NP 3

1.The nurse suspects that her client is in cardiac arrest. According to the American Heart
Association, the nurse should perform the actions listed below. Order these actions in the
sequence that the nurse should perform them.
I. Activate the emergency medical system. II. Assess responsiveness.
III. Call for a defibrillator.
IV. Provide two slow breaths.
V. Assess pulse.
VI. Assess breathing.
A. 2.1.3.6.4.5
B. 132456
C. 1,2,3,6,5,4
D. 2,3.1,5,6,4
2. A client comes to the ER complaining of chest pain. An electrocardiogram (ECG) reveals
myocardial ischemia and an anterior wall myocardial infarction (MI). Which ECG
characteristics indicates myocardial ischemia?
A. Prolonged PR interval B. Absent Q wave
C. Elevated ST segment D.Widened QRS complex
3. Nyosh admits himself on the ER following an intense chest pain and the doctor orders an
ECG. The result below will be interpreted as
A. AV bundle block
B. Sinus rhythm
C. Atrial flutter
D. Sinus arrhythmia
4. The electrocardiogram (ECG) tracing shown below, excluding the seventh beat, has a
normal QRS complex, one premature atrial contraction (PAC), and what other attributes?
A. P wave is identifiable, PR is 0.16 second, and sinus rhythm is at 95 beats/minute.
B. P wave and PR interval are unidentifiable and sinus arrhythmia is at 95 beats/minute. C. P
wave is identifiable, PR interval is 0.16 second, and sinus rhythm is at 95 beats/minute.
5. A client who is awake and diaphoretic has a palpable pulse. The nurse runs an
electrocardiogram (ECG) strip, which reveals the following pattern for the lead I. What does
the pattern indicate?
A. Normal sinus rhythm
B. Atrial fibrillation
C. Ventricular standstill
D. Ventricular tachycardia
6. Mrs. Chua a 78-year-old client is admitted with the diagnosis of mild chronic heart failure.
The nurse expects to hear when listening to client's lungs indicative of chronic heart failure
would be:
A. Stridor
D. P wave is identifiable, PR interval is
0.16 second, and sinus arrhythmia is at
95 beats/minute. //Way sure ni
B. Crackles
C. Wheezes
D. Friction rubs
7. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is
taking morphine. The nurse explains that morphine
A. Decrease anxiety and restlessness
B. Prevents shock and relieves pain
C. Dilates coronary blood vessels
D. Helps prevent fibrillation of the heart
8. Which of the following should the nurse teach the client about the signs of digitalis
toxicity?
A. Increased appetite
B. Elevated blood pressure
C. Skin rash over the chest and back
9. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning.
The reason for this is to help... A. Retard rapid drug absorption
B. Excrete excessive fluids accumulated at night
C. Prevents sleep disturbances during night
D. Prevention of electrolyte imbalance
10. What would be the primary goal of therapy for a client with pulmonary edema and heart
failure?
A. Enhance comfort
B. Increase cardiac output
C. Improve respiratory status
D. Peripheral edema decreased
11. Nurse Linda is caring for a client with head injury and monitoring the client with
decerebrate posturing. Which of the following is a characteristic of this type of posturing?
A. Upper extremity flexion with lower extremity flexion
B. Upper extremity flexion with lower extremity extension
D. Flexion of the extremities after stimulus
7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following
maybe experienced as side effects of this medication:
A. GI bleeding
B. Peptic ulcer disease
C. Abdominal cramps
D. Partial bowel obstruction
8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering
from myocardial infarction. Which of the following is the most essential nursing action?
A. Monitoring urine output frequently
B. Monitoring blood pressure every 4 hours C. Obtaining serum potassium levels daily
9. During the second day of hospitalization of the client after a Myocardial Infarction. Which
of the following is an expected outcome?
B. Severe chest pain
C. Can recognize the risk factors of Myocardial Infarction
D. Can Participate in cardiac rehabilitation walking program
C. Extension of the extremities after a
stimulus
D. Visual disturbances such as seeing
yellow spots
D. Obtaining infusion pump for the
medication
 A. Able to perform self-care activities
without pain
10. A 68-year-old client is diagnosed with a right-sided brain attack and is admitted to the
hospital. In caring for this client, the nurse should plan to:
A. Application of elastic stockings to prevent flaccid by muscle
C. Use a bed cradle to prevent dorsiflexion if feet
D. Do passive range of motion exercise
11. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left
nephrectomy. Nurse Liza’s highest priority would be...
A. Hourly urine output
B. Temperature
C. Able to turn side to side
D. Able to sips clear liquid
12. A 64-year-old male client with a long history of cardiovascular problem including
hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac
catheterization teaching, Nurse Cherry should inform the client that the primary purpose of
the procedure is...
A. To determine the existence of CHD
C. To obtain the heart chambers pressure D. To measure oxygen content of different heart
chambers
13. During the first several hours after a cardiac catheterization, it would be most essential
for nurse Cherry to...
A. Elevate client's bed at 45°
B. Instruct the client to cough and deep breathe every 2 hours
D. Monitor client’s temperature every hour
14. Kate who has undergone mitral valve replacement suddenly experiences continuous
bleeding from the surgical incision during postoperative period. Which of the following
pharmaceutical agents should Nurse Aiza prepare to administer to Kate?
A. Protamine Sulfate
B. Quinidine Sulfate C. Vitamin C
D. Coumadin
15. In reducing the risk of endocarditis, good dental care is an important measure. To
promote good dental care in client with mitral stenosis in teaching plan should include
proper use of...
A. Dental floss
B. Electric toothbrush
C. Manual toothbrush
D. Irrigation device
16. Among the following signs and symptoms, which would most likely be present in a client
with mitral regurgitation? A. Altered level of consciousness
B. Exceptional Dyspnea
C. Increase creatine phospholinase concentration
D. Chest pain
17. Kris with a history of chronic infection of the urinary system complains of urinary
frequency and burning sensation. To figure out whether the current problem is in renal
origin, the nurse should assess whether the client has discomfort or pain in the...
A. Urinary meatus
B. Pain in the Labium
C. Suprapubic area
D. Right or left costovertebral angle
B. Use hand roll and extend the left
upper extremity on a pillow to prevent
contractions
B. To visualize the disease process in
the coronary arteries
C. Frequently monitor client's apical
pulse and blood pressure
18. Nurse Perry is evaluating the renal function of a male client. After documenting urine
volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal
function.
A. Blood pressure
B. Consciousness
C. Distension of the bladder
D. Pulse rate
19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits
uncontrollable jerking movements. Nurse Gina documents that John experienced which type
of seizure?
A. Tonic seizure
B. Absence seizure
C. Myoclonic seizure D. Clonic seizure
20. Smoking cessation is critical strategy for the client with Burgher's disease, Nurse Jasmin
anticipates that the male client will go home with a prescription for which medication?
A. Paracetamol
B. Ibuprofen
C. Nitroglycerin
D. Nicotine (Nicotrol)
21. Which of the following lab studies should be done periodically if the client is taking
warfarin sodium (Coumadin)?
A. Stool specimen for occult blood
B. White blood cell count
C. Blood glucose
D. Erythrocyte count
22. A client is admitted with a diagnosis of polycythemia vera. The nurse should closely
monitor the client for:
A. Increased blood pressure
B. Decreased respirations C. Increased urinary output
D. Decreased oxygen saturation
23. The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia.
Which foods are highest in vitamin B12?
A. Meat, eggs, dairy products
B. Peanut butter, raisins
C. Broccoli, cauliflower, cabbage D. Shrimp, legumes, bran cereals
24. Which of the following arteries primarily feeds the anterior wall of the heart?
A. Circumflex artery
B. Internal mammary artery
C. Left anterior descending artery
D. Right coronary artery
25. When do coronary arteries primarily receive blood flow?
A. During inspiration
B. During diastole
C. During expiration D. During systole
26. Which of the following illnesses is the leading cause of death in the US?
A. Cancer
B. Coronary artery disease
C. Liver failure D. Renal failure
27. Which of the following conditions most commonly results in CAD?
A. Atherosclerosis
B. DM
C. MI
D. Renal failure
28. Atherosclerosis impedes coronary blood flow by which of the following mechanisms? A.
Plaques obstruct the vein
B. Plaques obstruct the artery
C. Blood clots form outside the vessel watreatment
D. Hardened vessels dilate to allow the blood
29. Which of the following risk factors for coronary artery disease cannot be corrected?
A. Cigarette smoking
B. DM
C. Heredity
D. HPN
30. Exceeding which of the following serum cholesterol levels significantly increases the risk
of coronary artery disease?
A. 100 mg/dl
B. 150 mg/dl C. 175 mg/dl D. 200 mg/dl
31. Which of the following actions is the first priority care for a client exhibiting signs and
symptoms of coronary artery disease?
A. Decrease anxiety
B. Enhance myocardial oxygenation
C. Administer sublingual nitroglycerin
D. Educate the client about his symptoms
32. Medical treatment of coronary artery disease includes which of the following
procedures?
A. Cardiac catheterization
B. Coronary artery bypass surgery
C. Oral medication administration
D. Percutaneous transluminal coronary angioplasty are invasive, surgical treatments.
33. Prolonged occlusion of the right coronary artery produces an infarction in which of the
following areas of the heart? A. Anterior
B. Apical
C. Inferior
D. Lateral
34. After an anterior wall myocardial infarction, which of the following problems is indicated
by auscultation of crackles in the lungs?
A. Left-sided heart failure
B. Pulmonic valve malfunction
C. Right-sided heart failure
D. Tricuspid valve malfunction
35. Which of the following diagnostic tools is most commonly used to determine the location
of myocardial damage?
A. Cardiac catheterization
B. Cardiac enzymes C. Echocardiogram
D. Electrocardiogram
36. What is the first intervention for a client experiencing myocardial infarction?
A. Administer morphine
B. Administer oxygen
C. Administer sublingual nitroglycerin D. Obtain an electrocardiogram
37. What is the most appropriate nursing response to a myocardial infarction client who is
fearful of dying?
A. “Tell me about your feeling right now.⠀ B. ⠀œWhen the doctor arrives, everything
will be fine.”
C. "This is a bad situation, but you'll feel better soon.”
D. “Please be assured we're doing everything we can to make you feel better.⠀
38. Which of the following classes of medications protects the ischemic myocardium by
blocking catecholamines and sympathetic nerve stimulation?
A. Beta-adrenergic blockers
B. Calcium channel blockers C. Narcotics
D. Nitrates
39. What is the most common complication of a myocardial infarction?
A. Cardiogenic shock
B. Heart failure
C. Arrhythmias
D. Pericarditis
40. With which of the following disorders is jugular vein distention most prominent?
A. Abdominal aortic aneurysm
B. Heart failure
C. Myocardial infarction D. Pneumothorax
41. What position should the nurse place the head of the bed in to obtain the most accurate
reading of jugular vein distention? A. High-Fowler's
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position
42. Which of the following parameters should be checked before administering digoxin?
A. Apical pulse
B. Blood pressure C. Radial pulse
D. Respiratory rate
43. Toxicity from which of the following medications may cause a client to see a green halo
around lights?
A. Digoxin
B. Furosemide C. Metoprolol D. Enalapril
44. Which of the following symptoms is most commonly associated with left-sided hear
failure?
A. Crackles
B. Arrhythmias
C. Hepatic engorgement D. Hypotension
45. In which of the following disorders would the nurse expect to assess sacral edema in
bedridden client?
A. DM
B. Pulmonary emboli
C. Renal failure
D. Right-sided heart failure
46. Which of the following symptoms might a client with right-sided heart failure exhibit? A.
Adequate urine output
B. Polyuria
C. Oliguria
D. Polydipsia
47. Which of the following classes of medications maximizes cardiac performance in clients
with heart failure by increasing ventricular contractility?
A. Beta-adrenergic blockers B. Calcium channel blockers C. Diuretics
D. Inotropic agents
48. Stimulation of the sympathetic nervous system produces which of the following
responses?
A. Bradycardia
B. Tachycardia
C. Hypotension
D. Decreased myocardial contractility
49. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions
would be of highest priority for this client?
A. Taking hourly blood pressures with mechanical cuff
B. Encouraging fluid intake of at least
200mL per hour
C. Position in high fowlers with knee gatch raised
D. Administering Tylenol as ordered
50. A newly admitted client has sickle cell crisis. The nurse is planning care based on
assessment of the client. The client is complaining of severe pain in his feet and hands. The
pulse oximetry is 92. Which of the following interventions would be implemented first?
Assume that there are orders for each intervention:
A. Adjust the room temperature
B. Give a bolus of IV fluids
C. Start Oxygen
D Administer meperidine (Demerol) 75mg IV push
D. Increase the suction pressure so that bubbling becomes vigorous
53. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors
the adult client and notes fluctuation of the fluid level in the water seal chamber after the
tube is inserted. Based on the assessment, which action would be appropriate?
A. Inform the physician
B. Continue to monitor the client C. Reinforce the occlusice dressing. D. Encouragetheclientto
deep-breathe
54. The nurse is caring for a male client with a chest tube, turns the client to the side and the
chest tube accidentally disconnects. The initial nursing action is to:
A. Call the physician
B. Place the tube in a bottle of sterile water
C. Immediately replace the chest tube system
D. Place the sterile dressing ove the disconnection site.
55. Nurse Paul is assisting a physician with the removal of a chest tube. The nurse should
instruct the client to:
A. Exhaleslowly
B. Stayverystill
C. Inhaleandexhalequickly
D. PerformtheValsalvamaneuver
56. While changing the tapes on a tracheostomy tube, the male client coughs and the tube is
dislodged. The initial nursing acting is to:
A. Call the physician to reinsert the tube
51.
for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory
distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would
be especially vigilant to include information about complying with medication therapy If the
client's baseline theophylline level was.
A. 10mcg/ml
B. 12mcg/ml C. 15mcg/ml D. 18mcg/ml
52. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the suction control chamber. What action is
appropriate?
B. Immediately clamp the chest tube and notify the physician
C. Check for an air leak because the bubbling should be intermittent
A male client who takes theophylline
A. Do nothing, because this is an
expected finding.
B. Grasp the retention sutures to
spread the opening
C.
D.
Call the respiratory therapy department to reinsert the tracheostomy
Cover the tracheostomy wite with sterile dressing to prevent infection.
tells the group that one of the first symptoms associated with tuberculosis is: A. Dyspnea
B. Chest pain
C. A bloody, productive cough
D.
61 A nurse performs an admission assessment on a female client With a diagnosis of
tuberculosis. The nurse reviews the results of which diagnostic test that Will confirm this
diagnosis?
A Bronchoscopy
B Sputum culture
C Chest x-ray
D Tuberculin skin test
62 The nursing instructor asks a nursing student to describe the route of transmission of
tuberculosis. The instructor concludes that the student understands this Information if the
student states that the tuberculosis is transmitted by:
A. Hand and mouth
B. The airborne route
C. The fecal-oral route D. Blood and body fluids
63. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse
assesses the oxygen flow rate to ensure that It does not exceed.
A. 1 L/min
B 2 L/min
C 6 Limin D 10 L/min
64. A nurse instructs a female client to use the pursed-lip method of breathing and the client
asks the nurse about the purpose of this type of breathing. The nurse responds, knowing
that the primary purpose of purSed-lip breathing is to:
57. A
immediately after removal of the endotracheal tube. The nurse reports which of the
following signs immediately if experienced by the client?
A. Stridor
B. Occasional, pink-tinged sputum
C. A few basilar lung crackles on the
right
D. Respiratory rate of 24 breaths/min
58. An emergency room nurse is assessing a female client who has sustained a blunt injury to
the chest wall. Which of these signs would indicate the presence of a pneumothorax in this
client?
A. Alowrespiratory
B. Diminishedbreathesounds
C. Thepresenceofabarrelchest
D. Asuckingsoundatthesiteofinjury
59. A nurse is caring for a male client hospitalized with acute exacerbation of chronic
obstructive pulmonary disease Which of the following would the nurse expect to note on
assessment of this client?
A. Hypocapnia
C. Increase oxygen saturation With exercise
D. A widened diaphragm noted on the chest xray
60. A community health nurse is conducting an educational session With community
members regarding tuberculosis. The nurse
nurse is caring for a male client
B. A hyperinflated chest noted on
A cough with the expectoration Of
mucoid sputum
the chest ray
A Promote oxygen intake.
B Strengthen the diaphragm.
C Strengthen the intercostal muscles.
D. Promote carbon dioxide elimination.
65. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the
following nursing actions will facilitate obtaining the specimen?
A. Limiting fluids
C. Asking the client to split into the collection container
D. Asking the client to obtain the specimen after eating
66 A nurse is caring for a female client after a bronchoscopy and biopsy. Which of the
following signs, if noted in the client, should be reported immediately to the physicians? A.
Dry cough
B Hematuria
C Bronchospasm
D Blood-streaked sputum
67. A nurse is suctioning fluids from a male client via a tracheostomy tube When suctioning,
the nurse must limit the suctioning time to a maximum of:
A. 1 minute
B. 5 seconds
C. 10 seconds
D. 30 seconds
68. A nurse is suctioning fluids from a female client through an endotracheal tube. During
the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing.
Which of the following is the appropriate nursing intervention?
A Continue to suction.
B. Notify the physician immediately.
D. Ensure that the suction is limited to 15 seconds
69. An unconscious male client is admitted to an emergency room. Arterial blood gas
measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a
normal oxygen level, and an elevated potassium level. These results indicate the presence of:
A. Metabolic acidosis
B. Respiratory acidosis
C. Overcompensated respiratory acidosis
D. Combined respiratory and metabolic acidosis
70 A female client is suspected of having a pulmonary embolus. A nurse assesses the client,
knowing that which of the following is a common clinical manifestation Of pulmonary
embolism?
A. Dyspnea
B Bradypnea
C Bradycardia
D Decreased respiratory
71. A nurse teaches a male client about the use of a respiratory inhaler. Which action by the
client indicates a need for further teaching?
B. Removes the cap and shakes the inhaler well before use
C. Presses the canister down with the finer as he breathes in
D. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
C. Stop the procedure and
breaths
reoxygenate the client.
B. Having the clients take three deep
A. Inhales the mist and quickly
exhales
72. A female client has just returned to a nursing unit following bronchoscopy. A nurse
would implement which Of the following nursing interventions for this client?
A. Administering atropine intravenously B. Administering small doses of midazolam (Versed)
C. Encouraging additional fluids for the next 24 hours
73. A nurse is assessing the respiratory status of a male client who has suffered a fractured
rib. The nurse would expect to note which of the following?
A. Slow deep respirations
B. Rapid deep respirations
C. Paradoxical respirations
D. Pain, especially With inspiration
74 A female client with chest injury has suffered flail chest. A nurse assesses the client for
which most distinctive sign of flail chest
A. Cyanosis
B. Hypotension
C. Paradoxical chest movement
D. Dyspnea, especially on exhalation
75 A male client has been admitted with chest trauma after a motor vehicle accident and has
undergone subsequent intubation. A nurse checks the client when the high-pressure alarm
on the ventilator sounds, and notes that the client has an absence of breath sounds in the
right upper lobe of the lung. The nurse immediately assesses for other signs of:
A Right pneumothorax
B Pulmonary embolism
C Displaced endotracheal tube
D Acute respiratory distress syndrome
76. A client has just been diagnosed with type 1 diabetes mellitus. Which comment by the
client correlates best with this disorder?
B. "It seemed like I had no appetite. I had to make myself eat."
C. "I had a cough and cold that just didn't seem to go away.'
D. "I noticed I had pain when I went to the bathroom.
77. Which outcome would indicate successful treatment of diabetes insipidus? A. Fluid
intake of less than 2,500 ml in 24 hours
B. Urine output of more than 200 ml/hr. C. Blood pressure of 90/50
D. pulse rate of 126 beats/minute
79. A nurse administered NPH insulin to a client with Diabetes mellitus at 7 am. At what time
would the nurse expect the client to be at greatest risk for a hypoglycemic reaction?
A.10am B Noon C.4pm D.10pm
80. Which instruction should be included in the teaching plan for a client requiring insulin?
A. Administer insulin
B. Administer insulin at a 45 degree angle into a deltoid muscle
C. Shake the vial of insulin vigorously before withdrawing the medication
D. Ensuring the return of the gag
A. "I was thirsty all the time. I just
couldn't get enough to drink."
reflex before offering food or fluids
D. Draw up clear insulin first when
mixing two types of insulin in one
syringe
81. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake
and oriented; has hot, dry skin; and has the following vital signs: temperature 38.1 degrees
Celsius, heart rate of 116 beats/min and blood pressure of 108/70 mmHg. Based on these
assessment findings, which nursing diagnosis takes highest priority?
B. Decreased cardiac output related to osmotic diuresis
C. Imbalanced Nutrition: less than body requirements related to insulin deficiency D.
Ineffective thermoregulation related to dehydration
82. For the first 72 hours after thyroidectomy surgery, a nurse would assess a client for
Chvostek's and Trousseau's signs because
they indicate:
A. Hypocalcemia
B. Hypercalcemia C. Hypokalemia D. Hyperkalemia
83. On a medical-surgical floor, the nurse is caring for a cluster of clients who have been
diagnosed with diabetes mellitus. Which client should the nurse assess first?
A. An 80-year-old client with a blood glucose level of 350 mg/dl
B. A 20-year-old client with a blood glucose level of 70 mg/dl
C. A 60-year-old client experiencing nausea and vomiting
84. The nurse is assigned to a 40-yr old client who has a diagnosis of chronic pancreatitis. The
nurse reviews the
laboratory results, anticipating a laboratory report that indicates a serum amylase level of:
A. 45 units/L
B. 100 units/L
C. 300 units/L
D. 500 units/L
85. What laboratory finding is the primary diagnostic indicator for pancreatitis?
A. Elevated blood urea nitrogen (BUN)
B. Elevated serum lipase
C. Elevated aspartate aminotransferase (AST)
D. Increased lactate dehydrogenase (LD)
86. A nurse is caring for client with pheochromocytoma. The client asks for a snack and
something warm to drink. The most appropriate choice for this client to meet nutritional
needs would be which of the following?
A. Crackers with cheese and tea
B. Graham crackers and warm milk
C. Toast with peanut butter and cocoa
D. Vanilla wafers and coffee with cream and Sugar
87. A nurse is performing an assessment on a client with pheochromocytoma. Which of the
following assessment data would indicate a potential complication associated with this
disorder?
A. A coagulation time of 5 minutes
B. A blood urea nitrogen level of 20 mg/dl C. A urinary output of 50 ml per hour
88. A nurse is preparing to provide instructions to a client with Addison's disease regarding
diet therapy. The nurse knows that which of the following diets most likely would be
prescribed for this client?
A. Deficient fluid volume related to
osmotic diuresis
D. A 55-year-old client complaining of
D. A heart rate that is 90 beats/min and
irregular
chest pressure
A. High fat intake
B. Low protein intake
C. Normal sodium intake D. Low carbohydrate intake
89. A nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the
client indicates an understanding of the treatment for this disorder?
A. "I take oral insulin instead of shots"
B. "By taking these medications, I am able to eat more."
C. "When I become ill, I need to increase the number of pills I take."
90. A nurse is providing discharge instructions to a client who has Cushing's syndrome.
Which client statement indicates that instructions related to dietary management are
understood?
B. "I will need to limit the amount of protein in my diet."
C. "I am fortunate that I can eat all the salty foods I enjoy."
D. "I am fortunate that I do not need to follow any special diet."
91. A client is taking NPH insulin daily every morning. The nurse instructs the client that the
most likely time for a hypoglycemic reaction to occur is:
A. 2 to 4 hours after administration
B. 4 to 12 hours after administration
C. 16 to 18 hours after administration D. 18 to 24 hours after administration
92. A nurse provides dietary instructions to a client with diabetes mellitus regarding the
prescribed diabetic diet. Which statement, if
made by the Client, indicates a need for further teaching?
A"I need to drink diet soft drinks
B."I will eat a balanced meal plan.
D"I'll snack on fruits instead of cake
93. A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should
assess the client for a hypoglycemic reaction at:
A 10:00 am B 11:00 am C 5:00 pm D. 11:00 pm
94. The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The
preoperative teaching instructions should include which most important statement?
A. *Your hair will need to be shaved." B. Deep breathing and coughing will be needed after
surgery.'
D. You will receive spinal anesthesia.
95. A nurse caring for a client with Addison's disease would expect to note which of the
following on assessment of the client?
A. Obesity
B. Edema
C. Hypotension D Hirsutism
96. A nurse is assessing a client with a diagnosis of goiter. Which of the following would the
nurse expect to note during the assessment of the client?
A Client complains of slow wound healing
C."I need to purchase special diabetic
foods— sure ni?
D. "The medications I'm taking help
release the insulin I already make.
A. "I can eat foods that have a lot of
potassium in them."
C Brushing your teeth will not be
permitted for at least 2 weeks following
surgery.
B. Client complains of chronic fatigue
C An enlarged thyroid gland
D. The presence of heart damage
97. The nurse is caring for a client following thyroidectomy. The nurse notes that calcium
gluconate is prescribed for the client. The nurse determines that this medication has been
prescribed to:
A. Treat thyroid storm
B Prevent cardiac irritability
C. Stimulate release of parathyroid hormone D. Treat hypocalcemia tetany
98. The client with type 1 diabetes mellitus is to begin an exercise program and the nurse is
providing instructions to the client regarding the program. Which of the following does the
nurse include in the teaching plan?
A. Exercise is best performed during peak times of insulin
B. Administer insulin after exercising
D. Try to exercise prior to mealtime
99. The nurse is preparing to administer an IV insulin injection. The vial of regular insulin has
been refrigerated On inspection of the vial, the nurse finds that the medication is frozen. The
nurse should:
A Wait for the insulin to thaw at room temperature
B. check the temperature settings of the refrigerator
C Discard the insulin and obtain another vial
D Rotate the vial between the hands until the medication becomes liquid.
100. A nurse is assessing the learning readiness 'of a client newly diagnosed with diabetes
mellitus. Which client behavior
indicates to the nurse that the client is not ready to learn?
B. The client asks if the spouse can attend the teaching session
C. The client asks for written materials about diabetes mellitus before class
D. The client asks appropriate questions about what will be taught
A. The client complains of fatigue
whenever the nurse plans a teaching
session
C. Take a blood glucose test before
exercising
NP 4
1. Select the main structures below that play a role with altering intracranial pressure:
I. Brain
II. Neurons III.CerebrospinalFluid IV.Blood V.Periosteum
VI. Dura mater
A. I, II, III
B. I, III, IV
C. III, IV, VI
D. All mentioned
2. The Monro-Kellie hypothesis explains the compensatory relationship among the structures
in the skull that play a role with intracranial pressure. Which of the following are NOT
compensatory mechanisms performed by the body to decrease intracranial pressure
naturally? Select all that apply:
I. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
II. Vasodilation of cerebral vessels
III. Decreasing cerebrospinal fluid production
IV. Leaking proteins into the brain barrier
A. landIl B. landIV C. llandIV D. IllandIV
3.A patient is being treated for increased intracranial pressure. Which activities below should
the patient avoid performing? Select all that apply;
I. Coughing
II. Sneezing
III. IV. V. VI.
A.
B. C. D.
Talking
Valsalva maneuver
Vomiting
Keeping the head of the bed between 30- 35 degrees
I, II, IV, V
IlIIV.V I,IV.V.VI IIIV.V.VI
4. A patient is experiencing hyperventilation and has a PaCO2 level of 52 The patient has an
ICP of 20 mmHg As the nurse you know that the PaCO2 level will?
A. cause vasoconstriction and decrease the ICP
B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP
D. cause vasodilation and decrease the ICP
5. You're providing education to a group of nursing students about ICP. You explain that
when cerebral perfusion pressure falls too low the brain is not properly perfused and brain
tissue dies. A student asks, "What is a normal cerebral perfusion pressure level? Your
response is:
A. 5-15mmHq
B. 60-100mmHg
C. 30-45mmHg D.160mmHg
6. Which patient below is at MOST risk for increasedintracranialpressure?
A patient who is experiencing severe hypotension.
C. A patient who recently experienced a myocardial infarction
D. Apatientpostopfromeyesurgery
B. A patient who is admitted with a
traumatic brain injury.
7. A patient with increased ICP has the following vital signs: blood pressure 99/60. HR 65,
Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. IP reading is 21 mmHg
Based on these findings you would?
A. Administered PR dose of a vasoresso! B. Administer 2 L Of oxvgen
D. Perform suctioning
8.A patient has a ventriculostomy. Which finding would you immediately report to the
doctor?
A. Temperature984'F B. CPP70mmHg
C. ICP 24 mmHg
D. PaC02 35
9. External ventricular drains monitor IP and are inserted where?
A. Subarachnoid space
B. Lateral Ventricle
C. Epidural space D. Right Ventricle
10. Which of the following is contraindicated in a patient with increased ICP?
A. Lumbar puncture
B. Midline position of the head
C, Hyperosmotis-diuretics. D. Barbiturate medications
11. You’re collecting vital signs on a patient with ICP. The patient has a Glascoma scale
rating 4. How will you assess the patient's temperature?
A. Rectal
B. Oral
C. Axillary D. Auricle
12. A patient who experienced a cerebral hemorrhage is at risk for developing increased
Which sign and symptom below is the EARLIEST indicator the patient is having this
complication?
A. Bradycardia
B. Decerebrate posturing C. Restlessness
D. Unequal pupil size
13. Select all the signs and symptoms that occur with increased ICP
I. Decorticate posturing
II. Tachycardia
III. Decrease in pulse pressure IV. Cheyne-stokes V.Hemiplegia VI.Decerebrateposturing
A. I, II, III, IV
B. I, IV. V. VI
C. III, IV, V, VI D. All mentioned
14. You're maintaining an external ventricular drain The ICP readings should be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg
15. Which patient below with ICP is experiencing Cushing's Triad? A patient with the
following:
A. BP 150/112, HR 110, RR 8
B. BP 90/60. HR 80. RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12
16. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's
cerebral pension pressure, and now do you interpret this as the nurse?
C. Remove extra blankets and give the
patient a cool patch
A. 90 mmHg, normal
B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHa, normal
17. Per question 16, the patient's blood pressure is 130/88. What is the patient's mean
arterial pressure (MAP)?
A. 42
B. 74
C. 102
D. 88
18. During the assessment of a patient with increased ICP, you note that the patient's
armsareextendedstraightoutandtoes pointed downward. You will document this as:
A.Decorticateposturing
B. Decerebrate posturing
C. Flaccid posturing D. Catatonia
19. While positioning a patient in bed with increased ICP, it important to avoid?
A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips
20. During the eye assessment of a patient with increased ICP, you need to assess tha
oculocephalic reflex. If the patient has brain stem damage what response will you find? A.
The eyes will move in the same direction as the head is moved side to side
B. The eyes will move in the opposite direction as the head is moved side to side C. The eves
will roll back as the head is moved side to side.
side.
21. All the following causes of Spinal Cord Injuries are non-traumatic in nature, which is not
included?
A. Rheumatoid Arthritis and Ankylosing
B. Spondylitis
C. Vascular problems D. Electric shock
22. Mr. Yoshihiro Sato, an Olympic swimmer, suffered from a diving accident and had
respiratory arrest before being transferred to the hospital. The nurse seeing the scene opens
the patient's airway to provide rescue breathing using which maneuver?
A. Headtilt
B. Jawthrust
C. Chinlift
D. Logrolltechnique
23. Injuries involving the spinal cord in the thoracic level will lead to a paralysis confined to
the lower limbs, a condition known as
A.Aletradlecia B.Hemiplegia C.Quadriplegia D.Paraplegia
24. Mr. Blake is confirmed to be having a spinal cord injury at the sacral level (S3). The nurse
includes in the plan of care of Mr. Blake, which interventions?
A Insertion of a foley catheter
B.Monitoring the patient while being hooked to a mechanical ventilator
C. Exercises to prevent atrophy of the paralyzed upper and lower extremities D.Coping
strategies for sensory and motor deficits on the left/right half of the body.
E All the above
D. The eyes will be in a fixed midline
position as the head is moved side to
25. Which of the ff. is given to a patient with spinal cord injury, primarily to address
hypotension?
A.Calcium channel blocker
B.Dextran
C.Methylprednisolone Sodium Succinate D.Mannitol
26. A nurse is reviewing the health care record of a client with a new diagnosis of
rheumatoid arthritis (RA). The nurse understands that which of the following is an early
clinical manifestation of RA?
A. Complaints of fatigue
B. Increased energy level C. Increased appetite
D. Weight gain
27. A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory
values would the nurse expect to note in the client
A Calcium level of 9.0 mg/dL
B. Uric acid level of 8.6 mg/dL
C. Potassium level of 4.1 mg/dL D. Phosphorus level 3.1 mg/dL
28. A nurse is caring for a client with osteoarthritis. The nurse performs an assessment,
knowing that which of the following is a clinical manifestation associated with the disorder?
A. Morning stiffness
B. A decreased sedimentation rate
C. Joint pain that diminishes after rest D. Elevated antinuclear antibody levels
29. The client has had surgery to repair a fractured hip. The nurse obtains which of the
following most important items from the unit storage area to use when repositioning the
client from side to side in bed?
A. Abductor splint
B. Adductor splint
C. Bed pillow
D. Overhead trapeze
30. The nurse has developed a plan of care for a client who is in traction and documents a
nursing diagnosis of self-care deficit. The nurse evaluates the plan of care and determines
which of the following observations indicates a successful outcome?
A. The client allows the nurse the nurse to complete the care daily
B. The client allows the family to assist in the care
C. The client refuses care
31. A home care nurse is visiting a client who is in a body cast. The nurse is performing an
assessment and Is assessing the psychosocial adjustment of the client to the cast. The nurse
would most appropriately assess the
A. Type of transportation available for follow-up care
B. Ability to perform activities of daily living C. Need for sensory stimulation
D. Amount of home care support available
32. A community health nurse is providing an educational session for community members
regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse
instructs the community members to increase dietary intake of which food known to be
helpful in minimizing this risk?
A. Yogurt
B. Turkey C. Spaghetti D. Shellfish
D. The client assists in self-care as much
as possible
33. A nurse is teaching a client with a right arm cast how to prevent stiff or frozen
shoulder. The nurse should instruct the client to:
A Keep a sling on the arm always
C. Avoid range-of-mation exercises D. Wear the sling at nighttime
34. A nurse is performing neurovascular assessment on a client with a cast on the left lower
leg. The nurse notes the presence of edema in the foot below the cast. The nurse would
interpret that this finding indicates:
A. Impaired arterial circulation
B. The presence of an infection
C. Impaired venous return
D. Arterial insufficiency
35. A client is complaining of knee pain. The knee is swollen, reddened and warm to touch.
The nurse interprets that the client's signs and symptoms are not compatible with:
A. Inflammation
B. Degenerative disease
C. Infection
D. Recent injury
36. A nurse witnesses a client sustain a fall and suspects that the right leg may be broken.
The nurse takes which priority action?
A. Take a set of vital signs
B. Call the radiology department
C. Reassure the client that everything will be
37. A nurse in the hospital emergency department is caring for a client with a fractured arm
and is preparing the client for a reduction of the fracture that will be done in the casting
room. Which of the following is unnecessary?
A. Explanation of the procedure to the client B. Administration of an analgesIc
C. Anesthesia consent
D. Consent for the procedure
38. A nurse has suggested specific leg exercises for a client immobilized in right skeletal
lower leg traction. The nurse determines that the client needs further instruction of the
nurse observes the client: A. Pulling up using the trapeze
B. Flexing and extending the feet
D. Doing quadriceps-setting and gluteal setting exercises
39. A client has a slight weakness in the right leg. Based on this assessment finding, the nurse
determines that the client would benefit most from the use of
A. walker
B. A wooden crutch
C. A Lofstrand crutch
D. A straight leg cranes
40. A client who has experienced a brain attack (stroke) has partial hemiplegia of the left leg.
The straight leg cane formerly used by the client is not quite sufficient now. The nurse
interprets that the client could benefit from the somewhat greater support and stability
provided by a
A. Quad cane
B. Wooden crutch C. Loistrand crutch D. Wheelchair
B.Lift the shoulder of the casted arm
over the head-periodically throughout
the day
C. Performing active range of motion to
the right ankle and knee
D. Immobilize the right leg before moving
the client.
41. A client who is learning to use a cane is afraid that they will slip with ambulation, causing
a fall. The nurse provides the client with the greatest reassurance by stating that.
A. Canes prevent falls; they do not cause ther
C. The physical therapist will determine if the cane is inadequate
D. The cane would help to break a fall, even if you do slip
42. A nurse in the hospital emergency department is assessing a client with an open leg
fracture. The nurse inquires about the date of the client's last
A. Physical examination B. Chest radiograph
C. Tetanus vaccine
D. Tuberculin test
43. A client has just been admitted to the hospital with a fractured femur and pelvic
fractures. The nurse plans to carefully monitor the client for which of the following signs and
symptoms?
A. Tachycardia, hypotension
B. Bradycardia, hypertension C. Fever, bradycardia
D. Fever, hypertension
44. A client is complaining of pain underneath a cast in a bony prominence. The nurse
interprets that this client may need:
A. To have the cast replaced with an air splint
B. To have extra padding put over this area of the cast
C. To have the cast bivalve
D. To have a window cut in the cast
45. A test for the presence of rheumatoid factor is performed in a client with a diagnosis of
rheumatoid arthritis. The nurse understands that this test assesses for the presence of:
A. Unusual antibodies of the IgG and IgM
type
B. Antigens of IgA
C. Inflammation
D. Infection in the body
46. You are initiating a nursing care plan for a patient with osteoporosis. These nursing
interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you
delegate to the nursing assistant?
A. Identify environmental factors that increase risk for falls.
B. Monitor gait, balance, and fatigue level with ambulation.
C. Collaborate with physical therapy to provide patient with walker
47. You are preparing to teach a newly diagnosed patient with osteoporosis about strategies
to prevent falls. Which of these points will you be sure to include? (Choose all that apply.)
D. You should expect a few bumps and bruises when you go home
E. When you are tired, you should rest.-
48. You discover these assessment findings when admitting a patient with Paget's disease.
Which finding indicates that the physician should be notified?
B. The cane has a flared tip with
concentric rings to give stability
D. Assist the patient with ambulation to
bathroom and in halls.
A. Wear a hip protector when
ambulating.-
B. Remove throw rugs and other
obstacles at home-
C. Exercise will help build your strength-
A. A. The patient has bowing of both legs and the k nees are asymmetricasymmetric
C. The patient is only 5 feet tall and weighs 120 pounds.
D. D. The patient's skull is soft, thick, and larger than normal
49. As charge nurse you observe the LPN/LVN providing these interventions for the patient
with Paget's disease. Which action requires that you intervene?
A. Administers 600 mg of ibuprofen to the patient
B. Encourages the patient to perform PT recommended exercises
D.Reminds the patient to drink milk and eat cottage cheese
50. As charge nurse you are making assignments for the day shift. Which patient would you
assign to the nurse who has been pulled from the post-anesthesia care unit (PACU) for the
day?
A. A 35-year-old patient with osteomyelitis who needs teaching prior to hyperbaric oxygen
therapy
B. A 62-year-old patient with osteomalacia who is being discharged to a long-term care
facility
C. A 68-year-Old patient with osteoporosis and a new orthotic device whose knowledge of
use of this device must be assessed.
51. A patient is admitted to the hospital after vomiting bright red blood and is diagnosed
with a bleeding duodenal ulcer. The patient develops a sudden, sharp pain in the
midepigastric region along with a rigid, boardlike abdomen. These clinical manitestations
most likely indicate which of the following?
A. An intestinal obstruction has developed.
B. The ulcer has perforated.
C. Additional ulcers have developed
D. The esophagus has become inflamed
52. The patient asks the nurse what causes a Peptic Ulcer to develop. The nurse responds
that recent research indicates that many peptic ulcers are the result of which of the
following?
A. Helicobacter pylori infection
B. Diets high in fat
C. Work-related stress.
D. A genetic defect in the gastric mucosa.
53. The nurse is preparing to teach a patient with a Peptic Ulcer about the diet that should
be followed by discharge. The nurse should explain that the diet will most likely consist of
the following.
A. Any foods that are tolerated.
B. Large amounts of milk. C. Bland foods.
D. High-protein foods.
54. A patient is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer.
The nurse knows that the patient understands proper drug administration of ranitidine when
she says that she will take the drug at which of the following times?
A. When pain occurs. B. Before meals.
C. With meals.
D. At Bedtime
55. Which of the following would be an expected outcome for a patient with Peptic Ulcer
disease?
B. The base of the patient's skull is
Invaginated (platypasia).
C. Applies ice and gentle massage to the
patient's lower extremities
D. A 72-year-old patient with Paget's
disease who has just returned from
surgery for total knee replacement
 A. The patient will explain the rationale
for eliminating alcohol from the diet.
B. The patient will verbalize the importance of monitoring hemoglobin and hematocrit every
3 months.
C. The patient will demonstrate appropriate use of analgesics to control pain.
D. The patient will eliminate contact sports from his or her lifestyle
56. A patient with suspected gastric cancer undergoes an endoscopy of the stomach. Which
of the following assessments made after the procedure would indicate the development of a
potential complication? A. The patient complains of a sore throat. B. The patient
demonstrates a lack of appetite C.Thepatientdisplayssignsofsedation.
57. After a subtotal Gastrectomy, the nurse should anticipate that NGT drainage will be what
color for about 12 to 24 hours after surgery?
A. Brightred.
B. Cloudywhite. C. Darkbrown. D. Bilegreen.
58. The nurse understands that the best position for the patient who has undergone a
Gastrectomy is:
A. Supine.
B. Prone.
C. LowFowlers
D. Right or left Sim's.
59. To reduce the risk of dumping syndrome, the nurse should teach the patient which of the
following interventions? A. Decrease the carbohydrate content of meals.
B. Avoid milk and other dairy products. C. Drink liquids with meals, avoiding caffeine
D. Sit upright for 30 minutes after meals.
60. Which of the following symptoms would be indicative of the Dumping Syndrome? A.
Diaphoresis.
B. Vomiting.
C. Hunger
D. Heartburn.
61. After surgery for gastric cancer, a patient is scheduled to undergo radiation therapy. It
will be most important for the nurse to include information about which of the following in
the patient's teaching plan?
A. Nutritionalintake
B. Exerciseandactivitylevels.
C. Managementofalopecia.
D. Accesstocommunityresources.
Situation: A patient who has been diagnosed with Gastroesophageal reflux disease (GERD)
complains of heartburn.
62.Todecreasetheheartburn,thenurse shouldinstructthepatienttoeliminatewhich of the
following items from the diet?
A. Hot chocolate.
B. Air-poppedpopcorn. C. Raw vegetables
D. Lean beef
63. The patient with GERD complains of a chronic cough. The nurse understands that in a
patient with GERD this symptom may be indicative of which of the following conditions.
A. Aspiration of gastric contents. B. Development of laryngeal cancer. C. Esophageal scar
tissue formation. D. Irritation of the esophagus.
D. The patient experiences a sudden
 increase in temperature
64.Thepatientattendstwosessionswith thedieticiantolearnaboutdiet modifications to
minimize Gastroesophageal Reflux. The teaching would be considered successful if the
patient says that she will decrease her intake of which of the following foods?
A. Fats
B. High-sodiumfoods
C. Carbohydrates.
D. High-calcium foods.
65. Which position would be ideal for the patient in the early postoperative period after a
Hemorrhoidectomy?
A. Supine.
B. Side-lying.
C. Trendelenburg D. High-Fowler's.
66. When the patient's common bile duct is obstructed, the nurse should evaluate the
patient for signs of which of the following complications?
A. Circulatoryoverload.--?
B. Urinarytractinfection.
C. Prolongedbleedingtime. D. Respiratorydistress.**
67. How much bile would the nurse expect the T- tube to drain during the first 24 hours after
a Choledocholithotomy?
A. 300to500mL.
B. 550to700mL. C. 50to100mL. D. 150to250mL
68. After a Cholecystectomy it is recommended that the patient follow a low-fat diet at
home. Which of the following foods would be most appropriate to include in a low-fat diet?
A. Roastbeef.
B. Cheeseomelet
C. Peanutbutter
D. Hamsaladsandwich
69. Which of the following discharge instructions would be appropriate for a patient who has
had a laparoscopic Cholecystectomy?
( Leave dressings in place until you see the surgeon at the postoperative visit. Sa quizlet)
B. Avoid showering for 48 hours after surgery.
C. Use acetaminophen (Tylenol) to control any fever
D. Return to work within 1 week.
70. Celso is admitted to the hospital with acute pancreatitis. The nurse taking a history
should question the client about which of these risks for developing pancreatitis?
A. inflammatory bowel disease
D. alcoholism
B. diabetes mellitus D. high-fiber diet
71. Which of the following factors should be the focus of nursing management in a client
with Acute Pancreatitis?
A. Fluid and electrolyte balance.-
B. Management of hypoglycemia C. Pain control.
D.Dietary management.
72. In alcohol-related pancreatitis, which of the following interventions is the best way to
reduce the exacerbation of pain?
A. Eating a low-fat diet.
B. Abstaining from alcohol.
C. Lying supine. D. Taking aspirin.
A. Change the dressing daily until the
incision nedis
73. Which of the following findings would strongly indicate the possibility of Cirrhosis?
A. Pruritus
B. Peripheral edema.
C. Hepatomegaly.
D. Dry skin.
74. The nurse is aware that the symptoms of Portal Hypertension in clients with liver
cirrhosis are chiefly the result of.
A. Infection of the liver parenchyma
B. Fatty degeneration of Kupffer cell
C. Obstruction of the portal circulation
D. Obstruction of the cystic and hepatic ducts
75. Which goal for the patient's care should take priority during the first day of
hospitalization for an exacerbation of Ulcerative Colitis?
A. Maintaining adequate nutrition.
B. Managing diarrhea.
C. Promoting self-care and independence. D. Promoting rest and comfort.
Situation: Pedro consulted a urologist because of his chronic renal problem. The physician
advised him to undergo peritoneal dialysis.
76.Whichofthefollowingassessments wouldbemostappropriateforthenurseto make while the
dialysis solution is dwelling within the patient's abdomen?
A. Check capillary refill time
B. Assess for urticaria.
C. Monitor electrolyte status
D. Observe respiratory status.
77. The dialysis solution is warmed before use in peritoneal dialysis primarily to:
A. force potassium back into the cells
B. promote abdominal muscle relaxation. C. add extra warmth to the body
D. encourage the removal of serum urea
78. During dialysis, the nurse observes that the flow of dialysate stops before all the solution
has drained out. The nurse should: A. Reposition the peritoneal catheter
B. Have the patient sit in a chair.
C. Have the patient walk.
D. Turn the patient from side to side.
79. Which of the following nursing interventions should be included in the patient's care plan
during dialysis therapy? A. Keep the patient NPO.
B. Monitor patient's blood pressure.
C. Limit the patient's visitors.
D. Pad the side rails of the bed.
80. What is the most potentially dangerous complication of peritoneal dialysis?
A. Muscle cramps.
B. Abdominal pain.
C. Gastrointestinal bleeding.
D. Peritonitis
81. After completion of peritoneal dialysis, the nurse would expect the patient to exhibit
which of the following characteristics?
A. Weightloss.
B. Hypertension.
C. Hematuria.
D. Increasedurineoutput.
Situation: Cecil a 38-year married woman, seeks consultation for painful urination, urgency in
voiding and fever for 3 days.
82. Which of the following symptoms would most likely indicate Pyelonephritis?
B Nausea and vomiting C. Ascites
D. Polyuria.
A. Costovertebral angle (CVA)
tenderness
83. The nurse is aware that one of the following laboratory values will support a diagnosis of
Pyelonephritis.
A. Myoglobinuria
B. Pyuria
C. Ketonuria
D. Lowwhitebloodcell(WBC)count
84. The patient with acute Pyelonephritis wants to know the possibility of developing chronic
Pyelonephritis. The nurse's response is based on knowledge that which of the following
disorders most commonly leads to chronic Pyelonephritis?
A. Acuterenalfailure
B. RecurrentUTI
C. Acutepyelonephritis. D. Glomerulonephritis.
Situation: Gina 24-year-old, patient who is newlywed comes to an ambulatory clinic in
moderate distress with a diagnosis of acute cystitis,
85. Which of the following symptoms would the nurse most likely expect the patient to
report during the assessment?
A. Hematuria
C. Flankpainandnausea D. Feverandchills
86. The patient asks the nurse, "How did I get this urinary tract infection?" The nurse should
explain that in most instances, cystitis is caused
A. Congenital strictures in the urethra. B. An infection elsewhere in the body C. Urine stasis in
the urinary bladder
87. The patient is afraid to discuss her diagnosis of Cystitis with her husband. Which would
be the nurse's best approach?
B. Talk first with the husband alone and then with both of them together to share the
husband's reactions.
C. Insist that the patient talk with her husband because good communication is necessary for
a successful marriage
D. Arrange a meeting with the patient, her husband the doctor and the nurse
88. The nurse teaches a patient some methodtorelieveherdiscomfortuntilthe antibiotic takes
effect. Which of the following responses by the patient would indicate that she understands
the Nurse's instructions? A. "I will place ice packs on my perineum." B. I will drink a cup of
warm tea every hour C. *I will take hot tub baths."
D. I will void every 5 to 6 hours.
89. Which of the following statements by the patient would indicate that she is at high risk
forrecurrenceofCystitis?
A. "I drink a lot of water during the day
B. "I take a tub bath every evening C."Iwipefromfronttobackaftervoiding.
90. A client who has been treated for chronic renal failure (CRF) is ready for discharge. The
nurse should reinforce which dietary instruction?
A. "Be sure to eat meat at every meal"
B. "Monitor your fruit intake, and eat plenty of bananas.
C. "Increase your carbohydrate intake
D. "Drink plenty of fluids, and use a salt
A. Spend time with the patient
addressing her concerns and then stay
with her while she talks with her
husband.
B. Frequencyandburningon
urination
D. "I can usually go 8 to 10 hours without
needing to empty my bladder.
D. An ascending infection from the
urethra.
substitute."
91. A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which
nursing diagnosis is most appropriate for this client?
A. Altered urinary elimination B. Toileting self-care deficit C. Risk for infection
D. Activity intolerance
92. The client underwent a transurethral resection of the prostate gland 24 hours ago and is
on continuous bladder irrigation. Which of the following nursing interventions is
appropriate?
A. Tell the client to try to urinate around the catheter to remove blood clots
B. Restrict fluids to prevent the client's bladder from becoming distended.
C. Prepare to remove the catheter.
93. The nurse is inserting a urinary catheter into a client who is extremely anxious about the
procedure. The nurse can facilitate the insertion by asking the client to:
A. initiate a stream of urine
B. breathe deeply
C. Turn to the side
D. hold the labia or shaft of penis.
94. Which steps should the nurse follow to insert a straight urinary catheter?
A. Create a sterile field, drape client, clean meatus, and insert catheter only 6
B. Put on gloves, prepare equipment, create a sterile field, expose urinary meatus, and insert
catheter 6"
D. Prepare client and equipment, sterile field test catheter balloon clean meals, and insert
catheter until unne flows
95. Which of the following is an appropriate nursing diagnosis for a client with renal calculi?
A.Ineffective tissue perfusion
B. Functional urinary incontinence
C.Risk for infection
D. Decreased cardiac output
96. Which clinical manifestation would lead the nurse to suspect that a client Is experiencing
hypermagnesemia?
A. Muscle pain and acute rhabdomyolysis B. Hot, flushed skin and diaphoresis C.Soft-tissue
calcification and hyperreflexia D. Increased respiratory rate and depth
97. Joshua is receiving furosemide and Digoxin, which laboratory data would be the most
important to assess in planning the care for the client?
A. Sodium level
B. Magnesium level
C. Potassium level
D. Calcium level
98. Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure
of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and
a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse
implement? A. Instructing the client to breathe slowly into a paper bag
B. Administering low-flow oxygen
D. Nothing, because these ABG values are within normal limits.
D. Use aseptic technique when irrigating
the catheter
C. Encouraging the client to cough and
C. Prepare client and equipment, Create
deep breathe
à sterile field, put on gloves, clean
urinary meatus, and insert catheter until
urine flows.
99. A client is diagnosed with metabolic acidosis, which would the nurse expect the health
care provider to order?
A. Potassium
B. Sodiumbicarbonate
C. Serumsodiumlevel D. Bronchodilator
100. Lee Angela's lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you
would interpret this serum chloride level as:
A. high
B. low
C. within normal range D. high normal

NP 5
1. A patient who has a hemorrhage in the vitreous cavity of the eye, the nurse knows that
blood is accumulating
A. in the aqueous humor.
B. between the lens and the retina
C. between the cornea and the lens.
D. in the space between the iris and the lens.
2. The nurse instructs a family member how to guide a visually impaired person when
ambulating by:
A. holding the visually impaired person by his or her nondominant arm and walking side by
side.
B. holding the nondominant hand, wrapping the arm around his or her waist, and walking
side by side.
D. allowing the visually impaired person to hold the shoulder of the helper and walk slightly
behind the helper.
3. The patient tells you that he has to hold his paper farther and farther away from his face
to read it. It has become a joke in his family about how far away he needs to hold reading
material. You tell the patient:
A. "You have myopia. Glasses will help you read.”
B. You may have astigmatism, and your eyes will get used to the problem.
D. "You may have an eye infection that is affecting your vision. You will need an antibiotic
ointment to instill into your eyes
4. A client with impaired vision is admitted to the hospital. The following interventions are
appropriate to meet the client's needs EXCEPT
A. Identify yourself by name
B. Stay in the client's field of vision.
C. Explain the sounds in the environment
5. The nurse should always assess the patient with an ophthalmic problem for A. Visual
acuity.
B. pupillary reactions
C. intraocular pressure
D. confrontation visual fields
6. Increased intraocular pressure may occur as a result of
A. edema of the corneal stroma
B. dilation of the retinal arterioles.
C. blockage of the lacrimal canals and ducts.
7. A patient is diagnosed with close-angle glaucoma. The nurse prepares the patient on what
diagnostic procedure to visualize the anterior chamber angle?
A. Ophthalmoscopy
B. Gonioscopy
C. Retinoscopy D. Bio microscopy
8. The nurse should specifically question patients using eyedrops to treat glaucoma about
A. use of corrective lenses.
B. their usual sleep patterns
C. a history of heart or lung disease.
D. sensitivity to opioids or depressants.
9. When assessing the visual fields in acute
D. Decrease background noise before
speaking.
C. allowing the visually impaired person
to hold the helper's arm, with the helper
slightly ahead.
D. increased production of aqueous
humor by the ciliary body.
C. "You have presbyopia, which is a
normal age-related change. Reading
glasses will help you.
glaucoma, the nurse would expect to find a: A. clear cornea.
B. marked blurring of vision.
C. constricted pupil.
D. watery ocular discharge
10. A client is diagnosed with acute angle glaucoma and is placed on oral osmotic diuretic
therapy. Which of the following will the Nurse include in his health teachings during acute
phase of his illness?
A. Measurement of intake and output.
B. Using metal eye patch to protect the eye. C. Otic drop administration.
D. Keeping his belonging well organized at all times. -?
11. When irrigating a patient's ear, the nurse will: straighten the ear canal and irrigate with a
large-tipped bulb syringe.
A. Straighten the ear canal and irrigate with a large-tipped bulb syringe
B. direct the solution to the middle of the canal to avoid damaging the ear.
D. repeat the irrigation with hotter water.
12. Nurse Sylvia was approached by a teenager crying in pain because of an ant that has
entered her ears. What should be Nurse Sylvia's action?
A. Irrigate the ear using a cerumenolytic agent.
B. Use a moist cotton bud to remove the insect.
C. Instill a small amount of mineral oil
D. Blow a smoke towards the patient's ear,
Situation: Mr. Timothy Harris, a 78-year-old patient, subjected himself to medical treatment
because of severely diminished
hearing acuity. His ears were inspected by an Otolaryngologist and it was found Out that
both of his auditory canals were obstructed by an impacted cerumen.
13. Nurse Savannah is knowledgeable that Mr. Harris' condition is most commonly caused
by:
A. an acute ear infection.
B. overactive ceruminous glands
C. poor hygiene.
D. Concurrent dermatosis
14. Initial intervention for an impacted cerumen involves irrigation of a cerumenolytic agent
to the involved ear. Nurse Savannah prepares which solution to most effectively soften the
impacted cerumen?
A. 0.9% NaCI solution
B. Gentamycin drops
C. Atropine Sulfate drops D. Peroxide in Glyceryl
15. When the nurse reads in the patient's history that the patient has experienced otalgia,
the nurse knows that the patient has:
A. difficulty hearing.
B. a buildup of cerumen. C. ear pain.
D. ringing in ears.
16. Nursing instructions for a patient suffering from external otitis should include the
A. Application of heat to the auricle.
B. Avoidance of swimming.
C. Ingestion of over-the-counter analgesics, such as aspirin.
D. All of the above.
17. The nurse points out to the client that of the activities in which he is regularly
C. use a body temperature solution and
have the patient hold a basin under the
ear while directing the solution toward
the top of the canal.
 involved, the one that contributes to accumulation of cerumen in the external ear is:
A. swimming in a chlorinated pool daily. B. drinking 1500 mL. of fluid a day.
C. trimming hair from the ears every week D. washing the ears with a washcloth every day.
Situation: Otitis media is currently considered as an important public health problem which
may produce long-term effects on language, auditory and cognitive development.
18. Which classification of otitis media according to duration is APPROPRIATELY described?
A Acute Otitis Media = resolves within 6 months
B. Chronic Otitis Media = occurs longer than 12 months
C. Subacute Otitis Media = occurs for 6 to 12 months
D. All of the above
E. None of the above
19. Identification of risk factors in key to prevention of Otitis Media. The nurse lists down the
risk factors and includes which of the following? (Select all that apply)
D. Exposure to secondhand smoke
20. Suppurative Otitis media can be due to the following BUT ONE
A. May follow a viral disease.
B. Barotrauma.
C. Tympanic membrane perforation
D. Follows a forceful nose blowing
Situation: Mr. Tonio a 49-year-old, a jolly person works at the Commercial bank for 13 years
had been informed for some changes in is work load.m
Three months after he was
observed of unbecoming behavior. He was diagnosed with Bipolar I disorder and
experiencing a Manic episode is newly admitted to the inpatient psychiatric unit.
21. Which nursing diagnosis is a priority at this time?
A. Risk for violence: other-directed R/T poor impulse control
B. Altered though process RT hallucinations
C. Social isolation R/T manic excitement
D. Low self-esteem R/T guilt about promiscuity
22. In the mental hospital Mr. Tonio is yelling at another peer in the milieu. Which nursing
intervention takes priority?
B. administer prescribed PRN intramuscular injection for agitation
C. notify the client to lower voice
D. obtain an order for seclusion to help decrease external stimuli
23. Another client diagnosed with bipolar Il disorder has a nursing djagnosis of impaired
social interactions R/T egocentrism. Which short-term outcome is an appropriate
expectation for this client problem?
day 4
B. the client will exchange personal information with peers at lunchtime
C. the client will verbalize the desire to interact with peers by day 2
D. the client will initiate an appropriate social relationship with a peer
A.Chronic upper respiratory infection
A. calmly redirect and remove the client
from the milieu
B.Congenital abnormalities (Cleft Palate
Down Syndrome)
C.Daily intake of aspirin
A. the client will have an appropriate
 one-on- one interaction with a peer by
24. An adult client 52 years old, diagnosed with major depressive disorder is being
considered for electroconvulsive therapy (ECT). Which client teaching should the nurse
prioritize?
A. empathize with the client about fears regarding ECT
B. monitor for any cardiac alterations to avoid possible negative outcomes
D. inform the client that injury related to induced seizure commonly occurs
25. A nursing instructor is teaching about the cause of mood disorders. Which statement by
a nursing student best indicates an understanding of the etiology of mood disorders?
A. When clients experience loss, they learn that it is inevitable and become hopeless and
helpless.
B. "There are alterations in the neurochemicals, such as serotonin, which cause the client's
symptoms
D. "There is a genetic component affecting the development of mood disorder."
Situation: Paulo 9 years old is diagnosed with an autistic disorder makes no eye contact; is
unresponsive to staff members and continuously twists, spins, and head bangs,
26. What is meant by the "fittingness" of a research study?
A. Truth of findings as judged by the participants
B. The appropriateness of the interview
questions posed
D. The adequacy of the coding system used
27. What is a characteristic of an intrinsic case study?
B. It provides a foundation to challenge a generalization.
C. It does not include quantitative data. D. It can scrutinize only uncomplicated Phenomena.
28. Which of the following is most accurate regarding the grounded-theory method?
A. Data are collected using an etic perspective.
B. It is a process of constructing human experience.
C. Secondary sources are sometires used D. It is an inductive approach.
29. Nursing Research can be classified according to the time frame the research study has
been made As a nurse, you know that the study entitled *Knowledge and practice of Staff
Nurses in preventing needle prick injuries in a private hospital in Manila is classified as
A. Basic Research
B. Historical Research
C. Descriptive Research D. Experimental Research
30. Nursing Research has a lot of purposes, Which of the following category do the study
about sociodemographic profile of nursing students and their risk for depression belong?
A. Prescription
B. Exploration
C. Prediction and control
C. "Evidence continues to support
C. Faithfulness to everyday reality of the
participants
A. It yields a better understanding of
each case.
C. discuss the client and family expected
short-term memory loss
multiple causations related to an
individual's susceptibility to mood
 symptoms.'
D. Explanation
31. In an experimental research, as a nurse there must be an essential aclivily wherein the
participants of the study will be able to understand the whole experimental design. This term
is called:
A. Desensitization
B. Experimental Proper C. Research Proper
D. Debriefing
32. Ethics in Nursing Research has always been an issue when it comes to the identity of the
respondents. When the topics of research are very sensitive, which of the following rights of
individual participants must be ensured when the researcher cannot link the information
given by the respondent from the source of the information?
A. Confidentiality
B. Anonymity
C. Virility
D. Volunteerism
33. In starting a focused group discussion, Nurse Dina wants to stress out the confidentiality
of the topics that they will be discussing. Which of the following instruction convey
confidentiality?
A. "This discussion should not only be confined within this group of people. Any information
discussed should be told publicly."
C "This discussion should not be confined within this group of people. Any information
discussed should not be told publicly.
D. "This discussion should only be confined within this group of people. Any information
discussed should be told publicly."
34. Based on the research title which of the following will be the general objective?
A. This study aims to determine the level of knowledge and practice of prevention of needle
prick injuries of Staff Nurses in a certain private hospital.
B. This study aims to determine if there is a significant relationship between levels of
knowledge regarding prevention of needle prick injuries and sociodemographic of Staff
nurses in a certain private hospital.
C. The study aims to determine the levels of knowledge regarding prevention of needle prick
injuries of staff nurses in a certain private hospital
35 All of these are specific objectives except
B. This study aims to determine if there is a significant relationship between levels of
knowledge regarding prevention of needle prick injunes and sociodemographic of Staff
Nurses in a certain private hospital.
C.This study aims to determine the levels of knowledge regarding prevention of needle prick
injuries of Staff Nurses in a certain private hospital.
D. This study aims to determine the sociodemographic of Staff Nurses in a certain private
hospital.
36 As a nurse, you know the appropriate data gathering tool, this is?
A. Survey
B. Questionnaire
C. Structured Discussion D. Interview Method
D. This study aims to determine the
isociodemographic of staff nurses in a
certain private hospital.
 A. This study is for nursing researchers
in the future.
B. "This discussion should only be
confined within this group of people.
Any information discussed should not
be told publicly."
37. As a nurse, these are the following topics in the scope and limitations except.
B. Limited only to the practice of preventing needle prick injuries of nursing personnel C. The
scope of the study involves the knowledge about prevention of needle prick injunes
D. The scope of the study involves the sociodemographic profile of nursing Personnel
38. Which of the following is not a null hypothesis?
A. There is no relationship between the level of knowledge and practice of prevention of
needle prick injuries
B. There is no relationship between the practice of prevention of needle prick injuries and
sociodemographic profile of staff nurses
D. All of the above. E. None of the above
39. Which of the following would correspond to Intervene in Nursing Process?
A. Select design plan
B. Report findings
C. Implement planned study
D. Select a plan analysis
40. Which of the following would correspond to Plan in Nursing Process?
A. Select design plan
B. Report findings
C. implement planned study D. Change the objectives after implementation
41. When it comes to steps in Problem Solving. Which of the following would be similar in
research where in you implement the planned study?
A. Theorize about facts and possible
B. Gather, analyze relevant information–
C. Report findings
D. Determine information needs
42. Using the Research perspective, when is the time that a nurse makes inferences? A.
Define purpose of review of literature
B. Formulate a problem, define variables C. Select design sample
D. Report findings
43. Which of the following is does not belong to the group?
A. Assess; Identify the problem
B. Plan: Theorize
C. Intervene: Gather relevant information D. Evaluate Outcomes
44. In selecting a problem, these are the following consideration except:
A. Time Factor
B. Talents
C. Cost
D. Data availability
45. These are the purpose of Review of Related Literature except:
A. Reveal investigations
B. Reveal sources of data
C. Reveal what is the problem–
D. Reveal the significant research personalities
46. As a nurse, you know the following a
function of theoretical framework, except:
A. Specifies relationship among the concepts
B. Give a graphic view of the data
A Limited to the hospital personnel of a
private hospital
C. There is a significant relationship
between the knowledge and
sociodemographic profile of staff nurses
in a certain private hospital.
C. Clarifies the concept on which the study is built
D. State assumptions
47. Which of the following would not be Qualitative Research?
A. Case study of Myocardial Infarction B. A Review on Corona Trial
C. A Review on the Nursing Uniform
48. Using statistics in nursing research is a very vital tool in presenting the data. As a nurse
you know the definition of sampling as:
A. Taking certain areas of the population dividing the areas into sections
C. Using every Nth name from the list of participants
D. Taking any sample as long as it comes up with the quota
49. A researcher plans to conduct a survey It the population on Marupok City is 67, 666, find
the sample size it the margin of error is 23%.
A. 19
B. 15
C. 23
D. 29
50. The nurse develops the following hypothesis: Elderly women receive less aggressive
treatment for breast cancer than do younger women. Which variable would be considered to
be the dependent variable?
A. Degree of treatment received
B. Age of the patient
C. Type of cancer being treated D. Use of inpatient treatment
51. in planning care for a newly admitted patient with depression, the highest priority for the
nurse is
A. orienting the patient to the unit.
B. encouraginq expression of feelings.
C. providing a safe environment
D. meeting the patient at an appropriato affective level.
52. A patient displays disorganized, difficult to understand speech, behavioral
disorganization, and a silly, inappropriate affect The patient prefers to sit alone and be
uninvolved in unit activities, and often appears to be listening and responding to unseen
stimuli. The nursing diagnosis that should be given priority is:
A. impaired verbal communication*** B. social isolation.
C. ineffective coping.
D. impaired social interaction.
53. The nurse should focus assessment for a patient with type 1 schizophrenia primarily on
gathering data about:
A. communication difficulties.
B. perceptual alterations.
C. social interactions. D. avolition.
54. A withdrawn patient exhibits peculiar gestures and waxy flexibility. She repeats what the
nurse says to her in a high-pitched voice but does not otherwise respond verbally. The nurse
should document that the patient demonstrates:
A. echolalia.
B. alogia
C. concrete thinking.
D. associative looseness.
D. A Review on the Performance in
Related Learning Experience of student
nurses
B. Process of selecting a portion of the
population to represent the entire
population
55. The emergency room phones the psychiatric unit to say that a patient demonstrating
symptoms of acute schizophrenia, including altered perceptions, is being admitted. The
nurse can anticipate care by considering that the type of perceptual alteration most
commonly displayed by patients with schizophrenia is: A. waxy flexibility.
B. auditory hallucinations.
C. inappropriate affect. D. loose associations.
56. A patient relates the following history Ile Plebence of continuous, intrusive thought her
house is contaminated with lethal bacteria, and the uncontrollable urge to continuously
clean the walls, Moors, and furniture. These symptoms are most consistent with the
DSM-/V-TR diagnosis ot A. social phobia.
B. panic disorder.
C. somatoform disorder
D. obsessive-compulsive disorder
57. A patient whose husband was killed in the World Trade Center explosion has become
unwilling to enter a tall building because she experiences severe physical and emotional
symptoms when she does, During these episodes, she becomes diaphoretic, her heart races,
and she feels as though she cannot breathe. She is filled with dread, thinking that the
building will explode The nurse can assess these symptoms as being most consistent with the
diagnosis of
A. obsessive-compulsive disorder
B. generalized anxiety disorder
C. acute stress disorder. D. specific phobia.
58. When working with a patient who has
dissociative amnesia, the nurse should plan to begin by
A. taking measures to prevent identity diffusion
B. setting mutual goals for behavioral changes
C. helping the patient develop a realistic self- concept.
59. The nurse notes that a patient with obsessive- compulsive disorder (OCD) is pacing up
and down the corridor while counting each circuit. The best action on the part of the nurse
Would be to:
A. ask her why she is pacing and cousin B. take her by the arm and lead her to her room
C. offer to play cards with her in the dayroom
60. A principle that should be applied when providing care for a patient with conversion
disorder is
B. structure care to provide time for rituals C. facilitate progressive review of the trauma.
D. permit dependence while the symplo is present.
61. Which symptom related to disordered communication is the nurse most likely to assess
in a patient who is having a manic episode?
A. Mutism
B. Flight of ideas
C. Loose associations D. echolalia
D. identifying and supporting patient
strengths
D. permit her to pace and count until
she's comfortable
A. give attention to the patient, not the
symptom
62. A principle of greatest value when interacting with a patient who is experiencing a
manic episode is:
A. use a calm matter of fact approach B.avoidmentioninglimits
C. do not interrupt patient D.encouragejoking
63. A nursing diagnosis that can be established for a grossly hyperactive manic patients who
runs wherever he goes, exercises wildly, and is argumentative with other patients is :
A. powerlessness
B. riskforinjury
C. deficient diversional activity D. disturbedthoughtprocesses
64. During community meeting, a manic patient tells another patient, You need to push
yourself away from the table more. You're too fat for your own good!" The nurse should
intervene by:
B. telling the patient that he must leave themeetingandgotohisroom.
C. telling the patient that he can remain in the meeting only if he apologizes.
D. suggesting that the patient take prn medication.
65. A patient with bipolar I disorder is noted to be laughing and giddy one minute and within
seconds is angry and sarcastic. The assessment that the nurse should make is that the
patient's mood is:
A. incongruent. B. inappropriate. C. incandescent. D. labile.
66. A psychiatric technician mentions to the nurse, "I think I heard the ED doctor say that
the patient I just brought to the unit has a personality disorder." To follow up on this, the
nurse could look at the diagnostic sheet under the DSM-IV-TR axis
A. I
B. II
C. III D. IV
67. A nursing diagnosis appropriate to consider for a patient with any of the personality
disorders is:
A. noncompliance.
B. impaired social interaction.
C. disturbed personal identity. D. disturbed sensory perception.
68. A patient who is suspicious of the motives of others has had a long-time feud with his
two siblings over their parents' wills. He reacts quickly with anger whenever he thinks that
someone is threatening his welfare. The nurse would assess these characteristics as being
most consistent with the profile known as:
A. schizoidpersonality.
B. paranoidpersonality. C. borderlinepersonality. D. narcissisticpersonality.
69. The characteristic of individuals with dramatic erratic personality disorders that makes it
advisable for staff to have frequent patient- centered meetings is the individuals propensity
for :
A. Behaving responsibly in the peer grou B. Quickly and successfully adapting to stress
C. manipulating others to evade limits D. coping successfully with a stressful Environment.
70. A 27-year-old is admitted for diagnostic
A. calmlytellingthepatientthatunit
rules do not permit insulting
others,
Workup. She is described as having a history of frequent intoxication and promiscuity.
Recently, she has stolen money from her grandmother to finance a trip to Las Vegas with her
new boyfriend. She indicates that she is not sorry for stealing the money. Only sorry that her
grandmother pressed charges instead of "being a good sport." The nurse assesses this as
being consistent with:
A. conductdisorder
C. antisocialpersonalitydisorder. D. Borderlinepersonalitydisorder.
71. The wife of a patient with a sexual disorder asks, "What's a paraphilia?" The nurse, who
knows that the physician has talked to the patient and spouse and has used this term,
assumes that the spouse is seeking information. The nurse should respond:
A. "Any homosexual act:
B. "Inhibition of the sexual response cycle
D. "Discomfort with one's biological gender."
72. When working with a patient regarding sexual concerns, a necessity for providing
nonjudgmental care is:
A. limit setting.
B. assertiveness training.
C. sexual self-awareness.
D. effective communication
73. A patient with premature ejaculation tells the nurse, "I feel like such a failure. It's so
awful for both me and my wife. Do you have any suggestions that would be helpful?" The
remark that clarifies the nurse's role is:
A. "Sex therapy isn't my specialty, but I will try to help.
C. "Have you spoken with your physician about using Viagra?"
D. "There are several techniques here in this pamphlet that might be helpful."
74. A patient who is a pedophile tells the nurse that he is feeling a huge amount of guilt and
shame over molesting a child. He is concerned about the impact on his family and states that
the family would be better off without him. The nurse should:
A. explore his feelings in greater depth. B. set limits on patient disclosure
D. provide prn anxiolytic medication.
75. A 56-year-old man has been feeling much tension since losing his job. He leaves home
one morning and, while sitting in the park feeding birds, impulsively exposes himself publicly
to a group of mothers and children. This behavior should be assessed as:
A. voyeurism.
B. dyspareunia.
C. exhibitionism.
D. sexual masochism.
76. When assessing a patient with cognitive disorder, the nurse should base observations on
knowledge that the foundation of the cognitive process is:
A. memory
B. reasoning. C. orientation, D. perception.
77. The highest priority for nursing care for a patient with dementia is
A. improving cognition.
B. "I can refer you to the sexual
disorders clinic to see a physician who
specializes in this disorder"
B. narcissisticpersonality
disorder.???
C. consider instituting suicide
C. "Intense sexual urges with an
precaution
abnormal focus.
B. individualizing care.
D. promoting self-confidence and self-
esteem.
78. An elderly individual is having difficulty recognizing ordinary objects such as pencils and
water faucets. When he fails to think of the word, he describes the function of the Object-
"that thing that writes" or "the thing that gives water." The nurse assesses this as
A. apraxia. B. aphasia. C. agnosia. D. amnesia.
79. The nurse notes that an elderly patient has fluctuating levels of awareness. She seems
anxious. She tells the nurse that she saw her granddaughter standing at the foot of the bed
during the night. Later, the nurse sees her moving her hands as though picking things out of
the air. The nurse should suspect:
A delirium.
B. dementia.
C bipolar disorder. D. schizophrenia.??
80. The patient need that is of primary importance in the care of a patient with severe
Alzheimer's disease is:
A. promotion of self-care activities.
C. demands that exceed capacity to function.
D. periodic change of routine and environment.
81. A patient with anorexia nervosa has the
nursing diagnosis "imbalanced nutrition: less than body requirements related to inadequate
food intake." The expected outcome should be that the patient will: A. gain 1 to 3 pounds
weekly
B. exhibit fewer signs of malnutrition.
D. identify cognitive distortions about weight and shape.
82. When a patient with anorexia nervosa spills milk over her plate of partially eaten food,
the best approach for the nurse to take would be to say
A. "Nice try, but it won't work."
B Why are you deliberately making mealtime difficult?
D. That little trick will cost you television privileges.
83. A personality characteristic the nurse would expect to find in a patient with an eating
disorder is:
A. extroversion.
B. high self-esteem.
C. perfectionism.
D. callous disregard for other
84. School nurses should be particularly vigilant for signs of eating disorders:
A. in fourth graders.
B. among unpopular, studious high school boys
C. among popular, high-achieving high school girls.
85. The nurse caring for individuals with eating disorders should determine that the
C. maintaining an optimal level of
function
C. restore healthy eating patterns and
normalize weight.
B. maintenance of nutrition and
hydration
C. "I'll get you another plate of food so
you can finish."
D. at transitions from elementary to
middle school and middle school to high
school.
general way in which bulimic and anorexic individuals differ is:
A. indiscernible
B. anorexia is life-threatening; bulimia is not C. bulimia has a biologic origin; anorexia does
not.
D. patients with anorexia are proud of their eating habits; patients with bulimia are
ashamed.
86. A patient asks the nurse, "How would I know if I were dependent on alcohol?" The nurse
should respond by telling the patient that dependence is defined by:
A. a compulsion to use the drug
B. a loss of control over use of the drug.
C. a physiologic need to use the drug.
D. continued use despite adverse consequences.
87. The wife of an individual who is alcohol- dependent asks the nurse, "What do you mean
when you ask if my husband ever experienced a blackout?" The best explanation would be
that "A blackout is:
A. a comatose period related to alcohol withdrawal."
B. a comatose period related to alcohol intoxication."
C. a time period in which the person is 'passed out."
88. The nurse would suspect a disulfiram (Antabuse)-alcohol reaction when a patient
presents with symptoms of:
A. skin rash, itching, and urticaria.
B. pallor, hypotension, and muscle cramping.
C. dry skin bradycardia fatigue, and headache
89. A patient report experiencing insomnia and taking diazepam and wine in increasing
amounts to be able to sleep. The nurse should teach the patient about:
A. the danger of ENS depression (CNS) B. the risk of acetaldehyde toxicity
C. the risk of fetal alcohol syndrome
D. diazepam and dietary precautions
90. nurse assessing an individual who is a multidrug abuser should ask about recent use of
the drug that produces the most sustained high, which is:
A. crack
B. heroin.
C. cocaine.
D. methamphetamine
91. An important ECT pretreatment responsibility of the nurse is to:
B. order and interpret skull and spine film C. obtain informed consent for treatment. D.
prepare the light box for early morning use
92. Which drug is the nurse most likely To administer 30 to 45 minutes before
ECT?
A. Anectine
B. Atropine C. Alprazolam D. Amobarbital
93. An 8-year-old boy is referred to the clinic for diagnosis and treatment. He is described by
his parents as disobedient and argumentative. He has an explosive temper and low
frustration tolerance. Other children relate poorly to him. These behaviors are
D. headache dyspnea, nausea, vomiting,
and flushing
A. thoroughly assess the patient's
pretreatment level of functioning.
D. a period of time in which the person
under the influence of alcohol functions
normally but later is unable to remember.
most consistent with the medical diagnosis of:
A. autistic disorder.
B. conduct disorder.
C. oppositional defiant disorder.
D. attention-deficit/hyperactivity disorder.
94. The behaviors the nurse would expect to document in a child who has Tourette's
syndrome are:
A. inattention and restlessness.
B. hostility and defiance.
C. body rocking and head banging.
95. A nursing diagnosis that would be universally applicable for children with autism is:
B. anxiety related to disturbed thought processes
C. chronic low self-esteem related to excessive negative feedback.
D. deficient fluid volume related to peculiar eating habits.
96. The nurse working with a victim of spousal abuse should factor into care planning the
fact that a deterrent to leaving the abusive situation is the events that occur in the:
A. tension-building sage
B. honeymoon stage
C. battering incident. D. processing stage
97. A woman who has been repeatedly abused by her partner comes to the ED for treatment
of severe contusions. As her injuries are being treated, she tells the nurse "He almost killed
me this time, I quess
I'm going to have to do something. The priority intervention for the nurse is to: A. tell the
abuser to stop the abuse and seek help.
C. encourage the patient to take independent action.
D. provide referrals contingent on the patient leaving the abuser.
98. A survivor of childhood abuse enters the hospital following an episode of wrist cutting.
The patient has a history of binge-purge eating disorder and difficulty trusting and relauna to
others. A nursing intervention of high priority is:
A. setting limits on self-harmful behavior.
B. fostering belief in and valuing family C. encouraging sharing of blame for the abuse with
the perpetrator.
D. identifying and confronting abnormal responses and feelings
99. The nurse caring for victims of violence should plan care based on the understanding that
most victims begin to react emotionally to the effect that the crime has on their lives. This
stage of recovery is known as:
A. impact
B.recoil
C.reorganization D.retribution
100. In preparing a care plan for an abuse victim, it is most important to include a long-term
outcome that addresses the need for:
B. providing support groups for long-term assistance.
C. using empathy to establish rapport and
D. involuntary motor movement and
B. Help the patient devise a safety or
escape plan.
vocalization.
A. impaired social interaction related to
inability to relate to others.
A. moving the individual from victim to
survivor status.
build trust.
D. shifting blame for the incident from patient to perpetrator.