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Philippine NLE Board Exam: Psychiatric Nursing Question & Answer w/ rationale PSYCHIATRIC NURSING 1. Mental health is defined as: A. The ability to distinguish what is real from what is not. B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively. C. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation D. Absence of mental illness Answer: (B) A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively. Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. A. This describes the ego function reality testing. C. This is the definition of Mental Health and Psychiatric Nursing. D. Mental health is not just the absence of mental illness. 2. Which of the following describes the role of a technician? A. Administers medications to a schizophrenic patient. B. The nurse feeds and bathes a catatonic client C. Coordinates diverse aspects of care rendered to the patient D. Disseminates information about alcohol and its effects. Answer: (A) Administers medications to a schizophrenic patient. Administration of medications and treatments, assessment, documentation are the activities of the nurse as a technician. B. Activities as a parent surrogate. C. Refers to the ward manager role. D. Role as a teacher. 3. Liza says, “Give me 10 minutes to recall the name of our college professor who failed many students in our anatomy class.” She is operating on her: A. Subconscious B. Conscious C. Unconscious D. Ego Answer: (A) Subconscious Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled spontaneously and voluntarily. B. This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in the environment. C. The largest potion of the mind that contains the memories of one’s past particularly the unpleasant. It is difficult to recall the unconscious content. D. The conscious self that deals and tests reality. 4. The superego is that part of the psyche that: A. Uses defensive function for protection. B. Is impulsive and without morals. C. Determines the circumstances before making decisions. D. The censoring portion of the mind. Answer: (D) The censoring portion of the mind. The critical censoring portion of one’s personality; the conscience. A. This refers to the ego function that protects itself from anything that threatens it.. B. The Id is composed of the untamed, primitive drives and impulses. C. This refers to the ego that acts as the moderator of the struggle between the id and the superego. 5. Primary level of prevention is exemplified by: A. Helping the client resume self care. B. Ensuring the safety of a suicidal client in the institution. C. Teaching the client stress management techniques D. Case finding and surveillance in the community Answer: (C) Teaching the client stress management techniques Primary level of prevention refers to the promotion of mental health and prevention of mental illness. This can be achieved by rendering health teachings such as modifying ones responses to stress. A. This is tertiary level of prevention that deals with rehabilitation. B and D. Secondary level of prevention which involves reduction of actual illness through early detection and treatment of illness.

6. Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse. Which of the following is the most appropriate for the nurse to ask? A. “Are you being threatened or hurt by your partner? B. “Are you frightened of you partner” C. “Is something bothering you?” D. “What happens when you and your partner argue?” Answer: (A) “Are you being threatened or hurt by your partner? The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse. 7. The wife admits that she is a victim of abuse and opens up about her persistent distaste for sex. This sexual disorder is: A. Sexual desire disorder B. Sexual arousal Disorder C. Orgasm Disorder D. Sexual Pain Disorder Answer: (A) Sexual desire disorder Has little or no sexual desire or has distaste for sex. B. Failure to maintain the physiologic requirements for sexual intercourse. C. Persistent and recurrent inability to achieve an orgasm. D. Also called dyspareunia. Individuals with this disorder suffer genital pain before, during and after sexual intercourse. 8. What would be the best approach for a wife who is still living with her abusive husband? A. “Here’s the number of a crisis center that you can call for help .” B. “Its best to leave your husband.” C. “Did you discuss this with your family?” D. “ Why do you allow yourself to be treated this way” Answer: (A) “Here’s the number of a crisis center that you can call for help .” Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. B. Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However discuss options available. C. The victim tends to isolate from friends and family. D. This is judgmental. Avoid in anyway implying that she is at fault. 9. Which comment about a 3 year old child if made by the parent may indicate child abuse? A. “Once my child is toilet trained, I can still expect her to have some" B. “When I tell my child to do something once, I don’t expect to have to tell" C. “My child is expected to try to do things such as, dress and feed.” D. “My 3 year old loves to say NO.” Answer: (B) “When I tell my child to do something once, I don’t expect to have to tell" Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old. 10. The primary nursing intervention for a victim of child abuse is: A. Assess the scope of the problem B. Analyze the family dynamics C. Ensure the safety of the victim D. Teach the victim coping skills Answer: (C) Ensure the safety of the victim The priority consideration is the safety of the victim. Attend to the physical injuries to ensure the physiologic safety and integrity of the child. Reporting suspected case of abuse may deter recurrence of abuse. A,B and D may be addressed later. 11. Situation: A 30 year old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results. The client has which somatoform disorder? A. Somatization Disorder B. Hypochondriaisis C. Conversion Disorder D. Somatoform Pain Disorder Answer: (D) Somatoform Pain Disorder

This is characterized by severe and prolonged pain that causes significant distress. A. This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. B. This is an unrealistic preoccupation with a fear of having a serious illness. C. Characterized by alteration or loss in sensory or motor function resulting from a psychological conflict. 12. Freud explains anxiety as: A. Strives to gratify the needs for satisfaction and security B. Conflict between id and superego C. A hypothalamic-pituitary-adrenal reaction to stress D. A conditioned response to stressors Answer: (B) Conflict between id and superego Freud explains anxiety as due to opposing action drives between the id and the superego. A. Sullivan identified 2 types of needs, satisfaction and security. Failure to gratify these needs may result in anxiety. C. Biomedical perspective of anxiety. D. Explanation of anxiety using the behavioral model. 13. The following are appropriate nursing diagnosis for the client EXCEPT: A. Ineffective individual coping B. Alteration in comfort, pain C. Altered role performance D. Impaired social interaction Answer: (D) Impaired social interaction The client may not have difficulty in social exchange. The cues do not support this diagnosis. A. The client maladaptively uses body symptoms to manage anxiety. B. The client will have discomfort due to pain. C. The client may fail to meet environmental expectations due to pain. 14. The following statements describe somatoform disorders: A. Physical symptoms are explained by organic causes B. It is a voluntary expression of psychological conflicts C. Expression of conflicts through bodily symptoms D. Management entails a specific medical treatment Answer: (C) Expression of conflicts through bodily symptoms Bodily symptoms are used to handle conflicts. A. Manifestations do not have an organic basis. B. This occurs unconsciously. D. Medical treatment is not used because the disorder does not have a structural or organic basis. 15. What would be the best response to the client’s repeated complaints of pain: A. “I know the feeling is real tests revealed negative results.” B. . “I think you’re exaggerating things a little bit.” C. “Try to forget this feeling and have activities to take it off your mind” D. “So tell me more about the pain” Answer: (A) “I know the feeling is real tests revealed negative results.” Shows empathy and offers information. B. This is a demeaning statement. C. This belittles the client’s feelings. D. Giving undue attention to the physical symptom reinforces the complaint. 16. Situation: A nurse may encounter children with mental disorders. Her knowledge of these various disorders is vital. When planning school interventions for a child with a diagnosis of attention deficit hyperactivity disorder, a guide to remember is to: A. provide as much structure as possible for the child B. ignore the child’s overactivity. C. encourage the child to engage in any play activity to dissipate energy D. remove the child from the classroom when disruptive behavior occurs Answer: (A) provide as much structure as possible for the child Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non – confrontational approach and setting limit to time allotted for activities. B. The child will not benefit from a lenient approach. C. Dissipate energy through safe activities. D. This indicates that the classroom environment lacks structure. 17. The child with conduct disorder will likely demonstrate: A. Easy distractibility to external stimuli. B. Ritualistic behaviors C. Preference for inanimate objects. D. Serious violations of age related norms.

Answer: (D) Serious violations of age related norms. This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression, vandalism, stealing, lying and truancy. A. This is characteristic of attention deficit disorder. B and C. These are noted among children with autistic disorder. 18. Ritalin is the drug of choice for chidren with ADHD. The side effects of the following may be noted: A. increased attention span and concentration B. increase in appetite C. sleepiness and lethargy D. bradycardia and diarrhea Answer: (A) increased attention span and concentration The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability. 19. School phobia is usually treated by: A. Returning the child to the school immediately with family support. B. Calmly explaining why attendance in school is necessary C. Allowing the child to enter the school before the other children D. Allowing the parent to accompany the child in the classroom Answer: (A) Returning the child to the school immediately with family support. Exposure to the feared situation can help in overcoming anxiety. A. This will not help in relieving the anxiety due separation from a significant other. C. and C. Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable. D. This will not help the child overcome the fear 20. A 10 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification: A. Profound B. Mild C. Moderate D. Severe Answer: (C) Moderate The child with moderate mental retardation has an I.Q. of 35-50 Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35. 21. The nurse teaches the parents of a mentally retarded child regarding her care. The following guidelines may be taught except: A. overprotection of the child B. patience, routine and repetition C. assisting the parents set realistic goals D. giving reasonable compliments Answer: (A) overprotection of the child The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. B,C, and D Children with mental retardation have learning difficulty. They should be taught with patience and repetition, start from simple to complex, use visuals and compliment them for motivation. Realistic expectations should be set and optimize their capability. 22. The parents express apprehensions on their ability to care for their maladaptive child. The nurse identifies what nursing diagnosis: A. hopelessness B. altered parenting role C. altered family process D. ineffective coping Answer: (B) altered parenting role Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. This is reflected in the parent’s inability to care for the child. A. This refers to lack of choices or inability to mobilize one’s resources. C. Refers to change in family relationship and function. D. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources 23. A 5 year old boy is diagnosed to have autistic disorder. Which of the following manifestations may be noted in a client with autistic disorder?

A. argumentativeness, disobedience, angry outburst B. intolerance to change, disturbed relatedness, stereotypes C. distractibility, impulsiveness and overactivity D. aggression, truancy, stealing, lying Answer: (B) intolerance to change, disturbed relatedness, stereotypes These are manifestations of autistic disorder. A. These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. C. These are manifestations of Attention Deficit Disorder D. These are the manifestations of Conduct Disorder 24. The therapeutic approach in the care of an autistic child include the following EXCEPT: A. Engage in diversionary activities when acting -out B. Provide an atmosphere of acceptance C. Provide safety measures D. Rearrange the environment to activate the child Answer: (D) Rearrange the environment to activate the child The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be rechannelled through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling. 25. According to Piaget a 5 year old is in what stage of development: A. Sensory motor stage B. Concrete operations C. Pre-operational D. Formal operation Answer: (C) Pre-operational Pre-operational stage (2-7 years) is the stage when the use of language, the use of symbols and the concept of time occur. A. Sensory-motor stage (0-2 years) is the stage when the child uses the senses in learning about the self and the environment through exploration. B. Concrete operations (7-12 years) when inductive reasoning develops. D. Formal operations (2 till adulthood) is when abstract thinking and deductive reasoning develop. 26. Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates: A. withdrawal B. tolerance C. intoxication D. psychological dependence Answer: (B) tolerance tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms. 27. The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending: A. delirium tremens B. Korsakoff’s syndrome C. esophageal varices D. Wernicke’s syndrome Answer: (A) delirium tremens Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination. 28. The care for the client places priority to which of the following: A. Monitoring his vital signs every hour B. Providing a quiet, dim room

C. Encouraging adequate fluids and nutritious foods D. Administering Librium as ordered Answer: (A) Monitoring his vital signs every hour Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety. 29. Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum. A. Heroin B. cocaine C. LSD D. marijuana Answer: (B) cocaine The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations. 30. A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with: A. Naltrexone (Revia) B. Narcan (Naloxone) C. Disulfiram (Antabuse) D. Methadone (Dolophine) Answer: (B) Narcan (Naloxone) Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroine 31. Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting: A. apraxia B. aphasia C. agnosia D. amnesia Answer: (C) agnosia This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory. 32. She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic? A. ”Don’t take it personally. Your mother does not mean it.” B. “Have you tried discussing this with your mother?” C. “This must be difficult for you and your mother.” D. “Next time ask your mother where her things were last seen.” Answer: (C) “This must be difficult for you and your mother.” This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings. 33. The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client: A. receives adequate nutrition and hydration B. will reminisce to decrease isolation C. remains in a safe and secure environment D. independently performs self care Answer: (C) remains in a safe and secure environment

Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently 34. She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is: A. “Your husband is dead. Let me serve you your breakfast.” B. “I’ve told you several times that he is dead. It’s time to eat.” C. “You’re going to have to wait a long time.” D. “What made you say that your husband is alive? Answer: (A) “Your husband is dead. Let me serve you your breakfast.” The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation. 35. Dementia unlike delirium is characterized by: A. slurred speech B. insidious onset C. clouding of consciousness D. sensory perceptual change Answer: (B) insidious onset Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium. 36. Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client? A. altered self-image B. fluid volume deficit C. altered nutrition less than body requirements D. altered family process Answer: (B) fluid volume deficit Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority. 37. What is the best intervention to teach the client when she feels the need to starve? A. Allow her to starve to relieve her anxiety B. Do a short term exercise until the urge passes C. Approach the nurse and talk out her feelings D. Call her mother on the phone and tell her how she feels Answer: (C) Approach the nurse and talk out her feelings The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother. 38. The client with anorexia nervosa is improving if: A. She eats meals in the dining room. B. Weight gain C. She attends ward activities. D. She has a more realistic self concept. Answer: (B) Weight gain Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. (C) Attending an activity does not indicate improvement in nutritional state. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement. 39. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals

A. have episodic binge eating and purging B. have repeated attempts to stabilize their weight C. have peculiar food handling patterns D. have threatened self-esteem Answer: (A) have episodic binge eating and purging Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. B and C are characteristics of a client with anorexia nervosa D. Low esteem is noted in both eating disorders 40. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is: A. Patient will learn problem solving skills B. Patient will have decreased symptoms of anxiety. C. Patient will perform self care activities daily. D. Patient will verbalize how to set limits on others. Answer: (A) Patient will learn problem solving skills if the client learns problem solving skills she will gain a sense of control over her life. (B) Anxiety is caused by powerlessness. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority. 41. In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT: A. Establish an atmosphere of trust B. Discuss their eating behavior. C. Help patients identify feelings associated with binge-purge behavior D. Teach patient about bulimia nervosa Answer: (B) Discuss their eating behavior. The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship 42. Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies The client is suffering from: A. agoraphobia B. social phobia C. Claustrophobia D. xenophobia Answer: (C) Claustrophobia Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers. 43. Initial intervention for the client should be to: A. Encourage to verbalize his fears as much as he wants. B. Assist him to find meaning to his feelings in relation to his past. C. Establish trust through a consistent approach. D. Accept her fears without criticizing. Answer: (D) Accept her fears without criticizing. The client cannot control her fears although the client knows its silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions. 44. The nurse develops a countertransference reaction. This is evidenced by: A. Revealing personal information to the client B. Focusing on the feelings of the client. C. Confronting the client about discrepancies in verbal or non-verbal behavior D. The client feels angry towards the nurse who resembles his mother. Answer: (A) Revealing personal information to the client A. Countertransference is an emotional reaction of the nurse on the client based on her unconscious

needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past. 45. Which is the desired outcome in conducting desensitization: A. The client verbalize his fears about the situation B. The client will voluntarily attend group therapy in the social hall. C. The client will socialize with others willingly D. The client will be able to overcome his disabling fear. Answer: (D) The client will be able to overcome his disabling fear. The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization. 46. Which of the following should be included in the health teachings among clients receiving Valium: A. Avoid taking CNS depressant like alcohol. B. There are no restrictions in activities. C. Limit fluid intake. D. Any beverage like coffee may be taken Answer: (A) Avoid taking CNS depressant like alcohol. Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium. 47. Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint. The nurse plans intervention based on which correct statement about conversion disorder? A. The symptoms are conscious effort to control anxiety B. The client will experience high level of anxiety in response to the paralysis. C. The conversion symptom has symbolic meaning to the client D. A confrontational approach will be beneficial for the client. Answer: (C) The conversion symptom has symbolic meaning to the client the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety. 48. Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is: A. “I can refer you to a spiritual counselor if you like.” B. “You shouldn’t allow anyone to pressure you into sex.” C. “It sounds like this problem is related to your paralysis.” D. “How do you feel about being pressured into sex by your boyfriend?” Answer: (D) “How do you feel about being pressured into sex by your boyfriend?” Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause. 49. Malingering is different from somatoform disorder because the former: A. Has evidence of an organic basis. B. It is a deliberate effort to handle upsetting events C. Gratification from the environment are obtained. D. Stress is expressed through physical symptoms. Answer: (B) It is a deliberate effort to handle upsetting events Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder. 50. Unlike psychophysiologic disorder Linda may be best managed with: A. medical regimen B. milieu therapy C. stress management techniques D. psychotherapy Answer: (C) stress management techniques

Stree management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best. 51. Which is the best indicator of success in the long term management of the client? A. His symptoms are replaced by indifference to his feelings B. He participates in diversionary activities. C. He learns to verbalize his feelings and concerns D. He states that his behavior is irrational. Answer: (C) He learns to verbalize his feelings and concerns C. The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors. A. The client is encouraged to acknowledge feelings rather than being indifferent to her feelings. B. Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success. D. Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor, not as irrational. 52. Situation: A young woman is brought to the emergency room appearing depressed. The nurse learned that her child died a year ago due to an accident. The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that supports this diagnosis is: A. “I feel envious of mothers who have toddlers” B. “I haven’t been able to open the door and go into my baby’s room “ C. “I watch other toddlers and think about their play activities and I cry.” D. “I often find myself thinking of how I could have prevented the death. Answer: (B) “I haven’t been able to open the door and go into my baby’s room “ This indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful use of denial is dysfunctional. A. This indicates acknowledgement of the loss. Expressing feelings openly is acceptable. C. This indicates the stage of depression in the grieving process. D. Remembering both positive and negative aspects of the deceased love one signals successful mourning. 53. The client said “I can’t even take care of my baby. I’m good for nothing.” Which is the appropriate nursing diagnosis? A. Ineffective individual coping related to loss. B. Impaired verbal communication related to inadequate social skills. C. Low esteem related to failure in role performance D. Impaired social interaction related to repressed anger. Answer: (C) Low esteem related to failure in role performance This indicates the client’s negative self evaluation. A sense of worthlessness may accompany depression. A,B and D are not relevant. The cues do not indicate inability to use coping resources, decreased ability to transmit/process symbols, nor insufficient quality of social exchange 54. The following medications will likely be prescribed for the client EXCEPT: A. Prozac B. Tofranil C. Parnate D. Zyprexa Answer: (D) Zyprexa This is an antipsychotic. A. This is a SSRI antidepressant. B. This antidepressant belongs to the Tricyclic group. C. This is a MAOI antidepressant. 55. Which is the highest priority in the post ECT care? A. Observe for confusion B. Monitor respiratory status C. Reorient to time, place and person D. Document the client’s response to the treatment Answer: (B) Monitor respiratory status A side effect of ECT which is life threatening is respiratory arrest. A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority. 56. Situation: A 27 year old writer is admitted for the second time accompanied by his wife. He is

demanding, arrogant talked fast and hyperactive. Initially the nurse should plan this for a manic client: A. set realistic limits to the client’s behavior B. repeat verbal instructions as often as needed C. allow the client to get out feelings to relieve tension D. assign a staff to be with the client at all times to help maintain control Answer: (A) set realistic limits to the client’s behavior The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety. B. Clear, concise directions are given because of the distractibility of the client but this is not the priority. C. The manic client tend to externalize hostile feelings, however only non-destructive methods of expression should be allowed D. Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic. 57. An activity appropriate for the client is: A. table tennis B. painting C. chess D. cleaning Answer: (D) cleaning The client’s excess energy can be rechanelled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension. A. Tennis is a competitive activity which can stimulate the client. 58. The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse does one of the following: A. Agree on a consistent approach among the staff assigned to the client. B. Suggest that the client take a leading role in the social activities C. Provide the client with extra time for one on one sessions D. Allow the client to negotiate the plan of care Answer: (A) Agree on a consistent approach among the staff assigned to the client. A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed. B. This is not therapeutic because the client tends to control and dominate others. C. Limits are set for interaction time. D. Allowing the client to negotiate may reinforce manipulative behavior. 59. The nurse exemplifies awareness of the rights of a client whose anger is escalating by: A. Taking a directive role in verbalizing feelings B. Using an authoritarian, confrontational approach C. Putting the client in a seclusion room D. Applying mechanical restraints Answer: (A) Taking a directive role in verbalizing feelings The client has the right to be free from unnecessary restraints. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger. B. This is a threatening approach. C and D. Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger. 60. A client on Lithium has diarrhea and vomiting. What should the nurse do first: A. Recognize this as a drug interaction B. Give the client Cogentin C. Reassure the client that these are common side effects of lithium therapy D. Hold the next dose and obtain an order for a stat serum lithium level Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia. 61. Situation: A widow age 28, whose husband died one year ago due to AIDS, has just been told that she has AIDS. Pamela says to the nurse, “Why me? How could God do this to me?” This reaction is one of:

A. Depression B. Denial C. anger D. bargaining Answer: (C) anger Anger is experienced as reality sets in. This may either be directed to God, the deceased or displaced on others. A. Depression is a painful stage where the individual mourns for what was lost. B. Denial is the first stage of the grieving process evidenced by the statement “No, it can’t be true.” The individual does not acknowledge that the loss has occurred to protect self from the psychological pain of the loss. D. In bargaining the individual holds out hope for additional alternatives to forestall the loss, evidenced by the statement “If only…” 62. The nurse’s therapeutic response is: A. “I will refer you to a clergy who can help you understand what is happening to you.” B. “ It isn’t fair that an innocent like you will suffer from AIDS.” C. “That is a negative attitude.” D. ”It must really be frustrating for you. How can I best help you?” Answer: (D) ”It must really be frustrating for you. How can I best help you?” This response reflects the pain due to loss. A helping relationship can be forged by showing empathy and concern. A. This is not therapeutic since it passes the buck or responsibility to the clergy. B. This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts. C. This statement passes judgment on the client. 63. One morning the nurse sees the client in a depressed mood. The nurse asks her “What are you thinking about?” This communication technique is: A. focusing B. validating C. reflecting D. giving broad opening Answer: (D) giving broad opening Broad opening technique allows the client to take the initiative in introducing the topic. A,B and C are all therapeutic techniques but these are not exemplified by the nurse’s statement. 64. The client says to the nurse ” Pray for me” and entrusts her wedding ring to the nurse. The nurse knows that this may signal which of the following: A. anxiety B. suicidal ideation C. Major depression D. Hopelessness Answer: (B) suicidal ideation The client’s statement is a verbal cue of suicidal ideation not anxiety. While suicide is common among clients with major depression, this occurs when their depression starts to lift. Hopelessness indicates no alternatives available and may lead to suicide, the statement and non verbal cue of the client indicate suicide. 65. Which of the following interventions should be prioritized in the care of the suicidal client? A. Remove all potentially harmful items from the client’s room. B. Allow the client to express feelings of hopelessness. C. Note the client’s capabilities to increase self esteem. D. Set a “no suicide” contract with the client. Answer: (A) Remove all potentially harmful items from the client’s room. Accessibility of the means of suicide increases the lethality. Allowing patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients bur not specifically for suicide. 66. Situation: A 14 year old male was admitted to a medical ward due to bronchial asthma after learning that his mother was leaving soon for U.K. to work as nurse. The client has which of the following developmental focus: A. Establishing relationship with the opposite sex and career planning. B. Parental and societal responsibilities. C. Establishing ones sense of competence in school. D. Developing initial commitments and collaboration in work

Answer: (A) Establishing relationship with the opposite sex and career planning. The client belongs to the adolescent stage. The adolescent establishes his sense of identity by making decisions regarding familial, occupational and social roles. The adolescent emancipates himself from the family and decides what career to pursue, what set of friends to have and what value system to uphold. B. This refers to the middle adulthood stage concerned with transmitting his values to the next generation to ensure his immortality through the perpetuation of his culture. C. This reflects school age which is concerned with the pursuit of knowledge and skills to deal with the environment both in the present and in the future. D. The stage of young adulthood is concerned with development of intimate relationship with the opposite sex, establishment of a safe and congenial family environment and building of one’s lifework. 67. The personality type of Ryan is: A. conforming B. dependent C. perfectionist D. masochistic Answer: (B) dependent A client with dependent personality is predisposed to develop asthma. A. The conforming nonassertive client is predisposed to develop hypertension because of the tendency to repress rage. C. The perfectionist and compulsive tend to develop migraine. D. The masochistic, self sacrificing type are prone to develop rheumatoid arthritis. 68. The nurse ensures a therapeutic environment for the client. Which of the following best describes a therapeutic milieu? A. A therapy that rewards adaptive behavior B. A cognitive approach to change behavior C. A living, learning or working environment. D. A permissive and congenial environment Answer: (C) A living, learning or working environment. A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms, limit setting, balance and unit modification. A. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. D. This is not congruent with therapeutic milieu. 69. Included as priority of care for the client will be: A. Encourage verbalization of concerns instead of demonstrating them through the body B. Divert attention to ward activities C. Place in semi-fowlers position and render O2 inhalation as ordered D. Help her recognize that her physical condition has an emotional component Answer: (C) Place in semi-fowlers position and render O2 inhalation as ordered Since psychopysiologic disorder has organic basis, priority intervention is directed towards diseasespecific management. Failure to address the medical condition of the client may be a life threat. A and B. The client has physical symptom that is adversely affected by psychological factors. Verbalization of feelings in a non threatening environment and involvement in relaxing activities are adaptive way of dealing with stressors. However, these are not the priority. D. Helping the client connect the physical symptoms with the emotional problems can be done when the client is ready. 70. The client is concerned about his coming discharge, manifested by being unusually sad. Which is the most therapeutic approach by the nurse? A. “You are much better than when you were admitted so there’s no reason to worry.” B. “What would you like to do now that you’re about to go home?” C. “You seem to have concerns about going home.” D. “Aren’t you glad that you’re going home soon?” Answer: (C) “You seem to have concerns about going home.” . This statement reflects how the client feels. Showing empathy can encourage the client to talk which is important as an alternative more adaptive way of coping with stressors.. A. Giving false reassurance is not therapeutic. B. While this technique explores plans after discharge, it does not focus on expression of feelings. D. This close ended question does not encourage verbalization of feelings. 71. Situation: The nurse may encounter clients with concerns on sexuality.

The most basic factor in the intervention with clients in the area of sexuality is: A. Knowledge about sexuality. B. Experience in dealing with clients with sexual problems C. Comfort with one’s sexuality D. Ability to communicate effectively Answer: (C) Comfort with one’s sexuality The nurse must be accepting, empathetic and non-judgmental to patients who disclose concerns regarding sexuality. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. A,B and D are important considerations but these are not the priority. 72. Which of the following statements is true for gender identity disorder? A. It is the sexual pleasure derived from inanimate objects. B. It is the pleasure derived from being humiliated and made to suffer C. It is the pleasure of shocking the victim with exposure of the genitalia D. It is the desire to live or involve in reactions of the opposite sex Answer: (D) It is the desire to live or involve in reactions of the opposite sex Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This refers to masochism. C. This describes exhibitionism. 73. The sexual response cycle in which the sexual interest continues to build: A. Sexual Desire B. Sexual arousal C. Orgasm D. Resolution Answer: (B) Sexual arousal Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. A. Sexual Desire refers to the ability, interest or willingness for sexual stimulation. C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. D. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state. 74. The inability to maintain the physiologic requirements in sexual intercourse is: A. Sexual Desire Disorder B. Sexual Arousal Disorder C. Orgasm Disorder D. Sexual Pain disorder Answer: (B) Sexual Arousal Disorder This describes sexual arousal disorder. A. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. D. Sexual Pain Disorder is characterized by genital pain before, during or after sexual intercourse. 75. The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies “If you want I can go naked for you.” The most therapeutic response by the nurse is: A. “You’re attractive but I’m not interested.” B. “You wouldn’t be the first that I will see naked.” C. “I will report you to the guard if you don’t control yourself.” D. “I only need access to your arm. Putting up your sleeve is fine.” Answer: (D) “I only need access to your arm. Putting up your sleeve is fine.” The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. A and B. These responses are not therapeutic because they are challenging and rejecting. C. Threatening the client is not therapeutic. 76. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive remarks. Which of the following statements is most appropriate to make to this patient? A. What is causing you to become agitated? B. You need to stop that behavior now. C. You will need to be restrained if you do not change your behavior. D. You will need to be placed in seclusion.

Answer: (A) What is causing you to become agitated? In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. B. Pacing is a tension relieving measure for an agitated client. C. This is a threatening statement that can heighten the client’s tension. D. Seclusion is used when less restrictive measures have failed. 77. The nurse closely observes the client who has been displaying aggressive behavior. The nurse observes that the client’s anger is escalating. Which approach is least helpful for the client at this time? A. Acknowledge the client’s behavior B. Maintain a safe distance from the client C. Assist the client to an area that is quiet D. Initiate confinement measures Answer: (D) Initiate confinement measures The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. . When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. A, B and C are appropriate approaches during the escalation phase of aggression. 78. The charge nurse of a psychiatric unit is planning the client assignment for the day. The most appropriate staff to be assigned to a client with a potential for violence is which of the following: A. A timid nurse B. A mature experienced nurse C. an inexperienced nurse D. a soft spoken nurse Answer: (B) A mature experienced nurse The unstable, aggressive client should be assigned to the most experienced nurse. A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient. 79. The nurse exemplifies awareness of the rights of a client whose anger is escalating by: A. Taking a directive role in verbalizing feelings B. Using an authoritarian, confrontational approach C. Putting the client in a seclusion room D. Applying mechanical restraints Answer: (A) Taking a directive role in verbalizing feelings Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. B. A confrontational approach can be threatening and adds to the client’s tension. C and D. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful. 80. The client jumps up and throws a chair out of the window. He was restrained after his behavior can no longer be controlled by the staff. Which of these documentations indicates the safeguarding of the patient’s rights? A. There was a doctor’s order for restraints/seclusion B. The patient’s rights were explained to him. C. The staff observed confidentiality D. The staff carried out less restrictive measures but were unsuccessful. Answer: (D) The staff carried out less restrictive measures but were unsuccessful. This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior. 81. Situation: Clients with personality disorders have difficulties in their social and occupational functions. Clients with personality disorder will most likely: A. recover with therapeutic intervention B. respond to antianxiety medication C. manifest enduring patterns of inflexible behaviors D. Seek treatment willingly from some personally distressing symptoms Answer: (C) manifest enduring patterns of inflexible behaviors Personality disorders are characterized by inflexible traits and characteristics that are lifelong. A and D. This disorder is manifested by life-long patterns of behavior. The client with this disorder will not likely present himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic intervention. B. Medications are generally not recommended for personality

disorders. 82. A client tends to be insensitive to others, engages in abusive behaviors and does not have a sense of remorse. Which personality disorder is he likely to have? A. Narcissistic B. Paranoid C. Histrionic D. Antisocial Answer: (D) Antisocial These are the characteristics of an individual with antisocial personality. A. Narcissistic personality disorder is characterized by grandiosity and a need for constant admiration from others. B. Individuals with paranoid personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as threatening. C. Individuals with histrionic have excessive emotionality, and attention-seeking behaviors. 83. The client joins a support group and frequently preaches against abuse, is demonstrating the use of: A. denial B. reaction formation C. rationalization D. projection Answer: (B) reaction formation Reaction formation is the adoption of behavior or feelings that are exactly opposite of one’s true emotions. A. Denial is refusal to accept a painful reality. C. Rationalization is attempting to justify one’s behavior by presenting reasons that sounds logical. D. Projection is attributing of one’s behaviors and feelings to another person. 84. A teenage girl is diagnosed to have borderline personality disorder. Which manifestations support the diagnosis? A. Lack of self esteem, strong dependency needs and impulsive behavior B. social withdrawal, inadequacy, sensitivity to rejection and criticism C. Suspicious, hypervigilance and coldness D. Preoccupation with perfectionism, orderliness and need for control Answer: (A) Lack of self esteem, strong dependency needs and impulsive behavior These are the characteristics of client with borderline personality. B. This describes the avoidant personality. C. These are the characteristics of a client with paranoid personality D. This describes the obsessive compulsive personality 85. The plan of care for clients with borderline personality should include: A. Limit setting and flexibility in schedule B. Giving medications to prevent acting out C. Restricting her from other clients D. Ensuring she adheres to certain restrictions Answer: (D) Ensuring she adheres to certain restrictions The client is manipulative. The client must be informed about the policies, expectations, rules and regulation upon admission. A. Limits should be firmly and consistently implemented. Flexibility and bargaining are not therapeutic in dealing with a manipulative client. B. There is no specific medication prescribed for this condition. C. This is not part of the care plan. Interaction with other clients are allowed but the client should be observed and given limits in her attempt to manipulate and dominate others. 86. Situation: A 42 year old male client, is admitted in the ward because of bizarre behaviors. He is given a diagnosis of schizophrenia paranoid type. The client should have achieved the developmental task of: A. Trust vs. mistrust B. Industry vs. inferiority C. Generativity vs. stagnation D. Ego integrity vs. despair Answer: (D) Ego integrity vs. despair The client belongs to the middle adulthood stage (30 to 65 yrs.) The developmental task generativity is characterized by concern and care for others. It is a productive and creative stage. (A) Infancy stage (0 – 18 mos.) is concerned with gratification of oral needs (B) School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies and social skills (C) Late adulthood ( 60 and

above) Concerned with reflection on the past and his contributions to others and face the future. 87. Clients who are suspicious primarily use projection for which purpose: A. deny reality B. to deal with feelings and thoughts that are not acceptable C. to show resentment towards others D. manipulate others Answer: (B) to deal with feelings and thoughts that are not acceptable Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to reduce anxiety. A. This is not true in all instances of projection C and D. This focuses on the self rather than others 88. The client says “ the NBI is out to get me.” The nurse’s best response is: A. “The NBI is not out to catch you.” B. “I don’t believe that.” C. “I don’t know anything about that. You are afraid of being harmed.” D. “ What made you think of that.” Answer: (C) “I don’t know anything about that. You are afraid of being harmed.” This presents reality and acknowledges the clients feeling A and B. are not therapeutic responses because these disagree with the client’s false belief and makes the client feel challenged D. unnecessary exploration of the false 89. The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting: A. tardive dyskinesia B. Pseudoparkinsonism C. akinesia D. dystonia Answer: (B) Pseudoparkinsonism Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by mask-like facies, pill rolling tremors, muscle rigidity A. Tardive dyskinesia is manifested by lip smacking, wormlike movement of the tongue C. Akinesia is characterized by feeling of weakness and muscle fatigue D. Dystonia is manifested by torticollis and rolling back of the eyes 90. The client is very hostile toward one of the staff for no apparent reason. The client is manifesting: A. Splitting B. Transference C. Countertransference D. Resistance Answer: (B) Transference Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another A. Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad C. Counterttransference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D. Resistance is the client’s refusal to submit himself to the care of the nurse 91. Situation: An 18 year old female was sexually attacked while on her way home from work. She is brought to the hospital by her mother. Rape is an example of which type of crisis: A. Situational B. Adventitious C. Developmental D. Internal Answer: (B) Adventitious Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life 92. During the initial care of rape victims the following are to be considered EXCEPT: A. Assure privacy. B. Touch the client to show acceptance and empathy C. Accompany the client in the examination room. D. Maintain a non-judgmental approach.

Answer: (B) Touch the client to show acceptance and empathy The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed. 93. The nurse acts as a patient advocate when she does one of the following: A. She encourages the client to express her feeling regarding her experience. B. She assesses the client for injuries. C. She postpones the physical assessment until the client is calm D. Explains to the client that her reactions are normal Answer: (C) She postpones the physical assessment until the client is calm The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher 94. Crisis intervention carried out to the client has this primary goal: A. Assist the client to express her feelings B. Help her identify her resources C. Support her adaptive coping skills D. Help her return to her pre-rape level of function Answer: (D) Help her return to her pre-rape level of function The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal 95. Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from: A. Adjustment disorder B. Somatoform Disorder C. Generalized Anxiety Disorder D. Post traumatic disorder Answer: (D) Post traumatic disorder Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months 96. Situation: A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus with what the doctor was saying. The nurse assesses the level of anxiety as: A. Mild B. Moderate C. Severe D. Panic Answer: (C) Severe The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization 97. Anxiety is caused by: A. an objective threat B. a subjectively perceived threat C. hostility turned to the self D. masked depression Answer: (B) a subjectively perceived threat Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression

98. It would be most helpful for the nurse to deal with a client with severe anxiety by: A. Give specific instructions using speak in concise statements. B. Ask the client to identify the cause of her anxiety. C. Explain i detail the plan of care developed D. Urge the client to focus on what the nurse is saying Answer: (A) Give specific instructions using speak in concise statements. The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus. 99. Which of the following medications will likely be ordered for the client?” A. Prozac B. Valium C. Risperdal D. Lithium Answer: (B) Valium Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic 100. Which of the following is included in the health teachings among clients receiving Valium?: A. Avoid foods rich in tyramine. B. Take the medication after meals. C. It is safe to stop it anytime after long term use. D. Double up the dose if the client forgets her medication. Answer: (B) Take the medication after meals. Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.

Philippine NLE Board Exam: Community Health Nursing Question & Answer w/ rationale COMMUNITY HEALTH NURSING 1. Which is the primary goal of community health nursing? A. To support and supplement the efforts of the medical profession in the promotion of health and prevention of illness B. To enhance the capacity of individuals, families and communities to cope with their health needs C. To increase the productivity of the people by providing them with services that will increase their level of health D. To contribute to national development through promotion of family welfare, focusing particularly on mothers and children. Answer: (B) To enhance the capacity of individuals, families and communities to cope with their health needs To contribute to national development through promotion of family welfare, focusing particularly on mothers and children. 2. CHN is a community-based practice. Which best explains this statement? A. The service is provided in the natural environment of people. B. The nurse has to conduct community diagnosis to determine nursing needs and problems. C. The services are based on the available resources within the community. D. Priority setting is based on the magnitude of the health problems identified. Answer: (B) The nurse has to conduct community diagnosis to determine nursing needs and problems. Community-based practice means providing care to people in their own natural environments: the home, school and workplace, for example. 3. Population-focused nursing practice requires which of the following processes?

A. Community organizing B. Nursing process C. Community diagnosis D. Epidemiologic process Answer: (C) Community diagnosis Population-focused nursing care means providing care based on the greater need of the majority of the population. The greater need is identified through community diagnosis. 4. R.A. 1054 is also known as the Occupational Health Act. Aside from number of employees, what other factor must be considered in determining the occupational health privileges to which the workers will be entitled? A. Type of occupation: agricultural, commercial, industrial B. Location of the workplace in relation to health facilities C. Classification of the business enterprise based on net profit D. Sex and age composition of employees Answer: (B) Location of the workplace in relation to health facilities Based on R.A. 1054, an occupational nurse must be employed when there are 30 to 100 employees and the workplace is more than 1 km. away from the nearest health center. 5. A business firm must employ an occupational health nurse when it has at least how many employees? A. 21 B. 101 C. 201 D. 301 Answer: (B) 101 Again, this is based on R.A. 1054. 6. When the occupational health nurse employs ergonomic principles, she is performing which of her roles? A. Health care provider B. Health educator C. Health care coordinator D. Environmental manager Answer: (D) Environmental manager Ergonomics is improving efficiency of workers by improving the worker’s environment through appropriately designed furniture, for example. 7. A garment factory does not have an occupational nurse. Who shall provide the occupational health needs of the factory workers? A. Occupational health nurse at the Provincial Health Office B. Physician employed by the factory C. Public health nurse of the RHU of their municipality D. Rural sanitary inspector of the RHU of their municipality Answer: (C) Public health nurse of the RHU of their municipality You’re right! This question is based on R.A.1054. 8. “Public health services are given free of charge.” Is this statement true or false? A. The statement is true; it is the responsibility of government to provide basic services. B. The statement is false; people pay indirectly for public health services. C. The statement may be true or false, depending on the specific service required. D. The statement may be true or false, depending on policies of the government concerned. Answer: (B) The statement is false; people pay indirectly for public health services. Community health services, including public health services, are pre-paid services, though taxation, for example. 9. According to C.E.Winslow, which of the following is the goal of Public Health? A. For people to attain their birthrights of health and longevity B. For promotion of health and prevention of disease C. For people to have access to basic health services D. For people to be organized in their health efforts Answer: (A) For people to attain their birthrights of health and longevity According to Winslow, all public health efforts are for people to realize their birthrights of health and

longevity. 10. We say that a Filipino has attained longevity when he is able to reach the average lifespan of Filipinos. What other statistic may be used to determine attainment of longevity? A. Age-specific mortality rate B. Proportionate mortality rate C. Swaroop’s index D. Case fatality rate Answer: (C) Swaroop’s index Swaroop’s index is the percentage of the deaths aged 50 years or older. Its inverse represents the percentage of untimely deaths (those who died younger than 50 years). 11. Which of the following is the most prominent feature of public health nursing? A. It involves providing home care to sick people who are not confined in the hospital. B. Services are provided free of charge to people within the catchment area. C. The public health nurse functions as part of a team providing a public health nursing services. D. Public health nursing focuses on preventive, not curative, services. Answer: (D) Public health nursing focuses on preventive, not curative, services. The catchment area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services. 12. According to Margaret Shetland, the philosophy of public health nursing is based on which of the following? A. Health and longevity as birthrights B. The mandate of the state to protect the birthrights of its citizens C. Public health nursing as a specialized field of nursing D. The worth and dignity of man Answer: (D) The worth and dignity of man This is a direct quote from Dr. Margaret Shetland’s statements on Public Health Nursing. 13. Which of the following is the mission of the Department of Health? A. Health for all Filipinos B. Ensure the accessibility and quality of health care C. Improve the general health status of the population D. Health in the hands of the Filipino people by the year 2020 Answer: (B) Ensure the accessibility and quality of health care (none) 14. Region IV Hospital is classified as what level of facility? A. Primary B. Secondary C. Intermediate D. Tertiary Answer: (D) Tertiary Regional hospitals are tertiary facilities because they serve as training hospitals for the region. 15. Which is true of primary facilities? A. They are usually government-run. B. Their services are provided on an out-patient basis. C. They are training facilities for health professionals. D. A community hospital is an example of this level of health facilities. Answer: (B) Their services are provided on an out-patient basis. Primary facilities government and non-government facilities that provide basic out-patient services. 16. Which is an example of the school nurse’s health care provider functions? A. Requesting for BCG from the RHU for school entrant immunization B. Conducting random classroom inspection during a measles epidemic C. Taking remedial action on an accident hazard in the school playground D. Observing places in the school where pupils spend their free time Answer: (B) Conducting random classroom inspection during a measles epidemic Random classroom inspection is assessment of pupils/students and teachers for signs of a health problem prevalent in the community. 17. When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating

A. Effectiveness B. Efficiency C. Adequacy D. Appropriateness Answer: (B) Efficiency Efficiency is determining whether the goals were attained at the least possible cost. 18. You are a new B.S.N. graduate. You want to become a Public Health Nurse. Where will you apply? A. Department of Health B. Provincial Health Office C. Regional Health Office D. Rural Health Unit Answer: (D) Rural Health Unit R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU. 19. R.A. 7160 mandates devolution of basic services from the national government to local government units. Which of the following is the major goal of devolution? A. To strengthen local government units B. To allow greater autonomy to local government units C. To empower the people and promote their self-reliance D. To make basic services more accessible to the people Answer: (C) To empower the people and promote their self-reliance People empowerment is the basic motivation behind devolution of basic services to LGU’s. 20. Who is the Chairman of the Municipal Health Board? A. Mayor B. Municipal Health Officer C. Public Health Nurse D. Any qualified physician Answer: (A) Mayor The local executive serves as the chairman of the Municipal Health Board. 21. Which level of health facility is the usual point of entry of a client into the health care delivery system? A. Primary B. Secondary C. Intermediate D. Tertiary Answer: (A) Primary The entry of a person into the health care delivery system is usually through a consultation in outpatient services. 22. The public health nurse is the supervisor of rural health midwives. Which of the following is a supervisory function of the public health nurse? A. Referring cases or patients to the midwife B. Providing technical guidance to the midwife C. Providing nursing care to cases referred by the midwife D. Formulating and implementing training programs for midwives Answer: (B) Providing technical guidance to the midwife The nurse provides technical guidance to the midwife in the care of clients, particularly in the implementation of management guidelines, as in Integrated Management of Childhood Illness. 23. One of the participants in a hilot training class asked you to whom she should refer a patient in labor who develops a complication. You will answer, to the A. Public Health Nurse B. Rural Health Midwife C. Municipal Health Officer D. Any of these health professionals Answer: (C) Municipal Health Officer A public health nurse and rural health midwife can provide care during normal childbirth. A physician should attend to a woman with a complication during labor.

24. You are the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need? A. 1 B. 2 C. 3 D. The RHU does not need any more midwife item. Answer: (A) 1 Each rural health midwife is given a population assignment of about 5,000. 25. If the RHU needs additional midwife items, you will submit the request for additional midwife items for approval to the A. Rural Health Unit B. District Health Office C. Provincial Health Office D. Municipal Health Board Answer: (D) Municipal Health Board As mandated by R.A. 7160, basic health services have been devolved from the national government to local government units. 26. As an epidemiologist, the nurse is responsible for reporting cases of notifiable diseases. What law mandates reporting of cases of notifiable diseases? A. Act 3573 B. R.A. 3753 C. R.A. 1054 D. R.A. 1082 Answer: (A) Act 3573 Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929, mandated the reporting of diseases listed in the law to the nearest health station. 27. According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following best illustrates this statement? A. The community health nurse continuously develops himself personally and professionally. B. Health education and community organizing are necessary in providing community health services. C. Community health nursing is intended primarily for health promotion and prevention and treatment of disease. D. The goal of community health nursing is to provide nursing services to people in their own places of residence. Answer: (B) Health education and community organizing are necessary in providing community health services. The community health nurse develops the health capability of people through health education and community organizing activities. 28. Which disease was declared through Presidential Proclamation No. 4 as a target for eradication in the Philippines? A. Poliomyelitis B. Measles C. Rabies D. Neonatal tetanus Answer: (B) Measles Presidential Proclamation No. 4 is on the Ligtas Tigdas Program. 29. The public health nurse is responsible for presenting the municipal health statistics using graphs and tables. To compare the frequency of the leading causes of mortality in the municipality, which graph will you prepare? A. Line B. Bar C. Pie D. Scatter diagram Answer: (B) Bar A bar graph is used to present comparison of values, a line graph for trends over time or age, a pie graph for population composition or distribution, and a scatter diagram for correlation of two

variables. 30. Which step in community organizing involves training of potential leaders in the community? A. Integration B. Community organization C. Community study D. Core group formation Answer: (D) Core group formation In core group formation, the nurse is able to transfer the technology of community organizing to the potential or informal community leaders through a training program. 31. In which step are plans formulated for solving community problems? A. Mobilization B. Community organization C. Follow-up/extension D. Core group formation Answer: (B) Community organization Community organization is the step when community assemblies take place. During the community assembly, the people may opt to formalize the community organization and make plans for community action to resolve a community health problem. 32. The public health nurse takes an active role in community participation. What is the primary goal of community organizing? A. To educate the people regarding community health problems B. To mobilize the people to resolve community health problems C. To maximize the community’s resources in dealing with health problems D. To maximize the community’s resources in dealing with health problems Answer: (D) To maximize the community’s resources in dealing with health problems Community organizing is a developmental service, with the goal of developing the people’s selfreliance in dealing with community health problems. A, B and C are objectives of contributory objectives to this goal. 33. An indicator of success in community organizing is when people are able to A. Participate in community activities for the solution of a community problem B. Implement activities for the solution of the community problem C. Plan activities for the solution of the community problem D. Identify the health problem as a common concern Answer: (A) Participate in community activities for the solution of a community problem Participation in community activities in resolving a community problem may be in any of the processes mentioned in the other choices. 34. Tertiary prevention is needed in which stage of the natural history of disease? A. Pre-pathogenesis B. Pathogenesis C. Prodromal D. Terminal Answer: (D) Terminal Tertiary prevention involves rehabilitation, prevention of permanent disability and disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally ill (those in the terminal stage of a disease) 35. Isolation of a child with measles belongs to what level of prevention? A. Primary B. Secondary C. Intermediate D. Tertiary Answer: (A) Primary The purpose of isolating a client with a communicable disease is to protect those who are not sick (specific disease prevention). 36. On the other hand, Operation Timbang is _____ prevention. A. Primary B. Secondary C. Intermediate D. Tertiary

Answer: (B) Secondary Operation Timbang is done to identify members of the susceptible population who are malnourished. Its purpose is early diagnosis and, subsequently, prompt treatment. 37. Which type of family-nurse contact will provide you with the best opportunity to observe family dynamics? A. Clinic consultation B. Group conference C. Home visit D. Written communication Answer: (C) Home visit Dynamics of family relationships can best be observed in the family’s natural environment, which is the home. 38. The typology of family nursing problems is used in the statement of nursing diagnosis in the care of families. The youngest child of the de los Reyes family has been diagnosed as mentally retarded. This is classified as a A. Health threat B. Health deficit C. Foreseeable crisis D. Stress point Answer: (B) Health deficit Failure of a family member to develop according to what is expected, as in mental retardation, is a health deficit. 39. The de los Reyes couple have a 6-year old child entering school for the first time. The de los Reyes family has a A. Health threat B. Health deficit C. Foreseeable crisis D. Stress point Answer: (C) Foreseeable crisis Entry of the 6-year old into school is an anticipated period of unusual demand on the family. 40. Which of the following is an advantage of a home visit? A. It allows the nurse to provide nursing care to a greater number of people. B. It provides an opportunity to do first hand appraisal of the home situation. C. It allows sharing of experiences among people with similar health problems. D. It develops the family’s initiative in providing for health needs of its members. Answer: (B) It provides an opportunity to do first hand appraisal of the home situation. Choice A is not correct since a home visit requires that the nurse spend so much time with the family. Choice C is an advantage of a group conference, while choice D is true of a clinic consultation. 41. Which is CONTRARY to the principles in planning a home visit? A. A home visit should have a purpose or objective. B. The plan should revolve around family health needs. C. A home visit should be conducted in the manner prescribed by the RHU. D. Planning of continuing care should involve a responsible family member. Answer: (C) A home visit should be conducted in the manner prescribed by the RHU. The home visit plan should be flexible and practical, depending on factors, such as the family’s needs and the resources available to the nurse and the family. 42. The PHN bag is an important tool in providing nursing care during a home visit. The most important principle of bag technique states that it A. Should save time and effort. B. Should minimize if not totally prevent the spread of infection. C. Should not overshadow concern for the patient and his family. D. May be done in a variety of ways depending on the home situation, etc. Answer: (B) Should minimize if not totally prevent the spread of infection. Bag technique is performed before and after handling a client in the home to prevent transmission of infection to and from the client. 43. To maintain the cleanliness of the bag and its contents, which of the following must the nurse do? A. Wash his/her hands before and after providing nursing care to the family members.

B. In the care of family members, as much as possible, use only articles taken from the bag. C. Put on an apron to protect her uniform and fold it with the right side out before putting it back into the bag. D. At the end of the visit, fold the lining on which the bag was placed, ensuring that the contaminated side is on the outside. Answer: (A) Wash his/her hands before and after providing nursing care to the family members. Choice B goes against the idea of utilizing the family’s resources, which is encouraged in CHN. Choices C and D goes against the principle of asepsis of confining the contaminated surface of objects. 44. The public health nurse conducts a study on the factors contributing to the high mortality rate due to heart disease in the municipality where she works. Which branch of epidemiology does the nurse practice in this situation? A. Descriptive B. Analytical C. Therapeutic D. Evaluation Answer: (B) Analytical Analytical epidemiology is the study of factors or determinants affecting the patterns of occurrence and distribution of disease in a community. 45. Which of the following is a function of epidemiology? A. Identifying the disease condition based on manifestations presented by a client B. Determining factors that contributed to the occurrence of pneumonia in a 3 year old C. Determining the efficacy of the antibiotic used in the treatment of the 3 year old client with pneumonia D. Evaluating the effectiveness of the implementation of the Integrated Management of Childhood Illness Answer: (D) Evaluating the effectiveness of the implementation of the Integrated Management of Childhood Illness Epidemiology is used in the assessment of a community or evaluation of interventions in community health practice. 46. Which of the following is an epidemiologic function of the nurse during an epidemic? A. Conducting assessment of suspected cases to detect the communicable disease B. Monitoring the condition of the cases affected by the communicable disease C. Participating in the investigation to determine the source of the epidemic D. Teaching the community on preventive measures against the disease Answer: (C) Participating in the investigation to determine the source of the epidemic Epidemiology is the study of patterns of occurrence and distribution of disease in the community, as well as the factors that affect disease patterns. The purpose of an epidemiologic investigation is to identify the source of an epidemic, i.e., what brought about the epidemic. 47. The primary purpose of conducting an epidemiologic investigation is to A. Delineate the etiology of the epidemic B. Encourage cooperation and support of the community C. Identify groups who are at risk of contracting the disease D. Identify geographical location of cases of the disease in the community Answer: (A) Delineate the etiology of the epidemic Delineating the etiology of an epidemic is identifying its source. 48. Which is a characteristic of person-to-person propagated epidemics? A. There are more cases of the disease than expected. B. The disease must necessarily be transmitted through a vector. C. The spread of the disease can be attributed to a common vehicle. D. There is a gradual build up of cases before the epidemic becomes easily noticeable. Answer: (D) There is a gradual build up of cases before the epidemic becomes easily noticeable. A gradual or insidious onset of the epidemic is usually observable in person-to-person propagated epidemics. 49. In the investigation of an epidemic, you compare the present frequency of the disease with the usual frequency at this time of the year in this community. This is done during which stage of the investigation? A. Establishing the epidemic

B. Testing the hypothesis C. Formulation of the hypothesis D. Appraisal of facts Answer: (A) Establishing the epidemic Establishing the epidemic is determining whether there is an epidemic or not. This is done by comparing the present number of cases with the usual number of cases of the disease at the same time of the year, as well as establishing the relatedness of the cases of the disease. 50. The number of cases of Dengue fever usually increases towards the end of the rainy season. This pattern of occurrence of Dengue fever is best described as A. Epidemic occurrence B. Cyclical variation C. Sporadic occurrence D. Secular variation Answer: (B) Cyclical variation A cyclical variation is a periodic fluctuation in the number of cases of a disease in the community. 51. In the year 1980, the World Health Organization declared the Philippines, together with some other countries in the Western Pacific Region, “free” of which disease? A. Pneumonic plague B. Poliomyelitis C. Small pox D. Anthrax Answer: (C) Small pox The last documented case of Small pox was in 1977 at Somalia. 52. In the census of the Philippines in 1995, there were about 35,299,000 males and about 34,968,000 females. What is the sex ratio? A. 99.06:100 B. 100.94:100 C. 50.23% D. 49.76% Answer: (B) 100.94:100 Sex ratio is the number of males for every 100 females in the population. 53. Primary health care is a total approach to community development. Which of the following is an indicator of success in the use of the primary health care approach? A. Health services are provided free of charge to individuals and families. B. Local officials are empowered as the major decision makers in matters of health. C. Health workers are able to provide care based on identified health needs of the people. D. Health programs are sustained according to the level of development of the community. Answer: (D) Health programs are sustained according to the level of development of the community. Primary health care is essential health care that can be sustained in all stages of development of the community. 54. Sputum examination is the major screening tool for pulmonary tuberculosis. Clients would sometimes get false negative results in this exam. This means that the test is not perfect in terms of which characteristic of a diagnostic examination? A. Effectiveness B. Efficacy C. Specificity D. Sensitivity Answer: (D) Sensitivity Sensitivity is the capacity of a diagnostic examination to detect cases of the disease. If a test is 100% sensitive, all the cases tested will have a positive result, i.e., there will be no false negative results. 55. Use of appropriate technology requires knowledge of indigenous technology. Which medicinal herb is given for fever, headache and cough? A. Sambong B. Tsaang gubat C. Akapulko D. Lagundi Answer: (D) Lagundi

Sambong is used as a diuretic. Tsaang gubat is used to relieve diarrhea. Akapulko is used for its antifungal property. 56. What law created the Philippine Institute of Traditional and Alternative Health Care? A. R.A. 8423 B. R.A. 4823 C. R.A. 2483 D. R.A. 3482 Answer: (A) R.A. 8423 (none) 57. In traditional Chinese medicine, the yielding, negative and feminine force is termed A. Yin B. Yang C. Qi D. Chai Answer: (A) Yin Yang is the male dominating, positive and masculine force. 58. What is the legal basis for Primary Health Care approach in the Philippines? A. Alma Ata Declaration on PHC B. Letter of Instruction No. 949 C. Presidential Decree No. 147 D. Presidential Decree 996 Answer: (B) Letter of Instruction No. 949 Letter of Instruction 949 was issued by then President Ferdinand Marcos, directing the formerly called Ministry of Health, now the Department of Health, to utilize Primary Health Care approach in planning and implementing health programs. 59. Which of the following demonstrates intersectoral linkages? A. Two-way referral system B. Team approach C. Endorsement done by a midwife to another midwife D. Cooperation between the PHN and public school teacher Answer: (D) Cooperation between the PHN and public school teacher Intersectoral linkages refer to working relationships between the health sector and other sectors involved in community development. 60. The municipality assigned to you has a population of about 20,000. Estimate the number of 1-4 year old children who will be given Retinol capsule 200,000 I.U. every 6 months. A. 1,500 B. 1,800 C. 2,000 D. 2,300 Answer: (D) 2,300 Based on the Philippine population composition, to estimate the number of 1-4 year old children, multiply total population by 11.5%. 61. Estimate the number of pregnant women who will be given tetanus toxoid during an immunization outreach activity in a barangay with a population of about 1,500. A. 265 B. 300 C. 375 D. 400 Answer: (A) 265 To estimate the number of pregnant women, multiply the total population by 3.5%. 62. To describe the sex composition of the population, which demographic tool may be used? A. Sex ratio B. Sex proportion C. Population pyramid D. Any of these may be used. Answer: (D) Any of these may be used. Sex ratio and sex proportion are used to determine the sex composition of a population. A population

pyramid is used to present the composition of a population by age and sex. 63. Which of the following is a natality rate? A. Crude birth rate B. Neonatal mortality rate C. Infant mortality rate D. General fertility rate Answer: (A) Crude birth rate Natality means birth. A natality rate is a birth rate. 64. You are computing the crude death rate of your municipality, with a total population of about 18,000, for last year. There were 94 deaths. Among those who died, 20 died because of diseases of the heart and 32 were aged 50 years or older. What is the crude death rate? A. 4.2/1,000 B. 5.2/1,000 C. 6.3/1,000 D. 7.3/1,000 Answer: (B) 5.2/1,000 To compute crude death rate divide total number of deaths (94) by total population (18,000) and multiply by 1,000. 65. Knowing that malnutrition is a frequent community health problem, you decided to conduct nutritional assessment. What population is particularly susceptible to protein energy malnutrition (PEM)? A. Pregnant women and the elderly B. Under-5 year old children C. 1-4 year old children D. School age children Answer: (C) 1-4 year old children Preschoolers are the most susceptible to PEM because they have generally been weaned. Also, this is the population who, unable to feed themselves, are often the victims of poor intrafamilial food distribution. 66. Which statistic can give the most accurate reflection of the health status of a community? A. 1-4 year old age-specific mortality rate B. Infant mortality rate C. Swaroop’s index D. Crude death rate Answer: (C) Swaroop’s index Swaroop’s index is the proportion of deaths aged 50 years and above. The higher the Swaroop’s index of a population, the greater the proportion of the deaths who were able to reach the age of at least 50 years, i.e., more people grew old before they died. 67. In the past year, Barangay A had an average population of 1655. 46 babies were born in that year, 2 of whom died less than 4 weeks after they were born. There were 4 recorded stillbirths. What is the neonatal mortality rate? A. 27.8/1,000 B. 43.5/1,000 C. 86.9/1,000 D. 130.4/1,000 Answer: (B) 43.5/1,000 To compute for neonatal mortality rate, divide the number of babies who died before reaching the age of 28 days by the total number of live births, then multiply by 1,000. 68. Which statistic best reflects the nutritional status of a population? A. 1-4 year old age-specific mortality rate B. Proportionate mortality rate C. Infant mortality rate D. Swaroop’s index Answer: (A) 1-4 year old age-specific mortality rate Since preschoolers are the most susceptible to the effects of malnutrition, a population with poor nutritional status will most likely have a high 1-4 year old age-specific mortality rate, also known as child mortality rate.

69. What numerator is used in computing general fertility rate? A. Estimated midyear population B. Number of registered live births C. Number of pregnancies in the year D. Number of females of reproductive age Answer: (B) Number of registered live births To compute for general or total fertility rate, divide the number of registered live births by the number of females of reproductive age (15-45 years), then multiply by 1,000. 70. You will gather data for nutritional assessment of a purok. You will gather information only from families with members who belong to the target population for PEM. What method of data gathering is best for this purpose? A. Census B. Survey C. Record review D. Review of civil registry Answer: (B) Survey A survey, also called sample survey, is data gathering about a sample of the population. 71. In the conduct of a census, the method of population assignment based on the actual physical location of the people is termed A. De jure B. De locus C. De facto D. De novo Answer: (C) De facto The other method of population assignment, de jure, is based on the usual place of residence of the people. 72. The Field Health Services and Information System (FHSIS) is the recording and reporting system in public health care in the Philippines. The Monthly Field Health Service Activity Report is a form used in which of the components of the FHSIS? A. Tally report B. Output report C. Target/client list D. Individual health record Answer: (A) Tally report A tally report is prepared monthly or quarterly by the RHU personnel and transmitted to the Provincial Health Office. 73. To monitor clients registered in long-term regimens, such as the Multi-Drug Therapy, which component will be most useful? A. Tally report B. Output report C. Target/client list D. Individual health record Answer: (C) Target/client list The MDT Client List is a record of clients enrolled in MDT and other relevant data, such as dates when clients collected their monthly supply of drugs. 74. Civil registries are important sources of data. Which law requires registration of births within 30 days from the occurrence of the birth? A. P.D. 651 B. Act 3573 C. R.A. 3753 D. R.A. 3375 Answer: (A) P.D. 651 P.D. 651 amended R.A. 3753, requiring the registry of births within 30 days from their occurrence. 75. Which of the following professionals can sign the birth certificate? A. Public health nurse B. Rural health midwife C. Municipal health officer D. Any of these health professionals

Answer: (D) Any of these health professionals D. R.A. 3753 states that any birth attendant may sign the certificate of live birth. 76. Which criterion in priority setting of health problems is used only in community health care? A. Modifiability of the problem B. Nature of the problem presented C. Magnitude of the health problem D. Preventive potential of the health problem Answer: (C) Magnitude of the health problem Magnitude of the problem refers to the percentage of the population affected by a health problem. The other choices are criteria considered in both family and community health care. 77. The Sentrong Sigla Movement has been launched to improve health service delivery. Which of the following is/are true of this movement? A. This is a project spearheaded by local government units. B. It is a basis for increasing funding from local government units. C. It encourages health centers to focus on disease prevention and control. D. Its main strategy is certification of health centers able to comply with standards. Answer: (D) Its main strategy is certification of health centers able to comply with standards. Sentrong Sigla Movement is a joint project of the DOH and local government units. Its main strategy is certification of health centers that are able to comply with standards set by the DOH. 78. Which of the following women should be considered as special targets for family planning? A. Those who have two children or more B. Those with medical conditions such as anemia C. Those younger than 20 years and older than 35 years D. Those who just had a delivery within the past 15 months Answer: (D) Those who just had a delivery within the past 15 months The ideal birth spacing is at least two years. 15 months plus 9 months of pregnancy = 2 years. 79. Freedom of choice is one of the policies of the Family Planning Program of the Philippines. Which of the following illustrates this principle? A. Information dissemination about the need for family planning B. Support of research and development in family planning methods C. Adequate information for couples regarding the different methods D. Encouragement of couples to take family planning as a joint responsibility Answer: (C) Adequate information for couples regarding the different methods To enable the couple to choose freely among different methods of family planning, they must be given full information regarding the different methods that are available to them, considering the availability of quality services that can support their choice. 80. A woman, 6 months pregnant, came to the center for consultation. Which of the following substances is contraindicated? A. Tetanus toxoid B. Retinol 200,000 IU C. Ferrous sulfate 200 mg D. Potassium iodate 200 mg. capsule Answer: (B) Retinol 200,000 IU Retinol 200,000 IU is a form of megadose Vitamin A. This may have a teratogenic effect. 81. During prenatal consultation, a client asked you if she can have her delivery at home. After history taking and physical examination, you advised her against a home delivery. Which of the following findings disqualifies her for a home delivery? A. Her OB score is G5P3. B. She has some palmar pallor. C. Her blood pressure is 130/80. D. Her baby is in cephalic presentation. Answer: (A) Her OB score is G5P3. Only women with less than 5 pregnancies are qualified for a home delivery. It is also advisable for a primigravida to have delivery at a childbirth facility. 82. Inadequate intake by the pregnant woman of which vitamin may cause neural tube defects? A. Niacin B. Riboflavin

C. Folic acid D. Thiamine Answer: (C) Folic acid It is estimated that the incidence of neural tube defects can be reduced drastically if pregnant women have an adequate intake of folic acid. 83. You are in a client’s home to attend to a delivery. Which of the following will you do first? A. Set up the sterile area. B. Put on a clean gown or apron. C. Cleanse the client’s vulva with soap and water. D. Note the interval, duration and intensity of labor contractions. Answer: (D) Note the interval, duration and intensity of labor contractions. Assessment of the woman should be done first to determine whether she is having true labor and, if so, what stage of labor she is in. 84. In preparing a primigravida for breastfeeding, which of the following will you do? A. Tell her that lactation begins within a day after delivery. B. Teach her nipple stretching exercises if her nipples are everted. C. Instruct her to wash her nipples before and after each breastfeeding. D. Explain to her that putting the baby to breast will lessen blood loss after delivery. Answer: (D) Explain to her that putting the baby to breast will lessen blood loss after delivery. Suckling of the nipple stimulates the release of oxytocin by the posterior pituitary gland, which causes uterine contraction. Lactation begins 1 to 3 days after delivery. Nipple stretching exercises are done when the nipples are flat or inverted. Frequent washing dries up the nipples, making them prone to the formation of fissures. 85. A primigravida is instructed to offer her breast to the baby for the first time within 30 minutes after delivery. What is the purpose of offering the breast this early? A. To initiate the occurrence of milk letdown B. To stimulate milk production by the mammary acini C. To make sure that the baby is able to get the colostrum D. To allow the woman to practice breastfeeding in the presence of the health worker Answer: (B) To stimulate milk production by the mammary acini Suckling of the nipple stimulates prolactin reflex (the release of prolactin by the anterior pituitary gland), which initiates lactation. 86. In a mothers’ class, you discuss proper breastfeeding technique. Which is of these is a sign that the baby has “latched on” to the breast properly? A. The baby takes shallow, rapid sucks. B. The mother does not feel nipple pain. C. The baby’s mouth is only partly open. D. Only the mother’s nipple is inside the baby’s mouth. Answer: (B) The mother does not feel nipple pain. When the baby has properly latched on to the breast, he takes deep, slow sucks; his mouth is wide open; and much of the areola is inside his mouth. And, you’re right! The mother does not feel nipple pain. 87. You explain to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs only up to ____. A. 3 months B. 6 months C. 1 year D. 2 years Answer: (B) 6 months After 6 months, the baby’s nutrient needs, especially the baby’s iron requirement, can no longer be provided by mother’s milk alone. 88. What is given to a woman within a month after the delivery of a baby? A. Malunggay capsule B. Ferrous sulfate 100 mg. OD C. Retinol 200,000 I.U., 1 capsule D. Potassium iodate 200 mg, 1 capsule Answer: (C) Retinol 200,000 I.U., 1 capsule A capsule of Retinol 200,000 IU is given within 1 month after delivery. Potassium iodate is given

during pregnancy; malunggay capsule is not routinely administered after delivery; and ferrous sulfate is taken for two months after delivery. 89. Which biological used in Expanded Program on Immunization (EPI) is stored in the freezer? A. DPT B. Tetanus toxoid C. Measles vaccine D. Hepatitis B vaccine Answer: (C) Measles vaccine Among the biologicals used in the Expanded Program on Immunization, measles vaccine and OPV are highly sensitive to heat, requiring storage in the freezer. 90. Unused BCG should be discarded how many hours after reconstitution? A. 2 B. 4 C. 6 D. At the end of the day Answer: (B) 4 While the unused portion of other biologicals in EPI may be given until the end of the day, only BCG is discarded 4 hours after reconstitution. This is why BCG immunization is scheduled only in the morning. 91. In immunizing school entrants with BCG, you are not obliged to secure parental consent. This is because of which legal document? A. P.D. 996 B. R.A. 7846 C. Presidential Proclamation No. 6 D. Presidential Proclamation No. 46 Answer: (A) P.D. 996 Presidential Decree 996, enacted in 1976, made immunization in the EPI compulsory for children under 8 years of age. Hepatitis B vaccination was made compulsory for the same age group by R.A. 7846. 92. Which immunization produces a permanent scar? A. DPT B. BCG C. Measles vaccination D. Hepatitis B vaccination Answer: (B) BCG BCG causes the formation of a superficial abscess, which begins 2 weeks after immunization. The abscess heals without treatment, with the formation of a permanent scar. 93. A 4-week old baby was brought to the health center for his first immunization. Which can be given to him? A. DPT1 B. OPV1 C. Infant BCG D. Hepatitis B vaccine 1 Answer: (C) Infant BCG Infant BCG may be given at birth. All the other immunizations mentioned can be given at 6 weeks of age. 94. You will not give DPT 2 if the mother says that the infant had A. Seizures a day after DPT 1. B. Fever for 3 days after DPT 1. C. Abscess formation after DPT 1. D. Local tenderness for 3 days after DPT 1. Answer: (A) Seizures a day after DPT 1. Seizures within 3 days after administration of DPT is an indication of hypersensitivity to pertussis vaccine, a component of DPT. This is considered a specific contraindication to subsequent doses of DPT. 95. A 2-month old infant was brought to the health center for immunization. During assessment, the infant’s temperature registered at 38.1°C. Which is the best course of action that you will take? A. Go on with the infant’s immunizations.

B. Give Paracetamol and wait for his fever to subside. C. Refer the infant to the physician for further assessment. D. Advise the infant’s mother to bring him back for immunization when he is well. Answer: (A) Go on with the infant’s immunizations. In the EPI, fever up to 38.5°C is not a contraindication to immunization. Mild acute respiratory tract infection, simple diarrhea and malnutrition are not contraindications either. 96. A pregnant woman had just received her 4th dose of tetanus toxoid. Subsequently, her baby will have protection against tetanus for how long? A. 1 year B. 3 years C. 10 years D. Lifetime Answer: (A) 1 year The baby will have passive natural immunity by placental transfer of antibodies. The mother will have active artificial immunity lasting for about 10 years. 5 doses will give the mother lifetime protection. 97. A 4-month old infant was brought to the health center because of cough. Her respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, her breathing is considered A. Fast B. Slow C. Normal D. Insignificant Answer: (C) Normal In IMCI, a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12 months. 98. Which of the following signs will indicate that a young child is suffering from severe pneumonia? A. Dyspnea B. Wheezing C. Fast breathing D. Chest indrawing Answer: (D) Chest indrawing In IMCI, chest indrawing is used as the positive sign of dyspnea, indicating severe pneumonia. 99. Using IMCI guidelines, you classify a child as having severe pneumonia. What is the best management for the child? A. Prescribe an antibiotic. B. Refer him urgently to the hospital. C. Instruct the mother to increase fluid intake. D. Instruct the mother to continue breastfeeding. Answer: (B) Refer him urgently to the hospital. Severe pneumonia requires urgent referral to a hospital. Answers A, C and D are done for a client classified as having pneumonia. 100. A 5-month old infant was brought by his mother to the health center because of diarrhea occurring 4 to 5 times a day. His skin goes back slowly after a skin pinch and his eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category? A. No signs of dehydration B. Some dehydration C. Severe dehydration D. The data is insufficient. Answer: (B) Some dehydration Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or irritable, sunken eyes, the skin goes back slow after a skin pinch. 101. Based on assessment, you classified a 3-month old infant with the chief complaint of diarrhea in the category of SOME DEHYDRATION. Based on IMCI management guidelines, which of the following will you do? A. Bring the infant to the nearest facility where IV fluids can be given. B. Supervise the mother in giving 200 to 400 ml. of Oresol in 4 hours.

C. Give the infant’s mother instructions on home management. D. Keep the infant in your health center for close observation. Answer: (B) Supervise the mother in giving 200 to 400 ml. of Oresol in 4 hours. In the IMCI management guidelines, SOME DEHYDRATION is treated with the administration of Oresol within a period of 4 hours. The amount of Oresol is best computed on the basis of the child’s weight (75 ml/kg body weight). If the weight is unknown, the amount of Oresol is based on the child’s age. 102. A mother is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. You will tell her to A. Bring the child to the nearest hospital for further assessment. B. Bring the child to the health center for intravenous fluid therapy. C. Bring the child to the health center for assessment by the physician. D. Let the child rest for 10 minutes then continue giving Oresol more slowly. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly. If the child vomits persistently, that is, he vomits everything that he takes in, he has to be referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10 minutes and then continuing with Oresol administration. Teach the mother to give Oresol more slowly. 103. A 1 ½ year old child was classified as having 3rd degree protein energy malnutrition, kwashiorkor. Which of the following signs will be most apparent in this child? A. Voracious appetite B. Wasting C. Apathy D. Edema Answer: (D) Edema Edema, a major sign of kwashiorkor, is caused by decreased colloidal osmotic pressure of the blood brought about by hypoalbuminemia. Decreased blood albumin level is due a protein-deficient diet. 104. Assessment of a 2-year old child revealed “baggy pants”. Using the IMCI guidelines, how will you manage this child? A. Refer the child urgently to a hospital for confinement. B. Coordinate with the social worker to enroll the child in a feeding program. C. Make a teaching plan for the mother, focusing on menu planning for her child. D. Assess and treat the child for health problems like infections and intestinal parasitism. Answer: (A) Refer the child urgently to a hospital for confinement. “Baggy pants” is a sign of severe marasmus. The best management is urgent referral to a hospital. 105. During the physical examination of a young child, what is the earliest sign of xerophthalmia that you may observe? A. Keratomalacia B. Corneal opacity C. Night blindness D. Conjunctival xerosis Answer: (D) Conjunctival xerosis The earliest sign of Vitamin A deficiency (xerophthalmia) is night blindness. However, this is a functional change, which is not observable during physical examination.The earliest visible lesion is conjunctival xerosis or dullness of the conjunctiva due to inadequate tear production. 106. To prevent xerophthalmia, young children are given Retinol capsule every 6 months. What is the dose given to preschoolers? A. 10,000 IU B. 20,000 IU C. 100,000 IU D. 200,000 IU Answer: (D) 200,000 IU Preschoolers are given Retinol 200,000 IU every 6 months. 100,000 IU is given once to infants aged 6 to 12 months. The dose for pregnant women is 10,000 IU. 107. The major sign of iron deficiency anemia is pallor. What part is best examined for pallor? A. Palms B. Nailbeds C. Around the lips D. Lower conjunctival sac

Answer: (A) Palms The anatomic characteristics of the palms allow a reliable and convenient basis for examination for pallor. 108. Food fortification is one of the strategies to prevent micronutrient deficiency conditions. R.A. 8976 mandates fortification of certain food items. Which of the following is among these food items? A. Sugar B. Bread C. Margarine D. Filled milk Answer: (A) Sugar R.A. 8976 mandates fortification of rice, wheat flour, sugar and cooking oil with Vitamin A, iron and/or iodine. 109. What is the best course of action when there is a measles epidemic in a nearby municipality? A. Give measles vaccine to babies aged 6 to 8 months. B. Give babies aged 6 to 11 months one dose of 100,000 I.U. of Retinol C. Instruct mothers to keep their babies at home to prevent disease transmission. D. Instruct mothers to feed their babies adequately to enhance their babies’ resistance. Answer: (A) Give measles vaccine to babies aged 6 to 8 months. Ordinarily, measles vaccine is given at 9 months of age. During an impending epidemic, however, one dose may be given to babies aged 6 to 8 months. The mother is instructed that the baby needs another dose when the baby is 9 months old. 110. A mother brought her daughter, 4 years old, to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital? A. Inability to drink B. High grade fever C. Signs of severe dehydration D. Cough for more than 30 days Answer: (A) Inability to drink A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken. 111. Management of a child with measles includes the administration of which of the following? A. Gentian violet on mouth lesions B. Antibiotics to prevent pneumonia C. Tetracycline eye ointment for corneal opacity D. Retinol capsule regardless of when the last dose was given Answer: (D) Retinol capsule regardless of when the last dose was given An infant 6 to 12 months classified as a case of measles is given Retinol 100,000 IU; a child is given 200,000 IU regardless of when the last dose was given. 112. A mother brought her 10 month old infant for consultation because of fever, which started 4 days prior to consultation. To determine malaria risk, what will you do? A. Do a tourniquet test. B. Ask where the family resides. C. Get a specimen for blood smear. D. Ask if the fever is present everyday. Answer: (B) Ask where the family resides. Because malaria is endemic, the first question to determine malaria risk is where the client’s family resides. If the area of residence is not a known endemic area, ask if the child had traveled within the past 6 months, where he/she was brought and whether he/she stayed overnight in that area. 113. The following are strategies implemented by the Department of Health to prevent mosquitoborne diseases. Which of these is most effective in the control of Dengue fever? A. Stream seeding with larva-eating fish B. Destroying breeding places of mosquitoes C. Chemoprophylaxis of non-immune persons going to endemic areas D. Teaching people in endemic areas to use chemically treated mosquito nets

Answer: (B) Destroying breeding places of mosquitoes Aedes aegypti, the vector of Dengue fever, breeds in stagnant, clear water. Its feeding time is usually during the daytime. It has a cyclical pattern of occurrence, unlike malaria which is endemic in certain parts of the country. 114. Secondary prevention for malaria includes A. Planting of neem or eucalyptus trees B. Residual spraying of insecticides at night C. Determining whether a place is endemic or not D. Growing larva-eating fish in mosquito breeding places Answer: (C) Determining whether a place is endemic or not This is diagnostic and therefore secondary level prevention. The other choices are for primary prevention. 115. Scotch tape swab is done to check for which intestinal parasite? A. Ascaris B. Pinworm C. Hookworm D. Schistosoma Answer: (B) Pinworm Pinworm ova are deposited around the anal orifice. 116. Which of the following signs indicates the need for sputum examination for AFB? A. Hematemesis B. Fever for 1 week C. Cough for 3 weeks D. Chest pain for 1 week Answer: (C) Cough for 3 weeks A client is considered a PTB suspect when he has cough for 2 weeks or more, plus one or more of the following signs: fever for 1 month or more; chest pain lasting for 2 weeks or more not attributed to other conditions; progressive, unexplained weight loss; night sweats; and hemoptysis. 117. Which clients are considered targets for DOTS Category I? A. Sputum negative cavitary cases B. Clients returning after a default C. Relapses and failures of previous PTB treatment regimens D. Clients diagnosed for the first time through a positive sputum exam Answer: (D) Clients diagnosed for the first time through a positive sputum exam Category I is for new clients diagnosed by sputum examination and clients diagnosed to have a serious form of extrapulmonary tuberculosis, such as TB osteomyelitis. 118. To improve compliance to treatment, what innovation is being implemented in DOTS? A. Having the health worker follow up the client at home B. Having the health worker or a responsible family member monitor drug intake C. Having the patient come to the health center every month to get his medications D. Having a target list to check on whether the patient has collected his monthly supply of drugs Answer: (B) Having the health worker or a responsible family member monitor drug intake Directly Observed Treatment Short Course is so-called because a treatment partner, preferably a health worker accessible to the client, monitors the client’s compliance to the treatment. 119. Diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy? A. Macular lesions B. Inability to close eyelids C. Thickened painful nerves D. Sinking of the nosebridge Answer: (C) Thickened painful nerves The lesion of leprosy is not macular. It is characterized by a change in skin color (either reddish or whitish) and loss of sensation, sweating and hair growth over the lesion. Inability to close the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms. 120. Which of the following clients should be classified as a case of multibacillary leprosy? A. 3 skin lesions, negative slit skin smear B. 3 skin lesions, positive slit skin smear C. 5 skin lesions, negative slit skin smear

D. 5 skin lesions, positive slit skin smear Answer: (D) 5 skin lesions, positive slit skin smear A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions. 121. In the Philippines, which condition is the most frequent cause of death associated with schistosomiasis? A. Liver cancer B. Liver cirrhosis C. Bladder cancer D. Intestinal perforation Answer: (B) Liver cirrhosis The etiologic agent of schistosomiasis in the Philippines is Schistosoma japonicum, which affects the small intestine and the liver. Liver damage is a consequence of fibrotic reactions to schistosoma eggs in the liver. 122. What is the most effective way of controlling schistosomiasis in an endemic area? A. Use of molluscicides B. Building of foot bridges C. Proper use of sanitary toilets D. Use of protective footwear, such as rubber boots Answer: (C) Proper use of sanitary toilets The ova of the parasite get out of the human body together with feces. Cutting the cycle at this stage is the most effective way of preventing the spread of the disease to susceptible hosts. 123. When residents obtain water from an artesian well in the neighborhood, the level of this approved type of water facility is A. I B. II C. III D. IV Answer: (B) II A communal faucet or water standpost is classified as Level II. 124. For prevention of hepatitis A, you decided to conduct health education activities. Which of the following is IRRELEVANT? A. Use of sterile syringes and needles B. Safe food preparation and food handling by vendors C. Proper disposal of human excreta and personal hygiene D. Immediate reporting of water pipe leaks and illegal water connections Answer: (A) Use of sterile syringes and needles Hepatitis A is transmitted through the fecal oral route. Hepatitis B is transmitted through infected body secretions like blood and semen. 126. Which biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer? A. DPT B. Oral polio vaccine C. Measles vaccine D. MMR Answer: (A) DPT DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8° C only. OPV and measles vaccine are highly sensitive to heat and require freezing. MMR is not an immunization in the Expanded Program on Immunization. 127. You will conduct outreach immunization in a barangay with a population of about 1500. Estimate the number of infants in the barangay. A. 45 B. 50 C. 55 D. 60 Answer: (A) 45 To estimate the number of infants, multiply total population by 3%. 128. In Integrated Management of Childhood Illness, severe conditions generally require urgent

referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital? A. Mastoiditis B. Severe dehydration C. Severe pneumonia D. Severe febrile disease Answer: (B) Severe dehydration The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol/nasogastric tube, Oresol/orem. When the foregoing measures are not possible or effective, tehn urgent referral to the hospital is done. 129. A client was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds? A. 3 B. 5 C. 8 D. 10 Answer: (A) 3 Adequate blood supply to the area allows the return of the color of the nailbed within 3 seconds. 130. A 3-year old child was brought by his mother to the health center because of fever of 4-day duration. The child had a positive tourniquet test result. In the absence of other signs, which is the most appropriate measure that the PHN may carry out to prevent Dengue shock syndrome? A. Insert an NGT and give fluids per NGT. B. Instruct the mother to give the child Oresol. C. Start the patient on intravenous fluids STAT. D. Refer the client to the physician for appropriate management. Answer: (B) Instruct the mother to give the child Oresol. Since the child does not manifest any other danger sign, maintenance of fluid balance and replacement of fluid loss may be done by giving the client Oresol. 131. The pathognomonic sign of measles is Koplik’s spot. You may see Koplik’s spot by inspecting the _____. A. Nasal mucosa B. Buccal mucosa C. Skin on the abdomen D. Skin on the antecubital surface Answer: (B) Buccal mucosa Koplik’s spot may be seen on the mucosa of the mouth or the throat. 132. Among the following diseases, which is airborne? A. Viral conjunctivitis B. Acute poliomyelitis C. Diphtheria D. Measles Answer: (D) Measles Viral conjunctivitis is transmitted by direct or indirect contact with discharges from infected eyes. Acute poliomyelitis is spread through the fecal-oral route and contact with throat secretions, whereas diphtheria is through direct and indirect contact with respiratory secretions. 133. Among children aged 2 months to 3 years, the most prevalent form of meningitis is caused by which microorganism? A. Hemophilus influenzae B. Morbillivirus C. Steptococcus pneumoniae D. Neisseria meningitidis Answer: (A) Hemophilus influenzae Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the peak incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles. Streptococcus pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is not specific in young children. 134. Human beings are the major reservoir of malaria. Which of the following strategies in malaria

control is based on this fact? A. Stream seeding B. Stream clearing C. Destruction of breeding places D. Zooprophylaxis Answer: (D) Zooprophylaxis Zooprophylaxis is done by putting animals like cattle or dogs close to windows or doorways just before nightfall. The Anopheles mosquito takes his blood meal from the animal and goes back to its breeding place, thereby preventing infection of humans. 135. The use of larvivorous fish in malaria control is the basis for which strategy of malaria control? A. Stream seeding B. Stream clearing C. Destruction of breeding places D. Zooprophylaxis Answer: (A) Stream seeding Stream seeding is done by putting tilapia fry in streams or other bodies of water identified as breeding places of the Anopheles mosquito 136. Mosquito-borne diseases are prevented mostly with the use of mosquito control measures. Which of the following is NOT appropriate for malaria control? A. Use of chemically treated mosquito nets B. Seeding of breeding places with larva-eating fish C. Destruction of breeding places of the mosquito vector D. Use of mosquito-repelling soaps, such as those with basil or citronella Answer: (C) Destruction of breeding places of the mosquito vector Anopheles mosquitoes breed in slow-moving, clear water, such as mountain streams. 137. A 4-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of “rice water” stools. The client is most probably suffering from which condition? A. Giardiasis B. Cholera C. Amebiasis D. Dysentery Answer: (B) Cholera Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary dysentery are characterized by the presence of blood and/or mucus in the stools. Giardiasis is characterized by fat malabsorption and, therefore, steatorrhea. 138. In the Philippines, which specie of schistosoma is endemic in certain regions? A. S. mansoni B. S. japonicum C. S. malayensis D. S. haematobium Answer: (B) S. japonicum S. mansoni is found mostly in Africa and South America; S. haematobium in Africa and the Middle East; and S. malayensis only in peninsular Malaysia. 139. A 32-year old client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on his history, which disease condition will you suspect? A. Hepatitis A B. Hepatitis B C. Tetanus D. Leptospirosis Answer: (D) Leptospirosis Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals, like rats. 140. MWSS provides water to Manila and other cities in Metro Manila. This is an example of which level of water facility? A. I

B. II C. III D. IV Answer: (C) III Waterworks systems, such as MWSS, are classified as level III. 141. You are the PHN in the city health center. A client underwent screening for AIDS using ELISA. His result was positive. What is the best course of action that you may take? A. Get a thorough history of the client, focusing on the practice of high risk behaviors. B. Ask the client to be accompanied by a significant person before revealing the result. C. Refer the client to the physician since he is the best person to reveal the result to the client. D. Refer the client for a supplementary test, such as Western blot, since the ELISA result may be false. Answer: (D) Refer the client for a supplementary test, such as Western blot, since the ELISA result may be false. A client having a reactive ELISA result must undergo a more specific test, such as Western blot. A negative supplementary test result means that the ELISA result was false and that, most probably, the client is not infected. 142. Which is the BEST control measure for AIDS? A. Being faithful to a single sexual partner B. Using a condom during each sexual contact C. Avoiding sexual contact with commercial sex workers D. Making sure that one’s sexual partner does not have signs of AIDS Answer: (A) Being faithful to a single sexual partner Sexual fidelity rules out the possibility of getting the disease by sexual contact with another infected person. Transmission occurs mostly through sexual intercourse and exposure to blood or tissues. 143. The most frequent causes of death among clients with AIDS are opportunistic diseases. Which of the following opportunistic infections is characterized by tonsillopharyngitis? A. Respiratory candidiasis B. Infectious mononucleosis C. Cytomegalovirus disease D. Pneumocystis carinii pneumonia Answer: (B) Infectious mononucleosis Cytomegalovirus disease is an acute viral disease characterized by fever, sore throat and lymphadenopathy. 144. To determine possible sources of sexually transmitted infections, which is the BEST method that may be undertaken by the public health nurse? A. Contact tracing B. Community survey C. Mass screening tests D. Interview of suspects Answer: (A) Contact tracing Contact tracing is the most practical and reliable method of finding possible sources of person-toperson transmitted infections, such as sexually transmitted diseases. 145. Antiretroviral agents, such as AZT, are used in the management of AIDS. Which of the following is NOT an action expected of these drugs. A. They prolong the life of the client with AIDS. B. They reduce the risk of opportunistic infections C. They shorten the period of communicability of the disease. D. They are able to bring about a cure of the disease condition. Answer: (D) They are able to bring about a cure of the disease condition. There is no known treatment for AIDS. Antiretroviral agents reduce the risk of opportunistic infections and prolong life, but does not cure the underlying immunodeficiency. 146. A barangay had an outbreak of German measles. To prevent congenital rubella, what is the BEST advice that you can give to women in the first trimester of pregnancy in the barangay? A. Advice them on the signs of German measles. B. Avoid crowded places, such as markets and moviehouses. C. Consult at the health center where rubella vaccine may be given. D. Consult a physician who may give them rubella immunoglobulin.

Answer: (D) Consult a physician who may give them rubella immunoglobulin. Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated in pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to pregnant women. 147. You were invited to be the resource person in a training class for food handlers. Which of the following would you emphasize regarding prevention of staphylococcal food poisoning? A. All cooking and eating utensils must be thoroughly washed. B. Food must be cooked properly to destroy staphylococcal microorganisms. C. Food handlers and food servers must have a negative stool examination result. D. Proper handwashing during food preparation is the best way of preventing the condition. Answer: (D) Proper handwashing during food preparation is the best way of preventing the condition. Symptoms of this food poisoning are due to staphylococcal enterotoxin, not the microorganisms themselves. Contamination is by food handling by persons with staphylococcal skin or eye infections. 148. In a mothers’ class, you discussed childhood diseases such as chicken pox. Which of the following statements about chicken pox is correct? A. The older one gets, the more susceptible he becomes to the complications of chicken pox. B. A single attack of chicken pox will prevent future episodes, including conditions such as shingles. C. To prevent an outbreak in the community, quarantine may be imposed by health authorities. D. Chicken pox vaccine is best given when there is an impending outbreak in the community. Answer: (A) The older one gets, the more susceptible he becomes to the complications of chicken pox. Chicken pox is usually more severe in adults than in children. Complications, such as pneumonia, are higher in incidence in adults. 149. Complications to infectious parotitis (mumps) may be serious in which type of clients? A. Pregnant women B. Elderly clients C. Young adult males D. Young infants Answer: (C) Young adult males Epididymitis and orchitis are possible complications of mumps. In post-adolescent males, bilateral inflammation of the testes and epididymis may cause sterility.

Philippine NLE Board Exam: Leadership Nursing Question & Answer w/ rationale LEADERSHIP, MANAGEMENT, BIOETHICS AND RESEARCH 1. Ms. Castro is newly-promoted to a patient care manager position. She updates her knowledge on the theories in management and leadership in order to become effective in her new role. She learns that some managers have low concern for services and high concern for staff. Which style of management refers to this? A. Organization Man B. Impoverished Management C. Country Club Management D. Team Management Answer: (C) Country Club Management Country club management style puts concern for the staff as number one priority at the expense of the delivery of services. He/she runs the department just like a country club where every one is happy including the manager. 2. Her former manager demonstrated passion for serving her staff rather than being served. She takes time to listen, prefers to be a teacher first before being a leader, which is characteristic of A. Transformational leader B. Transactional leader C. Servant leader D. Charismatic leader

Answer: (C) Servant leader Servant leaders are open-minded, listen deeply, try to fully understand others and not being judgmental 3. On the other hand, Ms. Castro notices that the Chief Nurse Executive has charismatic leadership style. Which of the following behaviors best describes this style? A. Possesses inspirational quality that makes followers gets attracted of him and regards him with reverence B. Acts as he does because he expects that his behavior will yield positive results C. Uses visioning as the core of his leadership D. Matches his leadership style to the situation at hand. Answer: (A) Possesses inspirational quality that makes followers gets attracted of him and regards him with reverence Charismatic leaders make the followers feel at ease in their presence. They feel that they are in good hands whenever the leader is around. 4. Which of the following conclusions of Ms. Castro about leadership characteristics is TRUE? A. There is a high correlation between the communication skills of a leader and the ability to get the job done. B. A manager is effective when he has the ability to plan well. C. Assessment of personal traits is a reliable tool for predicting a manager’s potential. D. There is good evidence that certain personal qualities favor success in managerial role. Answer: (C) Assessment of personal traits is a reliable tool for predicting a manager’s potential. It is not conclusive that certain qualities of a person would make him become a good manager. It can only predict a manager’s potential of becoming a good one. 5. She reads about Path Goal theory. Which of the following behaviors is manifested by the leader who uses this theory? A. Recognizes staff for going beyond expectations by giving them citations B. Challenges the staff to take individual accountability for their own practice C. Admonishes staff for being laggards. D. Reminds staff about the sanctions for non performance. Answer: (A) Recognizes staff for going beyond expectations by giving them citations Path Goal theory according to House and associates rewards good performance so that others would do the same 6. One leadership theory states that “leaders are born and not made,” which refers to which of the following theories? A. Trait B. Charismatic C. Great Man D. Situational Answer: (C) Great Man Leaders become leaders because of their birth right. This is also called Genetic theory or the Aristotelian theory 7. She came across a theory which states that the leadership style is effective dependent on the situation. Which of the following styles best fits a situation when the followers are self-directed, experts and arematured individuals? A. Democratic B. Authoritarian C. Laissez faire D. Bureaucratic Answer: (C) Laissez faire Laissez faire leadership is preferred when the followers know what to do and are experts in the field. This leadership style is relationship-oriented rather than task-centered. 8. She surfs the internet for more information about leadership styles. She reads about shared leadership as a practice in some magnet hospitals. Which of the following describes this style of leadership? A. Leadership behavior is generally determined by the relationship between the leader’s personality and the specific situation B. Leaders believe that people are basically good and need not be closely controlled C. Leaders rely heavily on visioning and inspire members to achieve results

D. Leadership is shared at the point of care. Answer: (D) Leadership is shared at the point of care. Shared governance allows the staff nurses to have the authority, responsibility and accountability for their own practice. 9. Ms. Castro learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader? A. Focuses on management tasks B. Is a caretaker C. Uses trade-offs to meet goals D. Inspires others with vision Answer: (D) Inspires others with vision Inspires others with a vision is characteristic of a transformational leader. He is focused more on the day-to-day operations of the department/unit. 10. She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? A. Have condescending trust and confidence in their subordinates B. Gives economic or ego awards C. Communicates downward to the staff D. Allows decision making among subordinates Answer: (A) Have condescending trust and confidence in their subordinates Benevolent-authoritative managers pretentiously show their trust and confidence to their followers 11. Harry is a Unit Manager I the Medical Unit. He is not satisfied with the way things are going in his unit. Patient satisfaction rate is 60% for two consecutive months and staff morale is at its lowest. He decides to plan and initiate changes that will push for a turnaround in the condition of the unit. Which of the following actions is a priority for Harry? A. Call for a staff meeting and take this up in the agenda. B. Seek help from her manager. C. Develop a strategic action on how to deal with these concerns. D. Ignore the issues since these will be resolved naturally. Answer: (A) Call for a staff meeting and take this up in the agenda. This will allow for the participation of every staff in the unit. If they contribute to the solutions of the problem, they will own the solutions; hence the chance for compliance would be greater. 12. She knows that there are external forces that influence changes in his unit. Which of the following is NOT an external force? A. Memo from the CEO to cut down on electrical consumption B. Demands of the labor sector to increase wages C. Low morale of staff in her unit D. Exacting regulatory and accreditation standards Answer: (C) Low morale of staff in her unit Low morale of staff is an internal factor that affects only the unit. All the rest of the options emanate from the top executive or from outside the institution. 13. After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to this? A. Collaboration B. Majority rule C. Dominance D. Compromise Answer: (B) Majority rule Majority rule involves dividing the house and the highest vote wins.1/2 + 1 is a majority. 14. One staff suggests that they review the pattern of nursing care that they are using, which is described as a A. job description B. system used to deliver care C. manual of procedure D. rules to be followed Answer: (B) system used to deliver care

A system used to deliver care. In the 70’s it was termed as methods of patient assignment; in the early 80’s it was called modalities of patient care then patterns of nursing care in the 90’s until recently authors called it nursing care systems. 15. Which of the following is TRUE about functional nursing? A. Concentrates on tasks and activities B. Emphasizes use of group collaboration C. One-to-one nurse-patient ratio D. Provides continuous, coordinated and comprehensive nursing services Answer: (A) Concentrates on tasks and activities Functional nursing is focused on tasks and activities and not on the holistic care of the patients 16. Functional nursing has some advantages, which one is an EXCEPTION? A. Psychological and sociological needs are emphasized. B. Great control of work activities. C. Most economical way of delivering nursing services. D. Workers feel secure in dependent role Answer: (A) Psychological and sociological needs are emphasized. When the functional method is used, the psychological and sociological needs of the patients are neglected; the patients are regarded as ‘tasks to be done ‘ 17. He raised the issue on giving priority to patient needs. Which of the following offers the best way for setting priority? A. Assessing nursing needs and problems B. Giving instructions on how nursing care needs are to be met C. Controlling and evaluating the delivery of nursing care D. Assigning safe nurse: patient ratio Answer: (A) Assessing nursing needs and problems This option follows the framework of the nursing process at the same time applies the management process of planning, organizing, directing and controlling 18. Which of the following is the best guarantee that the patient’s priority needs are met? A. Checking with the relative of the patient B. Preparing a nursing care plan in collaboration with the patient C. Consulting with the physician D. Coordinating with other members of the team Answer: (B) Preparing a nursing care plan in collaboration with the patient The best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively. 19. When Harry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority? A. Each patient as listed on the worksheet B. Patients who needs least care C. Medications and treatments required for all patients D. Patients who need the most care Answer: (D) Patients who need the most care In setting priorities for a group of patients, those who need the most care should be number-one priority to ensure that their critical needs are met adequately. The needs of other patients who need less care ca be attended to later or even delegated to assistive personnel according to rules on delegation. 20. She is hopeful that her unit will make a big turnaround in the succeeding months. Which of the following actions of Harry demonstrates that he has reached the third stage of change? A. Wonders why things are not what it used to be B. Finds solutions to the problems C. Integrate the solutions to his day-to-day activities D. Selects the best change strategy Answer: (C) Integrate the solutions to his day-to-day activities Integrate the solutions to his day-to-day activities is a expected to happen during the third stage of change when the change agent incorporate the selected solutions to his system and begins to create a change.

21. Julius is a newly-appointed nurse manager of The Good Shepherd Medical Center, a tertiary hospital located within the heart of the metropolis. He thinks of scheduling planning workshop with his staff in order to ensure an effective and efficient management of the department. Should he decide to conduct a strategic planning workshop, which of the following is NOT a characteristic of this activity? A. Long-term goal-setting B. Extends to 3-5 years in the future C. Focuses on routine tasks D. Determines directions of the organization Answer: (C) Focuses on routine tasks Strategic planning involves options A, B and D except C which is attributed to operational planning 22. Which of the following statements refer to the vision of the hospital? A. The Good Shepherd Medical Center is a trendsetter in tertiary health care in the Philippines in the next five years B. The officers and staff of The Good Shepherd Medical Center believe in the unique nature of the human person C. All the nurses shall undergo continuing competency training program. D. The Good Shepherd Medical Center aims to provide a patient-centered care in a total healing environment. Answer: (A) The Good Shepherd Medical Center is a trendsetter in tertiary health care in the Philippines in the next five years A vision refers to what the institution wants to become within a particular period of time. 23. The statement, “The Good Shepherd Medical Center aims to provide patient-centered care in a total healing environment” refers to which of the following? A. Vision B. Goal C. Philosophy D. Mission Answer: (B) Goal B 24. Julius plans to revisit the organizational chart of the department. He plans to create a new position of a Patient Educator who has a coordinating relationship with the head nurse in the unit. Which of the following will likely depict this organizational relationship? A. Box B. Solid line C. Broken line D. Dotted line Answer: (C) Broken line This is a staff relationship hence it is depicted by a broken line in the organizational structure 25. He likewise stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to? A. Scalar chain B. Discipline C. Unity of command D. Order Answer: (C) Unity of command The principle of unity of command means that employees should receive orders coming from only one manager and not from two managers. This averts the possibility of sowing confusion among the members of the organization 26. Julius orients his staff on the patterns of reporting relationship throughout the organization. Which of the following principles refer to this? A. Span of control B. Hierarchy C. Esprit d’ corps D. Unity of direction Answer: (B) Hierarchy Hierarchy refers to the pattern of reporting or the formal line of authority in an organizational

structure. 27. He emphasizes to the team that they need to put their efforts together towards the attainment of the goals of the program. Which of the following principles refers to this? A. Span of control B. Unity of direction C. Unity of command D. Command responsibility Answer: (B) Unity of direction Unity of direction means having one goal or one objective for the team to pursue; hence all members of the organization should put their efforts together towards the attainment of their common goal or objective. 28. Julius stresses the importance of promoting ‘esprit d corps’ among the members of the unit. Which of the following remarks of the staff indicates that they understand what he pointed out? A. “Let’s work together in harmony; we need to be supportive of one another” B. “In order that we achieve the same results; we must all follow the directives of Julius and not from other managers.” C. “We will ensure that all the resources we need are available when needed.” D. “We need to put our efforts together in order to raise the bar of excellence in the care we provide to all our patients.” Answer: (A) “Let’s work together in harmony; we need to be supportive of one another” The principle of ‘esprit d’ corps’ refers to promoting harmony in the workplace, which is essential in maintaining a climate conducive to work. 29. He discusses the goal of the department. Which of the following statements is a goal? A. Increase the patient satisfaction rate B. Eliminate the incidence of delayed administration of medications C. Establish rapport with patients. D. Reduce response time to two minutes. Answer: (A) Increase the patient satisfaction rate Goal is a desired result towards which efforts are directed. Options AB, C and D are all objectives which are aimed at specific end. 30. He wants to influence the customary way of thinking and behaving that is shared by the members of the department. Which of the following terms refer to this? A. Organizational chart B. Cultural network C. Organizational structure D. Organizational culture Answer: (D) Organizational culture An organizational culture refers to the way the members of the organization think together and do things around them together. It’s their way of life in that organization 31. He asserts the importance of promoting a positive organizational culture in their unit. Which of the following behaviors indicate that this is attained by the group? A. Proactive and caring with one another B. Competitive and perfectionist C. Powerful and oppositional D. Obedient and uncomplaining Answer: (A) Proactive and caring with one another Positive culture is based on humanism and affiliative norms 32. Stephanie is a new Staff Educator of a private tertiary hospital. She conducts orientation among new staff nurses in her department. Joseph, one of the new staff nurses, wants to understand the channel of communication, span of control and lines of communication. Which of the following will provide this information? A. Organizational structure B. Policy C. Job description D. Manual of procedures Answer: (A) Organizational structure Organizational structure provides information on the channel of authority, i.e., who reports to whom

and with what authority; the number of people who directly reports to the various levels of hierarchy and the lines of communication whether line or staff. 33. Stephanie is often seen interacting with the medical intern during coffee breaks and after duty hours. What type of organizational structure is this? A. Formal B. Informal C. Staff D. Line Answer: (B) Informal This is usually not published and oftentimes concealed. 34. She takes pride in saying that the hospital has a decentralized structure. Which of the following is NOT compatible with this type of model? A. Flat organization B. Participatory approach C. Shared governance D. Tall organization Answer: (D) Tall organization Tall organizations are highly centralized organizations where decision making is centered on one authority level. 35. Centralized organizations have some advantages. Which of the following statements are TRUE? 1. Highly cost-effective 2. Makes management easier 3. Reflects the interest of the worker 4. Allows quick decisions or actions. A. 1 & 2 B. 2 & 4 C. 2, 3& 4 D. 1, 2, & 4 Answer: (A) 1 & 2 Centralized organizations are needs only a few managers hence they are less expensive and easier to manage 36. Stephanie delegates effectively if she has authority to act, which is BEST defined as: A. having responsibility to direct others B. being accountable to the organization C. having legitimate right to act D. telling others what to do Answer: (C) having legitimate right to act Authority is a legitimate or official right to give command. This is an officially sanctioned responsibility 37. Regardless of the size of a work group, enough staff must be available at all times to accomplish certain purposes. Which of these purposes in NOT included? A. Meet the needs of patients B. Provide a pair of hands to other units as needed C. Cover all time periods adequately. D. Allow for growth and development of nursing staff. Answer: (B) Provide a pair of hands to other units as needed Providing a pair of hands for other units is not a purpose in doing an effective staffing process. This is a function of a staffing coordinator at a centralized model. 38. Which of the following guidelines should be least considered in formulating objectives for nursing care? A. Written nursing care plan B. Holistic approach C. Prescribed standards D. Staff preferences Answer: (D) Staff preferences

Staff preferences should be the least priority in formulating objectives of nursing care. Individual preferences should be subordinate to the interest of the patients. 41. Stephanie considers shifting to transformational leadership. Which of the following statements best describes this type of leadership? A. Uses visioning as the essence of leadership. B. Serves the followers rather than being served. C. Maintains full trust and confidence in the subordinates D. Possesses innate charisma that makes others feel good in his presence. Answer: (A) Uses visioning as the essence of leadership. Transformational leadership relies heavily on visioning as the core of leadership. 42. As a manager, she focuses her energy on both the quality of services rendered to the patients as well as the welfare of the staff of her unit. Which of the following management styles does she adopt? A. Country club management B. Organization man management C. Team management D. Authority-obedience management Answer: (C) Team management Team management has a high concern for services and high concern for staff. 43. Katherine is a young Unit Manager of the Pediatric Ward. Most of her staff nurses are senior to her, very articulate, confident and sometimes aggressive. Katherine feels uncomfortable believing that she is the scapegoat of everything that goes wrong in her department. Which of the following is the best action that she must take? A. Identify the source of the conflict and understand the points of friction B. Disregard what she feels and continue to work independently C. Seek help from the Director of Nursing D. Quit her job and look for another employment. Answer: (A) Identify the source of the conflict and understand the points of friction This involves a problem solving approach, which addresses the root cause of the problem. 44. As a young manager, she knows that conflict occurs in any organization. Which of the following statements regarding conflict is NOT true? A. Can be destructive if the level is too high B. Is not beneficial; hence it should be prevented at all times C. May result in poor performance D. May create leaders Answer: (B) Is not beneficial; hence it should be prevented at all times Conflicts are beneficial because it surfaces out issues in the open and can be solved right away. Likewise, members of the team become more conscientious with their work when they are aware that other members of the team are watching them. 45. Katherine tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my office later” when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use? A. Smoothing B. Compromise C. Avoidance D. Restriction Answer: (C) Avoidance This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect the problem remains unsolved and both parties are in a lose-lose situation. 46. Kathleen knows that one of her staff is experiencing burnout. Which of the following is the best thing for her to do? A. Advise her staff to go on vacation. B. Ignore her observations; it will be resolved even without intervention C. Remind her to show loyalty to the institution. D. Let the staff ventilate her feelings and ask how she can be of help. Answer: (D) Let the staff ventilate her feelings and ask how she can be of help. Reaching out and helping the staff is the most effective strategy in dealing with burn out. Knowing that someone is ready to help makes the staff feel important; hence her self-worth is enhanced.

47. She knows that performance appraisal consists of all the following activities EXCEPT: A. Setting specific standards and activities for individual performance. B. Using agency standards as a guide. C. Determine areas of strength and weaknesses D. Focusing activity on the correction of identified behavior. Answer: (D) Focusing activity on the correction of identified behavior. Performance appraisal deal with both positive and negative performance; is not meant to be a faultfinding activity 48. Which of the following statements is NOT true about performance appraisal? A. Informing the staff about the specific impressions of their work help improve their performance. B. A verbal appraisal is an acceptable substitute for a written report C. Patients are the best source of information regarding personnel appraisal. D. The outcome of performance appraisal rests primarily with the staff. Answer: (C) Patients are the best source of information regarding personnel appraisal. The patient can be a source of information about the performance of the staff but it is never the best source. Directly observing the staff is the best source of information for personnel appraisal. 49. There are times when Katherine evaluates her staff as she makes her daily rounds. Which of the following is NOT a benefit of conducting an informal appraisal? A. The staff member is observed in natural setting. B. Incidental confrontation and collaboration is allowed. C. The evaluation is focused on objective data systematically. D. The evaluation may provide valid information for compilation of a formal report. Answer: (C) The evaluation is focused on objective data systematically. Collecting objective data systematically can not be achieved in an informal appraisal. It is focused on what actually happens in the natural work setting. 50. She conducts a 6-month performance review session with a staff member. Which of the following actions is appropriate? A. She asks another nurse to attest the session as a witness. B. She informs the staff that she may ask another nurse to read the appraisal before the session is over. C. She tells the staff that the session is manager-centered. D. The session is private between the two members. Answer: (D) The session is private between the two members. The session is private between the manager and the staff and remains to be so when the two parties do not divulge the information to others. 51. Alexandra is tasked to organize the new wing of the hospital. She was given the authority to do as she deems fit. 51. She is aware that the director of nursing has substantial trust and confidence in her capabilities, communicates through downward and upward channels and usually uses the ideas and opinions of her staff. Which of the following is her style of management? A. Benevolent –authoritative B. Consultative C. Exploitive-authoritative D. Participative Answer: (B) Consultative A consultative manager is almost like a participative manager. The participative manager has complete trust and confidence in the subordinate, always uses the opinions and ideas of subordinates and communicates in all directions. 52. She decides to illustrate the organizational structure. Which of the following elements is NOT included? A. Level of authority B. Lines of communication C. Span of control D. Unity of direction Answer: (D) Unity of direction Unity of direction is a management principle, not an element of an organizational structure. 53. She plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?

A. Staffing B. Scheduling C. Recruitment D. Induction Answer: (A) Staffing Staffing is a management function involving putting the best people to accomplish tasks and activities to attain the goals of the organization. 54. She checks the documentary requirements for the applicants for staff nurse position. Which one is NOT necessary? A. Certificate of previous employment B. Record of related learning experience (RLE) C. Membership to accredited professional organization D. Professional identification card Answer: (B) Record of related learning experience (RLE) Record of RLE is not required for employment purposes but it is required for the nurse’s licensure examination. 55. Which phase of the employment process includes getting on the payroll and completing documentary requirements? A. Orientation B. Induction C. Selection D. Recruitment Answer: (B) Induction This step in the recruitment process gives time for the staff to submit all the documentary requirements for employment. 56. She tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this? A. Centralized B. Decentralized C. Matrix D. Informal Answer: (B) Decentralized Decentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow. 57. In a horizontal chart, the lowest level worker is located at the A. Leftmost box B. Middle C. Rightmost box D. Bottom Answer: (C) Rightmost box The leftmost box is occupied by the highest authority while the lowest level worker occupies the rightmost box. 58. She decides to have a decentralized staffing system. Which of the following is an advantage of this system of staffing? A. greater control of activities B. Conserves time C. Compatible with computerization D. Promotes better interpersonal relationship Answer: (D) Promotes better interpersonal relationship Decentralized structures allow the staff to solve decisions by themselves, involve them in decision making; hence they are always given opportunities to interact with one another. 59. Aubrey thinks about primary nursing as a system to deliver care. Which of the following activities is NOT done by a primary nurse? A. Collaborates with the physician B. Provides care to a group of patients together with a group of nurses C. Provides care for 5-6 patients during their hospital stay.

D. Performs comprehensive initial assessment Answer: (B) Provides care to a group of patients together with a group of nurses This function is done in team nursing where the nurse is a member of a team that provides care for a group of patients. 60. Which pattern of nursing care involves the care given by a group of paraprofessional workers led by a professional nurse who take care of patients with the same disease conditions and are located geographically near each other? A. Case method B. Modular nursing C. Nursing case management D. Team nursing Answer: (B) Modular nursing Modular nursing is a variant of team nursing. The difference lies in the fact that the members in modular nursing are paraprofessional workers. 61. St. Raphael Medical Center just opened its new Performance Improvement Department. Ms. Valencia is appointed as the Quality Control Officer. She commits herself to her new role and plans her strategies to realize the goals and objectives of the department. Which of the following is a primary task that they should perform to have an effective control system? A. Make an interpretation about strengths and weaknesses B. Identify the values of the department C. Identify structure, process, outcome standards & criteria D. Measure actual performances Answer: (B) Identify the values of the department Identify the values of the department will set the guiding principles within which the department will operate its activities 62. Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard? A. The patients verbalized satisfaction of the nursing care received B. Rotation of duty will be done every four weeks for all patient care personnel. C. All patients shall have their weights taken recorded D. Patients shall answer the evaluation form before discharge Answer: (B) Rotation of duty will be done every four weeks for all patient care personnel. Structure standards include management system, facilities, equipment, materials needed to deliver care to patients. Rotation of duty is a management system. 63. When she presents the nursing procedures to be followed, she refers to what type of standards? A. Process B. Outcome C. Structure D. Criteria Answer: (A) Process Process standards include care plans, nursing procedure to be done to address the needs of the patients. 64. The following are basic steps in the controlling process of the department. Which of the following is NOT included? A. Measure actual performance B. Set nursing standards and criteria C. Compare results of performance to standards and objectives D. Identify possible courses of action Answer: (D) Identify possible courses of action This is a step in a quality control process and not a basic step in the control process. 65. Which of the following statements refers to criteria? A. Agreed on level of nursing care B. Characteristics used to measure the level of nursing care C. Step-by-step guidelines D. Statement which guide the group in decision making and problem solving

Answer: (B) Characteristics used to measure the level of nursing care Criteria are specific characteristics used to measure the standard of care. 66. She wants to ensure that every task is carried out as planned. Which of the following tasks is NOT included in the controlling process? A. Instructing the members of the standards committee to prepare policies B. Reviewing the existing policies of the hospital C. Evaluating the credentials of all nursing staff D. Checking if activities conform to schedule Answer: (A) Instructing the members of the standards committee to prepare policies Instructing the members involves a directing function. 67. Ms. Valencia prepares the process standards. Which of the following is NOT a process standard? A. Initial assessment shall be done to all patients within twenty four hours upon admission. B. Informed consent shall be secured prior to any invasive procedure C. Patients’ reports 95% satisfaction rate prior to discharge from the hospital. D. Patient education about their illness and treatment shall be provided for all patients and their families. Answer: (C) Patients’ reports 95% satisfaction rate prior to discharge from the hospital. This refers to an outcome standard, which is a result of the care that is rendered to the patient. 68. Which of the following is evidence that the controlling process is effective? A. The things that were planned are done B. Physicians do not complain. C. Employees are contended D. There is an increase in customer satisfaction rate. Answer: (A) The things that were planned are done Controlling is defined as seeing to it that what is planned is done. 69. Ms. Valencia is responsible to the number of personnel reporting to her. This principle refers to: A. Span of control B. Unity of command C. Carrot and stick principle D. Esprit d’ corps Answer: (A) Span of control Span of control refers to the number of workers who report directly to a manager. 70. She notes that there is an increasing unrest of the staff due to fatigue brought about by shortage of staff. Which action is a priority? A. Evaluate the overall result of the unrest B. Initiate a group interaction C. Develop a plan and implement it D. Identify external and internal forces. Answer: (B) Initiate a group interaction Initiate a group interaction will be an opportunity to discuss the problem in the open. 71. Kevin is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following is an extraneous variable of the study? A. Date of admission B. Length of stay C. Age of patients D. Absence of complications Answer: (C) Age of patients An extraneous variable is not the primary concern of the researcher but has an effect on the results of the study. Adult patients may be young, middle or late adult. 72. He thinks of an appropriate theoretical framework. Whose theory addresses the four modes of adaptation? A. Martha Rogers B. Sr. Callista Roy C. Florence Nightingale

D. Jean Watson Answer: (B) Sr. Callista Roy Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode 73. He opts to use a self-report method. Which of the following is NOT TRUE about this method? A. Most direct means of gathering information B. Versatile in terms of content coverage C. Most accurate and valid method of data gathering D. Yields information that would be difficult to gather by another method Answer: (C) Most accurate and valid method of data gathering The most serious disadvantage of this method is accuracy and validity of information gathered 74. Which of the following articles would Kevin least consider for his review of literature? A. “Story-Telling and Anxiety Reduction Among Pediatric Patients” B. “Turnaround Time in Emergency Rooms” C. “Outcome Standards in Tertiary Health Care Institutions” D. “Environmental Manipulation and Client Outcomes” Answer: (B) “Turnaround Time in Emergency Rooms” The article is for pediatric patients and may not be relevant for adult patients. 75. Which of the following variables will he likely EXCLUDE in his study? A. Competence of nurses B. Caring attitude of nurses C. Salary of nurses D. Responsiveness of staff Answer: (C) Salary of nurses Salary of staff nurses is not an indicator of patient satisfaction, hence need not be included as a variable in the study. 76. He plans to use a Likert Scale to determine A. degree of agreement and disagreement B. compliance to expected standards C. level of satisfaction D. degree of acceptance Answer: (A) degree of agreement and disagreement Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study. 77. He checks if his instruments meet the criteria for evaluation. Which of the following criteria refers to the consistency or the ability to yield the same response upon its repeated administration? A. Validity B. Reliability C. Sensitivity D. Objectivity Answer: (B) Reliability Reliability is repeatability of the instrument; it can elicit the same responses even with varied administration of the instrument 78. Which criteria refer to the ability of the instrument to detect fine differences among the subjects being studied? A. Sensitivity B. Reliability C. Validity D. Objectivity Answer: (A) Sensitivity Sensitivity is an attribute of the instrument that allow the respondents to distinguish differences of the options where to choose from 79. Which of the following terms refer to the degree to which an instrument measures what it is

supposed to be measure? A. Validity B. Reliability C. Meaningfulness D. Sensitivity Answer: (A) Validity Validity is ensuring that the instrument contains appropriate questions about the research topic 80. He plans for his sampling method. Which sampling method gives equal chance to all units in the population to get picked? A. Random B. Accidental C. Quota D. Judgment Answer: (A) Random Random sampling gives equal chance for all the elements in the population to be picked as part of the sample. 81. Raphael is interested to learn more about transcultural nursing because he is assigned at the family suites where most patients come from different cultures and countries. Which of the following designs is appropriate for this study? A. Grounded theory B. Ethnography C. Case study D. Phenomenology Answer: (B) Ethnography Ethnography is focused on patterns of behavior of selected people within a culture 82. The nursing theorist who developed transcultural nursing theory is A. Dorothea Orem B. Madeleine Leininger C. Betty Newman D. Sr. Callista Roy Answer: (B) Madeleine Leininger Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture 83. Which of the following statements best describes a phenomenological study? A. Involves the description and interpretation of cultural behavior B. Focuses on the meaning of experiences as those who experience it C. Involves an in-depth study of an individual or group D. Involves collecting and analyzing data that aims to develop theories grounded in real-world observations Answer: (B) Focuses on the meaning of experiences as those who experience it Phenomenological study involves understanding the meaning of experiences as those who experienced the phenomenon. 84. He systematically plans his sampling plan. Should he decides to include whoever patients are admitted during the study he uses what sampling method? A. Judgment B. Accidental C. Random D. Quota Answer: (B) Accidental Accidental sampling is a non-probability sampling method which includes those who are at the site during data collection. 85. He finally decides to use judgment sampling. Which of the following actions of Raphael is correct? A. Plans to include whoever is there during his study. B. Determines the different nationality of patients frequently admitted and decides to get representations samples from each.

C. Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it. D. Decides to get 20 samples from the admitted patients Answer: (B) Determines the different nationality of patients frequently admitted and decides to get representations samples from each. Judgment sampling involves including samples according to the knowledge of the investigator about the participants in the study. 86. He knows that certain patients who are in a specialized research setting tend to respond psychologically to the conditions of the study. This is referred to as A. Bias B. Hawthorne effect C. Halo effect D. Horns effect Answer: (B) Hawthorne effect Hawthorne effect is based on the study of Elton Mayo and company about the effect of an intervention done to improve the working conditions of the workers on their productivity. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. They performed differently because they were under observation. 87. Which of the following items refer to the sense of closure that Raphael experiences when data collection ceases to yield any new information? A. Saturation B. Precision C. Limitation D. Relevance Answer: (A) Saturation Saturation is achieved when the investigator can not extract new responses from the informants, but instead, gets the same responses repeatedly. 88. In qualitative research the actual analysis of data begins with: A. search for themes B. validation of thematic analysis C. weave the thematic strands together D. quasi statistics Answer: (A) search for themes The investigator starts data analysis by looking for themes from the verbatim responses of the informants. 89. Raphael is also interested to know the coping abilities of patients who are newly diagnosed to have terminal cancer. Which of the following types of research is appropriate? A. Phenomenological B. Ethnographic C. Grounded Theory D. Case Study Answer: (C) Grounded Theory Grounded theory inductively develops a theory based on the observed processes involving selected people 90. Which of the following titles of the study is appropriate for this study? A. Lived Experiences of Terminally-Ill Cancer Patients B. Coping Skills of Terminally-Ill Cancer Patients in a Selected Hospital C. Two Case Studies of Terminally-Ill Patients in Manila D. Beliefs & Practices of Patients with Terminal Cancer Answer: (B) Coping Skills of Terminally-Ill Cancer Patients in a Selected Hospital The title has a specific phenomenon, sample and research locale. 91. Ms. Montana plans to conduct a research on the use of a new method of pain assessment scale. Which of the following is the second step in the conceptualizing phase of the research process? A. Formulating the research hypothesis B. Review related literature C. Formulating and delimiting the research problem D. Design the theoretical and conceptual framework

Answer: (B) Review related literature After formulating and delimiting the research problem, the researcher conducts a review of related literature to determine the extent of what has been done on the study by previous researchers. 92. Which of the following codes of research ethics requires informed consent in all cases governing human subjects? A. Helsinki Declaration B. Nuremberg Code C. Belmont Report D. ICN Code of Ethics Answer: (A) Helsinki Declaration Helsinki Declaration is the first international attempt to set up ethical standards in research involving human research subjects. 93. Which of the following ethical principles was NOT articulated in the Belmont Report? A. Beneficence B. Respect for human dignity C. Justice D. Non-maleficence Answer: (D) Non-maleficence Non-maleficence is not articulated in the Belmont Report. It only includes beneficence, respect for human dignity and justice. 39. Which one of the following criteria should be considered as a top priority in nursing care? A. Avoidance of destructive changes B. Preservation of life C. Assurance of safety D. Preservation of integrity Answer: (B) Preservation of life The preservation of life at all cost is a primary responsibility of the nurse. This is embodied in the Code of Ethics for registered nurses ( BON Resolution 220 s. 2004). 40. Which of the following procedures ensures that the investigator has fully described to prospective subjects the nature of the study and the subject's rights? A. Debriefing B. Full disclosure C. Informed consent D. Cover data collection Answer: (B) Full disclosure Full disclosure is giving the subjects of the research information that they deserve to know prior to the conduct of the study. 94. After the review session has been completed, Karen and the staff signed the document. Which of the following is the purpose of this? A. Agree about the content of the evaluation. B. Signify disagreement of the content of the evaluation. C. Document that Karen and the staff reviewed the evaluation. D. Serve as basis for future evaluation. Answer: (C) Document that Karen and the staff reviewed the evaluation. Signing the document is done to serve as a proof that performance review was conducted during that date and time. 95. A nurse who would like to practice nursing in the Philippines can obtain a license to practice by: A. Paying the professional tax after taking the board exams B. Passing the board exams and taking the oath of professionals C. Paying the examination fee before taking the board exams D. Undergoing the interview conducted by the Board of Nursing and taking the board exams Answer: (B) Passing the board exams and taking the oath of professionals For a nurse to obtain a license to practice nursing in the Philippines, s/he must pass the board examinations and then take the oath of professionals before the Board of Nursing. 96. Reciprocity of license to practice requires that the country of origin of the interested foreign nurse complies with the following conditions:

A. The country of origin has similar preparation for a nurse and has laws allowing Filipino nurses to practice in their country. B. The Philippines is recognized by the country of origin as one that has high quality of nursing education C. The country of origin requires Filipinos to take their own board examination D. The country of origin exempts Filipinos from passing their licensure examination Answer: (A) The country of origin has similar preparation for a nurse and has laws allowing Filipino nurses to practice in their country. According to the Philippine Nurses Act of 2002, foreign nurses wanting to practice in the Philippines must show proof that his/her country of origin meets the two essential conditions: a) the requirements for registration between the two countries are substantially the same; and b) the country of origin of the foreign nurse has laws allowing the Filipino nurse to practice in his/her country just like its own citizens. 97. Nurses practicing the profession in the Philippines and are employed in government hospitals are required to pay taxes such as: A. Both income tax and professional tax B. Income tax only since they are exempt from paying professional tax C. Professional tax which is paid by all nurses employed in both government and private hospitals D. Income tax which paid every March 15 and professional tax which is paid every January 31. Answer: (B) Income tax only since they are exempt from paying professional tax According to the Magna Carta for Public Health Workers, government nurses are exempted from paying professional tax. Hence, as an employee in the government, s/he will pay only the income tax. 98. According to RA 9173 Philippine Nursing Act of 2002, a graduate nurse who wants to take must licensure examination must comply with the following qualifications: A. At least 21 years old, graduate of BSN from a recognized school, and of good moral character B. At least 18 years old, graduate of BSN from a recognized school and of good moral character C. At least 18 years old, provided that when s/he passes the board exams, s/he must be at least 21 years old; BSN graduate of a recognized school, and of good moral character D. Filipino citizen or a citizen of a country where we have reciprocity; graduate of BSN from a recognized school and of good moral character Answer: (D) Filipino citizen or a citizen of a country where we have reciprocity; graduate of BSN from a recognized school and of good moral character RA 9173 section 13 states that the qualifications to take the board exams are: Filipino citizen or citizen of a country where the Philippines has reciprocity; of good moral character and graduate of BSN from a recognized school of nursing. There is no explicit provision about the age requirement in RA 9173 unlike in RA7164 (old law). 99. Which of the following is TRUE about membership to the Philippine Nurses Association (PNA)? A. Membership to PNA is mandatory and is stipulated in the Philippine Nursing Act of 2002 B. Membership to PNA is compulsory for newly registered nurses wanting to enter the practice of nursing in the country C. Membership to PNA is voluntary and is encouraged by the PRC Code of Ethics for Nurses D. Membership to PNA is required by government hospitals prior to employment Answer: (C) Membership to PNA is voluntary and is encouraged by the PRC Code of Ethics for Nurses Membership to any organization, including the PNA, is only voluntary and this right to join any organization is guaranteed in the 1987 constitution of the Philippines. However, the PRC Code of Ethics states that one of the ethical obligations of the professional nurse towards the profession is to be an active member of the accredited professional organization. 100. When the license of the nurse is revoked, it means that the nurse: A. Is no longer allowed to practice the profession for the rest of her life B. Will never have her/his license re-issued since it has been revoked C. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 D. Will remain unable to practice professional nursing Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued provided that the following conditions are met: a) the cause for revocation of license has already been corrected or

removed; and, b) at least four years has elapsed since the license has been revoked. 101. According to the current nursing law, the minimum educational qualification for a faculty member of a college of nursing is: A. Only a Master of Arts in Nursing is acceptable B. Masters degree in Nursing or in the related fields C. At least a doctorate in nursing D. At least 18 units in the Master of Arts in Nursing Program Answer: (B) Masters degree in Nursing or in the related fields According to RA 9173 sec. 27, the educational qualification of a faculty member teaching in a college of nursing must be masters degree which maybe in nursing or related fields like education, allied health professions, psychology. 102. The educational qualification of a nurse to become a supervisor in a hospital is: A. BSN with at least 9 units of post graduate studies in nursing administration B. Master of Arts in Nursing major in administration C. At least 2 years experience as a headnurse D. At least 18 units of post graduate studies in nursing administration Answer: (A) BSN with at least 9 units of post graduate studies in nursing administration According to RA 9173 sec. 29, the educational qualification to be a supervisor in a hospital is at least 9 units of postgraduate studies in nursing administration. A masters degree in nursing is required for the chief nurse of a secondary or tertiary hospital. 103. The Board of Nursing has quasi-judicial power. An example of this power is: A. The Board can issue rules and regulations that will govern the practice of nursing B. The Board can investigate violations of the nursing law and code of ethics C. The Board can visit a school applying for a permit in collaboration with CHED D. The Board prepares the board examinations Answer: (B) The Board can investigate violations of the nursing law and code of ethics Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as needed. 104. When a nurse causes an injury to the patient and the injury caused becomes the proof of the negligent act, the presence of the injury is said to exemplify the principle of: A. Force majeure B. Respondeat superior C. Res ipsa loquitur D. Holdover doctrine Answer: (C) Res ipsa loquitur Res ipsa loquitur literally means the thing speaks for itself. This means in operational terms that the injury caused is the proof that there was a negligent act. 105. Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of: A. Beneficence B. Autonomy C. Truth telling/veracity D. Non-maleficence Answer: (B) Autonomy Informed consent means that the patient fully understands what will be the surgery to be done, the risks involved and the alternative solutions so that when s/he give consent it is done with full knowledge and is given freely. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies the bioethical principle of autonomy. 106. When a nurse is providing care to her/his patient, s/he must remember that she is duty bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle: A. Non-maleficence B. Beneficence C. Justice D. Solidarity Answer: (A) Non-maleficence Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/client. To do good is referred as beneficence.

107. When the patient is asked to testify in court, s/he must abide by the ethical principle of: A. Privileged communication B. Informed consent C. Solidarity D. Autonomy Answer: (A) Privileged communication All confidential information that comes to the knowledge of the nurse in the care of her/his patients is considered privileged communications. Hence, s/he is not allowed to just reveal the confidential information arbitrarily. S/he may only be allowed to break the seal of secrecy in certain conditions. One such condition is when the court orders the nurse to testify in a criminal or medico-legal case. 108. When the doctor orders “do not resuscitate”, this means that A. The nurse need not give due care to the patient since s/he is terminally ill B. The patient need not be given food and water after all s/he is dying C. The nurses and the attending physician should not do any heroic or extraordinary measures for the patient D. The patient need not be given ordinary care so that her/his dying process is hastened Answer: (C) The nurses and the attending physician should not do any heroic or extraordinary measures for the patient Do not resuscitate” is a medical order which is written on the chart after the doctor has consulted the family and this means that the members of the health team are not required to give extraordinary measures but cannot withhold the basic needs like food, water, and air. It also means that the nurse is still duty bound to give the basic nursing care to the terminally ill patient and ensure that the spiritual needs of the patient is taken cared of. 109. Which of the following statements is TRUE of abortion in the Philippines? A. Induced abortion is allowed in cases of rape and incest B. Induced abortion is both a criminal act and an unethical act for the nurse C. Abortion maybe considered acceptable if the mother is unprepared for the pregnancy D. A nurse who performs induced abortion will have no legal accountability if the mother requested that the abortion done on her. Answer: (B) Induced abortion is both a criminal act and an unethical act for the nurse Induced abortion is considered a criminal act which is punishable by imprisonment which maybe up to a maximum of 12 years if the nurse gets paid for it. Also, the PRC Code of Ethics states that the nurse must respect life and must not do any action that will destroy life. Abortion is an act that destroys life albeit at the beginning of life. 110. Which of the following is NOT true about a hypothesis? Hypothesis is: A. testable B. proven C. stated in a form that it can be accepted or rejected D. states a relationship between variables Answer: (B) proven Hypothesis is not proven; it is either accepted or rejected. Hypothesis is testable and is defined as a statement that predicts the relationship between variables 111. Which of the following measures will best prevent manipulation of vulnerable groups? A. Secure informed consent B. Payment of stipends for subjects C. Protect privacy of patient D. Ensure confidentiality of data Answer: (A) Secure informed consent Securing informed consent will free the researcher from being accused of manipulating the subjects because by so doing he/she gives ample opportunity for the subjects to weigh the advantages/disadvantages of being included in the study prior to giving his consent. This is done without any element of force, coercion, threat or even inducement. 112. Which of the following procedures ensures that Ms. Montana has fully described to prospective subjects the nature of the study and the subject’s rights? A. Debriefing B. Full disclosure C. Informed consent D. Covert data collection

Answer: (B) Full disclosure Full disclosure is giving the subjects of the research information that they deserve to know prior to the conduct of the study 113. This technique refers to the use of multiple referents to draw conclusions about what constitutes the truth A. Triangulation B. Experiment C. Meta-analysis D. Delphi technique Answer: (A) Triangulation Triangulation makes use of different sources of information such as triangulation in design, researcher and instrument. 114. The statement, “Ninety percent (90%) of the respondents are female staff nurses validates previous research findings (Santos, 2001; Reyes, 2005) that the nursing profession is largely a female dominated profession is an example of A. implication B. interpretation C. analysis D. conclusion Answer: (B) interpretation Interpretation includes the inferences of the researcher about the findings of the study. 115. The study is said to be completed when Ms. Montana achieved which of the following activities? A. Published the results in a nursing journal. B. Presented the study in a research forum. C. The results of the study is used by the nurses in the hospital D. Submitted the research report to the CEO. Answer: (C) The results of the study is used by the nurses in the hospital The last step in the research process is the utilization of the research findings. 116. Situation : Stephanie is a nurse researcher of the Patient Care Services Division. She plans to conduct a literature search for her study. Which of the following is the first step in selecting appropriate materials for her review? A. Track down most of the relevant resources B. Copy relevant materials C. Organize materials according to function D. Synthesize literature gathered. Answer: (A) Track down most of the relevant resources The first step in the review of related literature is to track down relevant sources before copying these. The last step is to synthesize the literature gathered. 117. She knows that the most important categories of information in literature review is the: A. research findings B. theoretical framework C. methodology D. opinions Answer: (A) research findings The research findings is the most important category of information that the researcher should copy because this will give her valuable information as to what has been discovered in past studies about the same topic. 118. She also considers accessing electronic data bases for her literature review. Which of the following is the most useful electronic database for nurses? A. CINAHL B. MEDLINE C. HealthSTAR D. EMBASE Answer: (A) CINAHL This refers to Cumulative Index to Nursing and Allied Health Literature which is a rich source for literature review for nurses. The rest of the sites are for medicine, pharmacy and other health-related

sites. 119. While reviewing journal articles, Stephanie got interested in reading the brief summary of the article placed at the beginning of the journal report. Which of the following refers to this? A. Introduction B. Preface C. Abstract D. Background Answer: (C) Abstract Abstract contains concise description of the background of the study, research questions, research objectives, methods, findings, implications to nursing practice as well as keywords used in the study. 120. She notes down ideas that were derived from the description of an investigation written by the person who conducted it. Which type of reference source refers to this? A. Footnote B. Bibliography C. Primary source D. Endnotes Answer: (C) Primary source . This refers to a primary source which is a direct account of the investigation done by the investigator. In contrast to this is a secondary source, which is written by someone other than the original researcher. 121. She came across a study which is referred to as meta-analysis. Which of the following statements best defines this type of study? A. Treats the findings from one study as a single piece of data B. Findings from multiple studies are combined to yield a data set which is analyzed as individual data C. Represents an application of statistical procedures to findings from each report D. Technique for quantitatively combining and thus integrating the results of multiple studies on a given topic. Answer: (D) Technique for quantitatively combining and thus integrating the results of multiple studies on a given topic. Though all the options are correct, the best definition is option D because it combines quantitatively the results and at the same time it integrates the results of the different studies as one finding. 122. This kind of research gathers data in detail about a individual or groups and presented in narrative form, which is A. Case study B. Historical C. Analytical D. Experimental Answer: (A) Case study Case study focuses on in-depth investigations of single entity or small number of entities. It attempts to analyze and understand issues of importance to history, development or circumstances of the person or entity under study. 123. Stephanie is finished with the steps in the conceptual phase when she has conducted the LAST step, which is A. formulating and delimiting the problem. B. review of related literature C. develop a theoretical framework D. formulate a hypothesis Answer: (D) formulate a hypothesis The last step in the conceptualizing phase of the research process is formulating a hypothesis. The rest are the first three steps in this phase. 124. She states the hypothesis of the study. Which of the following is a null hypothesis? A. Infants who are breastfed have the same weight as those who are bottle fed. B. Bottle-fed infants have lower weight than breast-fed infants C. Cuddled infants sleep longer than those who are left by themselves to sleep. D. Children of absentee parents are more prone to experience depression than those who live with both parents. Answer: (A) Infants who are breastfed have the same weight as those who are bottle fed.

Null hypothesis predicts that there is no change, no difference or no relationship between the variables in the study 125. She notes that the dependent variable in the hypothesis “Duration of sleep of cuddled infants is longer than those infants who are not cuddled by mothers” is A. Cuddled infants B. Duration of sleep C. Infants D. Absence of cuddling Answer: (B) Duration of sleep Duration of sleep is the ‘effect’ (dependent variable) of cuddling ‘cause’ (independent variable). 126. Situation: Aretha is a nurse researcher in a tertiary hospital. She is tasked to conduct a research on the effects of structured discharge plan for post-open heart surgery patients. She states the significance of the research problem. Which of the following statements is the MOST significant for this study? A. Improvement in patient care B. Development of a theoretical basis for nursing C. Increase the accountability of nurses. D. Improves the image of nursing Answer: (A) Improvement in patient care The ultimate goal of conducting research is to improve patient care which is achieved by enhancing the practice of nurses when they utilize research results in their practice. 127. Regardless of the significance of the study, the feasibility of the study needs to be considered. Which of the following is considered a priority? A. Availability of research subjects B. Budgetary allocation C. Time frame D. Experience of the researcher Answer: (A) Availability of research subjects Availability is the most important criteria to be considered by the researcher in determining whether the study is feasible or not. No matter how significant the study may be if there are no available subjects/respondents, the study can not push through. 128. Aretha knows that a good research problem exhibits the following characteristics; which one is NOT included? A. Clearly identified the variables/phenomenon under consideration. B. Specifies the population being studied. C. Implies the feasibility of empirical testing D. Indicates the hypothesis to be tested. Answer: (D) Indicates the hypothesis to be tested. Not all studies require a hypothesis such as qualitative studies, which does not deal with variables but with phenomenon or concepts. 129. She states the purposes of the study. Which of the following describe the purpose of a study? 1. Establishes the general direction of a study 2. Captures the essence of the study 3. Formally articulates the goals of the study 4. Sometimes worded as an intent A. 1, 2, 3 B. 2, 3, 4 C. 1, 3, 4 D. 1, 2, 3, 4 Answer: (D) 1, 2, 3, 4 The purposes of a research study covers all the options indicated. 130. She opts to use interviews in data collection. In addition to validity, what is the other MOST serious weakness of this method? A. Accuracy B. Sensitivity

C. Objectivity D. Reliability Answer: (A) Accuracy Accuracy and validity are the most serious weaknesses of the self-report data. This is due to the fact that the respondents sometimes do not want to tell the truth for fear of being rejected or in order to please the interviewer. 131. She plans to subject her instrument to pretesting. Which of the following is NOT achieved in doing pretesting? A. Determines how much time it takes to administer the instrument package B. Identify parts that are difficult to read or understand C. Determine the budgetary allocation for the study D. Determine if the measures yield data with sufficient variability Answer: (C) Determine the budgetary allocation for the study Determining budgetary allocation for the study is not a purpose of doing a pretesting of the instruments. This is done at an earlier stage of the design and planning phase. 132. She tests the instrument whether it looks as though it is measuring appropriate constructs. Which of the following refers to this? A. Face validity B. Content validity C. Construct Validity D. Criterion-related validity Answer: (A) Face validity Face validity measures whether the instrument appears to be measuring the appropriate construct. It is the easiest type of validity testing. 133. Which of the following questions would determine the construct validity of the instrument? A. “What is this instrument really measuring?” B. “How representative are the questions on this test of the universe of questions on this topic?” C. “Does the question asked looks as though it is measuring the appropriate construct?” D. “Does the instrument correlate highly with an external criterion? Answer: (A) “What is this instrument really measuring?” Construct validity aims to validate what the instrument is really measuring. The more abstract the concept, the more difficult to measure the construct. 134. Which of the following experimental research designs would be appropriate for this study if she wants to find out a cause and effect relationship between the structured discharge plan and compliance to home care regimen among the subjects? A. True experiment B. Quasi experiment C. Post-test only design D. Solomon four-group Answer: (C) Post-test only design Post- Test only design is appropriate because it is impossible to measure the compliance to home care regimen variable prior to the discharge of the patient from the hospital. 135. One hypothesis that she formulated is “Compliance to home care regimen is greater among patients who received the structured discharge plan than those who received verbal discharge instructions.’ Which is the independent variable in this study? A. Structured discharge plan B. Compliance to home care regimen C. Post-open heart surgery patients D. Greater compliance Answer: (A) Structured discharge plan Structured discharge plan is the intervention or the ‘cause’ in the study that results to an ‘effect’, which is compliance to home care regimen or the dependent variable. 136. Situation : Alyssa plans to conduct a study about nursing practice in the country. She decides to refresh her knowledge about the different types of research in order to choose the most appropriate design for her study. She came across surveys, like the Social Weather Station and Pulse Asia Survey. Which of the

following is the purpose of this kind of research? A. Obtains information regarding the prevalence, distribution and interrelationships of variables within a population at a particular time B. Get an accurate and complete data about a phenomenon. C. Develop a tool for data gathering. D. Formulate a framework for the study Answer: (A) Obtains information regarding the prevalence, distribution and interrelationships of variables within a population at a particular time Surveys are done to gather information on people’s actions, knowledge, intentions, opinions and attitudes. 137. She will likely use self-report method. Which of the following self-report methods is the most respected method used in surveys? A. Personal interviews B. Questionnaires C. Telephone interviews D. Rating Scale Answer: (A) Personal interviews Personal interviews is the best method of collecting survey data because the quality of information they yield is higher than other methods and because relatively few people refuse to be interviewed in person. 138. Alyssa reads about exploratory research. Which of the following is the purpose of doing this type of research? A. Inductively develops a theory based on observations about processes involving selected people B. Makes new knowledge useful and practical. C. Identifies the variables in the study D. Finds out the cause and effect relationship between variables Answer: (C) Identifies the variables in the study Exploratory research is the first level of investigation and it deals with identifying the variables in the study. 139. She reviews qualitative design of research. Which of the following is true about ethnographic study? A. Develops theories that increase the knowledge about a certain phenomenon. B. Focuses on the meanings of life experiences of people C. Deals with patterns and experiences of a defined cultural group in a holistic fashion D. In-depth investigation of a single entity Answer: (C) Deals with patterns and experiences of a defined cultural group in a holistic fashion Ethnographic research deals with the cultural patterns and beliefs of certain culture groups. 140. She knows that the purpose of doing ethnographic study is to: A. Understand the worldview of a cultural group B. Study the life experiences of people C. Determine the relationship between variables D. Investigate intensively a single entity Answer: (A) Understand the worldview of a cultural group The aim of ethnographers is to learn from the members of a cultural group by understanding their way of life as they perceive and live it. 141. Alyssa wants to learn more about experimental design. Which is the purpose of this research? A. Test the cause and effect relationship among the variable under a controlled situation B. Identify the variables in the study C. Predicts the future based on current intervention D. Describe the characteristics, opinions, attitudes or behaviors of certain population about a current issue or event Answer: (A) Test the cause and effect relationship among the variable under a controlled situation Experimental research is a Level III investigation which determines the cause and effect relationship between variables. 142. She knows that there are three elements of experimental research. Which is NOT included? A. Manipulation B. Randomization

C. Control D. Trial Answer: (D) Trial Trial is not an element of experimental research. Manipulation of variables, randomization and control are the three elements of this type of research 143. Alyssa knows that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant. Which type of research is referred to this? A. Field study B. Quasi-experiment C. Solomon-Four group design D. Post-test only design Answer: (B) Quasi-experiment Quasi-experiment is done when randomization and control of the variables are not possible. 144. One of the related studies that she reads is a phenomenological research. Which of the following questions is answered by this type of qualitative research? A. ” What is the way of life of this cultural group?” B. “What is the effect of the intervention to the dependent variable?” C. “What the essence of the phenomenon is as experienced by these people?” D. “What is the core category that is central in explaining what is going on in that social scene?” Answer: (C) “What the essence of the phenomenon is as experienced by these people?” Phenomenological research deals with the meaning of experiences as those who experienced the phenomenon understand it. 145. Other studies are categorized according to the time frame. Which of the following refers to a study of variables in the present which is linked to a variable that occurred in the past? A. Prospective design B. Retrospective design C. Cross sectional study D. Longitudinal study Answer: (B) Retrospective design Retrospective studies are done in order to establish a correlation between present variables and the antecedent factors that have caused it. 146. Situation : Harry a new research staff of the Research and Development Department of a tertiary hospital is tasked to conduct a research study about the increased incidence of nosocomial infection in the hospital. Which of the following ethical issues should he consider in the conduct of his study? 1. Confidentiality of information given to him by the subjects 2. Self-determination which includes the right to withdraw from the study group 3. Privacy or the right not to be exposed publicly 4. Full disclosure about the study to be conducted A. 1, 2, 3 B. 1, 3, 4 C. 2, 3, 4 D. 1, 2, 3, 4 Answer: (D) 1, 2, 3, 4 This includes all the options as these are the four basic rights of subjects for research. 147. Which of the following is the best tool for data gathering? A. Interview schedule B. Questionnaire C. Use of laboratory data. D. Observation Answer: (C) Use of laboratory data. Incidence of nosocomial infection is best collected through the use of biophysiologic measures, particularly in vitro measurements, hence laboratory data is essential. 148. During data collection, Harry encounters a patient who refuses to talk to him. Which of the following is a limitation of the study? A. Patient’s refusal to fully divulge information.

B. Patients with history of fever and cough C. Patients admitted or who seeks consultation at the ER and doctors offices D. Contacts of patients with history of fever and cough Answer: (A) Patient’s refusal to fully divulge information. Patient’s refusal to divulge information is a limitation because it is beyond the control of Harry. 149. What type of research is appropriate for this study? A. Descriptive- correlational B. Experiment C. Quasi-experiment D. Historical Answer: (A) Descriptive- correlational Descriptive- correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection. 150. In the statement, “Frequent hand washing of health workers decreases the incidence of nosocomial infections among post-surgery patients”, the dependent variable is A. incidence of nosocomial infections B. decreases C. frequent hand washing D. post-surgery patients Answer: (A) incidence of nosocomial infections The dependent variable is the incidence of nosocomial infection, which is the outcome or effect of the independent variable, frequent hand washing. 151. Harry knows that he has to protect the rights of human research subjects. Which of the following actions of Harry ensures anonymity? A. Keep the identities of the subject secret B. Obtain informed consent C. Provide equal treatment to all the subjects of the study. D. Release findings only to the participants of the study Answer: (A) Keep the identities of the subject secret Keeping the identities of the research subject secret will ensure anonymity because this will hinder providing link between the information given to whoever is its source. 152. He is oriented to the use of electronic databases for nursing research. Which of the following will she likely access? A. MEDLINE B. National Institute of Nursing Research C. American Journal of Nursing D. International Council of Nurses Answer: (B) National Institute of Nursing Research National Institute for Nursing Research is a useful source of information for nursing research. The rest of the options may be helpful but NINR is the most useful site for nurses. 153. He develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration? A. Validity B. Specificity C. Sensitivity D. Reliability Answer: (D) Reliability Reliability is consistency of the research instrument. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration. 154. Harry is aware of the importance of controlling threats to internal validity for experimental research, which include the following examples EXCEPT: A. History B. Maturation C. Attrition D. Design

Answer: (D) Design Design is not a threat to internal validity of the instrument just like the other options. 155. His colleague asks about the external validity of the research findings. Which of the responses of Harry is appropriate? The research findings can be A. generalized to other settings or samples B. shown to result only from the effect of the independent variable C. reflected as results of extraneous variables D. free of selection biases Answer: (A) generalized to other settings or samples External validity refers to the generalizability of research findings to other settings or samples. This is an issue of importance to evidence-based nursing practice.

Philippine NLE Board Exam: Medical Surgical Nursing Question & Answer w/ rationale MEDICAL SURGICAL NURSING 1. Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse’s best response would be: A. “Pain will become less each day.” B. “This is a normal reaction after surgery.” C. “With a pillow, apply pressure against the incision.” D. “I will give you the pain medication the physician ordered.” Answer: (C) “With a pillow, apply pressure against the incision.” Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain. 2. The nurse needs to carefully assess the complaint of pain of the elderly because older people A. are expected to experience chronic pain B. have a decreased pain threshold C. experience reduced sensory perception D. have altered mental function Answer: (C) experience reduced sensory perception Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data. 3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse’s best A. The patient is having an allergic reaction to the drug. B. The patient needs a higher dose of this drug C. This is normal side-effect of AtSO4 D. The patient is anxious about upcoming surgery Answer: (C) This is normal side-effect of AtSO4 Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate. 4. Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question? A. Put the client in modified Trendelenberg's position. B. Administer oxygen at 100%. C. Monitor urine output every hour. D. Administer Demerol 50mg IM q4h Answer: (D) Administer Demerol 50mg IM q4h Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse. 5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach?

A. "Good evening, Mr. Pablo. Wasn't it a pleasant day, today?" B. "Mr, Pablo, you must be so worried, I'll leave you alone with your thoughts. C. “Mr. Pablo, you'll wear out the hospital floors and yourself at this rate." D. "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?" Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?" The client is showing signs of anxiety reaction to a stressful event. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns. 6. After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea. Which action would the nurse take? A. Call the physician immediately. B. Administer the prescribed antiemetic. C. Check the patency of the nasogastric tube for any obstruction. D. Change the patient’s position. Answer: (C) Check the patency of the nasogastric tube for any obstruction. Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention. 7. Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication provides little relief and he refuses to move. The nurse should plan to: A. Reassure him that the nurses will not hurt him B. Let him perform his own activities of daily living C. Handle him gently when assisting with required care D. Complete A.M. care quickly as possible when necessary Answer: (C) Handle him gently when assisting with required care Patients with cancer and bone metastasis experience severe pain especially when moving. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. During nursing care, the patient needs to be supported and handled gently. 8. A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24. What nursing action is most appropriate? A. Notify his physician. B. Take his vital signs again in 15 minutes. C. Take his vital signs again in an hour. D. Place the patient in shock position. Answer: (B) Take his vital signs again in 15 minutes. Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring. 9. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2story building. When assessing the client, the nurse would be most concerned if the assessment revealed: A. Reactive pupils B. A depressed fontanel C. Bleeding from ears D. An elevated temperature Answer: (C) Bleeding from ears The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation 10. Which of the ff. statements by the client to the nurse indicates a risk factor for CAD? A. “I exercise every other day.” B. “My father died of Myasthenia Gravis.”

C. “My cholesterol is 180.” D. “I smoke 1 1/2 packs of cigarettes per day.” Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.” Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention. 11. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug? A. It has positive inotropic and negative chronotropic effects B. The positive inotropic effect will decrease urine output C. Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems D. Do not give the drug if the apical rate is less than 60 beats per minute. Answer: (B) The positive inotropic effect will decrease urine output Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output. 12. Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva's maneuver? A. Use of stool softeners. B. Enema administration C. Gagging while toothbrushing. D. Lifting heavy objects Answer: (A) Use of stool softeners. Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver. 13. The nurse is teaching the patient regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? A. take the pulse rate once a day, in the morning upon awakening B. may be allowed to use electrical appliances C. have regular follow up care D. may engage in contact sports Answer: (D) may engage in contact sports The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator. 14. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching? A. “When your chest pain begins, lie down, and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes.” B. “Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.” C. “Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down.” D. “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. Answer: (D) “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention. 15. A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food? A. Whole milk B. Canned sardines C. Plain nuts D. Eggs Answer: (B) Canned sardines Canned foods are generally rich in sodium content as salt is used as the main preservative.

16. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate? A. Apply a heating pad to the involved site. B. Elevate the client's legs 90 degrees. C. Instruct the client about the need for bed rest. D. Provide active range-of-motion exercises to both legs at least twice every shift. Answer: (C) Instruct the client about the need for bed rest. In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism. 17. A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client? A. It dissolves existing thrombi. B. It prevents conversion of factors that are needed in the formation of clots. C. It inactivates thrombin that forms and dissolves existing thrombi. D. It interferes with vitamin K absorption. Answer: (B) It prevents conversion of factors that are needed in the formation of clots. Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot. 18. The nurse is conducting an education session for a group of smokers in a “stop smoking” class. Which finding would the nurse state as a common symptom of lung cancer? : A. Dyspnea on exertion B. Foamy, blood-tinged sputum C. Wheezing sound on inspiration D. Cough or change in a chronic cough Answer: (D) Cough or change in a chronic cough Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection. 19. Which is the most relevant knowledge about oxygen administration to a client with COPD? A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. C. Oxygen is administered best using a non-rebreathing mask D. Blood gases are monitored using a pulse oximeter. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive. 20. When suctioning mucus from a client's lungs, which nursing action would be least appropriate? A. Lubricate the catheter tip with sterile saline before insertion. B. Use sterile technique with a two-gloved approach C. Suction until the client indicates to stop or no longer than 20 second D. Hyperoxygenate the client before and after suctioning Answer: (C) Suction until the client indicates to stop or no longer than 20 second One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning. 21. Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to A. Cause less irritation to the gastrointestinal tract B. Destroy resistant organisms and promote proper blood levels of the drugs C. Gain a more rapid systemic effect D. Delay resistance and increase the tuberculostatic effect Answer: (D) Delay resistance and increase the tuberculostatic effect Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A prolonged

treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance. 22. Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Mario is placed in Fowler's position on either his right side or on his back to A. Reduce incisional pain. B. Facilitate ventilation of the left lung. C. Equalize pressure in the pleural space. D. Increase venous return Answer: (B) Facilitate ventilation of the left lung. Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. 23. A client with COPD is being prepared for discharge. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT A. Breath in and out as fully as possible before placing the mouthpiece inside the mouth. B. Inhale slowly through the mouth as the canister is pressed down C. Hold his breath for about 10 seconds before exhaling D. Slowly breath out through the mouth with pursed lips after inhaling the drug. Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug. If the client breathes out through the mouth with pursed lips, this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness. 24. A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse's highest priority of information would be A. Food and fluids will be withheld for at least 2 hours. B. Warm saline gargles will be done q 2h. C. Coughing and deep-breathing exercises will be done q2h. D. Only ice chips and cold liquids will be allowed initially. Answer: (A) Food and fluids will be withheld for at least 2 hours. Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours. 25. The nurse enters the room of a client with chronic obstructive pulmonary disease. The client's nasal cannula oxygen is running at a rate of 6 L per minute, the skin color is pink, and the respirations are 9 per minute and shallow. What is the nurse’s best initial action? A. Take heart rate and blood pressure. B. Call the physician. C. Lower the oxygen rate. D. Position the client in a Fowler's position. Answer: (C) Lower the oxygen rate. The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR. 26. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient? A. Fluid volume deficit B. Decreased tissue perfusion. C. Impaired gas exchange. D. Risk for infection Answer: (C) Impaired gas exchange. Pneumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess. 27. A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s

syndrome rather than obesity? A. large thighs and upper arms B. pendulous abdomen and large hips C. abdominal striae and ankle enlargement D. posterior neck fat pad and thin extremities Answer: (D) posterior neck fat pad and thin extremities “Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. All these are noted in a client with Cushing’s syndrome. 28. Which statement by the client indicates understanding of the possible side effects of Prednisone therapy? A. “I should limit my potassium intake because hyperkalemia is a side-effect of this drug.” B. “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.” C. “This medicine will protect me from getting any colds or infection.” D. “My incision will heal much faster because of this drug.” Answer: (B) “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.” The possible side effects of steroid administration are hypokalemia, increase tendency to infection and poor wound healing. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis 29. A client, who is suspected of having Pheochromocytoma, complains of sweating, palpitation and headache. Which assessment is essential for the nurse to make first? A. Pupil reaction B. Hand grips C. Blood pressure D. Blood glucose Answer: (C) Blood pressure Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure. 30. The nurse is attending a bridal shower for a friend when another guest, who happens to be a diabetic, starts to tremble and complains of dizziness. The next best action for the nurse to take is to: A. Encourage the guest to eat some baked macaroni B. Call the guest’s personal physician C. Offer the guest a cup of coffee D. Give the guest a glass of orange juice Answer: (D) Give the guest a glass of orange juice In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious client, he should be given immediately carbohydrates in the form of fruit juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV. 31. An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s disease, the best response would be: A. “The medication will limit thyroid hormone secretion.” B. “The medication limit synthesis of the thyroid hormones.” C. “The medication will block the cardiovascular symptoms of Grave’s disease.” D. “The medication will increase the synthesis of thyroid hormones.” Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s disease.” Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease. 32. During the first 24 hours after thyroid surgery, the nurse should include in her care: A. Checking the back and sides of the operative dressing B. Supporting the head during mild range of motion exercise C. Encouraging the client to ventilate her feelings about the surgery D. Advising the client that she can resume her normal activities immediately Answer: (A) Checking the back and sides of the operative dressing Following surgery of the thyroid gland, bleeding is a potential complication. This can best be

assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry and clear of drainage. 33. On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops: A. Intolerance to heat B. Dry skin and fatigue C. Progressive weight gain D. Insomnia and excitability Answer: (C) Progressive weight gain Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain. 34. What is the best reason for the nurse in instructing the client to rotate injection sites for insulin? A. Lipodystrophy can result and is extremely painful B. Poor rotation technique can cause superficial hemorrhaging C. Lipodystrophic areas can result, causing erratic insulin absorption rates from these D. Injection sites can never be reused Answer: (C) Lipodystrophic areas can result, causing erratic insulin absorption rates from these Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions. 35. Which of the following would be inappropriate to include in a diabetic teaching plan? A. Change position hourly to increase circulation B. Inspect feet and legs daily for any changes C. Keep legs elevated on 2 pillows while sleeping D. Keep the insulin not in use in the refrigerator Answer: (C) Keep legs elevated on 2 pillows while sleeping The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment. 36. Included in the plan of care for the immediate post-gastroscopy period will be: A. Maintain NGT to intermittent suction B. Assess gag reflex prior to administration of fluids C. Assess for pain and medicate as ordered D. Measure abdominal girth every 4 hours Answer: (B) Assess gag reflex prior to administration of fluids The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration. 36. Included in the plan of care for the immediate post-gastroscopy period will be: A. Maintain NGT to intermittent suction B. Assess gag reflex prior to administration of fluids C. Assess for pain and medicate as ordered D. Measure abdominal girth every 4 hours Answer: (B) Assess gag reflex prior to administration of fluids The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration. 37. Which description of pain would be most characteristic of a duodenal ulcer? A. Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake B. RUQ pain that increases after meal C. Sharp pain in the epigastric area that radiates to the right shoulder D. A sensation of painful pressure in the midsternal area Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake.

38. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to: A. Reposition the NGT by advancing it gently NSS B. Notify the MD of your findings C. Irrigate the NGT with 50 cc of sterile D. Discontinue the low-intermittent suction Answer: (B) Notify the MD of your findings The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention. 39. After Billroth II Surgery, the client developed dumping syndrome. Which of the following should the nurse exclude in the plan of care? A. Sit upright for at least 30 minutes after meals B. Take only sips of H2O between bites of solid food C. Eat small meals every 2-3 hours D. Reduce the amount of simple carbohydrate in the diet Answer: (A) Sit upright for at least 30 minutes after meals The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome. 40. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. Which of the following statements indicate an understanding of this data? A. Treatment will include Ranitidine and Antibiotics B. No treatment is necessary at this time C. This result indicates gastric cancer caused by the organism D. Surgical treatment is necessary Answer: (A) Treatment will include Ranitidine and Antibiotics One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer. 41. What instructions should the client be given before undergoing a paracentesis? A. NPO 12 hours before procedure B. Empty bladder before procedure C. Strict bed rest following procedure D. Empty bowel before procedure Answer: (B) Empty bladder before procedure Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure. 42. The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. What statement by the nurse would best explain the purpose of the diet? A. “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.” B. “The liver heals better with a high carbohydrates diet rather than protein.” C. “Most people have too much protein in their diets. The amount of this diet is better for liver healing.” D. “Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.” Answer: (A) “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.” The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins

in the GI tract. A protein-restricted diet will therefore decrease ammonia production. 43. Which of the drug of choice for pain controls the patient with acute pancreatitis? A. Morphine B. NSAIDS C. Meperidine D. Codeine Answer: (C) Meperidine Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic. 44. Immediately after cholecystectomy, the nursing action that should assume the highest priority is: A. encouraging the client to take adequate deep breaths by mouth B. encouraging the client to cough and deep breathe C. changing the dressing at least BID D. irrigate the T-tube frequently Answer: (B) encouraging the client to cough and deep breathe Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications. 45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to: A. Deflate the esophageal balloon B. Monitor VS C. Encourage him to take deep breaths D. Notify the MD Answer: (A) Deflate the esophageal balloon When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction 46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease? A. Chrons disease B. Ulcerative colitis C. Diverticulitis D. Peritonitis Answer: (B) Ulcerative colitis Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem. 47. A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should: A. Give laxative the night before and a cleansing enema in the morning before the test B. Render an oil retention enema and give laxative the night before C. Instruct the client to swallow 6 radiopaque tablets the evening before the study D. Place the client on CBR a day before the study Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema. 48. The client has a good understanding of the means to reduce the chances of colon cancer when he states: A. “I will exercise daily.” B. “I will include more red meat in my diet.” C. “I will have an annual chest x-ray.” D. “I will include more fresh fruits and vegetables in my diet.”

Answer: (D) “I will include more fresh fruits and vegetables in my diet.” Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer. 49. Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to A. Cover the wound with sterile, moist saline dressing B. Approximate the wound edges with tapes C. Irrigate the wound with sterile saline D. Hold the abdominal contents in place with a sterile gloved hand Answer: (A) Cover the wound with sterile, moist saline dressing Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process. 50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to A. Strain all urine. B. Ambulate. C. Remain on bed rest. D. Ask for medications to relax him. Answer: (B) Ambulate. Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination. 51. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance? A. Hyponatremia B. Hyperkalemia C. Hyperphosphatemia D. Hypercalcemia Answer: (A) Hyponatremia The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting 52. Assessing the laboratory findings, which result would the nurse most likely expect to find in a client with chronic renal failure? A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained. 53. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing action would be of highest priority with regard to the external shunt? A. Heparinize it daily. B. Avoid taking blood pressure measurements or blood samples from the affected arm. C. Change the Silastic tube daily. D. Instruct the client not to use the affected arm.

Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm. In the client with an external shunt, don’t use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt. 54. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching? A. TURP is the most common operation for BPH. B. Explain the purpose and function of a two-way irrigation system. C. Expect bloody urine, which will clear as healing takes place. D. He will be pain free. Answer: (D) He will be pain free. Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance. 55. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical examination, the nurse should be looking for tenderness on palpation at McBurney’s point, which is located in the A. left lower quadrant B. left upper quadrant C. right lower quadrant D. right upper quadrant Answer: (C) right lower quadrant To be exact, the appendix is anatomically located at the Mc Burney’s point at the right iliac area of the right lower quadrant. 56. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching should include A. telling him to avoid heavy lifting for 4 to 6 weeks B. instructing him to have a soft bland diet for two weeks C. telling him to resume his previous daily activities without limitations D. recommending him to drink eight glasses of water daily Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case. 57. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned? A. 18% B. 22% C. 31% D. 40% Answer: (C) 31% Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% head; 9% - each upper extremity; 18%- front chest and abdomen; 18% - entire back; 18% - each lower extremity and 1% - perineum. 58. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by: A. An increase in the total volume of intracranial plasma B. Excessive renal perfusion with diuresis C. Fluid shift from interstitial space D. Fluid shift from intravascular space to the interstitial space Answer: (D) Fluid shift from intravascular space to the interstitial space This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.

59. If a client has severe bums on the upper torso, which item would be a primary concern? A. Debriding and covering the wounds B. Administering antibiotics C. Frequently observing for hoarseness, stridor, and dyspnea D. Establishing a patent IV line for fluid replacement Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern. 60. Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures? A. Changing the location of the bed or the TV set, or both, daily B. Encouraging the client to chew gum and blow up balloons C. Avoiding the use of a pillow for sleep, or placing the head in a position of hyperextension D. Helping the client to rest in the position of maximal comfort Answer: (D) Helping the client to rest in the position of maximal comfort Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications. 61. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment is essential? A. evaluation of the peripheral IV site B. confirmation that the tube is in the stomach C. assess the bowel sound D. fluid and electrolyte monitoring Answer: (D) fluid and electrolyte monitoring Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight. 62. Which drug would be least effective in lowering a client's serum potassium level? A. Glucose and insulin B. Polystyrene sulfonate (Kayexalate) C. Calcium glucomite D. Aluminum hydroxide Answer: (D) Aluminum hydroxide Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects. 63. A nurse is directed to administer a hypotonic intravenous solution. Looking at the following labeled solutions, she should choose A. 0.45% NaCl B. 0.9% NaCl C. D5W D. D5NSS Answer: (A) 0.45% NaCl Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood. 64. A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT A. hypertension B. oliguria C. tachycardia D. tachypnea

Answer: (A) hypertension In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria. 65. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of A. assuring Maria that she will be cured of cancer B. assessing Maria's expectations and doubts C. maintaining a cheerful and optimistic environment D. keeping Maria's visitors to a minimum so she can have time for herself Answer: (B) assessing Maria's expectations and doubts Assessing the client’s expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed. 66. Maria refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should A. call the MD to change the dressing so Kathy can see the incision B. recognize that Kathy is experiencing denial, a normal stage of the grieving process C. reinforce Kathy’s belief for several days until her body can adjust to stress of surgery. D. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises. Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the grieving process A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient’s feelings and encourage verbalization. 67. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of the ff. statements about chemotherapy is true? A. it is a local treatment affecting only tumor cells B. it affects both normal and tumor cells C. it has been proven as a complete cure for cancer D. it is often used as a palliative measure. Answer: (B) it affects both normal and tumor cells Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression. 68. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics? A. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer B. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves. C. CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor D. Endoscopy provides direct view of a body cavity to detect abnormality. Answer: (C) CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors. 69. A post-operative complication of mastectomy is lymphedema. This can be prevented by A. ensuring patency of wound drainage tube B. placing the arm on the affected side in a dependent position C. restricting movement of the affected arm D. frequently elevating the arm of the affected side above the level of the heart. Answer: (D) frequently elevating the arm of the affected side above the level of the heart. Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling. 70. Which statement by the client indicates to the nurse that the patient understands precautions

necessary during internal radiation therapy for cancer of the cervix? A. “I should get out of bed and walk around in my room.” B. “My 7 year old twins should not come to visit me while I’m receiving treatment.” C. “I will try not to cough, because the force might make me expel the application.” D. “I know that my primary nurse has to wear one of those badges like the people in the x-ray department, but they are not necessary for anyone else who comes in here.” Answer: (B) “My 7 year old twins should not come to visit me while I’m receiving treatment.” Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself. 71. High uric acid levels may develop in clients who are receiving chemotherapy. This is caused by: A. The inability of the kidneys to excrete the drug metabolites B. Rapid cell catabolism C. Toxic effect of the antibiotic that are given concurrently D. The altered blood ph from the acid medium of the drugs Answer: (B) Rapid cell catabolism One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure. 72. Which of the following interventions would be included in the care of plan in a client with cervical implant? A. Frequent ambulation B. Unlimited visitors C. Low residue diet D. Vaginal irrigation every shift Answer: (C) Low residue diet It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions 73. Which nursing measure would avoid constriction on the affected arm immediately after mastectomy? A. Avoid BP measurement and constricting clothing on the affected arm B. Active range of motion exercises of the arms once a day. C. Discourage feeding, washing or combing with the affected arm D. Place the affected arm in a dependent position, below the level of the heart Answer: (A) Avoid BP measurement and constricting clothing on the affected arm A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm 74. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure. Nursing actions throughout this phase include observation for signs and symptoms of A. Hypervolemia, hypokalemia, and hypernatremia. B. Hypervolemia, hyperkalemia, and hypernatremia. C. Hypovolemia, wide fluctuations in serum sodium and potassium levels. D. Hypovolemia, no fluctuation in serum sodium and potassium levels. Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels. The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur. 75. An adult has just been brought in by ambulance after a motor vehicle accident. When assessing

the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation? A. A rapid pulse and increased RR B. Decreased physiologic functioning C. Rigid posture and altered perceptual focus D. Increased awareness and attention Answer: (A) A rapid pulse and increased RR The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival. 76. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurse's priority should be A. placing her in a trendeleburg position B. putting several warm blankets on her C. monitoring her hourly urine output D. assessing her VS especially her RR Answer: (D) assessing her VS especially her RR Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications. 77. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. The best indicator of adequate fluid balance during this period is A. Elevated hematocrit levels. B. Urine output of 30 to 50 ml/hr. C. Change in level of consciousness. D. Estimate of fluid loss through the burn eschar. Answer: (B) Urine output of 30 to 50 ml/hr. Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance. 78. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following? A. Spontaneous pneumothorax B. Ruptured diaphragm C. Hemothorax D. Pericardial tamponade Answer: (D) Pericardial tamponade Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal. 79. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except A. administering an irritant that will stimulate vomiting B. aspirating secretions from the pharynx if respirations are affected C. neutralizing the chemical D. washing the esophagus with large volumes of water via gastric lavage Answer: (A) administering an irritant that will stimulate vomiting Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the

concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed. 80. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest? A. Skin warm and dry B. Pupils equal and react to light C. Palpable carotid pulse D. Positive Babinski's reflex Answer: (C) Palpable carotid pulse Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after. 81. Chemical burn of the eye are treated with A. local anesthetics and antibacterial drops for 24 – 36 hrs. B. hot compresses applied at 15-minute intervals C. Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water D. cleansing the conjunctiva with a small cotton-tipped applicator Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tapwater eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done. 82. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to: A. Force air out of the lungs B. Increase systemic circulation C. Induce emptying of the stomach D. Put pressure on the apex of the heart Answer: (A) Force air out of the lungs The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material. 83. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should: A. ask them to stay in the waiting area until she can spend time alone with them B. speak to both parents together and encourage them to support each other and express their emotions freely C. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other D. ask the MD to medicate the parents so they can stay calm to deal with their son’s death. Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another. 84. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to: A. increase BP B. decrease mucosal swelling C. relax the bronchial smooth muscle D. decrease bronchial secretions Answer: (C) relax the bronchial smooth muscle Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles. 85. A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the A. upper half of the sternum

B. upper third of the sternum C. lower half of the sternum D. lower third of the sternum Answer: (C) lower half of the sternum The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration. 86. The nurse is performing an eye examination on an elderly client. The client states ‘My vision is blurred, and I don’t easily see clearly when I get into a dark room.” The nurse best response is: A. “You should be grateful you are not blind.” B. “As one ages, visual changes are noted as part of degenerative changes. This is normal.” C. “You should rest your eyes frequently.” D. “You maybe able to improve you vision if you move slowly.” Answer: (B) “As one ages, visual changes are noted as part of degenerative changes. This is normal.” Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision. 87. Which of the following activities is not encouraged in a patient after an eye surgery? A. sneezing, coughing and blowing the nose B. straining to have a bowel movement C. wearing tight shirt collars D. sexual intercourse Answer: (D) sexual intercourse To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP. 88. Which of the following indicates poor practice in communicating with a hearing-impaired client? A. Use appropriate hand motions B. Keep hands and other objects away from your mouth when talking to the client C. Speak clearly in a loud voice or shout to be heard D. Converse in a quiet room with minimal distractions Answer: (C) Speak clearly in a loud voice or shout to be heard Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly. 89. A client is to undergo lumbar puncture. Which is least important information about LP? A. Specimens obtained should be labeled in their proper sequence. B. It may be used to inject air, dye or drugs into the spinal canal. C. Assess movements and sensation in the lower extremities after the D. Force fluids before and after the procedure. Answer: (D) Force fluids before and after the procedure. LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure. 90. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following EXCEPT A. Inform the client that a warm, flushed feeling and a salty taste may be B. Maintain pressure dressing over the site of puncture and check for C. Check pulse, color and temperature of the extremity distal to the site of D. Kept the extremity used as puncture site flexed to prevent bleeding. Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding. Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site. 91. Which is considered as the earliest sign of increased ICP that the nurse should closely observed

for? A. abnormal respiratory pattern B. rising systolic and widening pulse pressure C. contralateral hemiparesis and ipsilateral dilation of the pupils D. progression from restlessness to confusion and disorientation to lethargy Answer: (D) progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially manifested by restlessness. 92. Which is irrelevant in the pharmacologic management of a client with CVA? A. Osmotic diuretics and corticosteroids are given to decrease cerebral edema B. Anticonvulsants are given to prevent seizures C. Thrombolytics are most useful within three hours of an occlusive CVA D. Aspirin is used in the acute management of a completed stroke. Answer: (D) Aspirin is used in the acute management of a completed stroke. The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding. 93. What would be the MOST therapeutic nursing action when a client’s expressive aphasia is severe? A. Anticipate the client wishes so she will not need to talk B. Communicate by means of questions that can be answered by the client shaking the head C. Keep us a steady flow rank to minimize silence D. Encourage the client to speak at every possible opportunity. Answer: (D) Encourage the client to speak at every possible opportunity. Expressive or motor aphasia is a result of damage in the Broca’s area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively. 94. A client with head injury is confused, drowsy and has unequal pupils. Which of the following nursing diagnosis is most important at this time? A. altered level of cognitive function B. high risk for injury C. altered cerebral tissue perfusion D. sensory perceptual alteration Answer: (C) altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage. 95. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia gravis? A. Pain B. High risk for injury related to muscle weakness C. Ineffective coping related to illness D. Ineffective airway clearance related to muscle weakness Answer: (D) Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation. 96. The client has clear drainage from th nose and ears after a head injury. How can the nurse determine if the drainage is CSF? A. Measure the ph of the fluid

B. Measure the specific gravity of the fluid C. Test for glucose D. Test for chlorides Answer: (C) Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage. 97. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. Which measure would be excluded from the teaching plan? A. Wash, dry, and inspect the stump daily. B. Treat superficial abrasions and blisters promptly. C. Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. D. Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a footstool). Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow. 98. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5 years ago. Which would be excluded from the clinical pathway for this client? A. Decrease the calorie count of her daily diet. B. Take warm baths when arising. C. Slide items across the floor rather than lift them. D. Place items so that it is necessary to bend or stretch to reach them. Answer: (D) Place items so that it is necessary to bend or stretch to reach them. Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient. 99. A client is admitted from the emergency department with severe-pain and edema in the right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the highest priority? A. Apply hot compresses to the affected joints. B. Stress the importance of maintaining good posture to prevent deformities. C. Administer salicylates to minimize the inflammatory reaction. D. Ensure an intake of at least 3000 ml of fluid per day. Answer: (D) Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones. 100. A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded from your plan of care? A. Before log rolling, place a pillow under the client's head and a pillow between the client's legs. B. Before log rolling, remove the pillow from under the client's head and use no pillows between the client's legs. C. Keep the knees slightly flexed while the client is lying in a semi-Fowler's position in bed. D. Keep a pillow under the client's head as needed for comfort. Answer: (B) Before log rolling, remove the pillow from under the client's head and use no pillows between the client's legs. Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing. 101. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care? A. providing emotional support to decrease fear

B. protecting the client from infection C. encouraging discussion about lifestyle changes D. identifying factors that decreased the immune function Answer: (B) protecting the client from infection Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection. 102. Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She has a fractured hip and is brought to the OR for surgery. After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at: A. 25 gtt/min B. 30 gtt/min C. 35 gtt/min D. 45 gtt/min Answer: (A) 25 gtt/min To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20) 103. The day after her surgery Joy asks the nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-term weight loss best occurs when: A. Fats are controlled in the diet B. Eating habits are altered C. Carbohydrates are regulated D. Exercise is part of the program Answer: (B) Eating habits are altered For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued 104. The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when Joy says that exercise will: A. Increase her lean body mass B. Lower her metabolic rate C. Decrease her appetite D. Raise her heart rate Answer: (A) Increase her lean body mass Increased exercise builds skeletal muscle mass and reduces excess fatty tissue. 105. The physician orders non-weight bearing with crutches for Joy, who had surgery for a fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is: A. Exercising the triceps, finger flexors, and elbow extensors B. Sitting up at the edge of the bed to help strengthen back muscles C. Doing isometric exercises on the unaffected leg D. Using the trapeze frequently for pull-ups to strengthen the biceps muscles Answer: (A) Exercising the triceps, finger flexors, and elbow extensors These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation. 106. The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on: A. The palms and axillary regions B. Both feet placed wide apart C. The palms of her hands D. Her axillary regions Answer: (C) The palms of her hands The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial

plexus) 107. Joey is a 46 year-old radio technician who is admitted because of mild chest pain. He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed. The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg. The nurse should administer: A. 8 minims B. 10 minims C. 12 minims D. 15 minims Answer: (C) 12 minims Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate 108. Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it: A. Will help prevent erratic heart beats B. Relieves pain and decreases level of anxiety C. Decreases anxiety D. Dilates coronary blood vessels Answer: (B) Relieves pain and decreases level of anxiety Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand. 109. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen: A. Converts to an alternate form of matter B. Has unstable properties C. Supports combustion D. Is flammable Answer: (C) Supports combustion The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use. 110. Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is the most reliable early indicator of myocardial insult is: A. SGPT B. LDH C. CK-MB D. AST Answer: (C) CK-MB The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage. 111. An early finding in the EKG of a client with an infarcted mycardium would be: A. Disappearance of Q waves B. Elevated ST segments C. Absence of P wave D. Flattened T waves Answer: (B) Elevated ST segments This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.

112. Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to: A. Allow him to release his feelings and then leave him alone to allow him to regain his composure B. Refocus the conversation on his fears, frustrations and anger about his condition C. Explain how his being upset dangerously disturbs his need for rest D. Attempt to explain the purpose of different hospital routines Answer: (B) Refocus the conversation on his fears, frustrations and anger about his condition This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand. 113. Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including: A. Shortness of breath B. Chest pain C. Elevated blood pressure D. Increased pulse rate Answer: (D) Increased pulse rate Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever. 114. Jose, who is admitted to the hospital for chest pain, asks the nurse, “Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to: A. Suggest he discuss his feelings of vulnerability with his physician. B. Tell him that he certainly needs to be especially careful about his diet and lifestyle. C. Avoid giving him direct information and help him explore his feelings D. Recognize that he is frightened and suggest he talk with the psychiatrist or counselor. Answer: (C) Avoid giving him direct information and help him explore his feelings To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs. 115. Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to: A. Store vitamin B12 B. Digest vitamin B12 C. Absorb vitamin B12 D. Produce vitamin B12 Answer: (C) Absorb vitamin B12 Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine. 116. Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer: A. 0.5 ml B. 1.0 ml C. 1.5 ml D. 2.0 ml Answer: (D) 2.0 ml First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin. 117. Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic

regimen concerning Vit. B12 will include: A. Oral tablets of Vitamin B12 will control her symptoms B. IM injections are required for daily control C. IM injections once a month will maintain control D. Weekly Z-track injections provide needed control Answer: (C) IM injections once a month will maintain control Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow 118. The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it: A. When she feels fatigued B. During exacerbations of anemia C. Until her symptoms subside D. For the rest of her life Answer: (D) For the rest of her life Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life. 119. Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as: A. Reaction Formation B. Sublimation C. Intellectualization D. Projection Answer: (D) Projection Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition. 120. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure: A. When the client would have normally had a bowel movement B. After the client accepts he had a bowel movement C. Before breakfast and morning care D. At least 2 hours before visitors arrive Answer: (A) When the client would have normally had a bowel movement Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit. 121. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he: A. Stops the flow of fluid when he feels uncomfortable B. Lubricates the tip of the catheter before inserting it into the stoma C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion D. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid insertion The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient. 122. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician : A. Abdominal cramps during fluid inflow B. Difficulty in inserting the irrigating tube C. Passage of flatus during expulsion of feces D. Inability to complete the procedure in half an hour

Answer: (B) Difficulty in inserting the irrigating tube Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour. 123. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing: A. A reaction formation to his recent altered body image. B. A difficult time accepting reality and is in a state of denial. C. Impotency due to the surgery and needs sexual counseling D. Suicide thoughts and should be seen by psychiatrist Answer: (B) A difficult time accepting reality and is in a state of denial. As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported 124. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat: A. Food low in fiber so that there is less stool B. Everything he ate before the operation but will avoid those foods that cause gas C. Bland foods so that his intestines do not become irritated D. Soft foods that are more easily digested and absorbed by the large intestines Answer: (B) Everything he ate before the operation but will avoid those foods that cause gas There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gasforming foods that cause distention and discomfort should be avoided. 125. Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated. When Eddie arrives in the emergency room, the assessment that assume the greatest priority are: A. Level of consciousness and pupil size B. Abdominal contusions and other wounds C. Pain, Respiratory rate and blood pressure D. Quality of respirations and presence of pulsesQuality of respirations and presence of pulses Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and presence of pulses Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished 126. Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to: A. Facilitate his verbal communication B. Maintain sterility of the ventilation system C. Assess his response to the equipment D. Prepare him for emergency surgery Answer: (C) Assess his response to the equipment It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding 127. A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to A. Prepare for chest tube removal B. Milk the tube toward the collection container as ordered C. Arrange for a stat Chest x-ray film. D. Clam the tube immediately Answer: (B) Milk the tube toward the collection container as ordered

This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber 128. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is: A. Increased breath sounds B. Constant bubbling in the drainage chamber C. Crepitus detected on palpation of chest D. Increased respiratory rate Answer: (A) Increased breath sounds The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function 129. In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is: A. Urinary output is 30 ml in an hour B. Central venous pressure reading of 2 cm H2O C. Pulse rates of 120 and 110 in a 15 minute period D. Blood pressure readings of 50/30 and 70/40 within 30 minutes Answer: (A) Urinary output is 30 ml in an hour A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain. 130. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the: A. Complete safety of the procedure B. Expectation of postoperative bleeding C. Risk of the procedure with his other injuries D. Presence of abdominal drains for several days after surgery Answer: (D) Presence of abdominal drains for several days after surgery Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation. 131. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should: A. Encourage bed rest with active and passive range of motion exercises B. Encourage frequent coughing and deep breathing C. Turn him from side to side at least every 2 hours D. Continue observing for dyspnea and crepitus Answer: (B) Encourage frequent coughing and deep breathing This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange. 132. A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to: A. Give him explanations of why there is a need to quickly increase his activity B. Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle C. Appear cheerful and non-critical regardless of his response to attempts at intervention D. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention. 133. The key factor in accurately assessing how body image changes will be dealt with by the client is the:

A. Extent of body change present B. Suddenness of the change C. Obviousness of the change D. Client’s perception of the change Answer: (D) Client’s perception of the change It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings. 134. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as: A. Reaction formation B. Sublimation C. Intellectualization D. Projection Answer: (C) Intellectualization People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets. 135. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to: A. Increase his activity level and ambulate frequently B. Sleep with the head of his bed slightly elevated C. Drink citrus juices frequently for nourishment D. Use a soft toothbrush and electric razor Answer: (D) Use a soft toothbrush and electric razor Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression. 136. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing: A. An anaphylactic transfusion reaction B. An allergic transfusion reaction C. A hemolytic transfusion reaction D. A pyrogenic transfusion reaction Answer: (C) A hemolytic transfusion reaction This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations. 137. A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be: A. “Your laugher is a cover for your fear.” B. “He who laughs on the outside, cries on the inside.” C. “Why are you always laughing?” D. “Does it help you to joke about your illness?” Answer: (D) “Does it help you to joke about your illness?” This non-judgmentally on the part of the nurse points out the client’s behavior. 138. In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to: A. Agree with and encourage the client’s denial B. Reassure the client that everything will be okay C. Allow the denial but be available to discuss death D. Leave the client alone to discuss the loss Answer: (C) Allow the denial but be available to discuss death This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving

and the nurse must be ready to intervene in all these stages. 139. During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be: A. +55 ml B. +137 ml C. +235 ml D. +485 ml Answer: (C) +235 ml The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake 140. Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find: A. Crushing chest pain B. Dyspnea on exertion C. Extensive peripheral edema D. Jugular vein distention Answer: (B) Dyspnea on exertion Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion. 141. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the: A. Distal tubule B. Collecting duct C. Glomerulus of the nephron D. Ascending limb of the loop of Henle Answer: (D) Ascending limb of the loop of Henle This is the site of action of Lasix being a potent loop diuretic. 142. Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is: A. 0.5 L B. 1.0 L C. 2.0 L D. 3.5 L Answer: (C) 2.0 L One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters. 143. Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the: A. Diuretic B. Vasodilator C. Bed-rest regimen D. Cardiac glycoside Answer: (D) Cardiac glycoside A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate. 144. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately: A. 2200 calories B. 2000 calories C. 2800 calories

D. 1600 calories Answer: (B) 2000 calories There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein 145. After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of: A. Magnesium B. Sodium C. Potassium D. Calcium Answer: (B) Sodium Restriction of sodium reduces the amount of water retention that reduces the cardiac workload 146. Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be: A. The medications he has been taking B. Any recent foreign travel C. His usual dietary pattern D. His working patterns Answer: (A) The medications he has been taking Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use 147. The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is: A. Three large meals large enough to supply adequate energy. B. Regular meals and snacks to limit gastric discomfort C. Limited food and fluid intake when he has pain D. A flexible plan according to his appetite Answer: (B) Regular meals and snacks to limit gastric discomfort Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding. 148. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by: A. Increasing HCO3 B. Decreasing PCO2 C. Decreasing pH D. Decreasing PO2 Answer: (B) Decreasing PCO2 Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis. 149. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately: A. 400 Kilocalories B. 600 Kilocalories C. 800 Kilocalories D. 1000 Kilocalories Answer: (B) 600 Kilocalories Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need. 150. Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by:

A. Encouraging adequate fluids B. Applying elastic stockings C. Massaging gently the legs with lotion D. Performing active-assistive leg exercises Answer: (D) Performing active-assistive leg exercises Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon 151. An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by: A. Emptying the drainage bag frequently B. Collecting a weekly urine specimen C. Maintaining the ordered hydration D. Assessing urine specific gravity Answer: (C) Maintaining the ordered hydration Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection 152. The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform: A. Flexion, extension and left and right rotation B. Abduction, flexion, adduction and extension C. Pronation, supination, rotation, and extension D. Dorsiflexion, plantar flexion, eversion and inversion Answer: (D) Dorsiflexion, plantar flexion, eversion and inversion These movements include all possible range of motion for the ankle joint 153. A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of: A. 30 degrees B. 45 degrees C. 60 degrees D. 90 degrees Answer: (A) 30 degrees Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores. 154. Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after surgery: A. Urinary control may be permanently lost to some degree B. Urinary drainage will be dependent on a urethral catheter for 24 hours C. Frequency and burning on urination will last while the cystotomy tube is in place D. His ability to perform sexually will be permanently impaired Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding. 155. The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include: A. Changing the abdominal dressing B. Maintaining patency of the cystotomy tube C. Maintaining patency of a three-way Foley catheter for cystoclysis D. Observing for hemorrhage and wound infection

Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis 156. In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is: A. Sepsis B. Hemorrhage C. Leakage around the catheter D. Urinary retention with overflow Answer: (B) Hemorrhage After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed. 157. Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to: A. Limit discomfort B. Provide hemostasis C. Reduce bladder spasms D. Promote urinary drainage Answer: (B) Provide hemostasis The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding. 158. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to: A. Irrigate the catheter with saline B. Milk the catheter tubing C. Remove the catheter D. Notify the physician Answer: (B) Milk the catheter tubing Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency. 159. The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:” A. Get out of bed into a chair for several hours daily B. Call the physician if my urinary stream decreases C. Attempt to void every 3 hours when I’m awake D. Avoid vigorous exercise for 6 months after surgery Answer: (B) Call the physician if my urinary stream decreases Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction. 160. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find: A. Lethargy, weight gain, and forgetfulness B. Weight loss, protruding eyeballs, and lethargy C. Weight loss, exopthalmos and restlessness D. Constipation, dry skin, and weight gain Answer: (C) Weight loss, exopthalmos and restlessness Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema. 161. Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy:

A. The entire thyroid gland is removed B. A small part of the gland is left intact C. One parathyroid gland is also removed D. A portion of the thyroid and four parathyroids are removed Answer: (B) A small part of the gland is left intact Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca. 162. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include: A. A crash cart with bed board B. A tracheostomy set and oxygen C. An airway and rebreathing mask D. Two ampules of sodium bicarbonate Answer: (B) A tracheostomy set and oxygen Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany. 163. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by: A. Observing for signs of tetany B. Checking her throat for swelling C. Asking her to state her name out loud D. Palpating the side of her neck for blood seepage Answer: (C) Asking her to state her name out loud If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking. 164. On a post-thyroidectomy client’s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops: A. Intolerance to heat B. Dry skin and fatigue C. Progressive weight loss D. Insomnia and excitability Answer: (B) Dry skin and fatigue Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism. 165. A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should: A. Elevate the head of my bed at night B. Avoid moving my extra-ocular muscles C. Avoid using a sleeping mask at night D. Avoid excessive blinking Answer: (C) Avoid using a sleeping mask at night The mask may irritate or scratch the eye if the client turns and lies on it during the night. 166. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is: A. 4.5% B. 9% C. 18 %

D. 22.5% Answer: (D) 22.5% The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5% 167. The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will: A. Inhibit bacterial growth B. Relieve pain from the burn C. Prevent scar tissue formation D. Provide chemical debridement Answer: (A) Inhibit bacterial growth Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes 168. Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide: A. 18 gtt/min B. 28 gtt/min C. 32 gtt/min D. 36 gtt/min Answer: (B) 28 gtt/min This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) 169. Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will: A. Debride necrotic epithelium B. Be sutured in place for better adherence C. Relieve pain and promote rapid epithelialization D. Frequently be used concurrently with topical antimicrobials. Answer: (C) Relieve pain and promote rapid epithelialization The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing. 170. A client with burns on the chest has periodic episodes of dyspnea. The position that would provide for the greatest respiratory capacity would be the: A. Semi-fowler’s position B. Sims’ position C. Orthopneic position D. Supine position Answer: (C) Orthopneic position The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion 171. Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces: A. Brief exaggeration of symptoms B. Prolonged symptomatic improvement C. Rapid but brief symptomatic improvement D. Symptomatic improvement of just the ptosis Answer: (C) Rapid but brief symptomatic improvement Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes. 172. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:

A. Develop a teaching plan B. Facilitate psychologic adjustment C. Maintain the present muscle strength D. Prepare for the appearance of myasthenic crisis Answer: (C) Maintain the present muscle strength Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy 173. The most significant initial nursing observations that need to be made about a client with myasthenia include: A. Ability to chew and speak distinctly B. Degree of anxiety about her diagnosis C. Ability to smile an to close her eyelids D. Respiratory exchange and ability to swallow Answer: (D) Respiratory exchange and ability to swallow Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration 174. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to: A. Administer the medication exactly on time B. Administer the medication with food or mild C. Evaluate the client’s muscle strength hourly after medication D. Evaluate the client’s emotional side effects between doses Answer: (C) Evaluate the client’s muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels. 175. Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to: A. Change her diet order from soft foods to clear liquids B. Place an emergency tracheostomy set in her room C. Assess her respiratory status before and after meals D. Coordinate her meal schedule with the peak effect of her medication, Mestinon Answer: (D) Coordinate her meal schedule with the peak effect of her medication, Mestinon Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.

Maternity Nursing Question & Answer w/ rationale MATERNITY NURSING 1. You performed the leopold’s maneuver and found the following: breech presentation, fetal back at the right side of the mother. Based on these findings, you can hear the fetal heart beat (PMI) BEST in which location? A. Left lower quadrant B. Right lower quadrant C. Left upper quadrant D. Right upper quadrant Answer: (B) Right lower quadrant Right lower quadrant. The landmark to look for when looking for PMI is the location of the fetal back in relation to the right or left side of the mother and the presentation, whether cephalic or breech. The best site is the fetal back nearest the head.

2. In Leopold’s maneuver step #1, you palpated a soft broad mass that moves with the rest of the mass. The correct interpretation of this finding is: A. The mass palpated at the fundal part is the head part. B. The presentation is breech. C. The mass palpated is the back D. The mass palpated is the buttocks. Answer: (D) The mass palpated is the buttocks. The palpated mass is the fetal buttocks since it is broad and soft and moves with the rest of the mass. 3. In Leopold’s maneuver step # 3 you palpated a hard round movable mass at the supra pubic area. The correct interpretation is that the mass palpated is: A. The buttocks because the presentation is breech. B. The mass palpated is the head. C. The mass is the fetal back. D. The mass palpated is the fetal small part Answer: (B) The mass palpated is the head. When the mass palpated is hard round and movable, it is the fetal head. 4. The hormone responsible for a positive pregnancy test is: A. Estrogen B. Progesterone C. Human Chorionic Gonadotropin D. Follicle Stimulating hormone Answer: (C) Human Chorionic Gonadotropin Human chorionic gonadotropin (HCG) is the hormone secreted by the chorionic villi which is the precursor of the placenta. In the early stage of pregnancy, while the placenta is not yet fully developed, the major hormone that sustains the pregnancy is HCG. 5. The hormone responsible for the maturation of the graafian follicle is: A. Follicle stimulating hormone B. Progesterone C. Estrogen D. Luteinizing hormone Answer: (A) Follicle stimulating hormone The hormone that stimulates the maturation if the of the graafian follicle is the Follicle Stimulating Hormone which is released by the anterior pituitary gland. 7. The most common normal position of the fetus in utero is: A. Transverse position B. Vertical position C. Oblique position D. None of the above Answer: (B) Vertical position Vertical position means the fetal spine is parallel to the maternal spine thus making it easy for the fetus to go out the birth canal. If transverse or oblique, the fetus can’t be delivered normally per vagina. 8. In the later part of the 3rd trimester, the mother may experience shortness of breath. This complaint maybe explained as: A. A normal occurrence in pregnancy because the fetus is using more oxygen B. The fundus of the uterus is high pushing the diaphragm upwards C. The woman is having allergic reaction to the pregnancy and its hormones D. The woman maybe experiencing complication of pregnancy Answer: (B) The fundus of the uterus is high pushing the diaphragm upwards From the 32nd week of the pregnancy, the fundus of the enlarged uterus is pushing the respiratory diaphragm upwards. Thus, the lungs have reduced space for expansion consequently reducing the

oxygen supply. 9. Which of the following findings in a woman would be consistent with a pregnancy of two months duration? A. Weight gain of 6-10 lbs. and presence of striae gravidarum B. Fullness of the breast and urinary frequency C. Braxton Hicks contractions and quickening D. Increased respiratory rate and ballottement Answer: (B) Fullness of the breast and urinary frequency Fullness of the breast is due to the increased amount of progesterone in pregnancy. The urinary frequency is caused by the compression of the urinary bladder by the gravid uterus which is still within the pelvic cavity during the first trimester. 10. Which of the following is a positive sign of pregnancy? A. Fetal movement felt by mother B. Enlargement of the uterus C. (+) pregnancy test D. (+) ultrasound Answer: (D) (+) ultrasound A positive ultrasound will definitely confirm that a woman is pregnant since the fetus in utero is directly visualized. 11. What event occurring in the second trimester helps the expectant mother to accept the pregnancy? A. Lightening B. Ballotment C. Pseudocyesis D. Quickening Answer: (D) Quickening Quickening is the first fetal movement felt by the mother makes the woman realize that she is truly pregnant. In early pregnancy, the fetus is moving but too weak to be felt by the mother. In the 18th20th week of gestation, the fetal movements become stronger thus the mother already feels the movements. 12. Shoes with low, broad heels, plus a good posture will prevent which prenatal discomfort? A. Backache B. Vertigo C. Leg cramps D. Nausea Answer: (A) Backache Backache usually occurs in the lumbar area and becomes more problematic as the uterus enlarges. The pregnant woman in her third trimester usually assumes a lordotic posture to maintain balance causing an exaggeration of the lumbar curvature. Low broad heels provide the pregnant woman with a good support. 13. When a pregnant woman experiences leg cramps, the correct nursing intervention to relieve the muscle cramps is: A. Allow the woman to exercise B. Let the woman walk for a while C. Let the woman lie down and dorsiflex the foot towards the knees D. Ask the woman to raise her legs Answer: (C) Let the woman lie down and dorsiflex the foot towards the knees Leg cramps is caused by the contraction of the gastrocnimeus (leg muscle). Thus, the intervention is to stretch the muscle by dosiflexing the foot of the affected leg towards the knee. 14. From the 33rd week of gestation till full term, a healthy mother should have prenatal check up every:

A. week B. 2 weeks C. 3 weeks D. 4 weeks Answer: (A) week In the 9th month of pregnancy the mother needs to have a weekly visit to the prenatal clinic to monitor fetal condition and to ensure that she is adequately prepared for the impending labor and delivery. 15. The expected weight gain in a normal pregnancy during the 3rd trimester is A. 1 pound a week B. 2 pounds a week C. 10 lbs a month D. 10 lbs total weight gain in the 3rd trimester Answer: (A) 1 pound a week During the 3rd trimester the fetus is gaining more subcutaneous fat and is growing fast in preparation for extra uterine life. Thus, one pound a week is expected. 16. In the Batholonew’s rule of 4, when the level of the fundus is midway between the umbilicus and xyphoid process the estimated age of gestation (AOG) is: A. 5th month B. 6th month C. 7th month D. 8th month Answer: (C) 7th month In Bartholomew’s Rule of 4, the landmarks used are the symphysis pubis, umbilicus and xyphoid process. At the level of the umbilicus, the AOG is approximately 5 months and at the level of the xyphoid process 9 months. Thus, midway between these two landmarks would be considered as 7 months AOG. 17. The following are ways of determining expected date of delivery (EDD) when the LMP is unknown EXCEPT: A. Naegele’s rule B. Quickening C. Mc Donald’s rule D. Batholomew’s rule of 4 Answer: (A) Naegele’s rule Naegele’s Rule is determined based on the last menstrual period of the woman. 18. If the LMP is Jan. 30, the expected date of delivery (EDD) is A. Oct. 7 B. Oct. 24 C. Nov. 7 D. Nov. 8 Answer: (C) Nov. 7 Based on the last menstrual period, the expected date of delivery is Nov. 7. The formula for the Naegele’s Rule is subtract 3 from the month and add 7 to the day. 19. Kegel’s exercise is done in pregnancy in order to: A. Strengthen perineal muscles B. Relieve backache C. Strengthen abdominal muscles D. Prevent leg varicosities and edema Answer: (A) Strengthen perineal muscles Kegel’s exercise is done by contracting and relaxing the muscles surrounding the vagina and anus in order to strengthen the perineal muscles 20. Pelvic rocking is an appropriate exercise in pregnancy to relieve which discomfort? A. Leg cramps B. Urinary frequency C. Orthostatic hypotension D. Backache

Answer: (D) Backache Backache is caused by the stretching of the muscles of the lower back because of the pregnancy. Pelvic rocking is good to relieve backache. 21. The main reason for an expected increased need for iron in pregnancy is: A. The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow B. The mother may suffer anemia because of poor appetite C. The fetus has an increased need for RBC which the mother must supply D. The mother may have a problem of digestion because of pica Answer: (A) The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow About 400 mgs of Iron is needed by the mother in order to produce more RBC mass to be able to provide the needed increase in blood supply for the fetus. Also, about 350-400 mgs of iron is need for the normal growth of the fetus. Thus, about 750-800 mgs iron supplementation is needed by the mother to meet this additional requirement. 22. The diet that is appropriate in normal pregnancy should be high in A. Protein, minerals and vitamins B. Carbohydrates and vitamins C. Proteins, carbohydrates and fats D. Fats and minerals Answer: (A) Protein, minerals and vitamins In normal pregnancy there is a higher demand for protein (body building foods), vitamins (esp. vitamin A, B, C, folic acid) and minerals (esp. iron, calcium, phosphorous, zinc, iodine, magnesium) because of the need of the growing fetus. 24. Which of the following signs will require a mother to seek immediate medical attention? A. When the first fetal movement is felt B. No fetal movement is felt on the 6th month C. Mild uterine contraction D. Slight dyspnea on the last month of gestation Answer: (B) No fetal movement is felt on the 6th month Fetal movement is usually felt by the mother during 4.5 – 5 months. If the pregnancy is already in its 6th month and no fetal movement is felt, the pregnancy is not normal either the fetus is already dead intra-uterine or it is an H-mole. 25. You want to perform a pelvic examination on one of your pregnant clients. You prepare your client for the procedure by: A. Asking her to void B. Taking her vital signs and recording the readings C. Giving the client a perineal care D. Doing a vaginal prep Answer: (A) Asking her to void A pelvic examination includes abdominal palpation. If the pregnant woman has a full bladder, the manipulation may cause discomfort and accidental urination because of the pressure applied during the abdominal palpation. Also, a full bladder can impede the accuracy of the examination because the bladder (which is located in front of the uterus) can block the uterus. 26. When preparing the mother who is on her 4th month of pregnancy for abdominal ultrasound, the nurse should instruct her to: A. Observe NPO from midnight to avoid vomiting B. Do perineal flushing properly before the procedure C. Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done D. Void immediately before the procedure for better visualization Answer: (C) Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done Drinking at least 2 liters of water 2 hours before the procedure will result to a distended bladder. A full bladder is needed when doing an abdominal ultrasound to serve as a “window” for the ultrasonic sound waves to pass through and allow visualization of the uterus (located behind the urinary bladder). 27. The nursing intervention to relieve “morning sickness” in a pregnant woman is by giving

A. Dry carbohydrate food like crackers B. Low sodium diet C. Intravenous infusion D. Antacid Answer: (A) Dry carbohydrate food like crackers Morning sickness maybe caused by hypoglycemia early in the morning thus giving carbohydrate food will help. 28. The common normal site of nidation/implantation in the uterus is A. Upper uterine portion B. Mid-uterine area C. Lower uterine segment D. Lower cervical segment Answer: (A) Upper uterine portion The embryo’s normal nidation site is the upper portion of the uterus. If the implantation is in the lower segment, this is an abnormal condition called placenta previa. 29. Mrs. Santos is on her 5th pregnancy and has a history of abortion in the 4th pregnancy and the first pregnancy was a twin. She is considered to be A. G 4 P 3 B. G 5 P 3 C. G 5 P 4 D. G 4 P 4 Answer: (B) G 5 P 3 Gravida refers to the total number of pregnancies including the current one. Para refers to the number of pregnancies that have reached viability. Thus, if the woman has had one abortion, she would be considered Para 3. Twin pregnancy is counted only as 1. 30. The following are skin changes in pregnancy EXCEPT: A. Chloasma B. Striae gravidarum C. Linea negra D. Chadwick's sign Answer: (D) Chadwick's sign Chadwick's sign is bluish discoloration of the vaginal mucosa as a result of the increased vascularization in the area. 31. Which of the following statements is TRUE of conception? A. Within 2-4 hours after intercourse conception is possible in a fertile woman B. Generally, fertilization is possible 4 days after ovulation C. Conception is possible during menstruation in a long menstrual cycle D. To avoid conception, intercourse must be avoided 5 days before and 3 days after menstruation Answer: (A) Within 2-4 hours after intercourse conception is possible in a fertile woman The sperms when deposited near the cervical os will be able to reach the fallopian tubes within 4 hours. If the woman has just ovulated (within 24hours after the rupture of the graafian follicle), fertilization is possible. 32. Which of the following are the functions of amniotic fluid? 1.Cushions the fetus from abdominal trauma 2.Serves as the fluid for the fetus 3.Maintains the internal temperature 4.Facilitates fetal movement A. 1 & 3 B. 1, 3, 4 C. 1, 2, 3 D. All of the above Answer: (D) All of the above All the four functions enumerated are true of amniotic fluid. 33. You are performing abdominal exam on a 9th month pregnant woman. While lying supine, she felt breathless, had pallor, tachycardia, and cold clammy skin. The correct assessment of the woman’s condition is that she is A. Experiencing the beginning of labor B. Having supine hypotension C. Having sudden elevation of BP

D. Going into shock Answer: (B) Having supine hypotension Supine hypotension is characterized by breathlessness, pallor, tachycardia and cold clammy skin. This is due to the compression of the abdominal aorta by the gravid uterus when the woman is on a supine position. 34. Smoking is contraindicated in pregnancy because A. Nicotine causes vasodilation of the mother’s blood vessels B. Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus C. The smoke will make the fetus and the mother feel dizzy D. Nicotine will cause vasoconstriction of the fetal blood vessels Answer: (B) Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus Carbon monoxide is one of the substances found in cigarette smoke. This substance diminishes the ability of the hemoglobin to bind with oxygen thus reducing the amount of oxygenated blood reaching the fetus. 35. Which of the following is the most likely effect on the fetus if the woman is severely anemic during pregnancy? A. Large for gestational age (LGA) fetus B. Hemorrhage C. Small for gestational age (SGA) baby D. Erythroblastosis fetalis Answer: (C) Small for gestational age (SGA) baby Anemia is a condition where there is a reduced amount of hemoglobin. Hemoglobin is needed to supply the fetus with adequate oxygen. Oxygen is needed for normal growth and development of the fetus. 36. Which of the following signs and symptoms will most likely make the nurse suspect that the patient is having hydatidiform mole? A. Slight bleeding B. Passage of clear vesicular mass per vagina C. Absence of fetal heart beat D. Enlargement of the uterus Answer: (B) Passage of clear vesicular mass per vagina Hydatidiform mole (H-mole) is characterized by the degeneration of the chorionic villi wherein the villi becomes vesicle-like. These vesicle-like substances when expelled per vagina and is a definite sign that the woman has H-mole. 37. Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the umbilicus, last menstrual period (LMP) 5 months ago, fetal heart beat (FHB) not appreciated. Which of the following is the most possible diagnosis of this condition? A. Hydatidiform mole B. Missed abortion C. Pelvic inflammatory disease D. Ectopic pregnancy Answer: (A) Hydatidiform mole Hydatidiform mole begins as a pregnancy but early in the development of the embryo degeneration occurs. The proliferation of the vesicle-like substances is rapid causing the uterus to enlarge bigger than the expected size based on ages of gestation (AOG). In the situation given, the pregnancy is only 5 months but the size of the uterus is already above the umbilicus which is compatible with 7 months AOG. Also, no fetal heart beat is appreciated because the pregnancy degenerated thus there is no appreciable fetal heart beat. 38. When a pregnant woman goes into a convulsive seizure, the MOST immediate action of the nurse to ensure safety of the patient is: A. Apply restraint so that the patient will not fall out of bed B. Put a mouth gag so that the patient will not bite her tongue and the tongue will not fall back C. Position the mother on her side to allow the secretions to drain from her mouth and prevent aspiration D. Check if the woman is also having a precipitate labor Answer: (C) Position the mother on her side to allow the secretions to drain from her mouth and

prevent aspiration Positioning the mother on her side will allow the secretions that may accumulate in her mouth to drain by gravity thus preventing aspiration pneumonia. Putting a mouth gag is not safe since during the convulsive seizure the jaw will immediately lock. The mother may go into labor also during the seizure but the immediate concern of the nurse is the safety of the baby. After the seizure, check the perineum for signs of precipitate labor. 39. A gravido-cardiac mother is advised to observe bedrest primarily to A. Allow the fetus to achieve normal intrauterine growth B. Minimize oxygen consumption which can aggravate the condition of the compromised heart of the mother C. Prevent perinatal infection D. Reduce incidence of premature labor Answer: (B) Minimize oxygen consumption which can aggravate the condition of the compromised heart of the mother Activity of the mother will require more oxygen consumption. Since the heart of a gravido-cardiac is compromised, there is a need to put a mother on bedrest to reduce the need for oxygen. 40. A pregnant mother is admitted to the hospital with the chief complaint of profuse vaginal bleeding, AOG 36 wks, not in labor. The nurse must always consider which of the following precautions: A. The internal exam is done only at the delivery under strict asepsis with a double set-up B. The preferred manner of delivering the baby is vaginal C. An emergency delivery set for vaginal delivery must be made ready before examining the patient D. Internal exam must be done following routine procedure Answer: (A) The internal exam is done only at the delivery under strict asepsis with a double set-up Painless vaginal bleeding during the third trimester maybe a sign of placenta praevia. If internal examination is done in this kind of condition, this can lead to even more bleeding and may require immediate delivery of the baby by cesarean section. If the bleeding is due to soft tissue injury in the birth canal, immediate vaginal delivery may still be possible so the set up for vaginal delivery will be used. A double set-up means there is a set up for cesarean section and a set-up for vaginal delivery to accommodate immediately the necessary type of delivery needed. In both cases, strict asepsis must be observed. 41. Which of the following signs will distinguish threatened abortion from imminent abortion? A. Severity of bleeding B. Dilation of the cervix C. Nature and location of pain D. Presence of uterine contraction Answer: (B) Dilation of the cervix In imminent abortion, the pregnancy will definitely be terminated because the cervix is already open unlike in threatened abortion where the cervix is still closed. 42. The nursing measure to relieve fetal distress due to maternal supine hypotension is: A. Place the mother on semi-fowler’s position B. Put the mother on left side lying position C. Place mother on a knee chest position D. Any of the above Answer: (B) Put the mother on left side lying position When a pregnant woman lies on supine position, the weight of the gravid uterus would be compressing on the vena cava against the vertebrae obstructing blood flow from the lower extremities. This causes a decrease in blood return to the heart and consequently immediate decreased cardiac output and hypotension. Hence, putting the mother on side lying will relieve the pressure exerted by the gravid uterus on the vena cava. 43. To prevent preterm labor from progressing, drugs are usually prescribed to halt the labor. The drugs commonly given are: A. Magnesium sulfate and terbutaline B. Prostaglandin and oxytocin C. Progesterone and estrogen D. Dexamethasone and prostaglandin Answer: (A) Magnesium sulfate and terbutaline Magnesium sulfate acts as a CNS depressant as well as a smooth muscle relaxant. Terbutaline is a

drug that inhibits the uterine smooth muscles from contracting. On the other hand, oxytocin and prostaglandin stimulates contraction of smooth muscles. 44. In placenta praevia marginalis, the placenta is found at the: A. Internal cervical os partly covering the opening B. External cervical os slightly covering the opening C. Lower segment of the uterus with the edges near the internal cervical os D. Lower portion of the uterus completely covering the cervix Answer: (C) Lower segment of the uterus with the edges near the internal cervical os Placenta marginalis is a type of placenta previa wherein the placenta is implanted at the lower segment of the uterus thus the edges of the placenta are touching the internal cervical opening/os. The normal site of placental implantation is the upper portion of the uterus. 45. In which of the following conditions can the causative agent pass through the placenta and affect the fetus in utero? A. Gonorrhea B. Rubella C. Candidiasis D. moniliasis Answer: (B) Rubella Rubella is caused by a virus and viruses have low molecular weight thus can pass through the placental barrier. Gonorrhea, candidiasis and moniliasis are conditions that can affect the fetus as it passes through the vaginal canal during the delivery process. 46. Which of the following can lead to infertility in adult males? A. German measles B. Orchitis C. Chicken pox D. Rubella Answer: (B) Orchitis Orchitis is a complication that may accompany mumps in adult males. This condition is characterized by unilateral inflammation of one of the testes which can lead to atrophy of the affected testis. About 20-30% of males who gets mumps after puberty may develop this complication. 47. Papanicolaou smear is usually done to determine cancer of A. Cervix B. Ovaries C. Fallopian tubes D. Breast Answer: (A) Cervix Papanicolaou (Paps) smear is done to detect cervical cancer. It can’t detect cancer in ovaries and fallopian tubes because these organs are outside of the uterus and the abnormal cells from these organs will not be detected from a smear done on the cervix. 48. Which of the following causes of infertility in the female is primarily psychological in origin? A. Vaginismus B. Dyspareunia C. Endometriosis D. Impotence Answer: (A) Vaginismus Vaginismus is primarily psychological in origin. Endometriosis is a condition that is caused by organic abnormalities. Dyspareunia is usually caused by infection, endometriosis or hormonal changes in menopause although may sometimes be psychological in origin. 49. Before giving a repeat dose of magnesium sulfate to a pre-eclamptic patient, the nurse should assess the patient’s condition. Which of the following conditions will require the nurse to temporarily suspend a repeat dose of magnesium sulfate? A. 100 cc. urine output in 4 hours B. Knee jerk reflex is (+)2 C. Serum magnesium level is 10mEg/L. D. Respiratory rate of 16/min Answer: (A) 100 cc. urine output in 4 hours The minimum urine output expected for a repeat dose of MgSO4 is 30 cc/hr. If in 4 hours the urine

output is only 100 cc this is low and can lead to poor excretion of Magnesium with a possible cumulative effect, which can be dangerous to the mother. 50. Which of the following is TRUE in Rh incompatibility? A. The condition can occur if the mother is Rh(+) and the fetus is Rh(-) B. Every pregnancy of an Rh(-) mother will result to erythroblastosis fetalis C. On the first pregnancy of the Rh(-) mother, the fetus will not be affected D. RhoGam is given only during the first pregnancy to prevent incompatibility Answer: (C) On the first pregnancy of the Rh(-) mother, the fetus will not be affected On the first pregnancy, the mother still has no contact with Rh(+) blood thus it has not antibodies against Rh(+). After the first pregnancy, even if terminated into an abortion, there is already the possibility of mixing of maternal and fetal blood so this can trigger the maternal blood to produce antibodies against Rh(+) blood. The fetus takes it’s blood type usually form the father. 51. Which of the following conditions will lead to a small-for-gestational age fetus due to less blood supply to the fetus? A. Diabetes in the mother B. Maternal cardiac condition C. Premature labor D. Abruptio placenta Answer: (B) Maternal cardiac condition In general, when the heart is compromised such as in maternal cardiac condition, the condition can lead to less blood supply to the uterus consequently to the placenta which provides the fetus with the essential nutrients and oxygen. Thus if the blood supply is less, the baby will suffer from chronic hypoxia leading to a small-for-gestational age condition. 52. The lower limit of viability for infants in terms of age of gestation is: A. 21-24 weeks B. 25-27 weeks C. 28-30 weeks D. 38-40 weeks Answer: (A) 21-24 weeks Viability means the capability of the fetus to live/survive outside of the uterine environment. With the present technological and medical advances, 21 weeks AOG is considered as the minimum fetal age for viability. 53. Which provision of our 1987 constitution guarantees the right of the unborn child to life from conception is A. Article II section 12 B. Article II section 15 C. Article XIII section 11 D. Article XIII section 15 Answer: (A) Article II section 12 The Philippine Constitution of 1987 guarantees the right of the unborn child from conception equal to the mother as stated in Article II State Policies, Section 12. 54. In the Philippines, if a nurse performs abortion on the mother who wants it done and she gets paid for doing it, she will be held liable because A. Abortion is immoral and is prohibited by the church B. Abortion is both immoral and illegal in our country C. Abortion is considered illegal because you got paid for doing it D. Abortion is illegal because majority in our country are catholics and it is prohibited by the church Answer: (B) Abortion is both immoral and illegal in our country Induced Abortion is illegal in the country as stated in our Penal Code and any person who performs the act for a fee commits a grave offense punishable by 10-12 years of imprisonment. The preferred manner of delivering the baby in a gravido-cardiac is vaginal delivery assisted by forceps under epidural anesthesia. The main rationale for this is: A. To allow atraumatic delivery of the baby B. To allow a gradual shifting of the blood into the maternal circulation C. To make the delivery effort free and the mother does not need to push with contractions D. To prevent perineal laceration with the expulsion of the fetal head

Answer: (C) To make the delivery effort free and the mother does not need to push with contractions Forceps delivery under epidural anesthesia will make the delivery process less painful and require less effort to push for the mother. Pushing requires more effort which a compromised heart may not be able to endure. 56. When giving narcotic analgesics to mother in labor, the special consideration to follow is: A. The progress of labor is well established reaching the transitional stage B. Uterine contraction is progressing well and delivery of the baby is imminent C. Cervical dilatation has already reached at least 8 cm. and the station is at least (+)2 D. Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours. Answer: (D) Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours. Narcotic analgesics must be given when uterine contractions are already well established so that it will not cause stoppage of the contraction thus protracting labor. Also, it should be given when delivery of fetus is imminent or too close because the fetus may suffer respiratory depression as an effect of the drug that can pass through placental barrier. 57. The cervical dilatation taken at 8:00 A.M. in a G1P0 patient was 6 cm. A repeat I.E. done at 10 A.M. showed that cervical dilation was 7 cm. The correct interpretation of this result is: A. Labor is progressing as expected B. The latent phase of Stage 1 is prolonged C. The active phase of Stage 1 is protracted D. The duration of labor is normal Answer: (C) The active phase of Stage 1 is protracted The active phase of Stage I starts from 4cm cervical dilatation and is expected that the uterus will dilate by 1cm every hour. Since the time lapsed is already 2 hours, the dilatation is expected to be already 8 cm. Hence, the active phase is protracted. 58. Which of the following techniques during labor and delivery can lead to uterine inversion? A. Fundal pressure applied to assist the mother in bearing down during delivery of the fetal head B. Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation C. Massaging the fundus to encourage the uterus to contract D. Applying light traction when delivering the placenta that has already detached from the uterine wall Answer: (B) Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation When the placenta is still attached to the uterine wall, tugging on the cord while the uterus is relaxed can lead to inversion of the uterus. Light tugging on the cord when placenta has detached is alright in order to help deliver the placenta that is already detached. 59. The fetal heart rate is checked following rupture of the bag of waters in order to: A. Check if the fetus is suffering from head compression B. Determine if cord compression followed the rupture C. Determine if there is utero-placental insufficiency D. Check if fetal presenting part has adequately descended following the rupture Answer: (B) Determine if cord compression followed the rupture After the rupture of the bag of waters, the cord may also go with the water because of the pressure of the rupture and flow. If the cord goes out of the cervical opening, before the head is delivered (cephalic presentation), the head can compress on the cord causing fetal distress. Fetal distress can be detected through the fetal heart tone. Thus, it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head. 60. Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated with blood within 2 hours post partum, PR= 80 bpm, fundus soft and boundaries not well defined. The appropriate nursing diagnosis is: A. Normal blood loss B. Blood volume deficiency C. Inadequate tissue perfusion related to hemorrhage D. Hemorrhage secondary to uterine atony Answer: (D) Hemorrhage secondary to uterine atony All the signs in the stem of the question are signs of hemorrhage. If the fundus is soft and boundaries not well defined, the cause of the hemorrhage could be uterine atony. 61. The following are signs and symptoms of fetal distress EXCEPT: A. Fetal heart rate (FHR) decreased during a contraction and persists even after the uterine

contraction ends B. The FHR is less than 120 bpm or over 160 bpm C. The pre-contraction FHR is 130 bpm, FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm D. FHR is 160 bpm, weak and irregular Answer: (C) The pre-contraction FHR is 130 bpm, FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm The normal range of FHR is 120-160 bpm, strong and regular. During a contraction, the FHR usually goes down but must return to its pre-contraction rate after the contraction ends. 62. If the labor period lasts only for 3 hours, the nurse should suspect that the following conditions may occur: 1.Laceration of cervix 2.Laceration of perineum 3.Cranial hematoma in the fetus 4.Fetal anoxia A. 1 & 2 B. 2 & 4 C. 2,3,4 D. 1,2,3,4 Answer: (D) 1,2,3,4 all the above conditions can occur following a precipitate labor and delivery of the fetus because there was little time for the baby to adapt to the passageway. If the presentation is cephalic, the fetal head serves as the main part of the fetus that pushes through the birth canal which can lead to cranial hematoma, and possible compression of cord may occur which can lead to less blood and oxygen to the fetus (hypoxia). Likewise the maternal passageway (cervix, vaginal canal and perineum) did not have enough time to stretch which can lead to laceration. 63. The primary power involved in labor and delivery is A. Bearing down ability of mother B. Cervical effacement and dilatation C. Uterine contraction D. Valsalva technique Answer: (C) Uterine contraction Uterine contraction is the primary force that will expel the fetus out through the birth canal Maternal bearing down is considered the secondary power/force that will help push the fetus out. 64. The proper technique to monitor the intensity of a uterine contraction is A. Place the palm of the hands on the abdomen and time the contraction B. Place the finger tips lightly on the suprapubic area and time the contraction C. Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction D. Put the palm of the hands on the fundal area and feel the contraction at the fundal area Answer: (C) Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction In monitoring the intensity of the contraction the best place is to place the fingertips at the fundal area. The fundus is the contractile part of the uterus and the fingertips are more sensitive than the palm of the hand. 65. To monitor the frequency of the uterine contraction during labor, the right technique is to time the contraction A. From the beginning of one contraction to the end of the same contraction B. From the beginning of one contraction to the beginning of the next contraction C. From the end of one contraction to the beginning of the next contraction D. From the deceleration of one contraction to the acme of the next contraction Answer: (B) From the beginning of one contraction to the beginning of the next contraction Frequency of the uterine contraction is defined as from the beginning of one contraction to the beginning of another contraction. 66. The peak point of a uterine contraction is called the A. Acceleration B. Acme

C. Deceleration D. Axiom Answer: (B) Acme Acme is the technical term for the highest point of intensity of a uterine contraction. 67. When determining the duration of a uterine contraction the right technique is to time it from A. The beginning of one contraction to the end of the same contraction B. The end of one contraction to the beginning of another contraction C. The acme point of one contraction to the acme point of another contraction D. The beginning of one contraction to the end of another contraction Answer: (A) The beginning of one contraction to the end of the same contraction Duration of a uterine contraction refers to one contraction. Thus it is correctly measure from the beginning of one contraction to the end of the same contraction and not of another contraction. 68. When the bag of waters ruptures, the nurse should check the characteristic of the amniotic fluid. The normal color of amniotic fluid is A. Clear as water B. Bluish C. Greenish D. Yellowish Answer: (A) Clear as water The normal color of amniotic fluid is clear like water. If it is yellowish, there is probably Rh incompatibility. If the color is greenish, it is probably meconium stained. 69. When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal introitus for possible cord prolapse. If there is part of the cord that has prolapsed into the vaginal opening the correct nursing intervention is: A. Push back the prolapse cord into the vaginal canal B. Place the mother on semifowler’s position to improve circulation C. Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position D. Push back the cord into the vagina and place the woman on sims position Answer: (C) Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position The correct action of the nurse is to cover the cord with sterile gauze wet with sterile NSS. Observe strict asepsis in the care of the cord to prevent infection. The cord has to be kept moist to prevent it from drying. Don’t attempt to put back the cord into the vagina but relieve pressure on the cord by positioning the mother either on trendellenberg or sims position 70. The fetal heart beat should be monitored every 15 minutes during the 2nd stage of labor. The characteristic of a normal fetal heart rate is A. The heart rate will decelerate during a contraction and then go back to its pre-contraction rate after the contraction B. The heart rate will accelerate during a contraction and remain slightly above the pre-contraction rate at the end of the contraction C. The rate should not be affected by the uterine contraction. D. The heart rate will decelerate at the middle of a contraction and remain so for about a minute after the contraction Answer: (A) The heart rate will decelerate during a contraction and then go back to its precontraction rate after the contraction The normal fetal heart rate will decelerate (go down) slightly during a contraction because of the compression on the fetal head. However, the heart rate should go back to the pre-contraction rate as soon as the contraction is over since the compression on the head has also ended. 71. The mechanisms involved in fetal delivery is A. Descent, extension, flexion, external rotation B. Descent, flexion, internal rotation, extension, external rotation C. Flexion, internal rotation, external rotation, extension D. Internal rotation, extension, external rotation, flexion Answer: (B) Descent, flexion, internal rotation, extension, external rotation The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur several days before true labor sets in the primigravida. Flexion, internal rotation and extension are

mechanisms that the fetus must perform as it accommodates through the passageway/birth canal. Eternal rotation is done after the head is delivered so that the shoulders will be easily delivered through the vaginal introitus. 72. The first thing that a nurse must ensure when the baby’s head comes out is A. The cord is intact B. No part of the cord is encircling the baby’s neck C. The cord is still attached to the placenta D. The cord is still pulsating Answer: (B) No part of the cord is encircling the baby’s neck The nurse should check right away for possible cord coil around the neck because if it is present, the baby can be strangulated by it and the fetal head will have difficulty being delivered. 73. To ensure that the baby will breath as soon as the head is delivered, the nurse’s priority action is to A. Suction the nose and mouth to remove mucous secretions B. Slap the baby’s buttocks to make the baby cry C. Clamp the cord about 6 inches from the base D. Check the baby’s color to make sure it is not cyanotic Answer: (A) Suction the nose and mouth to remove mucous secretions Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that maybe present allowing for better breathing. Also, if mucus is in the nose and mouth, aspiration of the mucus is possible which can lead to aspiration pneumonia. (Remember that only the baby’s head has come out as given in the situation.) 74. When doing perineal care in preparation for delivery, the nurse should observe the following EXCEPT A. Use up-down technique with one stroke B. Clean from the mons veneris to the anus C. Use mild soap and warm water D. Paint the inner thighs going towards the perineal area Answer: (D) Paint the inner thighs going towards the perineal area Painting of the perineal area in preparation for delivery of the baby must always be done but the stroke should be from the perineum going outwards to the thighs. The perineal area is the one being prepared for the delivery and must be kept clean 75. What are the important considerations that the nurse must remember after the placenta is delivered? 1.Check if the placenta is complete including the membranes 2.Check if the cord is long enough for the baby 3.Check if the umbilical cord has 3 blood vessels 4.Check if the cord has a meaty portion and a shiny portion A. 1 and 3 B. 2 and 4 C. 1, 3, and 4 D. 2 and 3 Answer: (A) 1 and 3 The nurse after delivering the placenta must ensure that all the cotyledons and the membranes of the placenta are complete. Also, the nurse must check if the umbilical cord is normal which means it contains the 3 blood vessels, 2 veins and 1 artery. 76. The following are correct statements about false labor EXCEPT A. The pain is irregular in intensity and frequency. B. The duration of contraction progressively lengthens over time C. There is no vaginal bloody discharge D. The cervix is still closed. Answer: (B) The duration of contraction progressively lengthens over time In false labor, the contractions remain to be irregular in intensity and duration while in true labor, the contractions become stronger, longer and more frequent. 77. The passageway in labor and deliver of the fetus include the following EXCEPT A. Distensibility of lower uterine segment B. Cervical dilatation and effacement

C. Distensibility of vaginal canal and introitus D. Flexibility of the pelvis Answer: (D) Flexibility of the pelvis The pelvis is a bony structure that is part of the passageway but is not flexible. The lower uterine segment including the cervix as well as the vaginal canal and introitus are all part of the passageway in the delivery of the fetus. 78. The normal umbilical cord is composed of: A. 2 arteries and 1 vein B. 2 veins and 1 artery C. 2 arteries and 2 veins D. none of the above Answer: (A) 2 arteries and 1 vein the umbilical cord is composed of 2 arteries and 1 vein. 79. At what stage of labor and delivery does a primigravida differ mainly from a multigravida? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 Answer: (A) Stage 1 In stage 1 during a normal vaginal delivery of a vertex presentation, the multigravida may have about 8 hours labor while the primigravida may have up to 12 hours labor. 80. The second stage of labor begins with ___ and ends with __? A. Begins with full dilatation of cervix and ends with delivery of placenta B. Begins with true labor pains and ends with delivery of baby C. Begins with complete dilatation and effacement of cervix and ends with delivery of baby D. Begins with passage of show and ends with full dilatation and effacement of cervix Answer: (C) Begins with complete dilatation and effacement of cervix and ends with delivery of baby Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends with the delivery of baby. Stage 1 begins with true labor pains and ends with full dilatation and effacement of the cervix. 81. The following are signs that the placenta has detached EXCEPT: A. Lengthening of the cord B. Uterus becomes more globular C. Sudden gush of blood D. Mother feels like bearing down Answer: (D) Mother feels like bearing down Placental detachment does not require the mother to bear down. A normal placenta will detach by itself without any effort from the mother. 82. When the shiny portion of the placenta comes out first, this is called the ___ mechanism. A. Schultze B. Ritgens C. Duncan D. Marmets Answer: (A) Schultze There are 2 mechanisms possible during the delivery of the placenta. If the shiny portion comes out first, it is called the Schultze mechanism; while if the meaty portion comes out first, it is called the Duncan mechanism. 83. When the baby’s head is out, the immediate action of the nurse is A. Cut the umbilical cord B. Wipe the baby’s face and suction mouth first C. Check if there is cord coiled around the neck D. Deliver the anterior shoulder Answer: (C) Check if there is cord coiled around the neck The nurse should check if there is a cord coil because the baby will not be delivered safely if the cord

is coiled around its neck. Wiping of the face should be done seconds after you have ensured that there is no cord coil but suctioning of the nose should be done after the mouth because the baby is a “nasal obligate” breather. If the nose is suctioned first before the mouth, the mucus plugging the mouth can be aspirated by the baby. 84. When delivering the baby’s head the nurse supports the mother’s perineum to prevent tear. This technique is called A. Marmet’s technique B. Ritgen’s technique C. Duncan maneuver D. Schultze maneuver Answer: (B) Ritgen’s technique Ritgen’s technique is done to prevent perineal tear. This is done by the nurse by support the perineum with a sterile towel and pushing the perineum downard with one hand while the other hand is supporting the baby’s head as it goes out of the vaginal opening. 85. The basic delivery set for normal vaginal delivery includes the following instruments/articles EXCEPT: A. 2 clamps B. Pair of scissors C. Kidney basin D. Retractor Answer: (D) Retractor For normal vaginal delivery, the nurse needs only the instruments for cutting the umbilical cord such as: 2 clamps (straight or curve) and a pair of scissors as well as the kidney basin to receive the placenta. The retractor is not part of the basic set. In the hospital setting, needle holder and tissue forceps are added especially if the woman delivering the baby is a primigravida wherein episiotomy is generally done. 86. As soon as the placenta is delivered, the nurse must do which of the following actions? A. Inspect the placenta for completeness including the membranes B. Place the placenta in a receptacle for disposal C. Label the placenta properly D. Leave the placenta in the kidney basin for the nursing aide to dispose properly Answer: (A) Inspect the placenta for completeness including the membranes The placenta must be inspected for completeness to include the membranes because an incomplete placenta could mean that there is retention of placental fragments which can lead to uterine atony. If the uterus does not contract adequately, hemorrhage can occur. 87. In vaginal delivery done in the hospital setting, the doctor routinely orders an oxytocin to be given to the mother parenterally. The oxytocin is usually given after the placenta has been delivered and not before because: A. Oxytocin will prevent bleeding B. Oxytocin can make the cervix close and thus trap the placenta inside C. Oxytocin will facilitate placental delivery D. Giving oxytocin will ensure complete delivery of the placenta Answer: (B) Oxytocin can make the cervix close and thus trap the placenta inside The action of oxytocin is to make the uterus contract as well make the cervix close. If it is given prior to placental delivery, the placenta will be trapped inside because the action of the drug is almost immediate if given parentally. 88. In a gravido-cardiac mother, the first 2 hours postpartum (4th stage of labor and delivery) particularly in a cesarean section is a critical period because at this stage A. There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. B. The maternal heart is already weak and the mother can die C. The delivery process is strenuous to the mother D. The mother is tired and weak which can distress the heart Answer: (A) There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. During the pregnancy, there is an increase in maternal blood volume to accommodate the need of the fetus. When the baby and placenta have been delivered, there is a fluid shift back to the maternal circulation as part of physiologic adaptation during the postpartum period. In cesarean section, the fluid shift occurs faster because the placenta is taken out right after the baby is delivered giving it less

time for the fluid shift to gradually occur. 89. The drug usually given parentally to enhance uterine contraction is: A. Terbutalline B. Pitocin C. Magnesium sulfate D. Lidocaine Answer: (B) Pitocin The common oxytocin given to enhance uterine contraction is pitocin. This is also the drug given to induce labor. 90. The partograph is a tool used to monitor labor. The maternal parameters measured/monitored are the following EXCEPT: A. Vital signs B. Fluid intake and output C. Uterine contraction D. Cervical dilatation Answer: (B) Fluid intake and output Partograph is a monitoring tool designed by the World Health Organization for use by health workers when attending to mothers in labor especially the high risk ones. For maternal parameters all of the above is placed in the partograph except the fluid intake since this is placed in a separate monitoring sheet. 91. The following are natural childbirth procedures EXCEPT: A. Lamaze method B. Dick-Read method C. Ritgen’s maneuver D. Psychoprophylactic method Answer: (C) Ritgen’s maneuver Ritgen’s method is used to prevent perineal tear/laceration during the delivery of the fetal head. Lamaze method is also known as psychoprophylactic method and Dick-Read method are commonly known natural childbirth procedures which advocate the use of non-pharmacologic measures to relieve labor pain. 92. The following are common causes of dysfunctional labor. Which of these can a nurse, on her own manage? A. Pelvic bone contraction B. Full bladder C. Extension rather than flexion of the head D. Cervical rigidity Answer: (B) Full bladder Full bladder can impede the descent of the fetal head. The nurse can readily manage this problem by doing a simple catheterization of the mother. 93. At what stage of labor is the mother is advised to bear down? A. When the mother feels the pressure at the rectal area B. During a uterine contraction C. In between uterine contraction to prevent uterine rupture D. Anytime the mother feels like bearing down Answer: (B) During a uterine contraction The primary power of labor and delivery is the uterine contraction. This should be augmented by the mother’s bearing down during a contraction. 94. The normal dilatation of the cervix during the first stage of labor in a nullipara is A. 1.2 cm./hr B. 1.5 cm./hr. C. 1.8 cm./hr D. 2.0 cm./hr Answer: (A) 1.2 cm./hr For nullipara the normal cervical dilatation should be 1.2 cm/hr. If it is less than that, it is considered a protracted active phase of the first stage. For multipara, the normal cervical dilatation is 1.5 cm/hr. 95. When the fetal head is at the level of the ischial spine, it is said that the station of the head is A. Station –1 B. Station “0”

C. Station +1 D. Station +2 Answer: (B) Station “0” Station is defined as the relationship of the fetal head and the level of the ischial spine. At the level of the ischial spine, the station is “0”. Above the ischial spine it is considered (-) station and below the ischial spine it is (+) station. 96. During an internal examination, the nurse palpated the posterior fontanel to be at the left side of the mother at the upper quadrant. The interpretation is that the position of the fetus is: A. LOA B. ROP C. LOP D. ROA Answer: (A) LOA The landmark used in determine fetal position is the posterior fontanel because this is the nearest to the occiput. So if the nurse palpated the occiput (O) at the left (L) side of the mother and at the upper/anterior (A) quadrant then the fetal position is LOA. 97. The following are types of breech presentation EXCEPT: A. Footling B. Frank C. Complete D. Incomplete Answer: (D) Incomplete Breech presentation means the buttocks of the fetus is the presenting part. If it is only the foot/feet, it is considered footling. If only the buttocks, it is frank breech. If both the feet and the buttocks are presenting it is called complete breech. 98. When the nurse palpates the suprapubic area of the mother and found that the presenting part is still movable, the right term for this observation that the fetus is A. Engaged B. Descended C. Floating D. Internal Rotation Answer: (C) Floating The term floating means the fetal presenting part has not entered/descended into the pelvic inlet. If the fetal head has entered the pelvic inlet, it is said to be engaged. 99. The placenta should be delivered normally within ___ minutes after the delivery of the baby. A. 5 minutes B. 30 minutes C. 45 minutes D. 60 minutes Answer: (B) 30 minutes The placenta is delivered within 30 minutes from the delivery of the baby. If it takes longer, probably the placenta is abnormally adherent and there is a need to refer already to the obstetrician. 100. When shaving a woman in preparation for cesarean section, the area to be shaved should be from ___ to ___ A. Under breast to mid-thigh including the pubic area B. The umbilicus to the mid-thigh C. Xyphoid process to the pubic area D. Above the umbilicus to the pubic area Answer: (A) Under breast to mid-thigh including the pubic area Shaving is done to prevent infection and the area usually shaved should sufficiently cover the area for surgery, cesarean section. The pubic hair is definitely to be included in the shaving 101. Postpartum Period: The fundus of the uterus is expected to go down normally postpartally about __ cm per day. A. 1.0 cm

B. 2.0 cm C. 2.5 cm D. 3.0 cm Answer: (A) 1.0 cm The uterus will begin involution right after delivery. It is expected to regress/go down by 1 cm. per day and becomes no longer palpable about 1 week after delivery. 102. The lochia on the first few days after delivery is characterized as A. Pinkish with some blood clots B. Whitish with some mucus C. Reddish with some mucus D. Serous with some brown tinged mucus Answer: (C) Reddish with some mucus Right after delivery, the vaginal discharge called lochia will be reddish because there is some blood, endometrial tissue and mucus. Since it is not pure blood it is non-clotting. 103. Lochia normally disappears after how many days postpartum? A. 5 days B. 7-10 days C. 18-21 days D. 28-30 days Answer: (B) 7-10 days Normally, lochia disappears after 10 days postpartum. What’s important to remember is that the color of lochia gets to be lighter (from reddish to whitish) and scantier everyday. 104. After an Rh(-) mother has delivered her Rh (+) baby, the mother is given RhoGam. This is done in order to: A. Prevent the recurrence of Rh(+) baby in future pregnancies B. Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby C. Ensure that future pregnancies will not lead to maternal illness D. To prevent the newborn from having problems of incompatibility when it breastfeeds Answer: (B) Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby In Rh incompatibility, an Rh(-) mother will produce antibodies against the fetal Rh (+) antigen which she may have gotten because of the mixing of maternal and fetal blood during labor and delivery. Giving her RhoGam right after birth will prevent her immune system from being permanently sensitized to Rh antigen. 105. To enhance milk production, a lactating mother must do the following interventions EXCEPT: A. Increase fluid intake including milk B. Eat foods that increases lactation which are called galactagues C. Exercise adequately like aerobics D. Have adequate nutrition and rest Answer: (C) Exercise adequately like aerobics All the above nursing measures are needed to ensure that the mother is in a healthy state. However, aerobics does not necessarily enhance lactation. 106. The nursing intervention to relieve pain in breast engorgement while the mother continues to breastfeed is A. Apply cold compress on the engorged breast B. Apply warm compress on the engorged breast C. Massage the breast D. Apply analgesic ointment Answer: (B) Apply warm compress on the engorged breast Warm compress is applied if the purpose is to relieve pain but ensure lactation to continue. If the purpose is to relieve pain as well as suppress lactation, the compress applied is cold. 107. A woman who delivered normally per vagina is expected to void within ___ hours after delivery. A. 3 hrs B. 4 hrs. C. 6-8 hrs D. 12-24 hours

Answer: (C) 6-8 hrs A woman who has had normal delivery is expected to void within 6-8 hrs. If she is unable to do so after 8 hours, the nurse should stimulate the woman to void. If nursing interventions to stimulate spontaneous voiding don’t work, the nurse may decide to catheterize the woman. 108. To ensure adequate lactation the nurse should teach the mother to: A. Breast feed the baby on self-demand day and night B. Feed primarily during the day and allow the baby to sleep through the night C. Feed the baby every 3-4 hours following a strict schedule D. Breastfeed when the breast are engorged to ensure adequate supply Answer: (A) Breast feed the baby on self-demand day and night Feeding on self-demand means the mother feeds the baby according to baby’s need. Therefore, this means there will be regular emptying of the breasts, which is essential to maintain adequate lactation. 109. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebitis is: A. Encourage the mother to ambulate to relieve the pain in the leg B. Instruct the mother to apply elastic bondage from the foot going towards the knee to improve venous return flow C. Apply warm compress on the affected leg to relieve the pain D. Elevate the affected leg and keep the patient on bedrest Answer: (D) Elevate the affected leg and keep the patient on bedrest If the mother already has thrombophlebitis, the nursing intervention is bedrest to prevent the possible dislodging of the thrombus and keeping the affected leg elevated to help reduce the inflammation. 110. The nurse should anticipate that hemorrhage related to uterine atony may occur postpartally if this condition was present during the delivery: A. Excessive analgesia was given to the mother B. Placental delivery occurred within thirty minutes after the baby was born C. An episiotomy had to be done to facilitate delivery of the head D. The labor and delivery lasted for 12 hours Answer: (A) Excessive analgesia was given to the mother Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally. Both B and D are normal and C is at the vaginal introitus thus will not affect the uterus. 111. According to Rubin’s theory of maternal role adaptation, the mother will go through 3 stages during the post partum period. These stages are: A. Going through, adjustment period, adaptation period B. Taking-in, taking-hold and letting-go C. Attachment phase, adjustment phase, adaptation phase D. Taking-hold, letting-go, attachment phase Answer: (B) Taking-in, taking-hold and letting-go Rubin’s theory states that the 3 stages that a mother goes through for maternal adaptation are: takingin, taking-hold and letting-go. In the taking-in stage, the mother is more passive and dependent on others for care. In taking-hold, the mother begins to assume a more active role in the care of the child and in letting-go, the mother has become adapted to her maternal role. 112. The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because: A. The pancreas is immature and unable to secrete the needed insulin B. There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin C. The baby is reacting to the insulin given to the mother D. His kidneys are immature leading to a high tolerance for glucose Answer: (B) There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin If the mother is diabetic, the fetus while in utero has a high supply of glucose. When the baby is born and is now separate from the mother, it no longer receives a high dose of glucose from the mother. In the first few hours after delivery, the neonate usually does not feed yet thus this can lead to hypoglycemia. 113. Which of the following is an abnormal vital sign in postpartum? A. Pulse rate between 50-60/min B. BP diastolic increase from 80 to 95mm Hg C. BP systolic between 100-120mm Hg

D. Respiratory rate of 16-20/min Answer: (B) BP diastolic increase from 80 to 95mm Hg All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy. 114. The uterine fundus right after delivery of placenta is palpable at A. Level of Xyphoid process B. Level of umbilicus C. Level of symphysis pubis D. Midway between umbilicus and symphysis pubis Answer: (B) Level of umbilicus Immediately after the delivery of the placenta, the fundus of the uterus is expected to be at the level of the umbilicus because the contents of the pregnancy have already been expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) everyday until it becomes no longer palpable above the symphysis pubis. 115. After how many weeks after delivery should a woman have her postpartal check-up based on the protocol followed by the DOH? A. 2 weeks B. 3 weeks C. 6 weeks D. 12 weeks Answer: (C) 6 weeks According to the DOH protocol postpartum check-up is done 6-8 weeks after delivery to make sure complete involution of the reproductive organs has be achieved. 116. In a woman who is not breastfeeding, menstruation usually occurs after how many weeks? A. 2-4 weeks B. 6-8 weeks C. 6 months D. 12 months Answer: (B) 6-8 weeks When the mother does not breastfeed, the normal menstruation resumes about 6-8 weeks after delivery. This is due to the fact that after delivery, the hormones estrogen and progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the Folicle-Stimulating Hormone (FSH) which in turn stimulates the ovary to again mature a graafian follicle and the menstrual cycle post pregnancy resumes. 117. The following are nursing measures to stimulate lactation EXCEPT A. Frequent regular breast feeding B. Breast pumping C. Breast massage D. Application of cold compress on the breast Answer: (D) Application of cold compress on the breast To stimulate lactation, warm compress is applied on the breast. Cold application will cause vasoconstriction thus reducing the blood supply consequently the production of milk. 118. When the uterus is firm and contracted after delivery but there is vaginal bleeding, the nurse should suspect A. Laceration of soft tissues of the cervix and vagina B. Uterine atony C. Uterine inversion D. Uterine hypercontractility Answer: (A) Laceration of soft tissues of the cervix and vagina When uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passageway such as the cervix or the vagina. 119. The following are interventions to make the fundus contract postpartally EXCEPT A. Make the baby suck the breast regularly B. Apply ice cap on fundus C. Massage the fundus vigorously for 15 minutes until contracted D. Give oxytocin as ordered

Answer: (C) Massage the fundus vigorously for 15 minutes until contracted Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feel firm and contracted. If massaging is vigorous and prolonged, the uterus will relax due to over stimulation. 120. The following are nursing interventions to relieve episiotomy wound pain EXCEPT A. Giving analgesic as ordered B. Sitz bath C. Perineal heat D. Perineal care Answer: (D) Perineal care Perineal care is primarily done for personal hygiene regardless of whether there is pain or not; episiotomy wound or not. 121. Postpartum blues is said to be normal provided that the following characteristics are present. These are 1. Within 3-10 days only; 2. Woman exhibits the following symptoms- episodic tearfulness, fatigue, oversensitivity, poor appetite; 3. Maybe more severe symptoms in primpara A. All of the above B. 1 and 2 C. 2 only D. 2 and 3 Answer: (A) All of the above All the symptoms 1-3 are characteristic of postpartal blues. It will resolve by itself because it is transient and is due to a number of reasons like changes in hormonal levels and adjustment to motherhood. If symptoms lasts more than 2 weeks, this could be a sign of abnormality like postpartum depression and needs treatment. 122. The neonatal circulation differs from the fetal circulation because A. The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blood. B. The blood at the left atrium of the fetal heart is shunted to the right atrium to facilitate its passage to the lungs C. The blood in left side of the fetal heart contains oxygenated blood while the blood in the right side contains unoxygenated blood. D. None of the above Answer: (A) The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blood. The fetal lungs is fluid-filled while in utero and is still not functioning. It only begins to function in extra uterine life. Except for the blood as it enters the fetus immediately from the placenta, most of the fetal blood is mixed blood. 123. The normal respiration of a newborn immediately after birth is characterized as: A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute B. 20-40 breaths per minute, abdominal breathing with active use of intercostals muscles C. 30-60 breaths per minute with apnea lasting more than 15 seconds, abdominal breathing D. 30-50 breaths per minute, active use of abdominal and intercostal muscles Answer: (A) Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 3060 breaths per minute A newly born baby still is adjusting to xtra uterine life and the lungs are just beginning to function as a respiratory organ. The respiration of the baby at this time is characterized as usually shallow and irregular with short periods of apnea, 30-60 breaths per minute. The apneic periods should be brief lasting not more than 15 seconds otherwise it will be considered abnormal. 124. The anterior fontanelle is characterized as: A. 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter, diamond shape B. 2-3 cm antero-posterior diameter and 3-4 cm transverse diameter and diamond shape C. 2-3 cm in both antero-posterior and transverse diameter and diamond shape D. none of the above

Answer: (A) 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter, diamond shape The anterior fontanelle is diamond shape with the antero-posterior diameter being longer than the transverse diameter. The posterior fontanelle is triangular shape. 125. The ideal site for vitamin K injection in the newborn is: A. Right upper arm B. Left upper arm C. Either right or left buttocks D. Middle third of the thigh Answer: (D) Middle third of the thigh Neonates do not have well developed muscles of the arm. Since Vitamin K is given intramuscular, the site must have sufficient muscles like the middle third of the thigh. 126. At what APGAR score at 5 minutes after birth should resuscitation be initiated? A. 1-3 B. 7-8 C. 9-10 D. 6-7 Answer: (A) 1-3 An APGAR of 1-3 is a sign of fetal distress which requires resuscitation. The baby is alright if the score is 8-10. 127. Right after birth, when the skin of the baby’s trunk is pinkish but the soles of the feet and palm of the hands are bluish this is called: A. Syndactyly B. Acrocyanosis C. Peripheral cyanosis D. Cephalo-caudal cyanosis Answer: (B) Acrocyanosis Acrocyanosis is the term used to describe the baby’s skin color at birth when the soles and palms are bluish but the trunk is pinkish. 128. The minimum birth weight for full term babies to be considered normal is: A. 2,000gms B. 1,500gms C. 2,500gms D. 3,000gms Answer: (C) 2,500gms According to the WHO standard, the minimum normal birth weight of a full term baby is 2,500 gms or 2.5 Kg. 129. The procedure done to prevent ophthalmia neonatorum is: A. Marmet’s technique B. Crede’s method C. Ritgen’s method D. Ophthalmic wash Answer: (B) Crede’s method Crede’s method/prophylaxis is the procedure done to prevent ophthalmia neonatorum which the baby can acquire as it passes through the birth canal of the mother. Usually, an ophthalmic ointment is used. 130. Which of the following characteristics will distinguish a postmature neonate at birth? A. Plenty of lanugo and vernix caseosa B. Lanugo mainly on the shoulders and vernix in the skin folds C. Pinkish skin with good turgor D. Almost leather-like, dry, cracked skin, negligible vernix caseosa Answer: (D) Almost leather-like, dry, cracked skin, negligible vernix caseosa A post mature fetus has the appearance of an old person with dry wrinkled skin and the vernix caseosa has already diminished. 131. According to the Philippine Nursing Law, a registered nurse is allowed to handle mothers in labor and delivery with the following considerations: 1. The pregnancy is normal.;

2. The labor and delivery is uncomplicated; 3. Suturing of perineal laceration is allowed provided the nurse had special training; 4. As a delivery room nurse she is not allowed to insert intravenous fluid unless she had special training for it. A. 1 and 2 B. 1, 2, and 3 C. 3 and 4 D. 1, 2, and 4 Answer: (B) 1, 2, and 3 To be allowed to handle deliveries, the pregnancy must be normal and uncomplicated. And in RA9172, the nurse is now allowed to suture perineal lacerations provided s/he has had the special training. Also, in this law, there is no longer an explicit provision stating that the nurse still needs special training for IV insertion. 132. Birth Control Methods and Infertility: In basal body temperature (BBT) technique, the sign that ovulation has occurred is an elevation of body temperature by A. 1.0-1.4 degrees centigrade B. 0.2-0.4 degrees centigrade C. 2.0-4.0 degrees centigrade D. 1.0-4.0 degrees centigrade Answer: (B) 0.2-0.4 degrees centigrade The release of the hormone progesterone in the body following ovulation causes a slight elevation of basal body temperature of about 0.2 – 0.4 degrees centigrade 133. Lactation Amenorrhea Method(LAM) can be an effective method of natural birth control if A. The mother breast feeds mainly at night time when ovulation could possibly occur B. The mother breastfeeds exclusively and regularly during the first 6 months without giving supplemental feedings C. The mother uses mixed feeding faithfully D. The mother breastfeeds regularly until 1 year with no supplemental feedings Answer: (B) The mother breastfeeds exclusively and regularly during the first 6 months without giving supplemental feedings A mother who breastfeeds exclusively and regularly during the first 6 months benefits from lactation amenorrhea. There is evidence to support the observation that the benefits of lactation amenorrhea lasts for 6 months provided the woman has not had her first menstruation since delivery of the baby. 134. Intra-uterine device prevents pregnancy by the ff. mechanism EXCEPT A. Endometrium inflames B. Fundus contracts to expel uterine contents C. Copper embedded in the IUD can kill the sperms D. Sperms will be barred from entering the fallopian tubes Answer: (D) Sperms will be barred from entering the fallopian tubes An intrauterine device is a foreign body so that if it is inserted into the uterine cavity the initial reaction is to produce inflammatory process and the uterus will contract in order to try to expel the foreign body. Usually IUDs are coated with copper to serve as spermicide killing the sperms deposited into the female reproductive tract. But the IUD does not completely fill up the uterine cavity thus sperms which are microscopic is size can still pass through. 135. Oral contraceptive pills are of different types. Which type is most appropriate for mothers who are breastfeeding? A. Estrogen only B. Progesterone only C. Mixed type- estrogen and progesterone D. 21-day pills mixed type Answer: (B) Progesterone only If mother is breastfeeding, the progesterone only type is the best because estrogen can affect lactation. 136. The natural family planning method called Standard Days (SDM), is the latest type and easy to use method. However, it is a method applicable only to women with regular menstrual cycles between ___ to ___ days.

A. 21-26 days B. 26-32 days C. 28-30 days D. 24- 36 days Answer: (B) 26-32 days Standard Days Method (SDM) requires that the menstrual cycles are regular between 26-32 days. There is no need to monitor temperature or mucus secretion. This natural method of family planning is very simple since all that the woman pays attention to is her cycle. With the aid of CycleBeads, the woman can easily monitor her cycles. 137. Which of the following are signs of ovulation? 1. Mittelschmerz; 2. Spinnabarkeit; 3. Thin watery cervical mucus; 4. Elevated body temperature of 4.0 degrees centigrade A. 1 & 2 B. 1, 2, & 3 C. 3 & 4 D. 1, 2, 3, 4 Answer: (B) 1, 2, & 3 Mittelschmerz, spinnabarkeit and thin watery cervical mucus are signs of ovulation. When ovulation occurs, the hormone progesterone is released which can cause a slight elevation of temperature between 0.2-0.4 degrees centigrade and not 4 degrees centigrade. 138. The following methods of artificial birth control works as a barrier device EXCEPT: A. Condom B. Cervical cap C. Cervical Diaphragm D. Intrauterine device (IUD) Answer: (D) Intrauterine device (IUD) Intrauterine device prevents pregnancy by not allowing the fertilized ovum from implanting on the endometrium. Some IUDs have copper added to it which is spermicidal. It is not a barrier since the sperms can readily pass through and fertilize an ovum at the fallopian tube. 139. Which of the following is a TRUE statement about normal ovulation? A. It occurs on the 14th day of every cycle B. It may occur between 14-16 days before next menstruation C. Every menstrual period is always preceded by ovulation D. The most fertile period of a woman is 2 days after ovulation Answer: (B) It may occur between 14-16 days before next menstruation Not all menstrual cycles are ovulatory. Normal ovulation in a woman occurs between the 14th to the 16th day before the NEXT menstruation. A common misconception is that ovulation occurs on the 14th day of the cycle. This is a misconception because ovulation is determined NOT from the first day of the cycle but rather 14-16 days BEFORE the next menstruation. 140. If a couple would like to enhance their fertility, the following means can be done: 1. Monitor the basal body temperature of the woman everyday to determine peak period of fertility; 2. Have adequate rest and nutrition; 3. Have sexual contact only during the dry period of the woman; 4. Undergo a complete medical check-up to rule out any debilitating disease A. 1 only B. 1 & 4 C. 1,2,4 D. 1,2,3,4 Answer: (C) 1,2,4 All of the above are essential for enhanced fertility except no. 3 because during the dry period the woman is in her infertile period thus even when sexual contact is done, there will be no ovulation, thus fertilization is not possible. 141. In sympto-thermal method, the parameters being monitored to determine if the woman is fertile

or infertile are: A. Temperature, cervical mucus, cervical consistency B. Release of ovum, temperature and vagina C. Temperature and wetness D. Temperature, endometrial secretion, mucus Answer: (A) Temperature, cervical mucus, cervical consistency The 3 parameters measured/monitored which will indicate that the woman has ovulated aretemperature increase of about 0.2-0.4 degrees centigrade, softness of the cervix and cervical mucus that looks like the white of an egg which makes the woman feel “wet”. 142. The following are important considerations to teach the woman who is on low dose (mini-pill) oral contraceptive EXCEPT: A. The pill must be taken everyday at the same time B. If the woman fails to take a pill in one day, she must take 2 pills for added protection C. If the woman fails to take a pill in one day, she needs to take another temporary method until she has consumed the whole pack D. If she is breast feeding, she should discontinue using mini-pill and use the progestin-only type Answer: (B) If the woman fails to take a pill in one day, she must take 2 pills for added protection If the woman fails to take her usual pill for the day, taking a double dose does not give additional protection. What she needs to do is to continue taking the pills until the pack is consumed and use at the time another temporary method to ensure that no pregnancy will occur. When a new pack is started, she can already discontinue using the second temporary method she employed. 143. To determine if the cause of infertility is a blockage of the fallopian tubes, the test to be done is A. Huhner’s test B. Rubin’s test C. Postcoital test D. None of the above Answer: (B) Rubin’s test Rubin’s test is a test to determine patency of fallopian tubes. Huhner’s test is also known as postcoital test to determine compatibility of the cervical mucus with sperms of the sexual partner. 144. Infertility can be attributed to male causes such as the following EXCEPT: A. Cryptorchidism B. Orchitis C. Sperm count of about 20 million per milliliter D. Premature ejaculation Answer: (C) Sperm count of about 20 million per milliliter Sperm count must be within normal in order for a male to successfully sire a child. The normal sperm count is 20 million per milliliter of seminal fluid or 50 million per ejaculate. 145. Spinnabarkeit is an indicator of ovulation which is characterized as: A. Thin watery mucus which can be stretched into a long strand about 10 cm B. Thick mucus that is detached from the cervix during ovulation C. Thin mucus that is yellowish in color with fishy odor D. Thick mucus vaginal discharge influence by high level of estrogen Answer: (A) Thin watery mucus which can be stretched into a long strand about 10 cm At the midpoint of the cycle when the estrogen level is high, the cervical mucus becomes thin and watery to allow the sperm to easily penetrate and get to the fallopian tubes to fertilize an ovum. This is called spinnabarkeit. And the woman feels “wet”. When progesterone is secreted by the ovary, the mucus becomes thick and the woman will feel “dry”. 146. Vasectomy is a procedure done on a male for sterilization. The organ involved in this procedure is A. Prostate gland B. Seminal vesicle C. Testes D. Vas deferens Answer: (D) Vas deferens Vasectomy is a procedure wherein the vas deferens of the male is ligated and cut to prevent the passage of the sperms from the testes to the penis during ejaculation. 147. Breast self examination is best done by the woman on herself every month during

A. The middle of her cycle to ensure that she is ovulating B. During the menstrual period C. Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen D. Just before the menstrual period to determine if ovulation has occurred Answer: (C) Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen The best time to do self breast examination is right after the menstrual period is over so that the hormonal level is low thus the breasts are not tender. 148. A woman is considered to be menopause if she has experienced cessation of her menses for a period of A. 6 months B. 12 months C. 18 months D. 24 months Answer: (B) 12 months If a woman has not had her menstrual period for 12 consecutive months, she is considered to be in her menopausal stage. 149. Which of the following is the correct practice of self breast examination in a menopausal woman? A. She should do it at the usual time that she experiences her menstrual period in the past to ensure that her hormones are not at its peak B. Any day of the month as long it is regularly observed on the same day every month C. Anytime she feels like doing it ideally every day D. Menopausal women do not need regular self breast exam as long as they do it at least once every 6 months Answer: (B) Any day of the month as long it is regularly observed on the same day every month Menopausal women still need to do self examination of the breast regularly. Any day of the month is alright provided that she practices it monthly on the same day that she has chosen. The hormones estrogen and progesterone are already diminished during menopause so there is no need to consider the time to do it in relation to the menstrual cycle. 150. In assisted reproductive technology (ART), there is a need to stimulate the ovaries to produce more than one mature ova. The drug commonly used for this purpose is: A. Bromocriptine B. Clomiphene C. Provera D. Esrogen Answer: (B) Clomiphene Clomiphene or Clomid acts as an ovarian stimulant to promote ovulation. The mature ova are retrieved and fertilized outside the fallopian tube (in-vitro fertilization) and after 48 hours the fertilized ovum is inserted into the uterus for implantation.

Kaplan Sample NCLEX-RN questions

Sample NCLEX-RN Quiz Safe and Effective Care Environment 1. A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse should assign the patient (A) to a private room so she will not infect other patients and health care workers. (B) to a private room so she will not be infected by other patients and health care workers. (C) to a semiprivate room so she will have stimulation during her hospitalization. (D) to a semiprivate room so she will have the opportunity to express her feelings about her illness. 2. The nurse teaches a group of mothers of toddlers how to prevent accidental poisoning. Which of

the following suggestions should the nurse give regarding medications? (A) Lock all medications in a cabinet. (B) Child proof all the caps to medication bottles. (C) Store medications on the highest shelf in a cupboard. (D) Place medications in different containers. 3. While inserting a nasogastric tube, the nurse should use which of the following protective measures? (A) Gloves, gown, goggles, and surgical cap. (B) Sterile gloves, mask, plastic bags, and gown. (C) Gloves, gown, mask, and goggles. (D) Double gloves, goggles, mask, and surgical cap. 4. A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions? (A) Sims'. (B) Side-lying. (C) Supine. (D) Prone. 5. A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN? (A) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. (B) A 42-year-old patient with cancer of the bone complaining of pain. (C) A 55-year-old patient with terminal cancer being transferred to hospice home care. (D) A 23-year-old patient with a fracture of the right leg who asks to use the urinal. Client Need 1: Safe and Effective Care Environment 1. The correct answer is B. Question: What are the needs of the patient with acute lymphocytic leukemia and thrombocytopenia? Needed Info: Lymphocytic leukemia, disease characterized by proliferation of immature WBCs. Immature cells unable to fight infection as competently as mature white cells. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegs, small frequent meals, O2, good skin care. (A) to a private room so she will not infect other patients and health care workers — poses little or no threat (B) to a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection (C) to a semiprivate room so she will have stimulation during her hospitalization — should be placed in a room alone (D) to a semiprivate room so she will have the opportunity to express her feelings about her illness — ensure that patient is provided with opportunities to express feelings about illness 2. The correct answer is A. Question: What is the BEST way to prevent accidental poisoning in children? Strategy: Picture toddlers at play. (A) Lock all medications in a cabinet — CORRECT: improper storage most common cause of poisoning; highest incidence in two-year-olds (B) Child proof all the caps to medication bottles — children can open (C) Store medications on the highest shelf in a cupboard — toddlers climb (D) Place medications in different containers — keep in original container 3. The correct answer is C. Question: What is the correct universal precaution? Strategy: Think about each answer choice. How is each measure protecting the nurse? Needed Info: Mask, eye protection, face shield protect mucous membrane exposure; used if activities are likely to generate splash or sprays. Gowns used if activities are likely to generate splashes or sprays. (A) Gloves, gown, goggles, and surgical cap — surgical caps offer protection to hair but aren't required. (B) Sterile gloves, mask, plastic bags, and gown — plastic bags provide no direct protection and aren't part of universal precautions (C) Gloves, gown, mask, and goggles — CORRECT: must use universal precautions on ALL patients; prevent skin and mucous membrane exposure when contact with blood or other body fluids is anticipated (D) Double gloves, goggles, mask, and surgical cap — surgical cap not required; unnecessary to double glove

4. The correct answer is B. Question: What is the best position after tonsillectomy to help with drainage of oral secretions? Strategy: Picture the patient as described. (A) Sims' — on side with top knee flexed and thigh drawn up to chest and lower knee less sharply flexed: used for vaginal or rectal examination (B) Side-lying — CORRECT: most effective to facilitate drainage of secretions from the mouth and pharynx; reduces possibility of airway obstruction. (C) Supine — increased risk for aspiration, would not facilitate drainage of oral secretions (D) Prone — risk for airway obstruction and aspiration, unable to observe the child for signs of bleeding such as increased swallowing 5. The correct answer is A. Question: Which patient is an appropriate assignment for the LPN/LVN? Strategy: Think about the skill level involved in each patient's care. Needed Info: LPN/LVN: assists with implementation of care; performs procedures; differentiates normal from abnormal; cares for stable patients with predictable conditions; has knowledge of asepsis and dressing changes; administers medications (varies with educational background and state nurse practice act). (A) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer — CORRECT: stable patient with an expected outcome (B) A 42-year-old patient with cancer of the bone complaining of pain — requires assessment; RN is the appropriate caregiver (C) A 55-year-old patient with terminal cancer being transferred to hospice home care — requires nursing judgement; RN is the appropriate caregiver (D) A 23-year-old patient with a fracture of the right leg who asks to use the urinal — standard unchanging procedure; assign to the nursing assistant Client Need 2: Health Promotion and Maintenance 1. An 18-year-old woman comes to the physician's office for a routine prenatal checkup at 34 weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart tone? (A) Below the umbilicus, on the mother's left side. (B) Below the umbilicus, on the mother's right side. (C) Above the umbilicus, on the mother's left side. (D) Above the umbilicus, on the mother's right side. 2. The nurse in an outpatient clinic is supervising student nurses administering influenza vaccinations. The nurse should question the administration of the vaccine to which of the following clients? (A) A 45-year-old male who is allergic to shellfish. (B) A 60-year-old female who says she has a sore throat. (C) A 66-year-old female who lives in a group home. (D) A 70-year-old female with congestive heart failure. 3. The nurse performs a home visit on a client who delivered two days ago. The client states that she is bottle-feeding her infant. The nurse notes white, curd-like patches on the newborn's oral mucous membranes. The nurse should take which of the following actions? (A) Determine the baby's blood glucose level. (B) Suggest that the newborn's formula be changed. (C) Remind the caretaker not to let the infant sleep with the bottle. (D) Explain that the newborn will need to receive some medication. 4. A two-month-old infant is brought to the pediatrician's office for a well-baby visit. During the examination, congenital subluxation of the left hip is suspected. The nurse knows that symptoms of congenital hip dislocation include (A) lengthening of the limb on the affected side. (B) deformities of the foot and ankle. (C) asymmetry of the gluteal and thigh folds. (D) plantar flexion of the foot. 5. The nurse teaches a 20-year-old primigravida how to measure the frequency of uterine contractions. The nurse should explain to the patient that the frequency of uterine contractions is determined (A) from the beginning of one contraction to the end of the next contraction. (B) from the beginning of one contraction to the end of the same contraction. (C) by the strength of the contraction at its peak. (D) by the number of contractions that occur within a given period of time Client Need 2: Health Promotion and Maintenance

1. The answer is B. Question: The fetus is ROA. Where should the nurse listen for the FHT? Strategy: Picture the situation described. It may be helpful for you to draw this out so that you can imagine where the heartbeat would be found. Needed Info: Describing fetal position: practice of defining position of baby relative to mother's pelvis. The point of maximum intensity (PMI) of the fetus: point on the mother's abdomen where the FHT is the loudest, usually over the fetal back. Divide the mother's pelvis into 4 parts or quadrants: right and left anterior, which is the front, and right and left posterior, which is the back. Abbreviated: R and L for right and left, and A and P for anterior and posterior. The head, particularly the occiput, is the most common presenting part, and is abbreviated O. LOA is most common fetal position and FHT heard on left side. In a vertex presentation, FHT is heard below the umbilicus. In a breech presentation, FHT is heard above the umbilicus. (A) Below the umbilicus, on the mother's left side — found on right not left side (B) Below the umbilicus, on the mother's right side — CORRECT: occiput and back are pressing against right side of mother's abdomen; FHT would be heard below umbilicus on right side (C) Above the umbilicus, on the mother's left side — found in breech presentation (D) Above the umbilicus, on the mother's right side — found in breech presentation 2. The correct answer is B. Question: What is a contraindication to receiving flu vaccine? Strategy: Think about what each answer choice means. Needed Info: Influenza vaccine: given yearly, preferably Oct.-Nov.; recommended for people age 65 or older; people under 65 with heart disease, lung disease, diabetes, immuno-suppression, chronic care facility residents. (A) A 45-year-old male who is allergic to shellfish — allergy to eggs is a contraindication (B) A 60-year-old female who says she has a sore throat — CORRECT: vaccine deferred in presence of acute respiratory disease (C) A 66-year-old female who lives in a group home — vaccine deferred only if patient has an active immunization (D) A 70-year-old female with congestive heart failure — no contraindication 3. The correct answer is D. Question: What is the treatment for thrush? Strategy: Determine the outcome of each answer choice. Needed Info: Thrush (oral candidiasis): white plaque on oral mucous membranes, gums, or tongue; treatment includes good handwashing, nystatin (Mycostatin). (A) Determine the baby's blood glucose level — thrush in newborns caused by poor handwashing or exposure to an infected vagina during birth (B) Suggest that the newborn's formula be changed — not related to thrush (C) Remind the caretaker not to let the infant sleep with the bottle — not related to thrush (D) Explain that the newborn will need to receive some medication — CORRECT: thrush most often treated with nystatin (Mycostatin) 4. The correct answer is C. Question: What will you see with congenital hip dislocation? Strategy: Form a mental image of the deformity. Needed Info: Subluxation: most common type of congenital hip dislocation. Head of femur remains in contact with acetabulum but is partially displaced. Diagnosed in infant less than 4 weeks old S/S: unlevel gluteal folds, limited abduction of hip, shortened femur affected side, Ortolani's sign (click). Treatment: abduction splint, hip spica cast, Bryant's traction, open reduction. (A) lengthening of the limb on the affected side — inaccurate (B) deformities of the foot and ankle — inaccurate (C) asymmetry of the gluteal and thigh folds — CORRECT: restricted movement on affected side (D) plantar flexion of the foot — seen with clubfoot 5. The correct answer is D. Question: How do you determine the frequency of uterine contractions? Needed Info: There must be at least 3 contractions to establish frequency. (A) from the beginning of one contraction to the end of the next contraction — not accurate (B) from the beginning of one contraction to the end of the same contraction — defines duration (C) by the strength of the contraction at its peak — describes intensity (D) by the number of contractions that occur within a given period of time — CORRECT Client Need 3: Psychosocial Integrity 1. An adolescent male being treated for depression arrives with his family at the Adolescent Day Treatment Center for an initial therapy meeting with the staff. The nurse explains that one of the goals of the family meeting is to encourage the adolescent to: (A) trust the nurse who will solve his problem.

(B) learn to live with anxiety and tension. (C) accept responsibility for his actions and choices. (D) use the members of the therapeutic milieu to solve his problems. 2. A 23-year-old-woman comes to the emergency room stating that she had been raped. Which of the following statements BEST describes the nurse's responsibility concerning written consent? (A) The nurse should explain the procedure to the patient and ask her to sign the consent form. (B) The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart. (C) The nurse should tell the physician that the patient agrees to have the examination. (D) The nurse should verify that the patient or a family member has signed the consent form. 3. The nurse cares for an elderly patient with moderate hearing loss. The nurse should teach the patient's family to use which of the following approaches when speaking to the patient? (A) Raise your voice until the patient is able to hear you. (B) Face the patient and speak quickly using a high voice. (C) Face the patient and speak slowly using a slightly lowered voice. (D) Use facial expressions and speak as you would normally. 4. A 52-year-old man is admitted to a hospital after sustaining a severe head injury in an automobile accident. When the patient dies, the nurse observes the patient's wife comforting other family members. Which of the following interpretations of this behavior is MOST justifiable? (A) She has already moved through the stages of the grieving process. (B) She is repressing anger related to her husband's death. (C) She is experiencing shock and disbelief related to her husband's death. (D) She is demonstrating resolution of her husband's death. 5. After two weeks of recieving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient's behavior by the nurse would be MOST accurate? (A) The treatment plan is not effective; the patient requires a larger dose of lithium. (B) This is a normal response to lithium therapy; the patient should continue with the current treatment plan. (C) This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior. (D) The treatment plan is not effective; the patient requires an antidepressant. Client Need 3: Psychosocial Integrity 1. The correct answer is C. Question: What is the goal of family therapy? Needed Info: Symptoms of depression: a low self-esteem, obsessive thoughts, regressive behavior, unkempt appearance, a lack of energy, weight loss, decreased concentration, withdrawn behavior. (A) trust the nurse who will solve his problem — not realistic (B) learn to live with anxiety and tension — minimizes concerns (C) accept responsibility for his actions and choices — CORRECT (D) use the members of the therapeutic milieu to solve his problems — must do it himself 2. The correct answer is B. Question: What is your responsibility concerning informed consent? Needed Info: Physician's responsibility to obtain informed consent. (A) The nurse should explain the procedure to the patient and ask her to sign the consent form — Physician should get patient to sign consent (B) The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart — CORRECT (C) The nurse should tell the physician that the patient agrees to have the examination — Physician should explain procedure and get consent form signed (D) The nurse should verify that the patient or a family member has signed the consent form — must be signed by patient unless unable to do 3. The correct answer is C. Question: What should you do to communicate with a person with a moderate hearing loss? Needed Info: Presbycusis: age-related hearing loss due to inner ear changes. Decreased ability to hear high sounds. (A) Raise your voice until the patient is able to hear you — would result in high tones patient unable to hear (B) Face the patient and speak quickly using a high voice — usually unable to hear high tones (C) Face the patient and speak slowly using a slightly lowered voice — CORRECT: also decrease background noise; speak at a slow pace, use nonverbal cues (D) Use facial expressions and speak as you would normally — nonverbal cues help, but need low tones 4. The correct answer is C.

Question: What is the reason for the wife's behavior? Needed Info: Stages of grief: 1) shock and disbelief, 2) awareness of pain and loss, 3) restitution. Acute period: 4-8 weeks, usual resolution: 1 year. (A) She has already moved through the stages of the grieving process — takes one year (B) She is repressing anger related to her husband's death — not accurate; second stage: crying, regression (C) She is experiencing shock and disbelief related to her husband's death — CORRECT: denial first stage; inability to comprehend reality of situation (D) She is demonstrating resolution of her husband's death — too soon 5. The correct answer is C. Question: Is the depression normal, or something to be concerned about? (A) The treatment plan is not effective; the patient requires a larger dose of lithium — not accurate (B) This is a normal response to lithium therapy; the patient should continue with the current treatment plan — does not address safety needs (C) This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior — CORRECT: delay of 1-3 weeks before med benefits seen (D) The treatment plan is not effective; the patient requires an antidepressant — normal response Client Need 4: Physiological Integrity 1. A 65-year-old patient with pneumonia is receiving garamycin (Gentamicin). It would be MOST important for a nurse to monitor which of the following laboratory values in this patient? (A) Hemoglobin and hematocrit. (B) BUN and creatinine. (C) Platelet count and clotting time. (D) Sodium and potassium. 2. A 22-year-old man is admitted to the hospital with complaints of fatigue and weight loss. Physical examination reveals pallor and multiple bruises on his arms and legs. The results of the patients tests reveal acute lymphocytic leukemia and thrombocytopenia. Which of the following nursing diagnoses MOST accurately reflects his condition? (A) Potential for injury. (B) Self-care deficit. (C) Potential for self-harm. (D) Alteration in comfort. 3. To enhance the percutaneous absorption of nitroglycerine ointment, it would be MOST important for the nurse to select a site that is (A) muscular. (B) near the heart. (C) non-hairy. (D) over a bony prominence. 4. A man is admitted to the Telemetry Unit for evaluation of complaints of chest pain. Eight hours after admission, the patient goes into ventricular fibrillation. The physician defibrillates the patient. The nurse understands that the purpose of defibrillation is to: (A) increase cardiac contractility and cardiac output. (B) cause asystole so the normal pacemaker can recapture. (C) reduce cardiac ischemia and acidosis. (D) provide energy for depleted myocardial cells. 5. A patient is to receive 3,000 ml of 0.9% NaCl IV in 24 hours. The intravenous set delivers 15 drops per milliliter. The nurse should regulate the flow rate so that the patient receives how many drops of fluid per minute? (A) 21 (B) 28 (C) 31 (D) 42 Client Need 4: Physiological Integrity 1. The correct answer is B. Question: Which lab values should you monitor for a patient receiving Gentamicin? Needed Info: Gentamicin: broad spectrum antibiotic. Side effects: neuromuscular blockage, ototoxic to eighth cranial nerve (tinnitus, vertigo, ataxia, nystagmus, hearing loss), nephrotoxic. Nursing responsibilities: monitor renal function, force fluids, monitor hearing acuity. Draw blood for peak levels 1 hr. after IM and 30 min - 1 hr. after IV infusion, draw blood for trough just before next dose. (A) Hemoglobin and hematocrit — can cause anemia; less common (B) BUN and creatinine — CORRECT: nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance

(C) Platelet count and clotting time — do not usually change (D) Sodium and potassium — hypokalemia infrequent problem 2. The correct answer is A. Question: What nursing diagnosis is seen with acute lymphocytic leukemia and thromocytopenia? Needed Info: Thromocytopenia: decreased platelet count increases the patient's risk for injury, normal count: 200,000-400,000 per mm3. Leukemia: group of malignant disorders involving overproduction of immature leukocytes in bone marrow. This shuts down normal bone marrow production of erythrocytes, platelets, normal leukocytes. Causes anemia, leukopenia, and thrombocytopenia leading to infection and hemorrhage. Symptoms: pallor of nail beds and conjunctiva, petechiae (small hemorrhagic spot on skin), tachycardia, dyspnea, weight loss, fatigue. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegs, small frequent meals, O2, good skin care. (A) Potential for injury — CORRECT: low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage. (B) Self-care deficit — may feel weak, doesn't address condition (C) Potential for self-harm — implies risk for purposeful self-injury, not given any info, assumption (D) Alteration in comfort — patient is not comfortable, and comfort measures would address problem 3. The correct answer is C. Question: What is the best site for nitroglycerine ointment? Strategy: Think about each site. Needed Info: Nitroglycerine: used in treatment of angina pectoris to reduce ischemia and relieve pain by decreasing myocardial oxygen consumption; dilates veins and arteries. Side effects: throbbing headache, flushing, hypotension, tachycardia. Nursing responsibilities: teach appropriate administration, storage, expected pain relief, side effects. Ointment applied to skin; sites rotated to avoid skin irritaion. Prolonged effect up to 24 hours. (A) muscular — not most important (B) near the heart — not most important (C) non-hairy — CORRECT: skin site free of hair will increase absorption; avoid distal part of extremities due to less than maximal absorption (D) over a bony prominence — most important is that the site be non-hairy 4. The correct answer is B. Question: Why is a patient defibrillated? Strategy: Think about each answer choice. Needed Info: Defibrillation: produces asystole of heart to provide opportunity for natural pacemaker (SA node) to resume as pacer of heart activity. (A) increase cardiac contractility and cardiac output — inaccurate (B) cause asystole so the normal pacemaker can recapture — CORRECT: allows SA node to resume as pacer of heart activity (C) reduce cardiac ischemia and acidosis — inaccurate (D) provide energy for depleted myocardial cells — inaccurate 5. The correct answer is C. Question: How should you regulate the IV flow rate? Strategy: Use formula and avoid making math errors. Needed Info: total volume x the drop factor divided by the total time in minutes. (A) 21 — inaccurate (B) 28 — inaccurate (C) 31 — CORRECT: 3,000 x 15 divided by 24 x 60 (D) 42 — inaccurate

Establishing Priorities

Establishing Priorities A.Prioritizing - decisions of which needs, problems require immediate attention or action and which ones could be delayed until a later time since they are not urgent B.Needs that are life-threatening or could result in harm to the client if left untreated are high priorities

C.Actual problems/needs have higher priority than potential problems/needs D.Problems/needs identified by client are of a higher priority E.Principles of Maslow or the ABCs may guide decisions F.Mutual decision-making for priorities may be made with the client based on the client's needs, desires, and safety Triage (nclex) Tips

Contents 1. Introduction &background 2. Goals of Triage 3. Role of Triage Personnel  General Triage Guidelines  Triage interview  Nursing process  Documentation standards  Triage nurse Qualification 4. Triage &Acuity Scale definitions 5. Setting Up the triage Area 6. Triage orientation Schedule 7. Quick look summary – Triage categories 1.INTRODUCTION & BACKGROUND What is triage & why do we do it? Triage in the simplest term is the sorting or prioritizing of items (client, patients, tasks,..) A/E Department is a busy facility associated with long queue and waiting time, attending to patients with major or minor illnesses. Carrying with them the concept of a ‘one stop convenience’. In an effort to cope with this increasing demand and ensuring smooth client flow, triage systems and protocols have been utilized. The word triage is derived from the French verb “trier”, which means “to pick or to sort”. Nurses are generally not comfortable with triaging and as a result are often inconsistent In their triage decision. This is mainly due to their inexperience and inadequate knowledge. This study aims to identify the difficulties experienced by nurse in triaging, and the possible solution to overcome them. Majority of the literature available address the problem of long waiting time. Few have looked into the difficulties encountered by the triage nurses. The authors perceived that local triage nurses are faced with the problems of communication breakdown, lack of training in triage and inadequate orientation and induction programs. As such they could be psychologically unprepared to adopt the demanding role of triaging. 2.GOAL OF TRIAGE  • To rapidly identify patients with urgent, life threatening conditions.  • To determine the most appropriate area for patients presenting to the A/E.  • To decrease congestion in emergency treatment areas.  • To provide ongoing assessment of patients.  • To provide information to patients and families regarding services expected care and waiting times.  • To contribute information that helps to define departmental acuity.

Rapid access to assessment by a health care provider increases patient satisfaction and enhances public relations. An efficient triage system should reduce client anxiety and increase satisfaction by reducing length of stay and waiting time in the emergency department. Factors, which influence triage design and operation, include; 1. Number of patient visits 2. Number of patients requiring rapid intervention 3. Availability of health care providers in the A/E treatment area 4. Availability of specialty services 5. Environmental, legal and administrative issues 6. Availability of community care resources 7. computer system used for admit, discharge, transfer, and patient care 3.ROLE OF TRIAGE PERSONNEL A- GENERAL TRIAGE GUIDELINES The triage nurse should have rapid access or be in view of the registration and waiting area at all time. 1. Greets client and family in a warm empathetic manner. 2. Performs brief visual assessments. 3. Documents the assessments. 4. Triage clients into priority groups using appropriate guidelines. 5. Transports client to treatment area when necessary. 6. Keeps patients/families aware of delays. 7. Reassesses waiting clients as necessary. 8. Instruct clients to notify triage nurse of any change in condition. Accurate assignment of triage levels is based on; • Practical knowledge gained through experience and training. • Correct identification of signs or symptoms. • Use of guidelines and triage protocols. When the triage nurse has categorized more than 3 urgent patients, it is his/her responsibility to prioritize these patients for the treatment nurse/ Emergency physician. Triage is a dynamic process; A patient’s condition may improve OR deteriorate during the wait for entry to the treatment area. The Triage Process: There can be confusion about the amount of detail required to assign a triage level. A short primary survey may be necessary to ensure patient flow and reduce delays to first contact with a health provider. 1. All patients should be assessed (at least visually) within 10 minutes of arrival. 2. Full patient assessments should not be done in the triage area unless there are no patients waiting to be seen. Only information required to assign a triage level should be recorded. 3. A primary survey (rapid assessment) should be used when there are 2 or more patients waiting to be triaged. After all patients have had some assessment done, level IV and V patients the have been sent to the waiting area should have a more complete assessment done by the triage personnel or treatment nurse. 4. The priority for car may change following a more complete assessment or as patient’s signs and symptoms change. There should be documentation of the initial triage as well as any changes. The initial triage level is still used for administrative purposes. 5. Level I, II, patients should be in a treatment area and have the complete primary nursing assessment done immediately. The triage assessment: 1. Chief complaint patient’s statement of the problem. 2. Validation and assessment of chief complaint.

A. Subjective: Onset/Course/Duration • When did it start (be exact with time)? What were you doing when it started? • How long did it last? • Dose it come and go? • Is it still present? • Where is the problem? Describe character and severity if painful (pain scale). • Radiation? • Aggravating or alleviating factors? • If pain is or was present, character and intensity (pain scale) to be documented. • Previous history of same? If yes, what was the diagnosis? B. Objective: this part of the triage assessment may be deferred to the treatment area if the patient requires rapid access to care/interventions (level I, II, III). • Physical appearance –color, skin, activities • Degree of distress: severe distress; NAD (no acute distress) • Emotional response: anxious, indifferent • Complete vital signs if time allows or necessary for assignment of triage level( Level I, IV,V) • Physical assessment C. Additional Information: 1. Allergies 2. Medications: • List by name, if available • List by category if patient doesn’t know name; B/P, heart, stomach, nerve, etc Triage is not a static process. It is important to remember that triage is a dynamic process and patients my move up or down on the urgency continuum while waiting for access to treatment areas, Triage systems should be accompanied by protocol on; • How quickly a patient is to be seen by the health care provider for specific complaint types? • How often patients in each triage category will be reassessed and where that information should be documented? • How patients with defined signs and symptom are categorized i.e, chief complaint • What types of intervention are expected to be initiated in triage? • What types of reassessments should be done? The options vary from a quick overview of the waiting room patients, to a repeat primary survey and repeat vital signs. • Designating time frames and methods of reassessment in your guidelines provides a framework for evaluating quality/outcomes and preventing patient deterioration Reassessment Objectives for time to time to nursing reassessment is related to triage level Level I Level II Level III Level IV Level V Continuous care Every15min Every 30min Every60min Every120min 1. There should be a nursing reassessment on all patients at time intervals recommended for physician assessment. 2. When patients have a medical diagnosis or are considered ‘stabilized’ the frequency of nursing assessment and care will depend on the existing care protocol or MD orders. 3. When patients have exceeded the time objective for MD assessment for their triage level they should be up triage to avoid unfair bumping and long delay to MD assessment. B- TIPS FOR THE TRIAGE INTERVIEW Open ended questions help elicit feeling and perceptions along with information. Closed question (with yes or no answers) are useful for obtaining facts. In general, initial questions should be open – ended (subjective assessment), whereas closed questions (objective assessment) can be used to validate information. Triage providers develop interview techniques that suit their communication style, the clientele, and the environment. Many factors influence effective communication at triage; Language barriers, age, pain level, hearing disability, mental competency. Non- verbal information is also an important source of information. Physical assessment accompanies the triage interview, chiefly through observation. Assessment my begin with the observation that the patient can speak and therefore has a patent airway. Physical assessment must be rapid, concise, and focused. In some patients objective measures such as

vital signs and/or O2 saturation may be reasonable while in others it would be a description of physical signs. Effective triage requires the use of sight, hearing, smell and touch. There are many non-verbal clues; facial grimaces, cyanosis, fear, … listen to what the patient is saying and pay attention to questions they are reluctant or unable to answer. Listen for a cough, hoarseness, laboured respiration…. Touch the patient; assess heart rate and skin temperature and moisture. Notice odours such as the smell of ketones, alcohol, or infection. Remember that the purpose of the triage interview is to gather enough information to make a clinical judgment for priority of care, not a final medical diagnosis. Often, the most time consuming task of triage is to allay patient and family anxiety. Attitude and empathy are important aspects of the triage nurse’s demeanor. Remaining consistent and non-judgmental toward all patients is important. Difficult patients such as those who are intoxicated and combative require special care. Any element of prejudice, leading to a moral judgment of patients, can increase patient risk due to incorrect assignment of triage levels, to low care needs priority. Do not to prejudge patients based on appearance or attitude. C- NURSING PROCESS Assessment:-subjective/objective data • 2-5 minute interview • Not a head to toe assessment (treatment nurse should complete). • Need enough critical information to determine patient acuity and any immediate care needs. Vital signs; Vital signs (VS) will be done on patients if required for categorization or if time permits. Otherwise VS are the responsibility of the treatment nurse. Any patient presenting to the ED who is level I or II will be taken immediately to an appropriate treatment area. It is the treatment nurse’s responsibility to do a full assessment (primary nursing assessment) including VS. Pain Scale: Should be attempted on all patients with pain. It is used, in conjunction with the presenting complaint, to assign patients with similar complaints, to different triage level. Pain scales are not absolute, but do allow the patient to communicate the intensity of a problem from their perspective. The more intense the pain (8-10/10) the more the care provider should be concerned about the need to identify or exclude serious illnesses and attempt to offer empathy or interventions that will diminish unnecessary pain and suffering. Because pain perception is very individual and may be influenced by age and cultural differences, it would be unwise to exclude serious problems when pain is not described as severe. The scales are less helpful(or reliable) at the extremes of age. Continued sever pain should lead to a reconsideration of the diagnosis and treatment. Pain scales are dependent on previous painful experiences. D- DOCUMENTATION STANDARDS 1. Date and time of triage assessment. 2. Nurse’s name. 3. Chief complaint or presenting concerns. 4. Limited subjective history; onset of injury/symptoms 5. Objective observation. 6. Triage level 7. Location in the department. 8. Report to treatment nurse. 9. Allergies. 10. Medications. 11. Diagnostic, first aid measures, therapeutic, interventions. 12. Reassessment.

E- TRIAGE NURSE QUALIFICATIONS 1. Communication skills are crucial. Provider must interact with patient-family-police-EMT-visitors.

2. Must have tact, patience, understanding, and discretion. 3. Organizational skills- patient line- ups, inquiries, etc. (Constantly under patient scrutiny) 4. Abel to perform in hectic situations. Can recognize who is sick. (Depends on experience, skill and expert clinical judgment). 4- TRIAGE & ACUITY SCALE CATEGORY These lists of presenting complaints or case scenarios are not be all inclusive or absolute in their application. Triage personnel are always encouraged to use their experience & instincts to ‘up triage’ priority, even if the patient does not seem to fit exactly with the facts or definitions on the triage scale ‘if they look sick then they probably are’. Level I Resuscitation

Condition that are threats to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions. Time to physician; IMMEDIATE Usual presentations; 1. Code/arrest; patients with cardiac and/or pulmonary arrest (or appears to be imminent) 2. Major trauma; Severe injury of any single body system or multiple system injury, Severe burns, Chest/abdominal injury with any or all of; altered mental state, hypotension, tachycardia, sever pain, respiratory signs or symptoms. 3. Shock states; Conditions where there is an imbalance between Oxygen supply (cardiogenic, pulmonary, blood loss,) and demand or utilization. Hypotension and or tachycardia and possibly bradycardia. 4. Unconscious; Intoxication/overdoses, CNS events, can all have an alteration of mental function from disorientation/confusion to completely unresponsive or actively seizuring. 5. Severe Respiratory Distress; There are many causes for respiratory distress but benign reasons can only be diagnosed by exclusion. Serious intracranial events, pneumothorax, near death asthma .COPD exacerbations, CHF, anaphylaxis and severe metabolic disturbances (renal failure, diabetic ketoacidosis). Typical patients; • Non responsive • Vital signs absent/unstable • Severe dehydration • Severe respiratory distress. Level II Emergent Conditions that are a potential threat to life limb or function, requiring rapid medical intervention or delegated acts. Time to physician assessment/interview 39 with signs of lethargy. 15. Vomiting and diarrhoea; With suspicion or signs of dehydration. 16. Acute psychosis/extreme agitation; 17. Diabetes; diabetics with hyper or hypoglycemia. Altered mental state, blurred vision, fever, vomiting, abnormal pulse and respiration. 18. Hypertension or Hypotension; should prompt immediate physician notification or assessment. 19. Headache; This presenting complaint appears in multiple triage levels. 20. Abuse/neglect/assault; These patients may not have life threatening problems but have very special needs that relate to their mental well being and specific requirements for the collection of samples for evidence, or the activation of local protocols for the use of assault teams and community services. 21. Drug withdrawal-severe-(Delirium tremens or other); these patients may be sometimes mistaken for acute psychiatric problems. Seizures, coma, hallucinations, confusion, agitation (shakes, tremors), tachycardia, hypertension, hyperpyrexia), chest/abdominal pain, vomiting, diarrhoea. 22. Chemotherapy; Patients on chemotherapy or immunocompromised patients (HIV, known immune deficiency, malignancy) with or without a fever are at higher risk of serious problems. These patients can deteriorate quickly. Level III Urgent Condition that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living. Time to physician