. These symptoms probably indicate that the patient is experiencing a. )ypo"alemia b. )yper"alemia c. 8norexia d. (ysphagia 18. #hich of the following statements about chest R>ray is false+ a. 0o contradictions exist for this test b. 9efore the procedure@ the patient should remove all 6ewelry@ metallic ob6ects@ and buttons above the waist

c. 8 signed consent is not re;uired d. -ating@ drin"ing@ and medications are allowed before this test 1=. The most appropriate time for the nurse to obtain a sputum specimen for culture is a. -arly in the morning b. 8fter the patient eats a light brea"fast c. 8fter aerosol therapy d. 8fter chest physiotherapy &?. 8 patient with no "nown allergies is to receive penicillin every 4 hours. #hen administering the medication@ the nurse observes a fine rash on the patients s"in. The most appropriate nursing action would be to a. #ithhold the moderation and notify the physician b. 8dminister the medication and notify the physician c. 8dminister the medication with an antihistamine d. 8pply corn starch soa"s to the rash &1. 8ll of the following nursing interventions are correct when using the O>trac" method of drug in6ection except a. 'repare the in6ection site with alcohol b. 7se a needle thats a least 1H long c. 8spirate for blood before in6ection d. 2ub the site vigorously after the in6ection to promote absorption &&. The correct method for determining the vastus lateralis site for ,.M. in6ection is to a. 5ocate the upper aspect of the upper outer ;uadrant of the buttoc" about 3 to 8 cm below the iliac crest b. 'alpate the lower edge of the acromion process and the midpoint lateral aspect of the arm c. 'alpate a 1H circular area anterior to the umbilicus d. (ivide the area between the greater femoral trochanter and the lateral femoral condyle into thirds@ and select the middle third on the anterior of the thigh &*. The mid>deltoid in6ection site is seldom used for ,.M. in6ections because it a. Can accommodate only 1 ml or less of medication b. 9ruises too easily c. Can be used only when the patient is lying down d. (oes not readily parenteral medication &/. The appropriate needle si$e for insulin in6ection is a. 18:@ 1 UH long b. &&:@ 1H long c. &&:@ 1 UH long d. &3:@ 3J8H long &3. The appropriate needle gauge for intradermal in6ection is a. &?: b. &&: c. &3: d. &4: &4. 'arenteral penicillin can be administered as an

a. ,M in6ection or an ,. solution b. ,. or an intradermal in6ection c. ,ntradermal or subcutaneous in6ection d. ,M or a subcutaneous in6ection &7. The physician orders gr 1? of aspirin for a patient. The e;uivalent dose in milligrams is a. ?.4 mg b. 1? mg c. 4? mg d. 4?? mg &8. The physician orders an ,. solution of dextrose 3I in water at 1??mlJhour. #hat would the flow rate be if the drop factor is 13 gtt T 1 ml+ a. 3 gttJminute b. 1* gttJminute c. &3 gttJminute d. 3? gttJminute &=. #hich of the following is a sign or symptom of a hemolytic reaction to blood transfusion+ a. )emoglobinuria b. Chest pain c. 7rticaria d. (istended nec" veins *?. #hich of the following conditions may re;uire fluid restriction+ a. %ever b. Chronic <bstructive 'ulmonary (isease c. 2enal %ailure d. (ehydration *1. 8ll of the following are common signs and symptoms of phlebitis except a. 'ain or discomfort at the ,. insertion site b. -dema and warmth at the ,. insertion site c. 8 red strea" exiting the ,. insertion site d. %ran" bleeding at the insertion site *&. The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to a. 8s" the patient if heJshe has used ear drops before b. )ave the patient repeat the nurses instructions using her own words c. (emonstrate the procedure to the patient and encourage to as" ;uestions d. 8s" the patient to demonstrate the procedure **. #hich of the following types of medications can be administered via gastrostomy tube+ a. 8ny oral medications b. Capsules whole contents are dissolve in water c. -nteric>coated tablets that are thoroughly dissolved in water d. Most tablets designed for oral use@ except for extended>duration compounds */. 8 patient who develops hives after receiving an antibiotic is exhibiting drug

a. Tolerance b. ,diosyncrasy c. !ynergism d. 8llergy *3. 8 patient has returned to his room after femoral arteriography. 8ll of the following are appropriate nursing interventions except a. 8ssess femoral@ popliteal@ and pedal pulses every 13 minutes for & hours b. Chec" the pressure dressing for sanguineous drainage c. 8ssess a vital signs every 13 minutes for & hours d. <rder a hemoglobin and hematocrit count 1 hour after the arteriography *4. The nurse explains to a patient that a cough a. ,s a protective response to clear the respiratory tract of irritants b. ,s primarily a voluntary action c. ,s induced by the administration of an antitussive drug d. Can be inhibited by GsplintingH the abdomen *7. 8n infected patient has chills and begins shivering. The best nursing intervention is to a. 8pply iced alcohol sponges b. 'rovide increased cool li;uids c. 'rovide additional bedclothes d. 'rovide increased ventilation *8. 8 clinical nurse specialist is a nurse who has a. 9een certified by the 0ational 5eague for 0ursing b. 2eceived credentials from the 'hilippine 0urses 8ssociation c. :raduated from an associate degree program and is a registered professional nurse d. Completed a masters degree in the prescribed clinical area and is a registered professional nurse. *=. The purpose of increasing urine acidity through dietary means is to a. (ecrease burning sensations b. Change the urines color c. Change the urines concentration d. ,nhibit the growth of microorganisms /?. Clay colored stools indicate a. 7pper :, bleeding b. ,mpending constipation c. 8n effect of medication d. 9ile obstruction /1. ,n which step of the nursing process would the nurse as" a patient if the medication she administered relieved his pain+ a. 8ssessment b. 8nalysis c. 'lanning d. -valuation /&. 8ll of the following are good sources of vitamin 8 except a. #hite potatoes

b. Carrots c. 8pricots d. -gg yol"s /*. #hich of the following is a primary nursing intervention necessary for all patients with a %oley Catheter in place+ a. Maintain the drainage tubing and collection bag level with the patients bladder b. ,rrigate the patient with 1I 0eosporin solution three times a daily c. Clamp the catheter for 1 hour every / hours to maintain the bladders elasticity d. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity //. The -5,!8 test is used to a. !creen blood donors for antibodies to human immunodeficiency virus E),.F b. Test blood to be used for transfusion for ),. antibodies c. 8id in diagnosing a patient with 8,(! d. 8ll of the above /3. The two blood vessels most commonly used for T'0 infusion are the a. !ubclavian and 6ugular veins b. 9rachial and subclavian veins c. %emoral and subclavian veins d. 9rachial and femoral veins /4. -ffective s"in disinfection before a surgical procedure includes which of the following methods+ a. !having the site on the day before surgery b. 8pplying a topical antiseptic to the s"in on the evening before surgery c. )aving the patient ta"e a tub bath on the morning of surgery d. )aving the patient shower with an antiseptic soap on the evening vTbefore and the morning of surgery /7. #hen transferring a patient from a bed to a chair@ the nurse should use which muscles to avoid bac" in6ury+ a. 8bdominal muscles b. 9ac" muscles c. 5eg muscles d. 7pper arm muscles /8. Thrombophlebitis typically develops in patients with which of the following conditions+ a. ,ncreases partial thromboplastin time b. 8cute pulsus paradoxus c. 8n impaired or traumati$ed blood vessel wall d. Chronic <bstructive 'ulmonary (isease EC<'(F /=. ,n a recumbent@ immobili$ed patient@ lung ventilation can become altered@ leading to such respiratory complications as a. 2espiratory acidosis@ ateclectasis@ and hypostatic pneumonia b. 8ppneustic breathing@ atypical pneumonia and respiratory al"alosis

c. Cheyne>!tro"es respirations and spontaneous pneumothorax d. Bussmails respirations and hypoventilation 3?. ,mmobility impairs bladder elimination@ resulting in such disorders as a. ,ncreased urine acidity and relaxation of the perineal muscles@ causing incontinence b. 7rine retention@ bladder distention@ and infection c. (iuresis@ natriuresis@ and decreased urine specific gravity d. (ecreased calcium and phosphate levels in the urine *oundation o+ Nursing ' Comprehensi,e Test Part $ Ans!ers and "ationale 1. D. ,n the circular chain of infection@ pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry@ such as bro"en s"in. &. C. 2espiratory isolation@ li"e strict isolation@ re;uires that the door to the door patients room remain closed. )owever@ the patients room should be well ventilated@ so opening the window or turning on the ventricular is desirable. The nurse does not need to wear gloves for respiratory isolation@ but good hand washing is important for all types of isolation. *. A. 5eu"openia is a decreased number of leu"ocytes Ewhite blood cellsF@ which are important in resisting infection. 0one of the other situations would put the patient at ris" for contracting an infectionL ta"ing broad>spectrum antibiotics might actually reduce the infection ris". /. A. !oaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. )ot water may lead to s"in irritation or burns. 3. A. (epending on the degree of exposure to pathogens@ hand washing may last from 1? seconds to / minutes. 8fter routine patient contact@ hand washing for *? seconds effectively minimi$es the ris" of pathogen transmission. 4. B. The urinary system is normally free of microorganisms except at the urinary meatus. 8ny procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria>free state. 7. C. 8ll invasive procedures@ including surgery@ catheter insertion@ and administration of parenteral therapy@ re;uire sterile techni;ue to maintain a sterile environment. 8ll e;uipment must be sterile@ and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. ,n the operating room@ the nurse and physician are re;uired to wear sterile gowns@ gloves@ mas"s@ hair covers@ and shoe covers for all invasive procedures. !trict isolation re;uires the use of clean gloves@ mas"s@ gowns and e;uipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and e;uipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of protective EreverseF isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms.

8. C. The edges of a sterile field are considered contaminated. #hen sterile items are allowed to come in contact with the edges of the field@ the sterile items also become contaminated. =. B. )air on or within body areas@ such as the nose@ traps and holds particles that contain microorganisms. Kawning and hiccupping do not prevent microorganisms from entering or leaving the body. 2apid eye movement mar"s the stage of sleep during which dreaming occurs. 1?. D. The inside of the glove is always considered to be clean@ but not sterile. 11. A. The bac" of the gown is considered clean@ the front is contaminated. !o@ after removing gloves and washing hands@ the nurse should untie the bac" of the gownL slowly move bac"ward away from the gown@ holding the inside of the gown and "eeping the edges off the floorL turn and fold the gown inside outL discard it in a contaminated linen containerL then wash her hands again. 1&. B. 8ccording to the Centers for (isease Control EC(CF@ blood>to>blood contact occurs most commonly when a health care wor"er attempts to cap a used needle. Therefore@ used needles should never be recappedL instead they should be inserted in a specially designed puncture resistant@ labeled container. #earing gloves is not always necessary when administering an ,.M. in6ection. -nteric precautions prevent the transfer of pathogens via feces. 1*. A. 0urses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. )owever@ research has shown that massage only increases the li"elihood of cellular ischemia and necrosis to the area. 1/. B. 9efore a blood transfusion is performed@ the blood of the donor and recipient must be chec"ed for compatibility. This is done by blood typing Ea test that determines a persons blood typeF and cross>matching Ea procedure that determines the compatibility of the donors and recipients blood after the blood types has been matchedF. ,f the blood specimens are incompatible@ hemolysis and antigen>antibody reactions will occur. 13. A. 'latelets are dis">shaped cells that are essential for blood coagulation. 8 platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after in6ury. ,t also is used to evaluate the patients potential for bleedingL however@ this is not its primary purpose. The normal count ranges from 13?@??? to *3?@???Jmm*. 8 count of 1??@???Jmm* or less indicates a potential for bleedingL count of less than &?@???Jmm* is associated with spontaneous bleeding. 14. D. 5eu"ocytosis is any transient increase in the number of white blood cells Eleu"ocytesF in the blood. 0ormal #9C counts range from 3@??? to 1??@???Jmm*. Thus@ a count of &3@???Jmm* indicates leu"ocytosis. 17. A. %atigue@ muscle cramping@ and muscle wea"nesses are symptoms of hypo"alemia Ean inade;uate potassium levelF@ which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypo"alemia in patients receiving diuretics. 8norexia is another symptom of hypo"alemia. (ysphagia means difficulty swallowing. 18. A. 'regnancy or suspected pregnancy is the only contraindication for a chest R> ray. )owever@ if a chest R>ray is necessary@ the patient can wear a lead apron to

protect the pelvic region from radiation. Dewelry@ metallic ob6ects@ and buttons would interfere with the R>ray and thus should not be worn above the waist. 8 signed consent is not re;uired because a chest R>ray is not an invasive examination. -ating@ drin"ing and medications are allowed because the R>ray is of the chest@ not the abdominal region. 1=. A. <btaining a sputum specimen early in this morning ensures an ade;uate supply of bacteria for culturing and decreases the ris" of contamination from food or medication. &?. A. ,nitial sensitivity to penicillin is commonly manifested by a s"in rash@ even in individuals who have not been allergic to it previously. 9ecause of the danger of anaphylactic shoc"@ he nurse should withhold the drug and notify the physician@ who may choose to substitute another drug. 8dministering an antihistamine is a dependent nursing intervention that re;uires a written physicians order. 8lthough applying corn starch to the rash may relieve discomfort@ it is not the nurses top priority in such a potentially life>threatening situation. &1. D. The O>trac" method is an ,.M. in6ection techni;ue in which the patients s"in is pulled in such a way that the needle trac" is sealed off after the in6ection. This procedure seals medication deep into the muscle@ thereby minimi$ing s"in staining and irritation. 2ubbing the in6ection site is contraindicated because it may cause the medication to extravasate into the s"in. &&. D. The vastus lateralis@ a long@ thic" muscle that extends the full length of the thigh@ is viewed by many clinicians as the site of choice for ,.M. in6ections because it has relatively few ma6or nerves and blood vessels. The middle third of the muscle is recommended as the in6ection site. The patient can be in a supine or sitting position for an in6ection into this site. &*. A. The mid>deltoid in6ection site can accommodate only 1 ml or less of medication because of its si$e and location Eon the deltoid muscle of the arm@ close to the brachial artery and radial nerveF. &/. D. 8 &3:@ 3J8H needle is the recommended si$e for insulin in6ection because insulin is administered by the subcutaneous route. 8n 18:@ 1 UH needle is usually used for ,.M. in6ections in children@ typically in the vastus lateralis. 8 &&:@ 1 UH needle is usually used for adult ,.M. in6ections@ which are typically administered in the vastus lateralis or ventrogluteal site. &3. D. 9ecause an intradermal in6ection does not penetrate deeply into the s"in@ a small>bore &3: needle is recommended. This type of in6ection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. 8 &?: needle is usually used for ,.M. in6ections of oil>based medicationsL a &&: needle for ,.M. in6ectionsL and a &3: needle@ for ,.M. in6ectionsL and a &3: needle@ for subcutaneous insulin in6ections. &4. A. 'arenteral penicillin can be administered ,.M. or added to a solution and given ,... ,t cannot be administered subcutaneously or intradermally. &7. D. gr 1? x 4?mgJgr 1 T 4?? mg &8. C. 1??mlJ4? min R 13 gttJ 1 ml T &3 gttJminute &=. A. )emoglobinuria@ the abnormal presence of hemoglobin in the urine@ indicates a hemolytic reaction Eincompatibility of the donors and recipients bloodF. ,n this reaction@ antibodies in the recipients plasma combine rapidly with donor 29CsL

the cells are hemoly$ed in either circulatory or reticuloendothelial system. )emolysis occurs more rapidly in 89< incompatibilities than in 2h incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. (istended nec" veins are an indication of hypervolemia. *?. C. ,n real failure@ the "idney loses their ability to effectively eliminate wastes and fluids. 9ecause of this@ limiting the patients inta"e of oral and ,... fluids may be necessary. %ever@ chronic obstructive pulmonary disease@ and dehydration are conditions for which fluids should be encouraged. *1. D. 'hlebitis@ the inflammation of a vein@ can be caused by chemical irritants E,... solutions or medicationsF@ mechanical irritants Ethe needle or catheter used during venipuncture or cannulationF@ or a locali$ed allergic reaction to the needle or catheter. !igns and symptoms of phlebitis include pain or discomfort@ edema and heat at the ,... insertion site@ and a red strea" going up the arm or leg from the ,... insertion site. *&. D. 2eturn demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching. **. D. Capsules@ enteric>coated tablets@ and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons@ and altering them destroys their purpose. The nurse should see" an alternate physicians order when an ordered medication is inappropriate for delivery by tube. */. D. 8 drug>allergy is an adverse reaction resulting from an immunologic response following a previous sensiti$ing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shoc". Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individuals uni;ue hypersensitivity to a drug@ food@ or other substanceL it appears to be genetically determined. Synergism@ is a drug interaction in which the sum of the drugs combined effects is greater than that of their separate effects. *3. D. 8 hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography. *4. A. Coughing@ a protective response that clears the respiratory tract of irritants@ usually is involuntaryL however it can be voluntary@ as when a patient is taught to perform coughing exercises. 8n antitussive drug inhibits coughing. !plinting the abdomen supports the abdominal muscles when a patient coughs. *7. C. ,n an infected patient@ shivering results from the bodys attempt to increase heat production and the production of neutrophils and phagocytotic action through increased s"eletal muscle tension and contractions. ,nitial vasoconstriction may cause s"in to feel cold to the touch. 8pplying additional bed clothes helps to e;uali$e the body temperature and stop the chills. 8ttempts to cool the body result in further shivering@ increased metabloism@ and thus increased heat production. *8. D. 8 clinical nurse specialist must have completed a masters degree in a clinical specialty and be a registered professional nurse. The 0ational 5eague of 0ursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The 8merican

0urses 8ssociation identifies re;uirements for certification and offers examinations for certification in many areas of nursing.@ such as medical surgical nursing. These certification EcredentialingF demonstrates that the nurse has the "nowledge and the ability to provide high ;uality nursing care in the area of her certification. 8 graduate of an associate degree program is not a clinical nurse specialist however@ she is prepared to provide bed side nursing with a high degree of "nowledge and s"ill. !he must successfully complete the licensing examination to become a registered professional nurse. *=. D. Microorganisms usually do not grow in an acidic environment. /?. D. 9ile colors the stool brown. 8ny inflammation or obstruction that impairs bile flow will affect the stool pigment@ yielding light@ clay>colored stool. 7pper :, bleeding results in blac" or tarry stool. Constipation is characteri$ed by small@ hard masses. Many medications and foods will discolor stool Q for example@ drugs containing iron turn stool blac".L beets turn stool red. /1. D. ,n the evaluation step of the nursing process@ the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase. /&. A. The main sources of vitamin 8 are yellow and green vegetables Esuch as carrots@ sweet potatoes@ s;uash@ spinach@ collard greens@ broccoli@ and cabbageF and yellow fruits Esuch as apricots@ and cantaloupeF. 8nimal sources include liver@ "idneys@ cream@ butter@ and egg yol"s. /*. D. Maintaing the drainage tubing and collection bag level with the patients bladder could result in reflux of urine into the "idney. ,rrigating the bladder with 0eosporin and clamping the catheter for 1 hour every / hours must be prescribed by a physician. //. D. The -5,!8 test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus E),.F. 8 positive -5,!8 test combined with various signs and symptoms helps to diagnose ac;uired immunodeficiency syndrome E8,(!F /3. D. Tachypnea Ean abnormally rapid rate of breathingF would indicate that the patient was still hypoxic Edeficient in oxygenF.The partial pressures of arterial oxygen and carbon dioxide listed are within the normal range. -upnea refers to normal respiration. /4. D. !tudies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the s"in. !having the site of the intended surgery might cause brea"s in the s"in@ thereby increasing the ris" of infectionL however@ if indicated@ shaving@ should be done immediately before surgery@ not the day before. 8 topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than rinse them away. /7. C. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen@ bac"@ and upper arms may be easily in6ured. /8. C. The factors@ "nown as .irchows triad@ collectively predispose a patient to thromboplebitisL impaired venous return to the heart@ blood hypercoagulability@

and in6ury to a blood vessel wall. ,ncreased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation@ commonly the result of anticoagulant EheparinF therapy. 8rterial blood disorders Esuch as pulsus paradoxusF and lung diseases Esuch as C<'(F do not necessarily impede venous return of in6ure vessel walls. /=. A. 9ecause of restricted respiratory movement@ a recumbent@ immobili$e patient is at particular ris" for respiratory acidosis from poor gas exchangeL atelectasis from reduced surfactant and accumulated mucus in the bronchioles@ and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions. 3?. B. The immobili$ed patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation@ which provide an excellent medium for bacterial growth leading to infection. ,mmobility also results in more al"aline urine with excessive amounts of calcium@ sodium and phosphate@ a gradual decrease in urine production@ and an increased specific gravity.