Nursing Final Exam Practice Questions with Answers, Exams of Nursing

Download Nursing Final Exam Practice Questions with Answers and more Exams Nursing in PDF only on Docsity! A. primary nursing method Nursing Final Exam Practice Questions with Answers new 2024 updates Scope of this Nursing Test I is parallel to the NP1 NLE Coverage: ▪ Foundation of Nursing ▪ Nursing Research ▪ Professional Adjustment ▪ Leadership and Management 1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP? A. Monitor the I&O of a comatose toddler client with salicylate poisoning B. Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall C. Check the IV of a preschooler with Kawasaki disease D. Give an oatmeal bath to an infant with eczema 2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse? A. A 9-year-old child diagnosed with rheumatic fever B. A young infant after pyloromyotomy C. A 4-year-old with VSD following cardiac catheterization D. A 5-month-old with Kawasaki disease 3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse? A. A child who had multiple injuries from a serious vehicle accident B. A child diagnosed with Kawasaki disease and with cardiac complications C. A child who has had a nephrectomy for Wilm’s tumor D. A child receiving an IV chelating therapy for lead poisoning 4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN? A. A client diagnosed with diabetes and who has an infected toe B. A client who had a CVA in the past two months C. A client with Chronic renal failure D. A client with chronic venous insufficiency 5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients’ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes the clients. This illustrates of what method of nursing care? A. Case management method B. Primary nursing method C. Team method D. Functional method 6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method? B. case method C. team method D. functional method 7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should: A. resign on the spot from the nursing position and apply for a position that does not require floating B. Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s lack of skill and feelings of hesitations and request assistance C. Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment D. Refuse the assignment and leave the unit requesting a vacation a day 8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a: 25. During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements? A. limit suction pressure to 150-180 mmHg B. suction for 15-20 seconds C. wear eye goggles D. remove the inner cannula 26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client? A. warm, flushed skin B. hunger and thirst C. increase urinary output D. palpitation and weakness 27. A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client? A. administering insulin-replacement therapy B. providing a low-sodium diet C. restricting fluids to 1500 ml/day D. reducing physical and emotional stress 28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia? A. aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning B. removing oral and nasal secretions C. encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions D. administering 100% oxygen to reduce the effects of airway obstruction during suctioning. 29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding? A. Facial edema with ecchymosis and handprint mark: crackles and wheezes B. Facial edema, with red marks; crackles in the lung C. Facial edema with ecchymosis that looks like a handprint D. Red bruise mark and ecchymosis on face 30. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority? A. an elderly woman complaining of a loss of appetite and fatigue for the past week B. A football player limping and complaining of pain and swelling in the right ankle C. A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw D. A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon 31. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention? A. check the laboratory data for serum albumin, hematocrit, and hemoglobin B. talk to the client about the caregiver and support system C. complete a police report on elder abuse D. complete a gastrointestinal and neurological assessment 32. The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse? A. chart that the patient fell B. call the physician C. chart that the client was found on the floor next to the bed D. fill out an incident report 33. The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask: A. The adult visiting, “The child’s name is ?” B. The child, “Is your name ?” C. Another staff nurse to identify this child D. The other children in the room what the child’s name is 34. The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast? A. “abnormally felt area in the right breast, drainage noted” B. “hard nodular mass in right breast nipple” C. “firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’ D. “mass in the right breast 4cmx1cm 35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to: A. outline the kidney vasculature B. determine the size, shape, and placement of the kidneys C. test renal tubular function and the patency of the urinary tract D. measure renal blood flow 36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to: A. bend all the way over and touch the toes B. stand up as straight and tall as possible C. bend over at a 90-degree angle from the waist D. bend over at a 45-degree angle from the waist 37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they: A. wash their hands when leaving B. put on gowns, gloves and masks C. avoid contact with the client’s roommate D. keep the client’s room door open 38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse? A. “Your baby eats too rapidly and overfills the stomach, which causes vomiting B. “Your baby can’t empty the formula that is in the stomach into the bowel” C. “The vomiting is due to the nausea that accompanies pyloric stenosis” D. “Your baby needs to be burped more thoroughly after feeding” 39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this? A. reactivation of an old tuberculosis infection B. increased incidence of new cases of tuberculosis in persons over 65 years old C. greater exposure to diverse health care workers D. respiratory problems are characteristic in this population 40. The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure: A. both the areas that look red and feel raised B. The entire area that feels itchy to the child C. Only the area that looks reddened D. Only the area that feels raised 41. A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern? A. Picture windows B. Unwashed dishes in the sink C. Clear and shiny floors D. Brightly lit rooms 42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse? A. examine the infant for any observable abnormalities B. confirm identification of the infant and apply bracelet to mother and infant C. instill prophylactic medication in the infant’s eyes D. wrap the infant in a prewarmed blanket and cover the head 43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas? A. elbow restraints to the arms B. Mittens to the hands C. Clove-hitch restraints to the hands D. A posey jacket to the torso 44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be: A. There is no way to determine this preoperatively B. Their baby was born with this condition C. Their baby developed this condition during the first few weeks of life D. Their baby acquired it due to a formula allergy 45. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is: A. pruritus B. pus in the urine C. WBC in the urine D. Dysuria 46. Which of the following would be the most important goal in the nursing care of an infant client with eczema? A. preventing infection B. maintaining the comfort level C. providing for adequate nutrition D. decreasing the itching 47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included? A. “Get a weekly WBC count” B. “Do not share a bathroom with children or pregnant woman” C. “Avoid contact with others while receiving chemotherapy” D. “Do frequent hand washing and maintain good hygiene” 48. The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is: A. Isopropyl alcohol B. Hexachlorophene (Phisohex) C. Soap and water D. Chlorhexidine gluconate (CHG) (Hibiclens) 49. The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother? A. “You and I need to review your rationale for this decision” B. “Your baby will not be able to attend day care without immunizations” C. “Your decision can be viewed as a form of child abuse and neglect” D. “You are needlessly placing other people at risk for communicable diseases” 50. The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer? A. tender, movable lump B. pain on breast self-examination C. round, well-defined lump D. dimpling of the breast tissue Answers and Rationales 1. D. Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can competently performed by an aid. 2. B. The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen. 37. A. Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room. 38. B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to the increasing amounts of formula the infant begins to consume coupled with the increasing thickening of the pyloric sphincter. 39. B. Increased incidence of TB has been seen in the general population with a high incidence reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations because of the aging process are just two of the contributing factors of tuberculosis in the elderly. 40. D. Parents should be taught to feel the area that is raised and measure only that. 41. C. It is a safety hazard to have shiny floors because they can cause falls. 42. D. The first priority, beside maintaining a newborn’s patent airway, is body temperature. 43. B. The purpose of restraints for this child is to keep the child from scratching the affected areas. Mittens restraint would prevent scratching, while allowing the most movement permissible. 44. C. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life. 45. B. Pus is usually the first symptom, because the bacteria reproduce in the bladder. 46. A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection. 47. D. Frequent hand washing and good hygiene are the best means of preventing infection. 48. D. CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time. 49. A. The mother may have many reasons for such a decision. It is the nurse’s responsibility to review this decision with the mother and clarify any misconceptions regarding immunizations that may exist. 50. D. The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance. The scope of this Nursing Test II is parallel to the NP2 NLE Coverage: ▪ Maternal and Child Health ▪ Community Health Nursing ▪ Communicable Diseases ▪ Integrated Management of Childhood Illness 1. The student nurse is assigned to take the vital signs of the clients in the pediatric ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the nurse? A. Notify the pediatrician of this finding B. Reassure the student that this is an acceptable action on the parent’s part C. Discuss this action with the parents D. Ask the student nurse to remove the pacifier from the toddler’s mouth 2. The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis. Which of the following statement if made by the mother would indicate to the nurse the need for further teaching about the medication regimen of the child? A. “My child might need an extra capsule if the meal is high in fat” B. “I’ll give the enzyme capsule before every snack” C. “I’ll give the enzyme capsule before every meal” D. “My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate 3. The mother brought her child to the clinic for follow-up check up. The mother tells the nurse that 14 days after starting an oral iron supplement, her child’s stools are black. Which of the following is the best nursing response to the mother? A. “I will notify the physician, who will probably decrease the dosage slightly” B. “This is a normal side effect and means the medication is working” C. “You sound quite concerned. Would you like to talk about this further?” D. “I will need a specimen to check the stool for possible bleeding” 4. An 8-year-old boy with asthma is brought to the clinic for check up. The mother asks the nurse if the treatment given to her son is effective. What would be the appropriate response of the nurse? A. I will review first the child’s height on a growth chart to know if the treatment is working B. I will review first the child’s weight on a growth chart to know if the treatment is working C. I will review first the number of prescriptions refills the child has required over the last 6 months to give you an accurate answer D. I will review first the number of times the child has seen the pediatrician during the last 6 months to give you an accurate answer 5. The nurse is caring to a child client who is receiving tetracycline. The nurse is aware that in taking this medication, it is very important to: A. Administer the drug between meals B. Monitor the child’s hearing C. Give the drug through a straw D. Keep the child out of the sunlight 6. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to the emergency department. During assessment, the nurse checks the apical pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of the following is the appropriate nursing action? A. Retake the apical pulse in 15 minutes B. Retake the apical pulse in 30 minutes C. Notify the pediatrician immediately D. Administer the medication as scheduled 7. The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy. Before administering the drug, the nurse should check the results of the child’s: A. CBC and platelet count B. Auditory tests C. Renal Function tests D. Abdominal and chest x-rays 8. Which of the following is the suited size of the needle would the nurse select to administer the IM injection to a preschool child? A. 18 G, 1-1/2 inch B. 25 G, 5/8 inch C. 21 G, 1 inch D. 18 G, 1inch 9. A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic fever. Which of the following activities performed by the child would give a best sign that the medication is effective? A. Listening to story of his mother B. Listening to the music in the radio C. Playing mini piano D. Watching movie in the dvd mini player 10. The physician decided to schedule the 4-year-old client for repair of left undescended testicle. The Injection of a hormone, HCG finds it less successful for treatment. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this client, in which position should the nurse place him? A. Supine with foot of bed elevated B. Prone with legs abducted C. Sitting with foot of bed elevated D. Side-lying with upper leg flexed 11. The nurse is caring to a 24-month-old child diagnosed with congenital heart defect. The physician prescribed digoxin (Lanoxin) to the client. Before the administration of the drug, the nurse checks the apical pulse rate to be 110 beats per minute and regular. What would be the next nursing action? A. Check the other vital signs and level of consciousness B. Withhold the digoxin and notify the physician C. Give the digoxin as prescribed D. Check the apical and radial simultaneously, and if they are the same, give the digoxin. 12. An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during: A. After meals B. Between meals C. After medication D. Around the child’s play schedule 13. The nurse is providing health teaching about the breastfeeding and family planning to the client who gave birth to a healthy baby girl. Which of the following statement would alert the nurse that the client needs further teaching? D. “Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don’t need any contraception until I stop breastfeeding” 30. A community nurse enters the home of the client for follow-up visit. Which of the following is the most appropriate area to place the nursing bag of the nurse when conducting a home visit? A. cushioned footstool B. bedside wood table C. kitchen countertop D. living room sofa 31. The nurse in the health center is making an assessment to the infant client. The nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects that the infant has eczema. Which of the following is the most important nursing goal: A. Preventing infection B. Providing for adequate nutrition C. Decreasing the itching D. Maintaining the comfort level 32. The nurse in the health center is providing immunization to the children. The nurse is carefully assessing the condition of the children before giving the vaccines. Which of the following would the nurse note to withhold the infant’s scheduled immunizations? A. a dry cough B. a skin rash C. a low-grade fever D. a runny nose 33. A mother brought her child in the health center for hepatitis B vaccination in a series. The mother informs the nurse that the child missed an appointment last month to have the third hepatitis B vaccination. Which of the following statements is the appropriate nursing response to the mother? A. “I will examine the child for symptoms of hepatitis B” B. “Your child will start the series again” C. “Your child will get the next dose as soon as possible” D. “Your child will have a hepatitis titer done to determine if immunization has taken place.” 34. The community health nurse implemented a new program about effective breast cancer screening technique for the female personnel of the health department of Valenzuela. Which of the following technique should the nurse consider to be of the lowest priority? A. Yearly breast exam by a trained professional B. Detailed health history to identify women at risk C. Screening mammogram every year for women over age 50 D. Screening mammogram every 1-2 years for women over age of 40. 35. Which of the following technique is considered an aseptic practice during the home visit of the community health nurse? A. Wrapping used dressing in a plastic bag before placing them in the nursing bag B. Washing hands before removing equipment from the nursing bag C. Using the client’s soap and cloth towel for hand washing D. Placing the contaminated needles and syringes in a labeled container inside the nursing bag 36. The nurse is planning to conduct a home visit in a small community. Which of the following is the most important factor when planning the best time for a home care visit? A. Purpose of the home visit B. Preference of the patient’s family C. Location of the patient’s home D. Length of time of the visit will take 37. The nurse assigned in the health center is counseling a 30-year-old client requesting oral contraceptives. The client tells the nurse that she has an active yeast infection that has recurred several times in the past year. Which statement by the nurse is inaccurate concerning health promotion actions to prevent recurring yeast infection? A. “During treatment for yeast, avoid vaginal intercourse for one week” B. “Wear loose-fitting cotton underwear” C. “Avoid eating large amounts of sugar or sugar-bingeing” D. “Douche once a day with a mild vinegar and water solution” 38. During immunization week in the health center, the parent of a 6-month-old infant asks the health nurse, “Why is our baby going to receive so many immunizations over a long time period?” The best nursing response would be: A. “The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented.” B. “You need to ask the physician” C. “The number of immunizations your baby will receive is determined by your baby’s health history and age” D. “It is easier on your baby to receive several immunizations rather than one at a time” 39. The community health nurse is conducting a health teaching about nutrition to a group of pregnant women who are anemic and are lactose intolerant. Which of the following foods should the nurse especially encourage during the third trimester? A. Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and iron supplements B. Prenatal iron and calcium supplements plus a regular adult diet C. Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins and iron supplements D. Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements 40. A woman with active tuberculosis (TB) and has visited the health center for regular therapy for five months wants to become pregnant. The nurse knows that further information is necessary when the woman states: A. “Spontaneous abortion may occur in one out of five women who are infected” B. “Pulmonary TB may jeopardize my pregnancy” C. “I know that I may not be able to have close contact with my baby until contagious is no longer a problem D. “I can get pregnant after I have been free of TB for 6 months” 41. The Department of Health is alarmed that almost 33 million people suffer from food poisoning every year. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the major goals is to promote proper food preparation. The community health nurse is tasks to conduct health teaching about the prevention of food poisoning to a group of mother everyday. The nurse can help identify signs and symptoms of specific organisms to help patients get appropriate treatment. Typical symptoms of salmonella include: A. Nausea, vomiting and paralysis B. Bloody diarrhea C. Diarrhea and abdominal cramps D. Nausea, vomiting and headache 42. A community health nurse makes a home visit to an elderly person living alone in a small house. Which of the following observation would be a great concern? A. Big mirror in a wall B. Scattered and unwashed dishes in the sink C. Shiny floors with scattered rugs D. Brightly lit rooms 43. The health nurse is conducting health teaching about “safe” sex to a group of high school students. Which of the following statement about the use of condoms should the nurse avoid making? A. “Condoms should be used because they can prevent infection and because they may prevent pregnancy” B. “Condoms should be used even if you have recently tested negative for HIV” C. “Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases” D. “Condoms should be used every time you have sex even if you are taking the pill because condoms can prevent the spread of HIV and gonorrhea” 44. The department of health is promoting the breastfeeding program to all newly mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan for a breast- feeding mother takes into account that breast-feeding is contraindicated when the woman: A. Is pregnant B. Has genital herpes infection C. Develops mastitis D. Has inverted nipples 45. The City health department conducted a medical mission in Barangay Marulas. Majority of the children in the Barangay Marulas were diagnosed with pinworms. The community health nurse should anticipate that the children’s chief complaint would be: A. Lack of appetite B. Severe itching of the scalp C. Perianal itching D. Severe abdominal pain 33. C. Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the first. 34. B. Because of the high incidence of breast cancer, all women are considered to be at risk regardless of health history. 35. B. Handwashing is the best way to prevent the spread of infection. 36. A. The purpose of the visit takes priority. 37. D. Frequent douching interferes with the natural protective barriers in the vagina that resist yeast infection and should be avoided. 38. A. Completion for the recommended schedule of infant immunizations does not require a large number of immunizations, but it also provides protection against multiple pediatric communicable and infectious diseases. 39. C. This is appropriate foods that are high in iron and calcium but would not affect lactose intolerance. 40. D. Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is declared to be free of TB before she should attempt pregnancy. 41. C. Salmonella organisms cause lower GI symptoms 42. C. It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and rugs should be removed. 43. C. Condoms do not prevent ALL forms of sexually transmitted diseases. 44. A. Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s sucking may stimulate uterine contractions. 45. C. Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing before eating and after using the toilet can assist in breaking the cycle. 46. C. Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this would lead to the nursing diagnosis of “altered comfort”. 47. C. Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest. 48. C. The primary goal is to prevent the spread of the disease to others. The child should experience no complication. Although the health department may need to be notified at some point, it is no the primary goal. It is also important to prevent discomfort as much as possible. 49. A. Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed. 50. D. The question asks about the immediate concern. The ABCs of community health care are always attending to people’s basic needs of food, shelter, and clothing The scope of this Nursing Test III is parallel to the NP3 NLE Coverage: ▪ Medical Surgical Nursing 1. The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this? A. Promote air and pleural drainage B. Prevent kinking of the tube C. Eliminate the need for a dressing D. Eliminate the need for a water-seal drainage 2. The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following will alert the nurse? A. Decreased pain in the fetal position B. Urine output of 35mL/hr C. CVP of 12 mmHg D. Cardiac output of 5L/min 3. The nurse in the morning shift is making rounds in the ward. The nurse enters the client’s room and found the client in discomfort condition. The client complains of stiffness in the joints. To reduce the early morning stiffness of the joints of the client,the nurse can encourage the client to: A. Sleep with a hot pad B. Take to aspirins before arising, and wait 15 minutes before attempting locomotion C. Take a hot tub bath or shower in the morning D. Put joints through passive ROM before trying to move them actively 4. The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client? A. Eating mainly bland food and milk or dairy products B. Reducing intake of high-fiber foods C. Eating small, frequent meals and a bedtime snack D. Eliminating intake of alcohol and coffee 22. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control her BP. Which potential nursing diagnosis will be a priority for discharge teaching? A. Sleep Pattern disturbance B. Impaired physical mobility C. Noncompliance D. Fluid volume excess 23. Following a needle biopsy of the kidney, which assessment is an indication that the client is bleeding? A. Slow, irregular pulse B. Dull, abdominal discomfort C. Urinary frequency D. Throbbing headache 24. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care regarding expectoration of thick sputum. Which nursing action is most effective? A. Place the client in a lateral position every 2 hour B. Splint the patient’s chest with pillows when coughing C. Use humified oxygen D. Offer fluids at regular intervals 25. The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should listen for at least: A. 5 minutes B. 60 seconds C. 30 seconds D. 2 minutes 26. The nurse encourages the client to wear compression stockings. What is the rationale behind in using compression stockings? A. Compression stockings promote venous return B. Compression stockings divert blood to major vessels C. Compression stockings decreases workload on the heart D. Compression stockings improve arterial circulation 27. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best nursing intervention is most likely to assist the client? A. Placing food in the unaffected side of the mouth B. Increasing fiber in the diet C. Asking the patient to speak slowly D. Increasing fluid intake 28. Following nephrectomy, the nurse closely monitors the urinary output of the client. Which assessment finding is an early indicator of fluid retention in the postoperative period? A. Periorbital edema B. Increased specific gravity of urine C. A urinary output of 50mL/hr D. Daily weight gain of 2 lb or more 29. A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician? A. Expanding ecchymosis B. Ascites and serum albumin of 3.2 g/dl C. Slurred speech D. Hematocrit of 37% and hemoglobin of 12g/dl 30. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will recommend to: A. Allow plenty of time after the insulin injection and before beginning the match B. Eat a carbohydrate snack before and during the badminton match C. Drink plenty of fluids before, during, and after bed time D. Take insulin just before starting the badminton match 31. A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting of head injury. Which of the following assessment findings would the nurse report to the physician? A. CVP of 5mmHa B. Glasgow Coma Scale score of 13 C. Polyuria and dilute urinary output D. Insomnia 32. Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object pierced the skin until later that evening. What problem does the client most probably have? A. Nephropathy B. Macroangiopathy C. Carpal tunnel syndrome D. Peripheral neuropathy 33. A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing care unit knows that the priority nursing intervention in the immediate post operative care of this client is: A. Elevate the stump on a pillow for the first 24 hours B. Encourage use of trapeze C. Position the client prone periodically D. Apply a cone-shaped dressing 34. A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be the initial nursing intervention by the nurse? A. Monitor the client’s vital signs B. Keep the client on bed rest C. Keep the patient on bed rest D. Give a stat dose of Sucralfate (Carafate) 35. After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when the client is transferred from the post anesthesia care unit? A. Notify the family to report the client’s condition B. Immediately administer the narcotic as ordered C. Keep client on right side supported by pillows D. Encourage coughing and deep breathing every 2 hours 36. The nurse is providing a discharge instruction about the prevention of urinary stasis to a client with frequent bladder infection. Which of the following will the nurse include in the instruction? A. Drink 3-4 quarts of fluid every day B. Empty the bladder every 2-4 hours while awake C. Encourage the use of coffee, tea, and colas for their diuretic effect D. Teach Kegel exercises to control bladder flow 37. A male client visits the clinic for check-up. The client tells the nurse that there is a yellow discharge from his penis. He also experiences a burning sensation when urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this client? A. Sex partner of 3 months ago must be treated B. Women with gonorrhea are symptomatic C. Use a condom for sexual activity D. Sex partner needs to be evaluated 38. A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the nurse is assessing the IV site, the client becomes confused and restless and the intravenous catheter becomes disconnected and minimal amount of the client’s blood spills onto the floor. Which action will the nurse take to remove the blood spill? A. Promptly clean with a 1:10 solution of household bleach and water B. Promptly clean up the blood spill with full-strength antimicrobial cleaning solution C. Immediately mop the floor with boiling water D. Allow the blood to dry before cleaning to decrease the possibility of cross-contamination 39. Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One hour later the client is still unable to sleep. The nurse review the client’s chart and note the physician’s prescription with an order to repeat. What should the nurse do next? A. Rub the client’s back until relaxed B. Prepare a glass of warm milk C. Give the second dose of pentobarbital sodium D. Explore the client’s feelings about surgery 40. The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to enter to the client’s room when a ventilator alarm sounds, what is the first action the nurse should do? A. Assess the lung sounds B. Suction the client right away C. Look at the client D. Turn and position the client 41. What effective precautions should the nurse use to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA)? A. Use gloves and handwashing before and after client contact B. Do nasal cultures on healthcare providers C. Place the client on total isolation D. Use mask and gown during care of the MRSA client 42. The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse, “When I will be allowed to eat three meals a day like the rest of my family?”. The appropriate nursing response is: A. “You will probably have to eat six meals a day for the rest of your life.” B. “Eating six meals a day can be a bother, can’t it?” C. “Some clients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you.” D. “ It varies from client to client, but generally in 6-12 months most clients can return to their previous meal patterns” 43. A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which of the following is the appropriate nursing response? A. “How much of a difference have you noticed” B. “It’s part of the swelling your body is experiencing” C. “It’s probably because you have been less physically active” D. “Your liver is not destroying estrogen hormones that all men produce” 44. A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of the nurse to the client includes: A. No eye pain is expected postoperatively B. Semi-fowler’s position will be used to reduce pressure in the eye. C. Eye patches may be used postoperatively D. Return of normal vision is expected following surgery 45. A 70-year-old client is brought to the emergency department with a caregiver. The client has manifestations of anorexia, wasting of muscles and multiple bruises. What nursing interventions would the nurse implement? A. Talk to the client about the caregiver and support system B. Complete a gastrointestinal and neurological assessment C. Check the lab data for serum albumin, hematocrit and hemoglobin D. Complete a police report on elder abuse 46. A nurse is providing a discharge instruction to the client about the self-catheterization at home. Which of the following instructions would the nurse include? A. Wash the catheter with soap and water after each use B. Lubricate the catheter with Vaseline C. Perform the Valsalva maneuver to promote insertion D. Replace the catheter with a new one every 24 hour 47. The nurse in the nursing care unit is assigned to care to a client who is Immunocompromised. The client tells the nurse that his chest is painful and the blisters are itchy. What would be the nursing intervention to this client? A. Call the physician B. Give a prn pain medication C. Clarify if the client is on a new medication D. Use gown and gloves while assessing the lesions 20. A. Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of impulses and increases fatigue. 21. A. Vigilant implementation of standard precautions and medical asepsis is an effective means of preventing infection 22. C. Noncompliance is a major problem in the management of chronic disease. In hypertension, the client often does not feel ill and thus does not see a need to follow a treatment regimen. 23. B. An accumulation of blood from the kidney into the abdomen would manifest itself with these symptoms 24. D. Fluids liquefy secretions and therefore make it easier to expectorate 25. D. Physical assessment guidelines recommend listening for atleast 2 minutes in each quadrant (and up to 5 minutes, not at least 5 minutes). 26. A. Compression stockings promote venous return and prevent peripheral pooling. 27. A. Placing food in the unaffected side of the mouth assists in the swallowing process because the client has sensation on that side and will have more control over the swallowing process. 28. D. Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance. 29. A. Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K deficiency. This could be a sign of bleeding 30. B. Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks with carbohydrates will help. 31. C. These are symptoms of diabetes insipidus. The patient can become hypovolemic and vasopressin may reverse the Polyuria. 32. D. Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not notice that the object pierced the skin. 33. A. The elevation of the stump on a pillow for the first 24 hours decreases edema and increases venous return. 34. B. The priority is to maintain client’s safety. With syncope and vertigo, the client is at high risk for falling. 35. D. Coughing and deep breathing are essential for re-expansion of the lung 36. B. Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent overdistention of the bladder and future urinary tract infections. 37. D. If infected, the sex partner must be evaluated and treated 38. A. A 1:10 solution of household bleach and water is recommended by the Centers for Disease Control and Prevention to kill the human immunodeficiency virus (HIV). 39. D. Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns related to surgery before further actions (which may mask the anxiety). 40. C. A quick look at the client can help identify the type and cause of the ventilator alarm. Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the obvious reasons that could trigger an alarm. 41. A. Contact isolation has been advised by the Centers for Disease Control and Prevention (CDC) to control transmission of MRSA, which includes gloves and handwashing. 42. D. In response to the question of the client, the nurse needs to provide brief, accurate information. Some clients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of clients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal. 43. A. This allows the client to elaborate his concern and provides the nurse a baseline of assessment 44. C. Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery. 45. B. Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, the bruises may be attributed to ataxia, frequent falls, vertigo, or medication. 46. A. The catheter should be washed with soap and water after withdrawal and placed in a clean container. It can be reused until it is too hard or too soft for insertion. Self-care, prevention of complications, and cost- effectiveness are important in home management. 47. D. The client may have herpes zoster (shingles), a viral infection. The nurse should use standard precautions in assessing the lesions. Immunocompromised clients are at risk for infection. 48. B. After a minimum of 24 hours of IV antibiotics, the client is no longer considered communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of care. 49. D. Stem of the question supports this choice by stating that the client has difficulty accepting the potential disability. 50. B. Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year. The scope of this Nursing Test IV is parallel to the NP4 NLE Coverage: ▪ Medical Surgical Nursing 1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid: A. Urinary tract infection. B. Fluid and electrolyte imbalance. C. Dehydration. D. Skin breakdown. 2. The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures: A. May be a forerunner of hemorrhage. B. Are related to diaphoresis and possible chilling. C. May indicate cerebral edema. D. Increase the cardiac output. 3. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct? A. Hematuria B. Dysuria C. Polyuria D. Dribbling 4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience? A. Visual hallucinations. B. Receptive aphasia. C. Hemiparesis. D. Personality changes. 5. A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of: A. Androgens B. Glucocorticoids C. Mineralocorticoids D. Estrogen 6. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that: A. Inspired air will move from the lung into the pleural space. B. There is greater negative pressure within the chest cavity. C. The heart and great vessels shift to the affected side. D. The other lung will collapse if not treated immediately. 7. During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern? A. Heavy consumption of alcohol. B. Frequent gum chewing. C. Nail biting. D. Poor dental habits. 8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse? A. Compact bone is stronger than cancellous bone because of its greater size. B. Compact bone is stronger than cancellous bone because of its greater weight. C. Compact bone is stronger than cancellous bone because of its greater volume. D. Compact bone is stronger than cancellous bone because of its greater density. 9. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the : A. Greater the blood viscosity. B. Higher the blood pH. C. Less it contributes to immunity. D. Lower the hematocrit. 10. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to: A. Aid in controlling involuntary muscle movements. A. Palpitation B. Visual disturbance C. Decreased pulse rate D. Lethargy 28. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication? A. Take the drug with an antacid. B. Lie down after meals. C. Avoid dairy products in diet. D. Change positions slowly. 29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in: A. The triglycerides B. The INR C. Chest pain D. Blood pressure 30. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of: A. Increasing the number of tablets if dizziness or hypertension occurs. B. Limiting the number of tablets to 4 per day. C. Making certain the medication is stored in a dark container. D. Discontinuing the medication if a headache develops. 31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states: A. “I will contact the physician immediately if I develop blurred vision.” B. “I will contact the physician immediately if I develop urinary retention.” C. “I will contact the physician immediately if I develop swallowing difficulty.” D. “I will contact the physician immediately if I develop feelings of irritability.” 32. The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the: A. Adverse effects of spironolactone (Aldactone) B. Adverse effects of digoxin (Lanoxin) C. Therapeutic effects of propranolol (Indiral) D. Therapeutic effects of furosemide (Lasix) 33. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if: A. Swelling of the ankles increases. B. Blood appears in the urine. C. Increased transient Ischemic attacks occur. D. The ability to concentrate diminishes. 34. Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that: A. Levodopa is inadequately absorbed if given with meals. B. Levodopa may cause the side effects of orthostatic hypotension. C. Levodopa must be monitored by weekly laboratory tests. D. Levodopa causes an initial euphoria followed by depression. 35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in: A. Muscle strength B. Symptoms C. Blood pressure D. Consciousness 36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s: A. Seizure activity B. Liver function C. Cardiac output D. Pain relief 37. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to: A. Ablate the cells of the thyroid gland that produce T4. B. Decrease the total basal metabolic rate. C. Decrease the size and vascularity of the thyroid. D. Maintain function of the parathyroid gland. 38. A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to: A. Increase amounts of angiotensin II to raise the client’s blood pressure. B. Control excessive loss of potassium salts. C. Prevent hypoglycemia and permit the client to respond to stress. D. Decrease cardiac dysrhythmias and dyspnea. 39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is effective, the nurse should monitor the client’s: A. Arterial blood pH B. Pulse rate C. Serum glucose D. Intake and output 40. A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct? A. Strain urine for crystals and stones B. Increase fluid intake. C. Stop the drug if the urinary output increases D. Maintain the exact time schedule for drug taking. 41. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the: A. Bone marrow B. Liver C. Lymph nodes D. Blood 42. The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to allow: A. Return of cortisone production by the adrenal glands. B. Production of antibodies by the immune system C. Building of glycogen and protein stores in liver and muscle D. Time to observe for return of increases intracranial pressure 43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is aware that fluid deficit can most accurately be assessed by: A. The presence of dry skin B. A change in body weight C. An altered general appearance D. A decrease in blood pressure 44. Which of the following is the most important electrolyte of intracellular fluid? A. Potassium B. Sodium C. Chloride D. Calcium 45. Which of the following client has a high risk for developing hyperkalemia? A. Crohn’s disease B. End-Stage renal disease C. Cushing’s syndrome D. Chronic heart failure 46. The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8 mEq/L. Which of the following is the initial nursing action? A. Call the cardiac arrest team to alert them B. Call the laboratory and repeat the test C. Take the client’s vital signs and notify the physician D. Obtain an ECG strip and have lidocaine available 47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is: A. Replacement of excessive losses B. Treatment of hyperpnea C. Prevention of flaccid paralysis D. Treatment of cardiac dysrhythmias 48. A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report immediately? A. Skin rash, diarrhea, and diplopia B. Development of tetaniy with muscles spasms C. Extreme muscle weakness and tachycardia D. Nausea, vomiting, and leg and stomach cramps. 49. The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to: A. Use strict sterile technique B. Use exactly 100mL of fluid to mix the medication C. Change the needle just before adding the medication D. Rotate the bag after adding the medication 50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Answers and Rationales 1. A. Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. 2. D. The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload. 3. B. Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy. 4. A. The occipital lobe is involve with visual interpretation. 5. C. Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension. 6. B. As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs. 7. A. Heavy alcohol ingestion predisposes an individual to the development of oral cancer. 8. D. The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals. 9. A. Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma. 10. C. Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability. 11. D. Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity. 12. C. The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the 48. C. Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop. 49. A. Because IV solutions enter the body’s internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes. 50. A. A low pH and bicarbonate level are consistent with metabolic acidosis. The scope of this Nursing Test V is parallel to the NP5 NLE Coverage: ▪ Psychiatric Nursing 1. A 17-year-old client has a record of being absent in the class without permission, and “borrowing” other people’s things without asking permission. The client denies stealing; rationalizing instead that as long as no one was using the items, there is no problem to use it by other people. It is important for the nurse to understand that psychodynamically, the behavior of the client may be largely attributed to a development defect related to the: A. Oedipal complex B. Superego C. Id D. Ego 2. A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best nursing response to this cient? A. “What are you going to do this time?” B. Say nothing. Wait for the client’s next comment C. “You seem upset. I am going to be here with you; perhaps you will want to talk about it” D. “Have you felt this way before?” 3. In crisis intervention therapy, which of the following principle that the nurse will use to plan her/his goals? A. Crises are related to deep, underlying problems B. Crises seldom occur in normal people’s lives C. Crises may go on indefinitely. D. Crises usually resolved in 4-6 weeks. 4. The nurse enters the room of the male client and found out that the client urinates on the floor. The client hides when the nurse is about to talk to him. Which of the following is the best nursing intervention? A. Place restriction on the client’s activities when his behavior occurs. B. Ask the client to clean the soiled floor. C. Take the client to the bathroom at regular intervals. D. Limit fluid intake. 5. A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric unit. In the past two months, the client has poor appetite, experienced difficulty in sleeping, was mute for long periods of time, just stayed in her room, grinning and pointing at things. What would be the initial nursing action on admitting the client to the unit? A. Assure the client that “ You will be well cared for.” B. Introduce the client to some of the other clients. C. Ask “Do you know where you are?” D. Take the client to the assigned room. 6. A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of the nurse? A. What food she likes. B. Her desired weight. C. Her body image. D. What causes her behavior. 7. On an adolescent unit, a nurse caring to a client was informed that her client’s closest roommate dies at night. What would be the most appropriate nursing action? A. Do not bring it up unless the client asks. B. Tell the client that her roommate went home. C. Tell the client, if asked, “You should ask the doctor.” D. Tell the client that her closest roommate died. 8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse should expect the woman’s initial reactions to include: A. Depression B. Withdrawal C. Apathy A. Acknowledge that the word has some special meaning for the client. B. Try to interpret what the client means. C. Divert the client’s attention to an aspect of reality. D. State that what the client is saying has not been understood and then divert attention to something that is really bound. 27. A male client diagnosed with depression tells the nurse, “I don’t want to look weak and I don’t even cry because my wife and my kids can’t bear it.” The nurse understands that this is an example of: A. Repression. B. Suppression. C. Undoing. D. Rationalization. 28. A female client tells the nurse that she is afraid to go out from her room because she thinks that the other client might kill her. The nurse is aware that this behavior is related to: A. Hallucination. B. Ideas of reference. C. Delusion of persecution. D. Illusion. 29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows less awareness of the physical body. What problem would the nurse be most concerned? A. Nausea. B. Gait disturbances. C. Bowel movements. D. Voiding. 30. A 6-year-old client dies in the nursing unit. The parents want to see the child. What is the most appropriate nursing action? A. Give the parents time alone with the body. B. Ask the physician for permission. C. Complete the postmortem care and quietly accompany the family to the child’s room. D. Suggest the parents to wait until the funeral service to say “good-bye.” 31. A 20-year-old female client is diagnosed with anxiety disorder. The physician prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be concerned? A. Tremor, drowsiness. B. Seizures, suicidal tendencies. C. Visual disturbance, headache. D. Excessive diaphoresis, diarrhea. 32. A nurse is assigned to activate a client who is withdrawn, hears voices and negativistic. What would be the best nursing approach? A. Mention that the “voices” would want the client to participate. B. Demand that the client must join a group activity. C. Give the client a long explanation of the benefits of activity. D. Tell the client that the nurse needs a partner for an activity. 33. A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy. The boy is very anxious and frightened. Which of the following statement by the nurse would be most appropriate to gain the child’s cooperation? A. “Be a big kid! Everyone’s waiting for you.” B. “Lie still now and I’ll let you have one of your presents before you even have your operation.” C. “Take a nice, big, deep breath and then let me hear you count to five.” D. “You look so scared. Want to know a secret? This won’t hurt a bit!” 34. A depressed client is on an MAO inhibitor? What should the nurse watch out for? A. Hypertensive crisis. B. Diet restrictions. C. Taking medication with meals. D. Exposure to sunlight. 35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the nurse caring to her that her step- father has made sexual advances to her. She got the chance to tell it to her mother but refuses to believe. What is the most therapeutic action of the nurse would be: A. Tell the client to work it out with her father. B. Tell the client to discuss it with her mother. C. Ask the father about it. D. Ask the mother what she thinks. 36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital. The client tells the nurse, “the FBI is following me. These people are plotting against me.” With this statement the nurse will need to: A. Acknowledge that this is the client’s belief but not the nurse’s belief. B. Ask how that makes the client feel. C. Show the client that no one is behind. D. Use logic to help the client doubt this belief. 37. A nurse is completing the routine physical examination to a healthy 16-year-old male client. The client shares to the nurse that he feels like killing his girlfriend because he found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to keep this a secret just between the two of them. The nurse reviews his chart and notes that there is no previously history of violence or psychiatric illness. Which of the following would be the best action of the nurse to take at this time? A. Suggest the teen meet with a counselor to discuss his feelings about his girlfriend. B. Tell the teen that his feelings are normal, and recommend that he find another girlfriend to take his mind off the problem. C. Recall the teenage boys often say things they really do not mean and ignore the comment. D. Regard the comment seriously and notify the teen’s primary health care provider and parents 38. Which of the following person will be at highest risk for suicide? A. A student at exam time B. A married woman, age 40, with 6 children. C. A person who is an alcoholic. D. A person who made a previous suicide attempt. 39. A male client is repetitively doing the handwashing every time he touches things. It is important for a nurse to understand that the client’s behavior is probably an attempt to: A. Seek attention from the staff. B. Control unacceptable impulses or feelings. C. Do what the voices the patient hears tell him or her to do. D. Punish himself or herself for guilt feeling. 40. In a mental health settings, the basic goal of nursing is to: A. Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness. B. Plan activity programs for clients. C. Understand various types of family therapy and psychological tests and how to interpret them. D. Maintain a therapeutic environment. 41. A 3-year-old boy is brought to the emergency department. After an hour, the boy dies of respiratory failure. The mother of the boy becomes upset, shouting and abusive, saying to the nurse, “If it had been your son, they would have done more to save it. “What should the nurse say or do? A. Touch her and tell her exactly what was done for her baby. B. Allow the mother to continue her present behavior while sitting quietly with her. C. “No, all clients are given the same good care.” D. “Yes, you’re probably right. Your son did not get better care.” 42. The nurse is interacting to a client with an antisocial personality disorder. What would be the most therapeutic approach of the nurse to an antisocial behavior? A. Gratify the client’s inner needs. B. Give the client opportunities to test reality. C. Provide external controls. D. Reinforce the client’s self-concept. 43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with him in the recovery room after the surgery, or he will be upset for not granting his request. What is the appropriate nursing response? A. “Do you get upset and confused often?” B. “You won’t need your glasses or hearing aid. The nurses will take care of you.” C. “I understand. You will be able to cooperate best if you know what is going on, so I will find out how I can arrange to have your glasses and hearing aid available to you in the recovery room.” D. I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know.”