Cardiovascular (Green highlight indicate that the questions are originally made by me)
1. A 54 year old client was brought to the ED with complaints of chest pain radiating to the jaw, lasting for 15 minutes, and is not relieved by the medication, NTG, he’s taking. He is suspected to have Myocardial Infarction. His attending physician orders a series of laboratory test to determine if it is MI or not. Which of the following diagnostic studies will rise first?
a. Troponin Level
b. CK-MB isoenzyme
c. White blood cell count
d. Total creatinine kinase level
Answer: A– Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.868-869
2. After a series of laboratory test. It was determined that the client has MI. which of the following nursing management will the nurse anticipate to give? SATA
e. Amiodarone hydrochloride
f. Oxygen via nasal cannula @ 2-5L/min
Answer: ALL– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.48 and Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.869-870
3. A nurse knows that Aspirin can be administered to a client experiencing MI because of its:
a. Analgesic action
b. Antipyretic action
c. Antiplatelet action
d. Antithrombotic action
Answer: D – Aspirin does have antipyretic, Antiplatelet, and analgesic actions, but the primary reason is administered to the client experiencing MI is its antithrombotic action. In clinical trials, the antithrombotic action of aspirin has been thought to account for improved outcomes in clients with MI --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.249 [#10]
4. A client with MI has developed CHF. Which of the following nursing management will the nurse anticipate to give to the client?
b. Digoxin (Lanoxin)
c. Furosemide (Lasix)
d. Dopamine (Inotropin)
e. Place the client with head of bed elevated
f. Weigh client daily at same time, on same scale, and in same clothing
Answer: ALL– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.54-56
5. A client with heart failure can be administered with Captorpil, an angiotensin-converting enzyme (ACE) inhibitor, because it acts as a:
c. Volume expander
d. Potassium-sparring diuretic
Answer: A – Ace inhibitors have become the vasodilators of choice in the client with mild-severe heart failure. Vasodilator drugs are the only class of drugs clearly known to improve survival in overt heart failure --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.251 [#34]
6. Determine which of the following manifestation is a Right-sided or Left-sided CHF:
a. Dependent edema --- Right
b. Dyspnea --- Left
c. Hepatomegaly --- Right
d. Increased BP --- Both
e. Tachypnea --- Left
f. Anorexia --- Right
Reference: Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.871
7. Which of the following nursing diagnosis for a client with heart failure and pulmonary edema should the nurse prioritize?
a. Constipation related to immobility
b. Impaired skin integrity related to pressure
c. Activity intolerance related to pump failure
d. Risk for infection related to stasis of alveolar secretions
Answer: C – Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to stasis of secretion or impaired skin integrity related to pressure. However, these are not the priority nursing diagnosis for a client with heart failure and pulmonary edema, nor is constipation related to immobility --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.251 [#31]
8. Which of the following statements is incorrect about pacemakers?
a. It is an electronic device that provides electrical stimuli to the heart
b. One of the problem that can occur is rhythmic diaphragmatic/chest wall twitching or hiccupping cause by myocardial wall perforation
c. Pulse generator is external and surgically implanted in the subcutaneous pocket below the clavicle ---internal
d. It can be powered by lithium battery with an average life span of 10 years, nuclear battery with an average life span of 20 years or longer, or designed to be charged externally
Answer: C – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.701-703 and Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.865
9. A 58 year old client was diagnosed with Raynauld’s Disease. Which of the following nursing intervention of the nurse is appropriate?
a. Tell the client to attend smoking cessation classes
b. Tell the client to avoid standing in one position for long periods of time ---Buerger’s Disease
c. Tell the client to avoid humid climate ---Buerger’s Disease
d. Tell the client to inspect feet frequently; keep clean and dry and use soft padding if necessary ---Buerger’s Disease
Answer: A– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.98-99
10. Which of the following assessment findings are about chest pain of a client with Pericarditis?
a. Substernal or retrosternal pain spreading across the chest. May radiate to inside of the arm, neck, or jaw; 5-15 minutes in duration; Precipitating events: Usually related to exertion, emotion, eating, cold ---angina pectoris
b. Substernal pain or pain over the precordium; may spread widely throughout the chest. Pain in the shoulders and hands may be present; >15 minutes in duration; Precipitating events: Occurs spontaneously but may sequel to unstable angina ---MI
c. Sharp, severe substernal pain or pain to the left of the sternum. May be felt in the epigastrium and may be referred to the neck, arms, and back; Intermittent in duration; Precipitating events: Sudden onset, pain increases with inspiration, swallowing, coughing, and rotation of the trunk
d. Substernal pain and may be projected around the chest and shoulder; 5-60 minutes in duration; Precipitating events: Recumbency, cold liquids, exercise; may occur spontaneously ---esophageal pain (hiatal hernia, reflux esophangitis, or spasm)
Answer: C – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.657-658
11. A 44 year old client was diagnosed of having Peripheral Vascular Disease. Which of the following are signs and symptoms of the disease? SATA
a. Thickened toenails
b. Intermittent claudication
c. White, pale color when legs are elevated
d. Dusky, purplish discoloration when feet are in a dependent position
Answer: ALL– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.89-90
12. Differentiate the following as to weather it is an Atrterial or a Venous PVD:
a. Pain is relieved by elevation --- Venous
b. Pain is relieved by dependent position --- Arterial
c. Has brawny (brown) pigment in the skin --- Venous
d. Ulcer is superficial and pink in color --- Venous
e. Ulcer is deep and pale in color --- Arterial
f. Gangrene can be its complication --- Arterial
Reference: Complication of Venous PVD is poor healing; Skin characteristics for Arterial PVD is dependent rubor, cool or cold temperature; Pulse assessment: Arterial - diminished or absent, and venous - present --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.89
13. How many inches should a nurse decompress the sternum when performing external chest compression on an adult?
a. 2-2.5 inches
b. 1.5-2 inches
c. 1-1.5 inches
d. 0.5-1 inches
Answer: B – An adult’s sternum must be depressed 1.5-2 inches with each compression to ensure adequate heart compression --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.256 [#98]
14. Which of the following conditions will increase the risk of having a large abdominal aortic aneurysm rupture?
a. High Blood Pressure
Answer: A – In the preoperative phase, the goal is to prevent rupture. The patient is placed in semi-Fowler’s position and in a quiet environment. The systolic blood pressure is maintained at the lowest level the client can tolerate. Anemia, dehydration, and hyperglycemia do not put the client at risk for rupture --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.256 [#86]
15. The client has been diagnosed of Rheumatic Heart Disease. Which of the following is correct regarding the said disease? SATA
a. It a chronic condition characterized by valvular deformity, which slowly progresses; follows an acute or repeated episode of rheumatic fever
b. In acute stage, valves tissue develops, leaflets become rigid and deformed; Stenosis or regurgitation may develop
c. In acute stage, valves becomes red, swollen, and inflamed with lesions developing on leaflets
d. Right heart valves are affected more often; mitral valve most often ---left heart valves
Answer: ABC– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.69
16. Which of the following are signs and symptoms of the above disease? SATA
a. Precordial chest discomfort
b. Bradycardia ---Tachycardia
d. Murmur from mitral or Aortic Stenosis may be noted ---Aortic Regurgitation
e. Pericardial friction rub and effusion
f. S₃ (atrial gallop) and S₄ (ventricular gallop)
Answer: ACEF– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.69
17. In discussing about nutritional needs to a client with hypertension, which of the following are the recommended grams of Na⁺ daily and blood cholesterol?
a. No more than 2-6 grams of Na⁺ daily and blood cholesterol of less than 200mg/dL
b. No more than 4-8 grams of Na⁺ daily and blood cholesterol of less than 200mg/dL
c. No more than 2-6 grams of Na⁺ daily and blood cholesterol of less than 250mg/dL
d. No more than 4-8 grams of Na⁺ daily and blood cholesterol of less than 250mg/dL
Answer: A– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.87
18. The nurse is ambulating a cardiac surgery client who has telemetry cardiac monitoring when another staff tells the nurse that the client has developed a supraventricular tachycardia with a rate of 146 beats/min. Order the following actions that a nurse will take:
a. Administer oxygen via nasal cannula
b. Check the client’s blood pressure
c. Call the client’s physician
d. Have the client sit down
Answer: DABC – The primary goal is to decrease the cardiac ischemia that is the likely cause of the patient’s tachycardia. This would be most rapidly accomplished by decreasing the workload of the heart and administering supplemental oxygen. Changes of blood pressure indicate the impact of the tachycardia on cardiac output and tissue perfusion. Finally, the physician should be notified about the patient’s response to the activity since changes in therapy may be indicated --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.181 [#26]
19. When teaching a client with hypertension about his 2-g Na⁺ diet, which food should the nurse teach the client to avoid?
a. Whole wheat bread
b. Beef tenderloin
c. Tomato juice
Answer: C – Canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juices --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.251-252 [#41]
20. A client went to the ED with complaints of calf pain and tenderness. After some laboratory studies, the client was diagnosed of having DVT. Which of the anticipated nursing management of the nurse is incorrect?
a. Maintain client on bed rest
b. Low-molecular weight Heparin (LMWH)
c. Elevate foot of bed 6-8 inches on blocks or elevate affected part
d. Administer mist heat to the involved extremity every 2-4 hours for 30 minutes ---4-6 hours
Answer: D – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.95
EENT (Green highlight indicate that the questions are originally made by me)
1. The nurse will be administering an eye drop medication on the right eye of a client with conjunctivitis. Order the following steps for eye drop administration:
a. Gently press on the lacrimal duct for 1 minute
b. Have the client to gently close the eye and move it around
c. Have the client sit down with head slightly Hyperextended
d. Gently pull downward to expose the lower conjunctival sac
e. Hold the dropper and stabilize the nurse’s hand on the client’s forehead
f. Have the client look up while the nurse instill the number of prescribed drops
Answer: CDEFBA – Have the client sit with head Hyperextended. Pulling the lower conjunctival sac creates a small pocket for the drops. Stabilizing the hand prevents accidentally poking the client’s eye. Having the client look up prevents the drop from falling on the cornea and stimulating the blink reflex. When the client gently moves the eye, the medication is distributed. Pressing on the lacrimal duct prevents systemic absorption --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.185 [#4]
2. Order the following steps for removal of a foreign body from the ear canal correctly:
a. Obtain history for type of object
b. Assess for possibility of perforation
c. Refer for treatment of external otitis
d. Inspect the tympanic membrane for trauma
e. Choose appropriate fluid for irrigation or instillation
Answer: ABEDC – The type of foreign body (e.g.: inspect, bean, bead) will determine the next steps. If there is a live insect, instill oil, vegetable or insect matter will swell if water is used for irrigation. Tightly wedged objects like beads are difficult to flush. If perforation is suspected or if the object is not easily removed, the nurse should not attempt irrigation or instillation. Check for trauma after the object is removed. If trauma occurred, the client should be referred for antibiotics to prevent infection --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.186 [#20]
3. While teaching the client who underwent cataract surgery about proper care for the eye, which instructions should the nurse anticipate to give? SATA
a. Can lift objects weighing 5 lbs
b. Using an eye shield at bedtime
c. Avoid rapid movements, straining, sneezing, coughing, bending, or vomiting
d. Glasses must be worn at all times for clients who didn’t underwent lens implantation
Answer: ALL – Also include: avoiding eye straining, avoid rubbing or placing pressure on the eye, take measure to prevent constipation, and wipe excess drainage or tearing with sterile wet cotton ball from the inner to the outer cannula --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.986
4. The client has undergone corneal transplant surgery. One of the most important nursing implications is teaching the client about signs of graft rejection. Which of the following is not a sign of rejection?
a. Bluish-purplish discoloration ---redness
b. Diminished visual acuity
Answer: A – Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.990
5. While assessing a client’s ear, which of the following findings in the Weber’s and Rinne’s Test will suggest that the client has conductive hearing loss?
a. Weber: sound is heard equally in both ears; Rinne: air conduction is audible longer than bone conduction ---normal hearing
b. Weber: sound heard best in affected ear; Rinne: sound heard as long or longer in affected ear
c. Weber: sound heard best in normal hearing ear; Rinne: air conduction is audible longer than bone conduction in affected ear ---sensorineural hearing loss
d. Weber: sound heard in unaffected ear; Rinne: bone conduction is audible longer than air conduction in unaffected ear
Answer: B – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.1796
6. While teaching the family of the client who has conductive hearing loss about how to facilitate communication. Which of the following teaching does the nurse anticipate to give? SATA
a. Using written word or sign language
b. Getting the attention of the client before beginning to speak
c. Moving close to the client and talk slowly and clearly
d. Talking in normal volume and at a higher pitch ---lower pitch; shouting is not helpful and higher frequencies are less easily heard
Answer: ABC – Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.994
7. A 55 year old client was brought in the ER department complaining of sudden eye pain, severe headache, N/V, and blurred vision with halos around lights. Upon assessment, it was found out that the client has Glaucoma. Which of the following nursing management shouldn’t anticipate?
a. Giving pilocarpine hydrochloride (Pilocar) ---miotics, drugs that constrict pupils
b. Avoid giving atropine sulfate (Isopto Atropine) ---mydraitics, drugs that dilate pupils
c. Urge the client to begin regular eye examination at age 50 and continue annually ---eye examination should start as early as age 40 and continue annually
d. Teach about importance of daily compliance with medications, and stress that noncompliance may lead to permanent loss of vision
Answer: C – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.190-191
8. Before a tonometry procedure, which of the following information should the nurse provide?
a. It is a painless procedure with no side effects
b. Oral pain medication will be given before the procedure
c. Blurred or double vision may occur after the procedure
d. Medication should be given to dilate the pupils before the procedure
Answer: A – Tonometry, which measures intraocular pressure, is a simple, noninvasive, and painless procedure that requires no particular preparation or post-procedure care and carries no side effects. It is not necessary to dilate the pupils for tonometry --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.515 [#21]
9. Which of the following symptoms are the classic triad symptoms of Ménière’s Disease?
a. Vertigo, headache, and otitis media
b. Tinnitus, vomiting and headache
c. Fluctuating hearing loss, tinnitus and vertigo
d. Otitis media, tinnitus and fluctuating hearing loss
Answer: C – Ménière’s disease involves the inner ear and is characterized by episodes of acute vertigo, tinnitus, and fluctuating, progressive hearing loss. The severe vertigo can lead to nausea and vomiting, but vomiting is not considered one of the classic triad of symptoms. Headache is not associated with Ménière’s disease. Otitis media is an inflammation of the middle ear --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.516 [#40]
10. Which of the following common infections and inflammatory disorders of the eye structures is defined as a sterile inflammatory process involving chronic granulomatous inflammation of the meibomian glands, and is manage by warm compress applied 3-4 times a day for 10-15 minutes?
a. Hordeolum (sty) ---acute suppurative infection of the glands of the eyelids caused by Staphylococcus aureus; manage by warm compress applied directly to the affected lid area 3-4 time a day for 10-15 minutes
b. Bacterial keratitis ---infection of the cornea by S.aureus, Streptococcus pneumoniae, and Pseudomonas aeruginosa
c. Blepharitis ---chronic bilateral inflammation of the eyelid margins. Manage by topical antibiotic treatment
Answer: D – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.1775
11. While helping a blind client with ambulation, which of the following nursing interventions is correct?
a. The nurse and client stand side-by-side while holding hands
b. The nurse slightly in front of the client while holding the clients arm
c. The nurse in front and client one step behind while listening to the nurse’s instructions
d. The nurse id one step behind and client in front while listening to the nurse’s instructions
Answer: C – When ambulating, allows the client to grasp the nurse’s arm at the elbow; the nurse keeps his or her arm close the direction of movement. Instruct the client to remain one step behind the nurse when ambulating --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.985
12. Which of the following interventions by the nurse while communicating with a blind client are incorrect? Except
a. Speaking in a loud voice while orienting the client to his environment
b. Approaching the client without making any noise
c. Speaking in a soft voice while leaving the room
d. Touching the client then introduce yourself
Answer: D – The nurse uses a normal tone of voice when communicating with a blind client. When approaching the client, the nurse should alert him or her--- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.985
13. Which of the following are true about presbyopia?
a. Structural Change: Drusen (yellowish aging spots in the retina) appear and coalesce in the macula. Abnormal choroidal blood vessels may lead to formation of fibrotic disciform scars in the macula; Functional Change: Central vision is affected ---Age-related macular degeneration (AMD)
b. Structural Change: Liquefaction and shrinkage of vitreous body; Functional Change: May lead to retinal tears and detachment ---Posterior vitreous detachment
c. Structural Change: Opacities in the normally crystalline lens; Functional Change: Interference with the focus of a sharp image on the retina ---Cataract
d. Structural Change: Loss of accommodative power in the lens; Functional Change: Reading materials must be held at increasing distance in order to focus
Answer: D – Presbyopia is due to loss of lens elasticity because of aging; less able to focus the eye for close work and images fall behind the retina --- Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.1754 and Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.985
14. Which of the following clients is at highest risk for macular degeneration when interpreted by a community health nurse?
a. Elderly client
b. Young adults with multiple allergies
c. Youth hit in the eye with a baseball
d. Biochemist exposed to various toxins
Answer: A – Age-related macular degeneration is the leading cause of loss of vision in clients over 50 years of age. Blunt traumas, exposure to toxins, and allergies are not known causes of macular degeneration --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.214 [#6]
15. Which of the following causes sensorineural hearing loss? SATA
a. Otosclerosis, inner ear involvement ---Otosclerosis, stapes fixation leads to conductive hearing loss
b. Swimmer’s ear ---also known as External otitis; conductive hearing loss
d. Ménière’s disease
e. Otitis media ---conductive hearing loss
f. Diabetes mellitus
Answer: CDF – Other causes of sensorineural hearing loss includes damage in the inner ear structure and 8th cranial nerve, prolonged exposure to loud noise, medications, trauma, inherited disorders, metabolic and circulatory disorders, infections, surgery, and myxedema--- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.993-998
16. Which of the following diagnostic tests are able to differentiate if a client has sensorineural or conductive hearing loss?
a. Audiometry ---to assess hearing
b. Weber test---with Rinne test; also known as tuning fork test
c. Tympanometry ---an indirect measurement of compliance of middle ear to sound transmission; conductive hearing loss
d. Brainstem auditory evoked response (BAER) ---sensorineural hearing loss
Answer: B – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.198-200
17. A nurse has been assigned to a hearing impaired client and who speech reads. Which of the following interventions should a nurse do in communicating with the client? SATA
a. Facing the client while talking
b. Avoid being silhouetted against strong light
c. Having bright light behind so the individual can see
d. Not blocking out the person’s view of the speaker’s mouth
e. Talking to the client while doing other nursing procedures
f. Ensuring the client is familiar with the subject material before discussing
Answer: ABDF – When working with a client who is hearing impaired and speech read, the presenter must face the person directly and devote full attention to the communication process. In addition, it will be useful not to be silhouetted against strong light or for the mouth to be blocked by the client’s view or by having any object in the mouth of the speaker. Finally, it is recommended that the presenter provide the client with needed information to study prior to reviewing. This will provide the client with the ability to use contextual clues in speech reading --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.515-516 [#31]
18. In managing a client with otitis media, antibiotic treatment with or without decongestants is given. How many days should the therapy be continue?
a. 3-5 days
b. 5-7 days
c. 7-10 days
d. 10-12 days
Answer: D – Medications include antibiotic therapy with or without decongestants; therapy often continued for 10-12 days; analgesics, and antipyretics --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.202
19. Order the following measures to stop the client’s epistaxis(nosebleed):
a. Estimate blood loss when possible; maintain an attitude of calm reassurance
b. Instruct the client to sit upright with head tilted forward
c. Encourage the client to expectorate blood to prevent nausea and vomiting resulting form swallowed blood
d. Apply pressure, by pinching nose toward septum, for 5-10 minutes
e. Assess for respiratory distress; supplemental oxygen as indicated
f. Apply ice packs to nose and/or forehead to promote vasoconstriction
Answer: EBDFCA – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.206
20. Which of the following nursing diagnosis is the most appropriate to a client with epistaxis?
c. Risk for infection
d. Risk for aspiration
Answer: B – Since the amount of blood loss in a nosebleed can be frightening to clients, anxiety is a priority nursing diagnosis. Blood draining into the nasopharynx poses a risk for aspiration. Risk for infection and pain are appropriate nursing diagnoses related to nasal packing but are not the priorities --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.214 [#8]
Endocrine (Green highlight indicate that the questions are originally made by me)
1. Which of the following signs and symptoms would a nurse anticipate to find in a 34 year old client diagnosed with hypothyroidism? SATA
a. Rapid pulse
d. Weight gain of 10 pounds
e. Fine, thin hair with hair loss
f. Decreased energy and fatigue
Answer: BCDF – Clients with hypothyroidism exhibit symptoms indicating lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problem, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.367 [#3]
2. The client is diagnosed of having Thyrotoxicosis (Thyroid storm, Thyrotoxic Crisis), a severe form of hyperthyroidism. Which of the following clinical manifestation would the nurse expect to find upon assessment? SATA
a. Hyperpyrexia ---high fever above 38.5°C (101.3°F)
b. Tachycardia ---more than 130 beats/minute
c. Abdominal pain
e. Somnolence ---altered neurologic or mental state such as delirium, psychosis, or coma
f. Chest pain
Answer: ALL – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.1223
3. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively to a client with a large goiter who is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. the nurse knows that SSKI is given to help:
a. Increase the body’s ability to secrete thyroxine
b. Decrease the body’s ability to store thyroxine
c. Reduce the vascularity of the thyroid gland
d. Slow progression of exophthalmos
Answer: C – SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that presents a hazard during surgery. Preparation for a client before surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exophthalmos, and it does not decrease the body’s ability to store thyroxine or increase the body’s ability to secrete thyroxine --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.368 [#11]
4. A nurse is teaching a diabetic client about ways of preventing/intervening mild hypoglycemia. Which of the following are consider a 10-15g of fast-acting simple carbohydrate?
a. 5 tbsp of sugar ---4 tsp of sugar
b. 2 sugar cubes ---4 sugar cubes
c. 12 oz low-fat milk ---8 oz of low-fat milk
d. 3 graham crackers
Answer: D – Other foods consider to have 10-15g of fast-acting simple carbohydrates are commercially prepared glucose tablets, 6-10 life savers or hard candy, 1 tbsp of honey or syrup, ½ cup of fruit juice or regular (nondiet) soft drink, and 6 saltine crackers --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.704
5. A nurse is assigned to a client with unstable type 1 Diabetes Mellitus. Which of the following findings would the nurse report immediately to the physician? SATA
a. HgAlC 10.2%
b. Triglycerides 425 mg/dL
c. (-)Urinary ketones
d. High density lipoprotein (HDL) of 30 mg/dL
e. Systolic blood pressure of 145 mmHg
f. Diastolic blood pressure of 87 mmHg
Answer: ABDEF – The clients with unstable DM is at risk for many microvascular and macrovascular complications. Heart disease is the leading cause of mortality in clients with diabetes. The goal blood pressure for diabetics is <130/80 mmHg. Therefore, the nurse would report any findings greater than 130/80 mmHg. The goal of HgAlC is <7%, thus a level of 10.2% needs to be reported. HDL <40 mg/dL and triglycerides >250 mg/dL are risks factors for heart disease. The nurse would need to report the clients HDL and triglyceride levels. The urinary ketones are negative, but this is a late sign of complications --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.369 [#27]
6. A client has been assigned to a diabetic client who is at risk of developing DKA. Which of the following laboratory findings should the nurse immediately report?
a. (-) serum ketones ---(+) at 1:2 dilutions
b. Serum glucose of >800 mg/dL --->300 mg/dL
c. Osmolarity of >350mOsm/L ---variable
d. High serum Na⁺
Answer: D – Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.705
7. The nurse is teaching a diabetic client, DM type 1, about taking isophane insulin suspension NPH (Humulin N) at 5pm each day. Which of the following instructions should be taught to a client that the greatest risk of having hypoglycemia is at?
a. 6pm, shortly after dinner
b. 1am, while sleeping
c. 11am, shortly before lunch
d. 1pm, shortly after lunch
Answer: B – The client with DM who is taking NPH (Humulin N) insulin in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6-12 hours. The client needs to eat a bedtime snack to help prevent hypoglycemia while sleeping --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.370 [#33]
8. Differentiate whether the following signs and symptoms are of Addison’s or Cushing’s disease?
a. Hypoglycemia ---Addison’s
b. Postural hypotension ---Addison’s
c. Fragile skin that easily bruises ---Cushing’s
d. Hyperpigmentation of skin (bronzed) ---Addison’s
e. Supraclavicular fat pads ---Cushing’s
f. Hirsutism ---Cushing’s
g. Impotence ---Addison’s
h. Reddish-purple striae on the abdomen and upper thighs ---Cushing’s
Reference: Other s/s of Addison’s disease: lethargy, fatigue, and muscle weakness, GI disturbances, weight loss, menstrual changes, hyponatremia, hyperkalemia, and hypercalcemia; Other s/s of Cushing’s disease: generalized muscle weakness and wasting, moon face, buffalo hump, truncal obesity with thin extremities, weight gain, hyperglycemia, hypernatremia, hypokalemia, hypocalcemia, and hypertension --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.694
9. A client is in Addisonian crisis. Which of the following would the nurse expect the client to manifest?
c. Fluid retention
d. Peripheral edema
Answer: A – Adrenal hormone deficiency can cause profound physiologic changes. The client may experience severe pain (headache, abdominal pain, back pain, or pain in the extremities). Inhibited gluconeogenesis commonly produces hypoglycemia, and impaired sodium retention caused decreased, not increased, fluid volume. Edema would not be expected. Gastrointestinal disturbances including nausea and vomiting are expected findings in Addison’s disease, not hunger --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.372 [#59]
10. Which of the following nursing diagnoses would be a priority for a client with Addison’s disease?
a. Fluid volume, deficient
b. Fluid volume, excess
c. Fluid volume, risk for deficient
d. Fluid volume, risk for imbalanced
Answer: A – Priority nursing diagnoses: deficient fluid volume; risk for injury --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.280
11. The client is admitted in the hospital with pheochromocytoma. The nurse assesses the client’s blood pressure frequently. Which of the following effects on blood pressure is due to the primary feature of the disease?
a. Hypertension that is resistant to treatment with drugs
b. Diastolic hypertension
c. Systolic hypertension
d. Widening pulse pressure
Answer: A – The release of catecholamines, epinephrine, and norepinephrine, causes hypertension that is resistant to treatment. Although pheochromocytoma accounts for less than 1% of the cases of hypertension, it is important to diagnose so the client may be correctly treated. The hypertension occurs with both systolic and diastolic pressures, and the pressures may be very labile. Widening pulse pressure is not related to pheochromocytoma --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.376 [#102]
12. Which of the following nursing diagnoses is a priority to a client with pheochromocytoma?
c. Cardiac output: decreased
d. Cardiac output: increased
Answer: A – Priority nursing diagnoses: Risk for injury; Pain --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.81
13. A client is at risk of developing myxedema coma as a result of his prolonged hypothyroidism. Which of the followings are not signs and symptoms of this complication? SATA
a. Lactic acidosis
c. Hypernatremia ---hyponatremia
d. Hypertension ---hypotension
Answer: CD – Also include: hypometabolic state, cardiovascular collapse. Hypothermia, and coma --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.270
14. Besides from polydipsia, polyuria, and polyphagia, which of the following is not an early manifestation of type 1 Diabetes Mellitus?
b. Weight loss
c. Blurred vision
d. Abdominal pain
Answer: C – Early manifestation of type1 DM includes fatigue, nausea, and vomiting; for type 2 DM includes polyuria, polydipsia, and weight gain --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.286
15. A client has been brought to the ED with symptoms of polyuria, excessive thirst, weakness, and dehydration. The client is suspected of having Diabetes Insipidus. Which of the following laboratory results will a nurse anticipate to find? except
a. Increased serum Na⁺ level
b. Increased urine osmolality ---decreased
c. Increased Vasopressin test ---diagnostic test for DI
d. Increased water deprivation test ---diagnostic test for DI
Answer: B – Other lab findings include low urine specific gravity, high serum osmolality, and decreased serum ADH levels --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.283-284
16. Which of the following nursing management would not be appropriate for a client with Diabetes Insipidus?
a. Desmopressin acetate (DDAVP)
b. Treatment is life long for chronic DI
c. Limit oral fluid intake ---limit OFI is for SIADH; it should be increase OFI
d. Low-Na⁺ diet, avoid caffeine
Answer: C – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.284
17. A client has been diagnosed of having hyperthyroidism. Which of the following treatment would a nurse anticipate to give to the client? except
a. Liotrix (Euthroid) ---hypothyroidism; also include levothyroxine sodium (Levothiroid, Synthroid), liothyroxine (Cytomel), and vasopressor agents
b. Propranolol (Inderal)
c. Lugol’s solution
Answer: A – Also include methimazole (Tapazole), propylthiouracil (PTU), glucocorticoids, and radioactive therapy --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.269
18. In monitoring the dietary intake of a client with thyroid hyperfunction disorder who is in a hypermetabolic state, the nurse knows that a client may require up to:
a. 1,000-2,000 calories
b. 2,000-3,000 calories
c. 3,000-4,000 calories
d. 4,000-5,000 calories
Answer: D – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.269
19. Which of the following nursing diagnoses would the nurse select as a priority for a client with hypoparathyroidism?
b. Risk for injury
c. Knowledge deficit
d. Risk for excess fluid volume
Answer: B – Risk for injury related to hypocalcemia is the priority diagnosis as injury may occur as a result of low calcium level and tetany. The client is at risk for fluid volume deficit, not excess, and anxiety and knowledge deficit would not take priority over injury --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.293 [#4]
20. The client is kept on bed rest for several days to stabilize the body’s need to steroid after surgery for bilateral adrenalectomy. In preparing a client for ambulation after a period of bed rest, which of the following exercises would be helpful?
a. Alternately stretching the Achilles tendon
b. Alternately flexing and extending the knees
c. Alternately abducting and adducting the legs
d. Alternately flexing and relaxing the quadriceps muscles
Answer: D – Alternately flexing and relaxing the quadriceps muscles helps prepare the client for ambulation. This exercise helps maintain the strength in the quadriceps. Which is the major muscle group used when walking. The other exercises listed do not increase a client’s readiness for walking --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.375 [#90]
Gastrointestinal (Green highlight indicate that the questions are originally made by me)
1. Which of the following findings will a nurse anticipate when assessing a client with Gastric Ulcer? SATA
d. Vomiting uncommon
e. Gnawing sharp pain in or left of the midepigastric region occurs 30-60 minutes after meal
f. Burning pain occurs in the midepigastric area 2-3 hours after meal; often awakened between 1-2 am
Answer: BCE – Gastric: Normal-hyposecretion of stomach acid (HCl), pain relieve by vomiting, weight loss may occur, and vomiting is common; Duodenal: Hypersecretion of stomach acid (HCl), pain relieve by ingestion of food, hemorrhage less likely, melena is common, and more likely to perforate --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.749, and Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.1015
2. A nurse is assigned to a client with a peptic ulcer disease. Which of the following medications should be avoided?
a. Nizatidine (Axid) ---H₂ Blockers; also include cimetidine (Tagamet), ranitidine (Zantac), and fomatidine (Pepcid)
b. Esomeprazole (Nexium) ---Proton Pump Inhibitors; also include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), and rabeprazole (Aciphex)
c. Synthetic E. prostaglandin (Cytotec) ---Cytoprotective agents
d. Acetylsalicylic acid (Aspirin) ---should be avoided with NSAID’s
Answer: D – Can also give sucralfate (Carafate), a mucosal barrier, and antacids. Antibiotics are also given to destroy H. pylori such as tetracycline hydrochloride (Achromycin) or clarithromycin (Biaxin) and metronidazole (Flagyl). Often recommended to give bismuth compound (Pepto-Bismol) with the antibiotics --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.222
3. While giving discharge teaching to a client with a peptic ulcer disease, which of the following diet would a nurse most likely to explain to the client?
a. Any foods that are tolerated
b. Large amount of milk
c. High-protein diet
d. Bland foods
Answer: A – Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.328 [#17]
4. After undergoing Gastric resection, the client is at risk of developing dumping syndrome. Which of the following client education is incorrect in preventing this complication?
a. Lie down after meals
b. Avoid sugar, salt, and milk
c. Take antispasmodic medications as prescribed ---to delay gastric emptying
d. Eat a low-protein, high-fat, and low-carbohydrate diet ---high-protein
Answer: D – Also include: Eat small meal and avoid consuming fluids with meals --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.750
5. A client with gastroesophageal reflux disease (GERD) is complaining of heartburn. Which of the following foods in her diet should be eliminated to decrease her heartburn?
a. Air-popped popcorn
b. Raw vegetables
c. Hot chocolate
d. Lean beef
Answer: C – With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that decrease the lower esophageal sphincter pressure includes fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.330 [#39]
6. A client has been diagnosed of having Hiatal Hernia. Which of the following nursing management is anticipated to be given to the client? SATA
a. Avoid giving H₂ Receptor blockers
b. Encourage to limit alcohol intake
c. Discourage high amounts of caffeine
d. Elevation of HOB during sleep
Answer: CD – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.224
7. The nurse is teaching the client who has had rectal surgery about the proper timing for sitz bath. The nurse knows that the client understands the teaching when the client states that it is most important to take a sitz bath at:
a. At bedtime
b. After a bowel movement
c. First thing each morning
d. As needed for discomfort
Answer: D – Adequate cleaning of the anal area is difficult but essential. After rectal surgery, sitz baths assist in this process, so the client should take a sitz bath after a bowel movement. Other times are dictated by the client --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.340 [#14]
8. The nurse is teaching a client about changes in stool characteristics that may signal a colon disease and the foods and medication that can alter its color. The client asks the nurse what food or medication can alter the color of her stool for it become yellow. The nurse knows that the substance that can alter the color of the stool is?
a. Carrots --- and beets - red
b. Licorice ---bismuth, iron, and charcoal - black
c. Cocoa --- dark red or brown
d. Senna ---a valuable purgative drug
Answer: D – Meat protein-dark brown; spinach-green; barium-milky white --- Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.946
9. The client went to the ED complaining of bluish –purplish lesion on the mouth. Which of the following disorder in the mouth has this signs and symptoms and possibly cause by an HIV infection?
a. Krythoplakia ---red patch on the oral mucous membrane; possible cause is nonspecific inflammation; frequently seen in the elderly
b. Kaposi’s sarcoma
c. Lichen planus ---white papules at the intersection of a network of interlacing lesions; usually ulcerated and painful; recurrence is common; may lead to a malignant process; unknown cause
d. Aphthous stomatitis ---shallow ulcer with a white or yellow center and red border; seen on the inner side of the lip or cheek or on the tongue; it begins with a burning or tingling sensation and slight swelling; painful; usually last for 7-10 days and heals without a scar; associated with emotional or mental stress, fatigue, hormonal factors, minor trauma (such as biting), allergies, acidic foods and juices, and dietary deficiencies; associated with HIV infection; may recur
Answer: B – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.960-961
10. A client has been admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. Upon assessing the client it has been found out that he has a history of Crohn’s disease. The nurse would anticipate which of the following laboratory findings?
Answer: A – Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn’s disease, however, the client’s potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.341 [#28]
11. A client with ulcerative colitis has been placed on steroid therapy. The client asks the nurse why is he on this kind of therapy if steroid can be potentially dangerous to him. Which of the following statements by the nurse is correct regarding the use of steroid therapy to a client with ulcerative colitis?
a. “Steroids are used in severe flare-ups because they can decrease the incidence of bleeding”
b. “The side effects of steroids outweigh their benefits to client with ulcerative colitis”
c. “Long-term use of steroids will prolong periods of remission”
d. “Ulcerative colitis can be cured by the use of steroids ”
Answer: A – Steroids are effective in management of the acute symptoms of ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assess carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential side effects --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.340 [#22]
12. The client has been diagnosed of having intestinal obstruction. Which of the following nursing diagnoses would the most appropriate for the client?
a. Deficient Fluid Volume related to nausea an vomiting
b. Urinary Retention related to deficient fluid volume
c. Chronic Pain related to abdominal distention
d. Impaired Swallowing related to NPO status
Answer: A – A client with an intestinal obstruction is particularly susceptible to deficient fluid volume and electrolyte imbalances. NPO status does not impair swallowing. Urinary retention is not caused by deficient fluid volume. The client’s pain is acute in nature, not chronic --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.341 [#36]
13. A client with diverticulitis has undergone a series of laboratory tests. Which of the following findings would the nurse anticipate?
a. Decreased platelet count
b. Elevated red blood cell count
c. Elevated white blood cell count
d. Elevated serum blood urea nitrogen concentration
Answer: C – Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occurs in clients with aplastic anemia or malignant blood disorders, as a side effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen is usually associated with renal conditions--- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.343 [#58]
14. A client with cholecystitis has undergone a surgical exploration of the common bile duct and a T-tube has been placed for drainage. Which of the following nursing interventions in the care of a T-tube are appropriate? SATA
a. Position the client in a semi-Fowler’s position ---to facilitate drainage
b. Keep the drainage below the level of the gallbladder
c. Irrigate, aspirate, or clamp the T-tube as prescribed
d. Clamp the tube after a meal and observe for abdominal discomfort and distention ---before a meal; observe also for nausea, chills, or fever; unclamp if nausea and vomiting occurs
Answer: ABC – Other interventions include monitor the amount, color, consistency, and odor of the drainage; report sudden increases in bile output to the physician; monitor for inflammation and protect the skin from irritation; monitor for foul odor and purulent drainage and report its presence to the physician --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.761
15. A client who has viral hepatitis has been admitted to the hospital with jaundice and flu-like symptoms. The nurse knows that these symptoms can be seen in which of the following stages of viral hepatitis?
a. Convalescent stage ---same with Posticteric stage
b. Preicteric stage
c. Icteric stage ---associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stool
d. Posticteric stage ---convalescent stage of hepatitis, in which the jaundice decreases and the color of the urine and stool return to normal
Answer: B – Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.762
16. Which of the following risk factors will predispose a client to develop cholecystitis?
a. Cholelithiasis ---also include diet high in fat content
b. Crohn’s disease ---Cholelithiasis; other risk factors include aging process, family history, cirrhosis, sickle-cell anemia, hyperlipidemia, congenital malformation of the biliary ducts, obesity and rapid weight loss, drugs that can reduce cholesterol, and hyperalimintation
c. Diabetes mellitus ---Cholelithiasis and Pancreatic Cancer
d. Abdominal trauma ---Pancreatitis; also include alcohol in men, gallstones in women, hyperlipidemia, hyperparathyroidism, and viral infection
Answer: A – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.241
17. Which of the following medications should be avoided by a client with cirrhosis?
a. Spironolactone (Aldactone) ---diuretics, drug of choice; include furosemide (Lasix)
b. Acetaminophen (Tylenol) ---medication highly metabolized by the liver; also includes barbiturates, sedatives, and alcohol-containing products
c. Neomycin (Mycifradin) ---and lactulose (Chronulac) reduce high ammonia level by metabolism of lactose to organic acids by intestinal bacteria and decrease pH of colon
d. Vitamin K (Aquamephyton) ---to enhance clotting
Answer: B – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.243-244
18. The client is initially diagnosed of having pancreatitis if there is an elevation of which of the following serum values?
Answer: B – The primary diagnostic tests for pancreatitis are serum amylase, serum lipase, and urine amylase. All three laboratory results are typically elevated. Serum amylase is the most common test; the results are usually higher than 200units/dL. Serum glucose may be elevated in pancreatitis because of beta-cell damage, but this is not used to diagnose pancreatitis. Serum potassium and Trypsin is not affected in pancreatitis --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.352 [#15]
19. In assessing a client who is in the early stage of liver cirrhosis, which of the following sign would the nurse anticipate to find?
d. Peripheral edema
Answer: C – Early clinical manifestations of cirrhosis are subtle and usually include gastrointestinal symptoms such as anorexia, nausea, vomiting, and changes in bowel patterns. These changes are caused by the liver’s altered ability to metabolize carbohydrate, proteins, and fats. Peripheral edema, Ascites, and jaundice are later signs of liver failure and portal hypotension --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.355 [#48]
20. A client with hiatal hernia has been prescribed with cimetidine (Tagamet). The nurse knows that the drug is used to prevent which of the following conditions?
c. Ulcer formation
d. Esophageal reflux
Answer: B – Cimetidine (Tagamet) is a histamine receptor antagonist that decreases the quantity of gastric secretions. It may be used in hiatal hernia therapy to prevent or treat the esophangitis and heartburn associated with reflux. Cimetidine is not used to prevent reflux,. Dysphagia, or ulcer development --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.331 [#53]
Leadership, Management, Bioethics, Research and Fundamentals of Nursing
Prof. Candelario, RN, MAN, US-RN
1. Which of the following statements by the nurse would be most helpful to assist patients in clarifying their values?
a. That was not a good decision. Why do you think it would work?
b. The most important thing is to follow the plan of care. Did you follow all your doctor’s orders?
c. Some people might have a different decision. What lead you to make your decision?
d. If you had asked me, I would have given you my opinion about what to do. Now, how do you feel about your choice?
Rationale: This is most effective communication technique because it allows the client to analyze their values that can affect their decision making.
2. A child who has been in a car accident has been shown to have no brain function. The parents refuse to allow life support to be withdrawn. Although the nurse believes the child should be allowed to die, the nurse supports their decision. What moral principle provides the best basis for the nurse’s action?
a. Respect for autonomy
Rationale: Autonomy is respecting an individual’s right to make decisions. The nurse supports the client’s decision even when it conflicts with his/her own preferences or choices.
3. The nurse is caring for a patient admitted to the emergency room after a MVA. The nurse must obtain informed consent before treatment unless the patient:
a. Mentally ill and there are relatives present with the patient
b. Refuses to give informed consent
c. Is in emergency situation
d. Asks the nurse to give substituted consent
Rationale: informed consent need to be obtained before any treatment can be given to clients condition and immediate treatment is necessary to save life, the emergency rule can be applied.
4. A patient became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who is likely to be held liable?
a. No one because it was an accident
b. The hospital
c. The nurse
d. The nurse and the hospital
Rationale: both the nurse and the hospital can be sued for the damages if a mistake the nurse makes injuries the client. The nurse is always responsible for her own actions. The hospital, as the employer, will be liable for the negligent behavior of its nurses under its employ.
5. A nurse needs assistance transferring a confused, elderly patient to bed. The nurse leaves the patient to find someone to assist her with the transfer. While the nurse is gone, the patient falls and hurt herself. The nurse is at fault because she hasn’t:
a. Properly educated the patient about safety measures
b. Restrained the patient
c. Documented that she left the patient
d. Arranged or continual care of the patient.
Rationale: The nurse’s responsibility is to take care of the client and if in case the nurse needs to leave the client, the nurse needs to always arrange for somebody to care for the client especially if the client is confused.
6. In the above scenario, what ethical principle and the nurse not observe?
a. Respect for autonomy c. non-maleficence
b. Beneficence d. Fidelity
Rationale: The nurse’s duty is to prevent or avoid harm whether intentional or unintentional.
7. The nursing staff is sitting in the break room and talking about a patient who was admitted and diagnosed with sexually transmitted disease. What ethical principle is being violated by the nursing staff?
a. Respect for autonomy c. Fidelity
b. Beneficence d. Confidentiality
Rationale: Information relating to the condition and treatment of clients requires confidentiality and protection against invasion of privacy.
8. A nursing instructor provides a lecture to the nursing students regarding the issue of privacy. Which of the following if identified by the student indicates an understanding of a violation of this patient’s rights?
a. Performing a procedure without consent
b. Telling the patient that he/she cannot leave the hospital
c. Threatening to give the patient a medication
d. Observing care provided to a patient without the patient’s permission
Rationale: A client has the right to refuse to participate in clinical teaching. Nurse need to obtain consent before any teaching conference is done.
9. An 80 year old lady was brought to the ER for a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the patient’s legs and chest. The nurse reports to the social welfare worker in the hospital despite the patient’s refusal. What ethical principle is involved in this situation?
a. Confidentiality b. Fidelity c. Veracity d. Justice
Rationale: Confidentiality is the social contract guaranteeing another’s privacy, Clients should be assured that information is kept confidential, unless it places the nurse under s legal obligation. The nurse must report situations related to child or elderly abuse, gunshot wounds and certain infectious disease.
10. In the above situation, what ethical principle justifies the nurse’s action?
a. Beneficence b. Justice c. Non-maleficence d. Fidelity
Rationale: Beneficence is the principle of attempting to do things that benefit others.
11. A new registered nurse is employed in a busy tertiary hospital. She was asked to float to the ICU for the day because the ICU was understaffed. The nurse has never worked in the ICU and refused the assignment. What ethical principle is involved here?
a. Respect for persons c. Non-maleficence
b. Beneficence d. Justice
Rationale: The nurse’s duty is to prevent or avoid harm whether intentional or unintentional. The nurse should not assume responsibility beyond the level of their experience or education.
12. The following are elements of informed consent:
a. 1,2,3 b. 2,3,4 c. 1,3,4` d. 1,2,3,4
Rationale: Informed consent means the operation has been fully explained to the client, including complications. It has be explained in terms that the patient understand. Written or verbal consent can be given by alert, coherent, or otherwise competent adults. Contents should be signed and witnessed.
13. If a patient is no longer legally capable of making health care decisions, a legal document sucha s an advance directive may be utilized by the patient. Which of the following are considered to be advance directives?
a. Power of attorney
b. Living wills
c. Do not resuscitate
d. B and C
Rationale: Legal, written or oral statement made by a person who is mentally competent about treatment preferences are known as advanced directives. These include living wills and durable power of attorney.
14. Confidential information can be disclosed under which circumstances?
a. When a patient is a danger to him/herself
b. Presence of a communicable disease
c. In cases of suspected abuse
d. All of the above
Rationale: Confidentiality is the social contract guaranteeing another’s privacy. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. The nurse report situations related to child or elderly abuse, gunshot wounds and certain infectious disease.
15. When nurses accurately, promptly and legibly document their care given to patient’s what ethical principle is the nurse observing?
a. Fidelity b. Veracity c. Justice d. Confidentiality
Rationale: Veracity is the duty to tell the truth. Documentation should be factual, objective, accurate and complete.
16. Being updated about commonly used drugs in her field of practice, the nurse is fulfilling which ethical principle?
a. Fidelity b. Veracity c. Beneficence d. Justice
Rationale: Fidelity is the duty to do what one has promised. Nurses have the responsibility to their patients to be updated with current and safe clinical nursing practice which includes safe administration of medications.
17. A 70 year old patient is to undergo cholecystectomy at 6am. The nurse should do the following pre-operatively except:
a. Use written and verbal teaching methods
b. Use return demonstration of physical skills such as use of incentives spirometer
c. Assess the patient’s knowledge before and after teaching
d. Let the patient’s relatives sign the consent
Rationale: The client is mentally competent to give consent for the procedure. It is only in cases wherein a client is considered to be incompetent can another person or guardian sign the consent for him/her.
18. The following are exceptions to informed consent:
a. Emergency treatment
b. If compulsory treatment is mandated by a court order
c. If patient waives the right to consent and ask not to be informed
d. All of the above
Rationale: Informed consent need to be obtained before any treatment can be given to clients but informed consent cannot be obtained because of the client’s condition and immediate treatment is necessary to save life, the emergency rule can be applied.
19. A professional nurse with a commitment to social justice is most apt to:
a. Provide honest information to patients and the public
b. Promote universal access to healthcare
c. Plan to care in partnership with patients
d. Document care accurately and honestly
Rationale: Justice is the principle that distributes, as fairly as possible, benefits, resources and burdens.
20. A nurse is hesitant to go inside the room of a patient diagnosed with Alzheimer’s disease. No relatives are usually present and the patient is incontinent of stools and urine. The patient has to be changed frequently and the nurse tries to avoid doing the hard work. Instead, she attends to the needs of the other patients who requires less care. What ethical principle is the nurse violating in this case?
a. Autonomy b. beneficence c. justice d. fedility
Rationale: Justice is the principle of treating all clients fairly. Justice implies that there is no discrimination on the basis of sex, race, religion, age, health condition and socioeconomics status.
21. A new registered nurse is taking care of a patient diagnosed with COPD. Prior to discharge, the nurse reminds the patient to stop smoking. The nurse is observing what ethical principle?
a. Respect for autonomy b. Beneficence c. Justice d. Fidelity
Rationale: The nurse has a responsibility to do good for the clients. Giving health teachings that will benefit clients is a benevolent act.
22. A public health nurse who performs a careful safety assessment of the home of a frial elderly patient to prevent harm to the patient is acting in accord with which of the principle of bioethics?
a. Autonomy b. Beneficence c. Fidelity d. Non-maleficence
Rationale: Non-maleficence is the obligation to do or cause no harm to another. Making a thorough assessment of the client’s house prior to discharge will reduce the risk of accidents and injuries.
23. A professional nurse committed to the principle of autonomy would be careful to:
a. Provide information and support a patient when they need to make decisions
b. Treat each patient fairly, trying to given everyone his/her due
c. Keep any promises made to a patient or another professional caregiver
d. Avoid causing harm to the patient.
Rationale: Autonomy is the right of an individual to make their own decisions without interference. The client hasa right to be informed about treatments, test and surgeries and they must be able to understand the intended outcome and potentially harmful results.
24. Reporting a nurse who have been verbally abusing a mentally incompetent patient is acting on the principle of:
a. Beneficence b. Justice c. Fidelity d. Veracity
Rationale: Beneficence is doing good for the client. The nurse has the responsibility to protect the client from incompetent, unethical and illegal behavior of other health care workers.
25. The use of placebo is one common situation that usually violates which ethical principle?
a. Fidelity b. veracity c. beneficence d. non-maleficence
Rationale: Veracity is the duty to tell the truth. Placebos may be used in experimental research where the patient is involved in the decision making process and is aware that placebos are being used the treatment regimen. However, the use of placebo as a substitute for an active drug to show that the patient does not have a real symptom is deceptive.
26. When insurance companies refuses to pay for individualized or group therapies for patients with mental illness and instead, opt to pay for pharmaceutical interventions, they are violating the principle of:
a. Justice b. Fidelity c. Beneficence d. Non-maleficence
Rationale: The principle of justice states that all clients should be treated alike. If the individual is mentally ill, they should be given treatment that is based on individual need and not be deprived of it just because of their health condition.
27. In health care situations, the practice of using restraints on patients to limit the potential of harm to him/herself is an example of using the principle.
a. Beneficence b. Non-maleficence c. Justice d. Fidelity
Rationale: Non-maleficence is the duty not to inflict harm as well as to prevent and remove harm. Restraints are acceptable for the limited purpose of protecting the client from injury-not for convenience of the personnel.
28. This principle entails overriding a patient’s expressed wishes or not consulting a patient at all in his or her health care decisions in an effort to achieve the best outcome for the patient:
a. Fidelity b. Veracity c. Paternalism d. Autonomy
Rationale: paternalism is the intentional limitation of another’s autonomy. Under this principle, prevention of harm takes precedence over any potential evils caused by interference with the individuals autonomy.
29. When adolescents seek treatment for substance abuse, the nurse has the responsibility not to disclose it to the adolescent parents. This in line with the principle of:
a. Veracity b. Beneficence c. paternalism d. Confidentiality
Rationale: Confidentiality relates to the concept of privacy. Information obtained from the client will not be disclosed to another unless it will benefit the person.
30. A type of advance directive that allows a person to make decisions about their health care when they are not able to do so anymore is known as:
a. Power of attorney c. Durable power of attorney
b. Living wills d. surrogate acts
Rationale: Living will is a legal document stating a person does not wish to have extraordinary lifesaving measures when not able to make decisions about own care.
31. Mrs. Nueva tells you that she is hearing voices telling her to smother her newborn but tells you not to tell anybody. The nurse reports this to Mrs. Nueva’s husband. what principle is involved in this situation?
a. Veracity b. Fidelity c. Confidentiality d. paternalism
Rationale: Paternalism is the intentional limitation of another’s autonomy. Under this principle, the prevention of harm takes precedence over any potential evils caused by interference with the individual’s autonomy.
32. Disclosing all pertinent information to the patient about their health condition and the option for treatment is part of:
a. Veracity b. Fidelity c. Autonomy d. paternalism
Rationale: Autonomy entails the ability to make a choice free from external constraints. Clients can only make a well-formed decision if they are fully informed about the treatment, its benefits and its risks.
33. A good nurse is sensitive to the emotional state of a patient because it addresses the overall needs of the patient. This is in line with the principle of:
a. Beneficence b. Non-maleficence c. Justice d. Fidelity
Rationale: Beneficence of doing good for the client. Taking care of the client holistically (physically, emotionally, spiritually) is a benevolent act because it promotes the good of the client.
34. Washing one’s hands before and after patient contact to prevent the spread of infection and disease is an example of using the principle of:
a. Beneficence b. non-maleficence c. justice d. fidelity
Rationale: Frequent hand washing is the number one way of preventing the transmission of microorganisms. This act satisfies the principle of non-maleficence which is not to inflict harm as well as to prevent and remove harm.
35. Taking time to read get well cards to patient is an example of:
a. Beneficence b. Non-maleficence c. Justice d. Fidelity
Rationale: Beneficence is doing good for the client. Reading well cards for the client is one way of showing care and compassion to clients.
36. Giving discharge teachings to clients and being responsive to their needs is an example of using the principle of:
a. Beneficence b. Non-maleficence c. Justice d. Fidelity
Rationale: Giving of health teachings to clients is one of the obligations of nurse. Fidelity is being faithful to one’s commitments.
37. Requesting permission from the client before touching them involves the principle of:
a. Beneficence b. Non-maleficence c. Informed consent d. Privacy
Rationale: Privacy is the right of an individual to withhold self and own life from public scrutiny. Client has the right to refuse to participate in clinical teaching and other forms of treatment.
38. Treating two people with differing abilities and needs in an identical and fair way follows the principle of:
a. Beneficence b. Non-maleficence c. Justice d. Fidelity
Rationale: Justice is the equal treatment of equal cases and equal distribution of benefits no discrimination on the basis of sex, race, religion, age and socioeconomic status.
39. A registered nurse arrives at work and is told to report to another unit because they are understaffed. The nurse has never worked in that unit before. Which of the following is the most appropriate nursing action?
a. Refuse to report to that unit
b. Call the hospital lawyer
c. Call the nursing supervisor
d. Report to the unit and identify tasks that they can be performed safely
Rationale: Floating to another unit is an acceptable, legal practice used by hospitals to solve understaffing problems. Nurses are allowed to float to another unit ass long as they do not assume responsibility beyond their level of experience or qualification.
40. Mrs. Buena is scheduled to have a hysterectomy. When discussing the pre-operative preparation, the nurse identifies that the client has no understanding of the surgery. The nurse should:
a. Describe the proposed surgery to the client
b. Proceed with implementing the pre-operative plan
c. Notify the physician that the clients needs further information
d. Explain to the client gently that she should have asked more questions
Rationale: The person who is performing the surgery is responsible to inform the client about the procedure. The nurse may clarify information, witness the client’s signature and co-sign the consent form.
41. A client in labor is being prepared for cesarean section. The most important nursing intervention before the anesthesia is administered is to:
a. Prepare the abdomen
b. Obtain the informed consent
c. Initiate an IV infusion
d. Insert an indwelling catheter
Rationale: This is the priority before anesthesia is administered. The other options can be done later.
42. When obtaining informed consent for surgery from Ms. Cruz, a mentally challenged adult the nurse must be sure that the:
a. Parent or guardian signs the consent
b. Client comprehends the outcome of the procedure
c. Client is fully able to explain what the procedure entails
d. Parent or guardian has encouraged the client to make the decision.
Rationale: The client must be intellectually competent to comprehend the procedure to give informed consent. If the person is considered to be incompetent, parents or guardians should be the one to give the consent.
43. When a nurse suspects that a child has been abused, the nurse’s primary responsibility must be able to:
a. Treat the child’s injuries
b. Confirm the suspected child abuse
c. Protect the child from any future abuse
d. Have the child examined by the physicians
Rationale: Protection takes priority over immediate treatment.
44. After speaking with the parents of a child dying from leukemia, the physician gives verbal DNR order but refuses to put in writing. The nurse should:
a. Follow the order as given by the physician
b. Refuse to follow the order, unless the nursing supervisor allows it
c. Ask the physician to write the order in pencil on the client’s chart before leaving
d. Determine whether the family is in accord with the physician and follow hospital policy
Rationale: This verifies family and physician agreement and uses institutional policy developed by the ethics committee.
45. An infant is scheduled for emergency surgery. The nurse notes that the baby’s mother is 13 years old and the father is 16 years old. The baby’s father and the paternal grandmother are at the bedside. The nurse obtain the informed consent from the:
a. Paternal grandmother c. Sixteen year old father
b. Hospital administrator d. Thirteen year old mother
Rationale: Minors who are married or emancipated from parents can consent for themselves and give consent for those people they are responsible for. In this case, the 16 year old father can give consent for his baby.
46. Before administering the per-operative medication to a client, the nurse should plan to:
a. Verify the consent c. check vital signs
b. Have the client void d. Remove the client’s dentures
Rationale: Consent must be acquired when the client is fully oriented and in a clear mental state.
47. A client is scheduled for surgery. Leally, the client may not sign the operative consent if:
a. Ambivalent feelings regarding the operation are present
b. Any sedative type of medication has recently been given
c. A discussion of alternatives with 2 physicians has not occurred
d. A complete history and physical has not been performed and recorded
Rationale: Any client who has been sedative type of medication has recently been given sign the consent for a surgical procedure.
48. A22 year old male client with end stage testicular cancer signs a “do not resuscitate” (DNR) order when he is admitted to the hospital. When respiratory arrest occurs 3 weeks later, the client is not resuscitated. Which of the following statements about DNR is true?
a. Age is an important factor in the decision not to resuscitate
b. The decision not to resuscitate resides with the client’s physical
c. The status of the DNR order is contingent on the policies of the institution
d. Once the order has been signed, it remains in force for the entire hospitalization
Rationale: policies relative to DNR orders vary among hospitals and the nurse must adhere to the policies of the institution.
49. Dr. Pedro ordered an antibiotic for Nurse Nena’s patient, Mr. Toribio. But she knows that the order is wrong, what should Nurse Nena do?
a. Carry out the order since the physician is the one who is in authority
b. Refuse to carry out the order and report the incident to the nursing supervisor
c. Call the MD and clarify the order
d. Give the dosage that she thinks is appropriate
Rationale: Nurse Nena should not carry out the order but first inform the MD. She needs to record that she clarified the order with the MD and record whatever decision she makes. Report the incident to the nursing supervisor afterwards.
50. When faced with an ethical dilemma in the care of a client, what should guide the nurse’s action?
a. Strong religious beliefs
b. Respect for client autonomy
c. Thorough understanding of the law
d. The physician’s orders
Rationale: Respect for the client self-determination is at the core of any nursing code of ethics.
51. Non-renewal of license for 5 consecutive years will result in:
a. Cancellation of one’s license
b. Violation of Code ethics
c. Inefficiency in one’s practice
d. Being considered inactive
Rationale: According to RA9173, non-renewal of professional license for 5 consecutive years will render the nurse inactive according to PRC-BON registry. To become active again one needs to undergo special training in a hospital accredited by the BON.
52. To ensure that the major areas of nursing care covered in the nursing licensure examination, the Nursing Law provides that in the Board of Nursing
a. The members of the BON must represent the areas of nursing education, nursing research and nursing practice
b. The three major areas of nursing: community health, nursing education and nursing service must be represented in the BON
c. The test framework must cover all the major areas of nursing practice
d. The specialties of nursing must be represented in the BON
Rationale: Section 4 of RA9173 states that the 3 major areas: nursing education, nursing service, and community health nursing must be represented in the Board of Nursing.
53. Specialization in nursing is a trend now in nursing practice. The current nursing law encourages this by having provisions to ensure the advance training of nurses in the different specialties. These provisions in RA 9173 are found in:
a. Section 30 b. Section 31 c. Section 33 d. Both b and C
Rationale: RA 9173 section 31 refers to the development of the specialty training program and section 33 refers to the provision of funding for the program which will be administered by DOH.
54. The nurse researcher role is stipulated in what provision of the nursing law?
a. Section 28 Scope of nursing practice
b. Section 29 Nursing service administration
c. Section 27 Nursing education
d. Section 35 Prohibitions in the practice of nursing
Rationale: In the scope of practice is defined as RA 9173, the role of the nurse as a researcher is stated in the duty/function #5 of section 28 which states that the nurse shall undertake in-service training, education and research.
55. If a nurse from Australia would like to practice nursing in the Philippines, she will be allowed if she complies with the requirements for reciprocity which include the following:
1. Her country recognizes that the Philippines has world class nursing education
2. Australia has laws that grants the same privileges to Filipino registered nurse
3. Her country has substantially the same requirement for licensure
4. Australia is a member of ASEAN
a. 1 and 2 b. 2 and 3 c. 1 and 4 d. 1 and 3
Rationale: According to RA 9173 reciprocity is granted if the two conditions are met such as: a.) Australian laws grant the same privilege to practice nursing as our country would grant to an Australian nurse; and b) the requirement to obtain a license for nurses are substantially the same.
56. The license to practice one’s profession like nursing is considered a:
a. Privilege b. natural right C. Inborn right d. vested interest
Rationale: The right to practice one’s profession is a vested right or a privilege which a nurse acquires when s/he passes the licensure exam. Once registered the privilege becomes a vested right that can only be withdrawn for a cause as stipulated in section 23 of RA 9173 on causes for revocation/suspension of license.
57. When a member of the Board of Nursing commits an irregularly in the conduct of the board examinations, s/he can removed from office by:
a. The chairman of PRC c. The President of the Philippines
b. The President of PNA d. Order of the courts
Rationale: The members of the Board of Nursing are presidential appointees. Thus only the president of the Philippines can remove the erring person from office. The principle being followed is: he who has the power to appoint, also has the power to remove from office.
58. If found guilty of the violating the provision of the nursing law on prohibited acts, the person can be penalized which could be:
1. A fine of not less than Php 50,000 but not more than Php 100,000
2. An imprisonment of not less than one year but not more than 6 years
3. A fine of not less than Php 10,000 but not more than php 20,000
4. An imprisonment of 6months to 6 years
a. 1 and 2 b. 2 and 3 c. 3 and 4 d. 2 and 4
Rationale: (A) Section 35 of RA 9173 stipulates the provision on prohibited acts and the penalties. The penalties can ranged from a fine of Php 50,000 to Php 100,000 and an imprisonment of not les than one year but not to exceed 6 years.
59. Suppose you took the licensure exam last june but failed it. If you repeat the exam in December, what rule on rating will apply to you based on RA 9173?
a. You need to get a grade of 75 in all the subjects you will repeat
b. Your scores must all be 60 in above
c. The general average must be at least 75% with no grade below 60 in any subject
d. The general average can be below 75% since it is a repeat of the board exam
Rationale: Section 15 of RA 9173 states that if one has not had an average of 75% in the repeat exam with no grade below 60 in any subject.
60. Who among the following are qualified to the dean of a new college of nursing?
a. One who has a BSN,RN and an MA in nursing
b. One who has a BSN, RN, and completed all academic units for MA in Nursing
c. A former chief nurse with at least 9 units of graduate studies in nursing
d. A former clinical instructor, with Phd in Education
Rationale: According to RA 9173, the educational qualification of a dean is a Master of Arts in Nursing completed. A PhD is desirable but not required. Option D does not specify if the former clinical instructor has a completed degree in MA Nursing.
61. Which of the following actions will make the nurse become an accessory in a crime?
a. The nurse informed a client where to go for abortion that a police raid will be done to allow the doctor to leave before the raid.
b. The nurse informed a client where to go for abortion services
c. The nurse acted as the circulating nurse in a surgical abortion procedure
d. The nurse inserted a catheter into the uterus to initiate uterine contraction
Rationale: An accessory in a crime participates in the crime after the act itself is done like allowing the abortionist to escape being apprehended. Option B is an act of being an a compliance or accessory before the fact. While Options C and D are acts of a principle in a crime.
62. All of the following actions will make a nurse the principle in a criminal abortion EXCEPT:
a. Performing the D and C itself
b. Throwing away the abortus after the D and C was completed
c. Masterminding the crime
d. Assisting the obstetrician perform the surgical abortion as t eh scrub nurse
Rationale: As a principal, the nurse performs the act itself or masterminded the doing of the crime or does an act that is essential and simultaneous to the commission of the crime itself like being the scrub nurse. If the participation is after the commission of the crime like throwing away the evidence, the act is as an accessory.
63. Which of the following examples illustrates a consummated crime?
a. The nurse purposefully gave overdose of insulin to kill the patient but the patient recovered from the overdose.
b. The nurse planned to give her patient an overdose of tranquilizer to end the patient’s misery due to an incurable disease.
c. A private duty nurse killed her patient by mixing arsenic with the food she feeds her patient
d. The patient was removed from the respirator but had spontaneous breathing in spite of being detached from the machine
Rationale: A consummated crime is one where the objective of the crime has been achieved like in option C, to kill the patient. Option A is an example of frustrated crime and B is still a plan not yet executed.
64. Which of the following illustrates the doctrine of res ipsa loquitur?
a. The patient had a mosquito forcep left inside the abdomen after abdominal surgery as shown by abdominal x-ray
b. The nurse failed to ask the patient to sign the OR consent from the surgery
c. The nurse forgot to give the 8am dose of digitalis
d. The nurse did not check the deep tendon reflex of a woman in severe pre-eclampsia before repeat dose of magnesium sulfate is given
Rationale: Res ipsa loquitur means that evidence of the negligent act is the injury caused. In option A the proof o fteh negligence is the presence of the mosquito forcep seen inside the abdomen.
65. If the attending doctor gives a telephone order for a new medication, the nurse’s BEST action is to:
a. Request the nurse supervisor to take the order
b. Refuse to take the order because phone orders are not legal
c. Request the medical intern to write down the order and sign it
d. Request the resident on duty to receive the call and write the order as well as sign it
Rationale: The best action of the nurse is option D because to make the telephone order legal there is a need for the order to be written and signed by a licensed physician. A resident is a licensed physician. An outright refusal is also wrong and medical intern or the nurse supervisor are not legally allowed to write medical orders.
66. When a patient is accidentally injured during an earthquake that occurred, the nurse cannot be held liable for the injury because the situation is considered an example of:
a. Res ipsa loquitur
b. Respondeat superior
c. Force majeure
d. Due process
Rationale: When force majeure is present in a situation the nurse is exempted from liability. Force refers to a natural event or an event that is unpredictable and the injury caused is beyond the control of the nurse.
67. In respondent superior, the nurse supervisor is also accountable for the action of her staff. The supervisor can protect herself from legal accountability if she does the following actions EXCEPT:
a. Orient her staff nurses adequately to the policies and procedures
b. Develop a manual of procedures and policies for the guidance of the staff
c. Remind the staff of their responsibilities thru memoranda, circulars and policies
d. Hire graduate nurses awaiting for the board results only when there is lack of staff
Rationale: Staff nurse must be licensed. They are the only legally qualified nurse to be hired as staff. A graduate nurse who is not yet a board passer is not qualified and there is no certification/license from the Board that she/is a safe practitioner.
68. A staff nurse supervised a nursing student perform a nursing procedure for the first time and the patient got injured. The student’s liability in this situation is correctly described as:
a. The student is as liable as the staff nurse since both of them did the procedure together
b. The student is less liable because she is still a student
c. Only the staff nurse is liable since the student is exempted from liability based on the nursing law.
d. The school in which the student is enrolled in is liable for the patient’s injury.
Rationale: In Section 28 of RA 9173 5th paragraph, the law state that students who perform the nursing functions are not held liable provided that they are supervised while performing nursing actions. Hence, only the staff nurse who is the employee of the hospital in which the patient is confined, will be held liable since she was directly supervising the student perform the procedure when the injury occurred.
69. Maria, registered nurse has her professional ID expiring by June 30. Which of the following statements is correct regarding renewal of professional ID?
a. The appropriate time to renew one’s PRC ID is every 3 years preferably at the beginning of the year.
b. Renewal of PRCID maybe done anytime fromJUne1-30 to avoid penalty
c. According to PRC policy, she will be allowed to renew her PRC ID only on June 30
d. Renewal is every 3 years on one’s birthday.
Rationale: PRC policy is that renewal of PRC ID is every 3 years on one’ birth month not just on the day of one’s birthday. If renewal is only on one’s birthday, this is too limiting because the day may fall on a “no office” day e.g. Saturday, Sunday or Holiday.
70. When a member of the Board of Nursing has her/his term ended, s/he does not leave office until someone is appointed by the President of the Philippines to replace the person. This is based on the principle called:
a. Respondent superior C. Due process
b. Hold over d. Primos inter pares
Rationale: Holdover is a principle that allows appointed officials to continue to hold office even when their term ha already expired provided on one has been appointed to replace him/her.
71. Which of the following factors will make a person less liable of the crime he/she has committed?
a. The nurse was drunk while assisting in surgery which lead to wrong sponge count
b. An insane patient slaps her nurse while attempting to give her medication
c. An OB nurse assisted the obstetrician perform an abortion as the sterile nurse
d. The nurse reported immediately an error of medication she committed
Rationale: When a nurse voluntarily reports the error so that immediate action can be done to counteract the error, the action will reduce or mitigate her liability since one of the factors that can decrease one’s liability in a criminal act is voluntary surrender.
72. One of the important conditions that must be present in a negligent act to be considered as force majeure is:
a. The nurse is unable to predict the possible occurrence of the action hence, she cant prevent it
b. The injury is within the domain of nursing practice
c. The patient did not voluntarily participate in the action
d. The superior is also accountable for the action
Rationale: In force majeure, the action is considered an act of God which is either unpredictable or if predictable is uncontrolled within the usual human capability.
73. When a nurse fails to protect a patient from failing off the during an eclamptic seizure, the nurse will be considered negligent. The first and foremost question asked when determining liability of the nurse in a negligent act is:
a. Did the patient contribute to the occurrence of the injury?
b. Is there a breach of hospital policy?
c. Is it the duty of the nurse to protect the patient from the injury received?
d. Did the health team fail to protect the patient?
Rationale: When determining liability in a negligent act the first question to ask is whether there is a duty on the part of the nurse to protect the patient from the injury. If no duty exist, the nurse can not be held liable.
74. Which of the following are causes for revocation or suspension of professional license of a nurse?
a. Fraud or deceit in obtaining one’s license and negligence
b. Negligence and being accused of a criminal act
c. Negligence and non-renewal of license
d. Failure to pay professional tax and non-renewal of license
Rationale: According to Ra 9173, the two actions in letter D are causes for revocation/suspension. In letter B, being accused is not the same as conviction of a criminal offense, while non-renewal or license or non-payment of professional tax are not cause for revocation or suspension based on the nursing law.
75. Foreign nurses who would like to practice nursing in the Philippines will be allowed To get a special permit if the nurse is:
a. An internationally recognized expert in a field of nursing
b. The nurse would like to setup her own clinic in a rural community
c. The nurse is part of a regular team that perform surgery in a well known hospital in the Philippines
d. The nurse is from a country where we have no existing mutual recognition agreement
Rationale: According to RA 9173 section 21, special permit maybe granted to an internationally recognized nurse expert or two one who will do free medical mission but not to one who will be charging professional fees.
76. Which of the following is a TRUE statement about revoke license?
a. Once revoked, it can never be re-issued
b. Revocation means permanent withdrawal of the privilege to practice and will not be re-issued
c. Revoked license maybe re-issued provided that the cause of revocation has already been removed
d. Revocation like suspension is a permanent disqualification to practice nursing
Rationale: According to RA 9173 section 24, a revoked license may still be re-issued provided 2 conditions are satisfied one of which is that the cause for revocation has already been corrected or removed.
77. Who among the following nurse would qualify to be a dean of a college of nursing in the Philippines?
a. One with PhD in education, MA in Nursing with 10 years experience in nursing
b. One with an MA in education, 10 years practice in a hospital as chief nurse
c. One with MA in Nursing with 18 units in PhD in Nursing, 3 years experience in teaching
d. One with PhD in Nursing, MA in Nursing and 2 years in teaching
Rationale: While a PhD in Nursing will be a plus factor, what the nursing law requires is only a Masters in Nursing and at least 5 years experience. The current nursing law does not specify whether the experience is in the hospital or in teaching.
78. Which of the following actions of the nurse is now covered in RA 9173 which was not very clear in the old nursing law?
a. The nurse can take care of geriatric clients
b. The nurse can do private practice
c. The nurse is allowed to handle normal delivery and do suturing of perineal lacerations after training
d. Give intravenous injections without need for special training
Rationale: According to RA 9173 section 28, a nurse is allowed to handle normal delivery, do internal examination in the absence of bleeding and do suturing of perineal laceration provided s/he has undergone a special training. Now the law is silent about the need for special training for intravenous which can be interpreted as allowing the nurse to give IV even without special training.
79. When a nurse decides to be an independent nurse practitioner, she must consider that she is primarily responsible as an independent practitioner to activities that are:
a. Activities within health promotion and disease prevention are her primary domain
b. Curative and rehabilitative activities are her primary focus
c. The whole range of activities covering health promotion as well as cure and rehabilitation are well within her field of practice
d. For her to be allowed to practice independently, she needs to have a tie-up with a doctor for safety
Rationale: For independent practice, the nurse’s primary focus is health promotion and disease prevention. This is particularly stipulated in RA 9173 section 28.
80. If a professional nurse has not practiced her profession for the past six years and wants to practice again, she needs to do which of the following actions?
a. Pay first professional tax before applying for renewal of PRC license
b. Undertake the special training approved by BON before applying for renewal
c. Write a letter of request justifying to the BON the reason for non-renewal
d. Do the re-take exam and pass it
Rationale: Not practicing the profession for 5 consecutive years will make the nurse classified as inactive. In order to become active again, one must undertake the special training approved by BON which is a one month didactic and 3months of practicum.
81. Which of the following qualifications for a chief nurse is NOT mandated in the nursing law?
a. Masters in Nursing or related field
b. At least 5 years experience in a supervisory capacity
c. For a primary hospital, BSN with at least 9 units of management courses at the graduate level
d. For a military hospital, in addition to masters, a completion of the General Staff course
Rationale: The educational qualification for a chief nurse of a secondary or tertiary hospital is at least a masters in nursing degree. Only in a primary hospital does the law allow a less than masters degree qualifications.
82. According to RA 9173, the minimum base pay for a nurse working in government hospitals should be Salary Grade:
a. 10 b. 12 c. 14 d. 15
Rationale: According to section 23 of the current nursing law, the minimum base pay of a nurse government should be salary grade 15. However, this provision is still awaiting implementation.
83. When a nurse renders service to an injured person from a car accident she saw lying on the street, she will not be held liable for any possible further she may cause because she is covered by the principle of:
a. Re ipsa loquitur C. Good Samaritan Act
b. Respondeat superior d. Force majeure
Rationale: According to the principle of Good Samaritan Act, if a nurse assist an injured person who is not under her direct supervision or is a stranger to her/him and cause unintentional injury, s/he will not be held liable for it.
84. A nurse is suppose to render service to those who needs his/her service regardless of race, creed or nationality. This action refers to which doctrine?
a. Medical neutrality c. Res ipsa loquitur
b. Privileged communication d. Hold over
Rationale: One of the basic ethical principles that nurses subscribe to is medical neutrality which means that s/he will render service as needed without consideration for race, nationality or political belief.
85. The Philippine Nurses Association is considered as the accredited professional organization (APO) for nursing in the Philippine. This means that PNA is recognized
a. To be the political party to represent nurses in all matters related to the profession
b. By PRC as the official representative of the nursing profession in matters affecting nurses and nursing in the country
c. By the ICN as the organization officially representing the Philippines in the international community
d. As the duty elected by the nurses as their representative when dealing with the government
Rationale: Accreditation of Professional organizations is given by the Professional Regulation Commission. A professional organization, once accredited becomes the official representative of the profession. When government would like to deal with nurses, it will coordinate and collaborate with the APO.
86. When a Filipino nurse wants to work abroad, s/he needs to have all her documents ready. To secure a Philippine passport, the most important document needed is:
a. Baptismal certification c. Birth Certificate
b. Certification of employment d. NBI clearance
Rationale: A passport is proof of citizenship. Locally, when one wants to show proof of Filipino citizenship, one must his/her birth certificate which is given the National statistics office. When on travel, the proof of citizenship recognized by the international community is the Philippine passport.
87. A passport has only a period of validity, usually 5 year. When it expires and the nurse is out of the country, where should s/he go for renewal?
a. Philippine Embassy c. Overseas Welfare Administration
b. Department of Foreign Affairs d. Philippine Overseas Employment Administration
Rationale: In a foreign country, the office that represents our government is the Philippine Embassy or Consulate. One must go to the nearest embassy or consulate for renewal of passport. Department of Foreign Affairs is located in the Philippines. The other offices are not directly concerned with passport renewal.
88. A work contract must be valid. To be valid it must meet the certain conditions. Which of the following conditions are required?
1. The parties involved are of legal age and sound mind
2. The subject matter covered by the contract is lawful
3. The persons voluntarily agree to the terms of the contract
4. The employer is a recognized company in the Philippines
a. 1,2,3,4 b. 1,2,3 c. 1,2 d. 2,3
Rationale: All the three conditions are required to make a work contract valid. The employer being a foreign national and/or the employment being abroad is not a necessary condition for validity of the contract.
89. Which of the following examples will make a contract null and void?
a. The contract is only verbal
b. The contract was signed not in the presence of the witnesses
c. The contract is not notarized
d. One of the contracting parties is only 18 years old
Rationale: To make a contract valid, both of the contracting parties must be of legal age or at least 18 years old. According to RA 6809, legal age in the Philippines has been lowered to 18 years old.
90. A terminally-ill patient wants to make his last will and testament. He asks the nurse to help him make one. Which of the following actions is appropriate for the nurse?
a. Act as the testator for the patient
b. Serve as one of the witnesses voluntarily
c. Take one of the responsibility of helping the patient make his last will and testament because this is one of her duties as the nurse in charge of the patient
d. Failure to assist the patient make his last will and testament can be considered a form of negligence on the part of the nurse
Rationale: Actions pertinent to the making of the last will and testament are only voluntarily for the nurse. She is not legally required to help the patient make his last will and testament. She can refuse to assist and just refer him to his own lawyer.
91. When a contract is written and all the terms of the agreement are specified, what would you consider this type of contract?
a. Implied contract c. Informal contract
b. Expressed contract d. Legal contract
Rationale: A contract is said to be expressed when all the terms of the agreement are specified at the time the contract is made regardless of whether the contract is written following the legal format or simply verbal.
92. When looking for a possible witness in the making of a last will and testament, the nurse needs to look at the qualifications of the prospective witness. Which of the following characteristics will make a person disqualified from being a witness?
a. Can read and write
b. Is one of the beneficiaries
c. Not deaf, dumb or blind
d. Not intoxicated with alcohol
Rationale: Being a beneficiary of the last will and testament can lead to conflict of interest so this makes the person disqualified.
93. Which of the following examples is NOT legal order of the doctor?
a. The doctor sent a text message giving the order for a new antibiotic to be given to his patient
b. The doctor called by phone to ask for the results of the latest laboratory exam which will serve as his basis for his new medical orders
c. The first year resident wrote the admitting orders for a new patient
d. The anesthesiologist wrote the pre-medication orders in his prescription pad with his name and signature
Rationale: A legal order of the physician is defined as one that is written and signed by a licensed physician. An order for antibiotic given as a text message does not meet these criteria being written and being signed by a licensed physician.
94. A urologist who is visiting his relative confined for a kidney condition wants to see the patient’s chart. Which of the following action is BEST for the nurse in charge to do?
a. Refuse to allow the urologist to read the chart and send a compliant to the medical department
b. Refuse to allow the urologist to read the chart and refer him to the attending physician for the information he needs
c. Show the urologist the chart after all he is also a specialist in kidney disorders
d. Ask your immediate supervisor to deal with the problem for you
Rationale: Information found in the patient’s chart is confidential and part of privileged communication. The chart must be accessible only to those who are directly in charge of the care of the patient. Simply refusing is also not a professional behavior of a nurse. What she should do is refer the urologist to the attending physician and let them discuss the patients condition.
95. The following conditions will aggravate the liability of a person in a crime EXCEPT:
a. The person who committed the crime is over 70 years old
b. The person has authority over the person s/he has abused
c. The crime was done during a calamity
d. There was intent and deceit in committing the crime
Rationale: Persons who are already over 70 years old are already considered less liable for the crime committed. The same is true of minors who commit a crime. They are considered mitigated or less liable for the crime committed.
96. For the doctrine force majeure to apply thus making a nurse less liable for the negligent act, the following conditions must be satisfied.
1. There was no intention to commit the crime
2. There was no negligence attendant to the act
3. The injury caused is purely accidental
4. The action itself is lawful
a. 1,2,3,4 b. 1,3,4 c. 3,4 d. 2,3,4
Rationale: All the four conditions must be present in order for force majeure to apply in a negligent act. If one of the four conditions is not fulfilled, this principle of force majeure will apply and the nurse will not be exempted from liability.
97. When a staff nurse gives the wrong medication to her patient, the head nurse and supervisor are also made responsible for the error. This is based on what doctrine?
a. Respondent superior c. Good Samaritan Act
b. Res ipsa loquitur d. hold over doctrine
Rationale: Respondent superior means that the superior is also accountable for the error/mistake committed by his/her subordinate. In the case of the staff, the immediate superior is the headnure and supervisor. They are both liable including the chief nurse and the hospital because of the employer-employee relationship.
98. When an adult patient would like to go home but there is no medical order for discharge the nurse cannot stop the patient from going home. If she refuses to allow the patient to go home, she can be held liable for what crime?
a. Assault b. Illegal detention c. Hold over doctrine d. Disrespect for authority
Rationale: An adult patient who is competent and would like to go home despite the absence of a doctor’s order has the right to insist on going home. This is his right, the right to autonomy. He can charge the nurse and the hospital with the crime of illegal detention or false imprisonment.
99. A married woman wants to have tubal ligation done on her. There should be consent not only from herself but also from the husband. The reason for this is:
a. Tubal ligation is a surgery thus the legal spouse must know
b. Tubal ligation although a simple procedure may have some serious complications so the husband must also know
c. The operation will result in the incapacitation of the woman to bear a child which will affect the right of the husband to have children
d. The husband usually pays the hospital bills so he needs to know
Rationale: Operations that will result to sterilization of the woman requires the consent also of the husband because the surgery will affect the husband’s right to have children.
100. Which of the following circumstances will justify a person to commit a crime or injure someone?
a. In defense of oneself or one’s property
b. To protect oneself from oral defamation
c. When the person doing the action is insane
d. When the person doing the act is minor
Rationale: The only justifying circumstances that will allow a person to injure another without incurring a liability is in defense of oneself or one’s property. If the one who committed the crime is insane, that person is exempted but not justified. If the person is a minor, that person will only be mitigated but not justified.
Musculoskeletal (Green highlight indicate that the questions are originally made by me)
1. The client with a right above-the-knee amputation asks the nurse why people like him experience phantom limb pain. The best response of the nurse is:
a. “Phantom limb pain is not real pain, but is remembered pain”
b. “Phantom limb pain is not explained or predicted by any one theory”
c. “Phantom limb pain will not interfere with your activities of daily living”
d. “Phantom limb pain occurs because your body thinks your leg is still present”
Answer: B – The three theories being researched with regard to PLP. The peripheral nervous system theory implies that sensation remain as a result of severing peripheral nervous during amputation. The central nervous system theory states that PLP results from a loss of inhibitory signals that are generated through afferent impulses from the amputated limb. The psychological theory helps predict and explain PLP in that stress, anxiety, and depression often trigger or worsen an episode of PLP --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.187 [#19]
2. The nurse will be giving instructions to a client about crutch use. Which of the following procedure is about swing-through gait?
a. Both crutches and the foot of the affected extremity are advanced together, followed by the foot of the unaffected extremity ---three-point gait
b. The right crutch is advanced, then the left foot, then the left crutch, and then the right foot ---four-point gait
c. Both crutches are advanced together, and then both legs are lifted and placed down the spot behind the crutches. The feet and crutches form a tripod ---swing-to gait
d. Both crutches are advanced together; then both legs are lifted through and beyond the crutches and placed down again at a point in front of the crutches
Answer: D – Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.1081
3. A post-stroke client needs health teaching about how to use a cane for ambulation. Which of the following nursing interventions by the nurse is incorrect?
a. The client’s elbow should be flexed at a 15-30 degrees angle
b. Instruct the client to hold the cane 4-6 inches to the side of the foot
c. Instruct the client to hold the cane in the hand on the affected side ---unaffected side
d. Instruct the client to move the cane at the same time as the affected leg
Answer: C – A nurse should stand at the affected side of the client when ambulating; instruct the client to inspect the rubber tips regularly for worn places --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.1082
4. A client with Buck’s extension traction is in pain and keeps on sliding down that the weights almost touch the floor. Which of the following nursing intervention should a nurse prioritize?
a. Address the pain of the client
b. Notify the attending physician
c. Remove and change the weight
d. Assess the Buck’s extension traction
Answer: A – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.2027-2028
5. A client was brought in the ED after an automobile accident and needs immediate surgical intervention because of a fracture cervical spine. After the surgery, the client is brought into the ward with a skeletal traction. Which of the following nursing interventions should the nurse give the highest priority?
a. Maintaining position
b. Preventing skin breakdown
c. Maintaining effective traction
d. Monitoring neurovascular status
Answer: C – The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Removal of the weights completely defeats their purpose and may result in injury to the patient --- Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.2028
6. Weights are use in skeletal tractions. How much weight should be use to achieve a therapeutic effect?
a. 2-3.5 kg ---skin traction
b. 4.5-9 kg ---pelvic traction
c. 7-12 kg
d. 10-15 kg
Answer: C – Skeletal traction frequently uses 7-12 kg (15-25 lbs) to achieve the therapeutic effect. The weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing--- Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.2028
7. The nurse would identify which of the following factor is the least likely to contribute to a client’s peripheral vascular disease to avoid amputation?
a. Current age of 39 years
b. Uncontrolled diabetes mellitus for 15 years
c. A 20-pack-year history of cigarette smoking
d. A serum cholesterol concentration of 275 mg/dL
Answer: A – Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease. Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because of the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol level greater than 200 mg/dL are considered a risk factor for peripheral vascular disease --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.448 [#54]
8. While teaching a client with hip prosthesis about ways to prevent dislocation, which of the following instruction is correct? SATA
a. Keep the knees apart at all times
b. Put a pillow between the legs when sleeping
c. Use a high-seated chair and a raised toilet seat
d. Affected leg should not cross the center of the body
e. Hip should be bend on a 90 degree angle when in a sitting position
f. Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes
Answer: ALL – The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Removal of the weights completely defeats their purpose and may result in injury to the patient --- Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.2033
9. A client is suspected to have Rheumatoid Arthritis. Which of the following are diagnostic criteria for the said disease? SATA
a. Tender subcutaneous masses found on olecraton bursae or extension surface of forearm over pressure areas ---firm, nontender; rheumatoid nodules
b. Morning stiffness lasting for at least 1 hour and persisting over at least 6 weeks
c. Arthritis of wrist, MCP, or PIP joints persisting for at least 6 weeks
d. (+) serum rheumatoid factor
Answer: BCD – Also include: Arthritis with swelling or effusion of three or more joints for at least 6 weeks, symmetric arthritis with simultaneous involvement of corresponding joints on both sides of the body, and characteristic radiologic changes (erosions or decalcifications) of rheumatoid arthritis noted in hands and wrists --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.161
10. A 55 year old client is suspected to have Rheumatoid Arthritis. Which joint deformity has a hyperextension of PIP joints with flexion of DIP joints?
a. Ulnar drift ---joint deformity characteristic of RA
b. Swan neck
c. Rheumatoid nodules ---firm, nontender subcutaneous masses found on olecraton bursae or extension surface of forearm over pressure areas
d. Boutonnière deformities ---flexion of PIP joint and hyperextension of DIP joint
Answer: B – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.161
11. Which of the following drugs are used by a client with gouty arthritis for acute attacks?
a. Allopurinol (Zyloprim) ---used for prophylactic treatment and chronic gouty arthritis
b. Probenecid (Benemid) ---also used for prophylactic treatment
c. Sulfinpyrazone (Anturane) ---used for prophylactic treatment and chronic gouty arthritis
d. Auranofin (Ridaura) ---disease-modifying drug used for Rheumatoid Arthritis
Answer: B – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.161, 163
12. When caring for a client receiving continuous passive motion (CPM) therapy, postoperatively, which of the following would the nurse perform?
a. Adjusting the setting as needed to prevent client discomfort
b. Discontinuing the CPM therapy when range of motion increases to 90°
c. Increasing the range-of-motion (ROM) setting at least 8 hours
d. Maintaining proper positioning of the joint on the CPM machine
Answer: D – The nurse must frequently evaluate the positioning of the client’s leg to prevent misalignment and development of possible contractures. Initially the client may experience some discomfort when using a CPM machine. If the client cannot tolerate the discomfort, the physician should be notified to obtain an order to adjust the settings. The settings for the machine are determined by the physician and cannot be changed without an order. Although the optimal degree of flexion is 90 degrees, therapy will continue until the individual regains the maximal degree flexion in the knee as determined by the doctor --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.443 [#12]
13. An elderly client with osteoporosis was brought in the ED after slipping down in the bathroom. Which of the following nursing management should the nurse anticipate to give to the client? except
a. Aspirin (ASA) for pain
b. Recognize and treat early complications such as fat emboli, or DVT
c. Assess 5 Ps
d. Elevate extremity and apply an ice pack to relieves edema
Answer: A – Even though ASA has analgesic action, it should not be given to the client because there is bleeding especially if it’s an open fracture --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.176-177
14. Muscular Dystrophy is a genetically transmitted disease by recessive gene on X-chromosome (mother to son). A client was diagnosed of having Duchenne’s muscular dystrophy, a rapidly progressing form of the disease. Which of the following are signs and symptoms of DMD?
a. Waddling gait and toe walking
b. Progressive immobility
c. Death in early adulthood secondary to respiratory or cardiac failure
d. Generalized muscle involvement ---Becker’s MD: onset 5-15 years of age; X-linked recessive
e. Face, neck, and shoulder muscles involved with muscle inflammation ---Fascioscapulohumeral MD: onset 10-30 years; autosomal dominant
f. Shoulder and pelvic muscle involvement; upper and lower extremity weakness in proximal muscles ---Limb-girdle MD: onset 10-30 years; cause varies
Answer: ABC – Other signs and symptoms includes symptoms present around 2-3 years of age with frequent falls, pseudohypertophy of the muscles in the lower extremities, kyphosis, and cardiac involvement in later stage of illness ---Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.167-168
15. The client is suspected of having Paget’s disease (Osteitis Deformans), a chronic bone inflammatory bone disease. Which of the following diagnostic tests will suggest that the client has the said disease? SATA
a. Elevated hydroxiproline in the urine ---hydroxiproline is an amino acid present in urine of clients with Paget’s disease
b. Decreased serum alkaline phosphate ---elevated
c. Bone scans reveal active bone remodeling
d. X-rays reveal bone deformities, bone enlargement, widening of bone cortex
Answer: ACD – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.167-168
16. In giving nursing care to a client with Paget’s disease, which of the following is incorrect for a nurse to do?
a. Assess for signs and symptoms of hypocalcemia caused by increased osteoclast activity ---hypercalcemia
b. Instruct client to increase fluid intake 2-3 liters/day
c. Instruct on safety to prevent pathologic fractures
d. NSAID’s, calcitonin (Calcimar), alendronate (Fosamax)
Answer: A – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.166-167
17. A client went to the ED complaining of having muscle weakness, hair loss, rashes in the face and painless lesion in the mouth. She is suspected to have Systemic Lupus Erythematosus (SLE). Which of the following is a definitive diagnostic test for this disease?
a. (+) Serum antinuclear antibody (ANA) ---but not exclusive for SLE
b. (+) Anti-DNA antibody ---definitive for SLE
c. Elevated Serum complement levels ---Decreased Serum complement levels
d. Elevated ESR
Answer: B – Other diagnostic tests: CBC (positive for anemia, leucopenia, and/or thrombocytopenia), Urinalysis (positive for proteinuria and/or hematuria), Elevated BUN and Creatinine, and false (+) Serum syphilis --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.171-172
18. The nurse is teaching the client after undergoing spinal fusion about wearing a back brace. Which of the following statements made by the client indicates effective teaching?
a. “I can use baby powder under the brace to absorb perspiration”
b. “I should wear a thin cotton undershirt under the brace”
c. “I will be sure to pad the area around my iliac crest”
d. “I will apply lotion before putting on the brace”
Answer: B – The client should wear a thin cotton undershirt under the brace to prevent the brace from abrading directly against the skin. The cotton material also aids in absorbing any moistures, such as perspiration, which could lead to skin irritation and breakdown. Applying lotion is not recommended before applying the brace because further skin breakdown can result and irritants from lotion can cause further irritation. Applying extra padding is not recommended because the padding can become wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder is not recommended because the irritation from the talcum also cause irritation and skin breakdown --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.447-448 [#49]
19. The nurse is observing the nursing assistant performing all of the following intervention for a client with Carpal Tunnel Syndrome (CTS). Which action requires the nurse to intervene immediately?
a. Arrange the client’s lunch tray and cut the meat
b. Remind the client not to lift very heavy objects
c. Provide warm water and assist the client with a bath
d. Replace the client’s splint in hyperextension position
Answer: D – When a client with CTS has a splint used for immobilization of the wrist, it is placed either in the neutral position or in slight extension. The other interventions are correct and are within the scope of practice for a nursing assistant. Nursing assistants may remind clients about elements of their care plans such as avoiding heavy lifting --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.186 [#9]
20. The client with Buck’s Extension Traction asks the nurse about what are his activity limitations. The most appropriate response by the nurse is that:
a. “You can turn your body”
b. “You must lien on you stomach”
c. “You can sit up whenever you want”
d. “You must lie flat on your back most of the time”
Answer: D – The client can sit up in bed, remaining in the supine position so that an even, sustained amount traction is maintained under the bandage used in the Buck’s traction. Maintenance of even, sustained traction decreases the chance that the bandage or traction strap might slip and cause compression or stress on the nerves or vascular tracts, resulting in permanent damage. The client does not have to remain flat but may adjust the head of the bed to varying degrees of elevation while remaining in a supine position. The client should not turn his body to another position, because the bandage may slip --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.452 [#85]
Neurological (Green highlight indicate that the questions are originally made by me)
1. While the nurse reassesses a client, after a CT scan, she is flaccid, with no response to verbal or painful stimulation. Her pupils are dilated and non-reactive to light. Her vital signs: BP of 190/40; PR of 40; RR of 14; Temperature of 96.0°F; O₂ saturation of 92%. Which of the following complication is the nurse priority at of this moment?
c. Respiratory acidosis
d. Brain stem herniation
Answer: D – The client’s fixed and dilated pupils, widened pulse pressure, and bradycardia caused by increasing pressure on the brain stem and indicates that she is at risk of herniation of the brain stem through the tentorial notch which would result to brain death. Immediate surgical intervention is needed to prevent this complication. She is at risk for other complications, but they are not as life-threatening --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.207 [#10]
2. Which of the following is incorrect regarding Cerebral Blood Flow (CBF) and Cerebral Perfusion Pressure (CPP)?
a. Normally the CBF is 750mL/min
b. Normal CPP ranges from 40-60 mmHg; determines CBF ---60-100 mmHg
c. Hypercarbia: PaCO₂ greater than 45 mmHg produces vasodilation; increases ICP by increasing volume
d. Hypocarbia: PaCO₂ less than 25 mmHg produces rebound cerebral vasodilation, loss of autoregulation
Answer: B – Hyperpefusion and increased ICP occur with CPP greater than 100 mmHg, Hyporefusion and cerebral ischemia: with CPP 40-60 mmHg, Irreversible ischemia and infarction: with CPP less than 40 mmHg, and Brain death: with CPP 0-40 mmHg --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.111
3. Which of the following cranial nerves are responsible for a person’s gag reflex and if he/she develops dysphagia?
a. Cranial Nerve VII and VIII
b. Cranial Nerve VIII and IX
c. Cranial Nerve IX and X
d. Cranial Nerve X and XI
Answer: C– Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.1029 and 1039
4. In giving nursing care to a client following craniotomy, which action is incorrect?
a. Monitor vital signs and neurological status every 30-60 minutes
b. Maintain mechanical ventilation and slight hyperventilation for the first 24-48 hours as prescribed to prevent increased intracranial pressure
c. Monitor the Hemovac or Jackson-Pratt drain, which may be placed for 24 hours
d. Notify the physician if drainage is more than the normal amount of 10-20 mL per shift ---30-50mL
Answer: D– Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.1031
5. Which of the following position will you place the client after Infratentorial surgery?
a. The client should be turned from the back to the nonoperative side, but not to the side operated on ---removal of a bone flap for decompression
b. Position to the client on the side, with pillow under the head for support and not on the back ---posterior fossa surgery
c. Flat position without head elevation or the physician may order the head of the bed to be elevated at 30-45 degrees
d. The head of the bed to be elevated at 30 degrees to promote venous outflow through the jugular veins ---supratentorial surgery
Answer: C – Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.1032
6. After craniotomy, a client who is regaining consciousness becomes restless and attempts to pull out his intravenous line. Which nursing intervention should a nurse do to protect the client without increasing his ICP?
a. Place him in a jacket restraint
b. Apply a wrist restraint to each arm
c. Wrap her arms in soft “mitten” restraints
d. Tuck her arms and hands under the draw sheet
Answer: C – It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or a wrist restraint or tucking the client’s arms and hands under the draw sheet restrict movement and add feelings of being confined, all of which would increase his agitation and increase ICP --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.423 [#11]
7. A client with ICP is at risk to develop hypoxia due to cerebral vasodilation. Which of the following interventions of the nurse is incorrect?
a. Maintain PaO₂ greater than 60 mmHg
b. Maintain oxygen therapy
c. Suction every shift ---frequent suctioning can cause increase ICP
d. Maintain a patent airway
Answer: C – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.1864
8. Which of the following are signs and symptoms of Autonomic Dysreflexia? SATA
a. Bradycardia ---Spinal Shock
b. Severe hypertension
c. Hypotension ---Spinal Shock
e. Paralytic ileus ---Spinal Shock
f. Nasal stuffiness
Answer: BDF– Signs and Symptoms of Spinal Shock also includes flaccid paralysis, and loss of reflex activity below the level of the lesion. Signs and Symptoms of Autonomic Dysreflexia also include sudden onset, severe, throbbing headache, flushing above the level of the lesion, pale extremities below the level of the lesion, nausea, dilated pupils or blurred vision, sweating, and restlessness and feeling of apprehension --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.1036
9. A client has been diagnosed of having Multiple Sclerosis. Which of the following medications is given to the client to lessen muscle spasticity?
a. Baclofen (Lioresal) ---also can use Dantrolene (Dantrium), and Diazepam (Valium)
b. Carbamazepine (Tegretol) ---used to treat paresthesia
c. Oxybutinin chloride (Ditropan) ---used to decrease bladder spasm and control urge incontinence and frequency
d. Propranolol (Inderal) ---also can use Clonazepam (Klonopin) to treat cerebellar ataxia
Answer: A– Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.1041
10. Which of the following are signs and symptoms of a client that have a CVA/stroke? SATA
a. Altered level of consciousness
b. Unequal pupils
Answer: ALL – Signs and Symptoms also includes stertorous breathing, inability to make decisions, loss of memory, and gait instability --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.118
11. After having a stroke, the client develops homonymous hemianopsia (loss of half of the visual field). Which nursing management will a nurse anticipate to do? SATA
a. Place objects within intact field of vision
b. Approach the patient opposite from the neglected side
c. Instruct the client to turn head in the direction of visual loss to compensate for loss of visual field
d. When teaching the patient, do so within patient’s intact visual field
Answer: ALL – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.1890
12. A client with ischemic CVA is on thrombolytic therapy. During the first 24 hours of treatment, the primary goal is to control which of the client’s vital sign?
d. Blood Pressure
Answer: D – Control blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major side effect of thrombolytic therapy. Vital signs are monitored, and the blood pressure is maintained as identified by the physician and specific to the client’s ischemic tissue needs and risk of bleeding form treatment --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.426 [#37]
13. A client with Parkinson’s disease needs a long time to complete her morning hygiene. The nurse offers assistance but the client refuses and becomes annoyed. Which is the best initial response by the nurse at this moment?
a. Tell the client firmly that she needs assistance and help her with her care
b. Suggest to the client that if she insists on self-care, she should at least modify her routine
c. Praise her client for her desire to be independent and give her extra time and encouragement
d. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help
Answer: C – Ongoing self-care is a major focus for clients with Parkinson’s disease. The clients should be given additional time as needed and praised for her efforts to remain independent. Firmly telling the client that she needs assistance will undermine her self-esteem and defeat her efforts to be independent. Telling the client that her perception is unrealistic does not foster hope in her ability to care for herself. Suggesting that the client modify her routine seems to put the hospital or the nurse’s time schedule before the patient’s needs. This will only decrease the client’s self-esteem and her desire to try to continue self-care, which is obviously important to her --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.428 [#61]
14. Which of the following are signs and symptoms of Meningitis? SATA
a. Nuchal rigidity
b. Dysphagia ---a sign of increased ICP
d. Dilated pupils ---a sign of increased ICP
f. Bradycardia ---Tachycardia
Answer: ABCDE – A client with Meningitis can also manifest signs and symptoms of increased ICP --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.128-129
15. The physician decides to change the analgesic medication of the client from meperidine hydrochloride (Demerol) 75 mg IM q 4 as needed to meperidine hydrochloride by oral route. Which of the following dosage of the said medication is required to provide an equivalent analgesic dose?
a. 250-300 mg
b. 125-150 mg
c. 75-100 mg
d. 25-50 mg
Answer: A – Although meperidine hydrochloride can be given orally, it is more effective when given intramuscularly. The equivalent analgesic dose of oral meperidine hydrochloride is up to four times the intramuscular dose (75x4 = 300) --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.431 [#93]
16. A client is suspected to have Myasthenia Gravis. When conducting a Tensilon test, which of the following is a correct understanding about Cholinergic Crisis?
a. It is an acute exacerbation of the disease
b. It results in depolarization of the motor and plates
c. The crisis is caused by a rapid, unorganized progression of the disease, inadequate amount of medication, infection, fatigue, or stress
d. The client has signs and symptoms of increased PR, RR and BP, bowel and bladder incontinence, decreased urine output ,and absent cough and gag reflex
Answer: B – The signs and symptoms of a patient having Cholinergic Crisis includes abdominal cramps, nausea, vomiting, diarrhea, blurred vision, pallor, facial muscle twitching, hypotension, and papillary miosis --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.1042
17. A nurse obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
c. Specific gravity
Answer: B – The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether body fluid is mucus or CSF. CSF contains glucose; mucus does not --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.423 [#7]
18. In providing safety management to a client during seizure, which of the following action is incorrect?
a. Do not restrain
b. Protect from injury
c. Using a tongue depressor
d. Turn to side to keep open during postictal period
Answer: C – Do not force hard object between teeth --- Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.133
19. A mother of a client suspected to have Guillain-Barré Syndrome, ask the nurse “What is Guillain-Barré Syndrome?” The nurse knows that Guillain-Barré Syndrome is: except
a. Is a chronic, rapidly progressing inflammation of peripheral motor and sensory nerves ---acute
b. Paralysis that ascends symmetrically from lower extremities in most cases
c. Is caused by a cell-mediated immune reaction which is triggered by a viral illness or immunization
d. Signs and symptoms include partial paralysis, paresthesia, muscle aches, nighttime pain, decreasing O₂ saturation, autonomic dysfunction, hypertension, diaphoresis, and orthostatic hypotension
Answer: A – Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.133-134
20. The nursing responsibilities for the client with a patient-controlled analgesia (PCA) system would include:
a. Reassuring the client that pain will be relieved
b. Titrating of the client’s pain medication until the client is free of pain
c. Documenting the client’s response to pain medication on a routine basis
d. Instructing the client to continue pressing the system’s button whenever pain occurs
Answer: C – It is essential that the nurse document the client’s response to pain medication on a routine, systematic basis. Reassuring the client that pain will be relieved is often not realistic. A client who continually presses the PCA button may not be getting adequate pain relief, but through careful assessment and documentation, the effectiveness of pain relief interventions can be evaluated and modified. Pain medication is not titrated until the client is free from pain but rather until an acceptable level of pain management is reached --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.431 [#101]
Prof. Candelario, RN, MAN, US-RN
1. Mental health and psychiatric nursing is the:
a. Assessment of behavior and care of individuals with mental disorder
b. Use of interactions between the nurse and the individual to address problems
c. Dependent, interdependent and independent functions of the nurse to regain mental health
d. Promotion of optimal mental health, and early diagnosis, treatment and rehabilitation of the mentally ill
Rationale: Mental Health and psychiatric nursing is an interpersonal process that includes the promotive, preventive, curative and rehabilitative aspects of care of the individual, family or community.
2. The mind structure that focuses on reality principle by distinguishing fantasy from what exist in the environment is:
a. Id b. Ego c. Superego d. Unconscious
Rationale: The ego operates on the reality principle and meets and interacts with the outside world. The Id is the unconscious reservoir of primitive drives and is dominated by the pleasure principle. The superego acts as a censoring force and is composed of morals and values.
3. The ability to recall the name of one’s classmate in high school who went out with you most of the time is a manifestation of the:
a. Subconscious b. Conscious c. Unconscious d. Both conscious and subconscious
Rationale: Subconscious are memories that can be recalled to consciousness consist of memories and conflict that cannot be recalled at will and are said to be repressed.
4. According to Freud a child who idolizes and imitates her mother is noted in which stage of development?
a. Oral b. Anal c. Phallic d. Latency
Rationale: The resolution of the Electra complex occurs in the phallic stage and this entails incestuous feelings towards the father and identification of the girl with the same sex.
5. Protective processes to prevent mental illness include the following except:
a. Enhance self esteem
b. Supportive relationship
c. Taking new opportunities for growth
d. Maintenance of usual life patterns during stress
Rationale: Maintenance of the usual life patterns during stress difficulty in adjusting to changes in life that disturb one’s equilibrium. The other choices indicate characteristics of a mentally healthy individual who achieves self actualization.
6. A model that emphasizes the importance of interpersonal relationship and communication on behavior was proposed by:
a. Piaget b. Sullivan c. Glasser d. Selve
Rationale: the interpersonal theory by Sullivan is based on the assumption that interpersonal relationships facilitate development of the self system. Faulty patterns of relating interfere with maturity and security. Piaget views intellectual development as a result of a constant interaction between environmental influences development as a result of a constant interaction between environmental influences and genetically determined attributes. Glasser who proposed the reality therapy model cited that psychological needs must be met responsibly and within the context of reality. Selye’s stress model assumes that inadequate handling of stress can lead to physical and mental illness.
7. A 5 year old division chief teaches his assistant techniques in the company’s business dealings. Which of the following statements best describes the chief’s behavior?
a. His behavior is expected in his developmental stage
b. He feels threatened of his advancing age
c. He wants to control other people
d. He is making up for the pat mistakes
Rationale: The chief is in the middle adult stage where an individual’s task is generativity. Adult behavior that reflects mastery of this stage is passing on one’s good traits to the next generation and other societal responsibilities.
8. Which of the following behaviors exemplifies the use of rationalization?
a. An unattractive girl who wears stylish clothes and make up to draw attention
b. A young woman who is angry engages in a tennis match
c. A student who fails a quiz claims that the lectures were not sufficient
d. A secretary has kind words for her boss who reprimanded her for her incompetence
Rationale: In rationalization on attempts to justify one’s behavior. Choice A is an example of compensation where one overemphasizes a desirable trait to cover up a weakness. Choice B is channeling one’s instinctual drives into acceptable activities known as sublimation. Choice D is reaction formation where one shows an exact opposite of what one feels.
9. Situation: One of the basic tools that the nurse uses in dealing with her client is the therapeutic use of the self:
The therapeutic use of self is best described as:
a. The ability to effect a change in the patient by imposing spiritual values
b. Being accurate in analyzing the patient’s behavior
c. The ability to establish relatedness and structure nursing interventions
d. Being skillful and artistic in rendering care
Rationale: The nurse uses aspects of the self to help clients grow, change and heal. The nurse’s personal strengths, understanding of human behavior, and the nurse’s clinical skills are essential in meeting the client’s needs.
10. A client tells the nurse “I’m going to kill myself tonight but don’t tell the others about it.” When the nurse responds”I can’t keep the promise not to tell as this involves our safety” reflects an essential characteristic of the nurse that must be established early in the therapeutic relationship as:
a. Acceptance c. Trustworthiness
b. Genuine interest d. Concreteness
Rationale: Trustworthiness is when the nurse is consistent in her words and actions and can be relied on what she says. Acceptance is avoiding judgment of the client not matter what the behavior is. Genuineness is when the nurse is authentic when interacting with the patient. Concreteness is being specific and realistic, not theoretical in her response to the client.
11. The general feelings or emotional reference the nurse uses on organizing her knowledge about the world are referred to as:
a. Attitudes b. Values c. Beliefs d. Culture
Rationale: Attitudes refer to how one views people and the world which may affect how the nurse will express her feelings and how she will behave towards others. Values are abstract standards that give the person a notion of right and wrong. Beliefs are ideas that one holds to be true. Culture consists of socially learned behaviors, values and beliefs transmitted from one generation to another.
12. Which behavior by the nurse would be least effective in helping the client to achieve growth:
a. Completing a task for the client instead of repeatedly prompting him to finish it
b. Taking time to adjust to the slower pace of the client
c. Making self available to the client who refuses to interact
d. Using listening and observation skills
Rationale: Completing task for the client is ineffective and may interfere in the client’s ability to achieve goals. Adjusting to the client’s pace avoids frustration. Making self available to the client, listening and skillfully observing the client makes him feel important and gives him encouragement to complete a task or achieve goals.
13. The psychiatric nurse’s role in tertiary prevention is:
a. Prevent the chronicity of disease
b. Promote mental health through anticipatory guidance
c. Case finding for early diagnosis of the disease
d. Rehabilitation programs to prevent the crippling effects of illness
Rationale: Rehabilitation is aimed at optimizing the function of the patient and preventing the disability caused by the illness. A and C belong to the secondary level of prevention while B is primary level of prevention.
14. Situation: The nurse engages the client in a corrective interpersonal experience:
During the assessment process the nurse:
a. Establishes a therapeutic contract
b. Participate in nursing conferences
c. Collaborates with other nurses
d. Uses a system of data collection
Rationale: A system of data collection that includes mental status examination, history taking through interview and observation leads to a more precise documentation. This serves as a well founded basis in planning the care of the client.
15. In dealing with the client’s problems, the nurse prioritizes the nursing diagnosis according to:
a. The established goals of care
b. The ward’s priority list
c. Life threatening potential
d. Focus on resolution of patient’s problem
Rationale: Nursing diagnosis is the identification of the patient’s problem based on the conclusions of the client’s behavior and verbalizations. The safety of the client is a prime consideration in emergency situations like suicide, aggression, and other destructive behaviors. These serves as a basis for planning interventions to protect the client and in negotiating a no harm contract with the client.
16. The nurse ensures an accepting atmosphere in the unit where the client can relax and secure in sharing thoughts and feelings is assuming the role of a:
a. Socializing agent c. Patient advocate
b. Milieu therapist d. Technician
Rationale: As a creator of a therapeutic milieu the nurse creates an environment where a client feels secure and a client that encourages improvement and positive change in behavior. As s socializing agent the nurse helps the client improve their social skills and participate in group activities. The nurse informs the client about his rights and upholds these rights in her role as a patient advocate. The nurse as a technician does the activities of assessment, documentation, administration of medications and carrying out treatments.
17. An appropriate topic to be discussed in the working phase of the nurse-client relationship is:
a. A summary of the relationships and the client’s growth
b. The client’s problems and coping are explored
c. The clients perception of her illness
d. Setting the boundaries of the relationship
Rationale: Problem solving occurs in the working phase of the nurse-client relationship. The client who has learned to trust the nurse may be encouraged to share her problems and concerns and alternative behaviors and techniques are explored. A summary of the relationship and the client’s growth are done in the termination phase. The client’s perception of her illness is part of the initial assessment done in the orientation phase. Setting the time, place and duration of each meeting are part of the contract set at the start of the relationship.
18. A newly admitted client shouts at the staff she has just met for no apparent reason. The client is likely manifesting:
a. Transference b. Countertransference c. Rsistance d. Splitting
Rationale: Transference is one of the impasses in the nurse client relationship where positive and negative feelings associated with a significant other in the client’s past is unconsciously assigned to another person like the nurse.
19. Situation: Various treatment modalities and interventions may be utilized for clients be conducted. Which response by the nurse is in context with a therapeutic community:
a. “Ok let’s play cards”
b. “Let’s discuss this with the head nurse.”
c. “You can ask other patients to play with you.”
d. “we can discuss this together with the staff and other patients.”
Rationale: Therapeutic community calls for a group effort. A joint planning and decision making among the patients and staff is done. The other choices do not indicate group effort and open communication in the community.
20. The nurse gives an extra privilege to a client who regularly participates in ward activities is an example of:
a. Role modeling c. Behavior modification
b. Aversion therapy d. Logotherapy
Rationale: Behavior modification is a treatment modality that consists of rewarding good behavior with physical reinforcers while withholding these reinforcers if a maladaptive behavior occurs. Role modeling is where a nurse perform certain behaviors that the client can emulate. Aversion therapy is the use of unpleasant or noxious stimuli to change inappropriate behavior. Logo therapy focuses on searching for meaning in the client’s life.
21. Which of the following best describes the patient’s benefit from group therapy?
a. It offers a venue where the client can openly talk about feelings
b. Patient gets support from the leader
c. It reinforces the client’s strength
d. The patient can learn how their behavior affect others
Rationale: Group therapy offers a venue for interpersonal learning or learning about oneself in relation to others. Choices A and D are benefits that may be attained on an individual as well as group setting. Effective group leaders focus on group process and encourage participation of group members and do not focus on only one member.
22. A member of group therapy who actively seeks control thru incessant talking is a:
a. Monopolizer b. complainer c. moralist d. seducer
Rationale: A monopolizer takes control by dominating the discussion. A complainer discourages positive work and vents anger. A moralist serves as the judge of the right and the wrong. A seducer attempts to gain personal attention.
23. In counseling the nurse does one of the following:
a. Rewards a client with anorexia nervosa whenever she attains the desired weight
b. Helps the parents of a client with attention deficit hyperactivity to establish communication
c. Helps clients enhance coping by discussing their concerns
d. Refers the depressed client to a post discharge support group
Rationale: Counseling is a form of supportive psychotherapy in which the nurse offers guidance or assistance to the client in viewing options to problems that are discussed by the client in the context of the nurse-client relationship geared at health promotion. Rewarding the client for adaptive behavior is achieved in behavior therapy. Educating parents on how to handle a hyperactive client is done though educational group therapy. Referral is not a form of therapy.
24. Situation: The management of clients with various psychosocial concerns maybe facilitated by the nurse’s communication skills. When attempting to engage the client in conversation which technique is most effective?
a. Silence b. Exploring c. Broad opening d. Focusing
Rationale: Broad opening technique indicates that the client takes the lead in the interaction. In a client who is hesitant in interacting this technique may stimulate him to take the initiative.
25. During the one on one interaction with the nurse the client states, “I’m worried about going home.” The nurse responds, “I’d rather you wouldn’t worry.” This response by the nurse is:
a. Therapeutic because this helps the client become aware of what the nurse thinks
b. Therapeutic, because the nurse is being direct without feeling blunt
c. Non-therapeutic because the nurse is passing judgment on the client.
d. Non-therapeutic because it indicates that only the nurse knows what is best
Rationale: The nurse is not therapeutic because she is disapproving the client. The nurse should not pass judgment on the client.
26. A withdrawn client asks the nurse, ”Do you think they’ll ever let me out of here? ” The nurse’s best reply would be:
a. “Why don’t you ask your doctor?”
b. “Everyone says you’re doing just fine.”
c. “Why don’t you think you’re ready t o leave?”
d. “You have the feeling that you might not leave?”
Rationale: Directing back to the client her feelings is reflecting technique. This makes the client aware of what she feels that may pave the way to verbalization. Choice A gives advice which implies that only the nurse knows what is best for the client. Choice D is a false reassurance which attempts to dispel the client’s anxiety disregards the client’s feelings. Choice C demands the client to explain and may intimidate the client.
27. The nurse initiates conversation with the client by saying “Is there something you would like to talk about?” but the nurse has her arms crossed and is looking at another client. Which of the following describes the nurse’s approach?
a. There is incongruence between her verbal and non-verbal communication
b. The nurse is attempting to make the client less tense by looking away
c. The nurse is trying to maintain appropriate boundaries
d. The nurse is being judgmental
Rationale: The nurse is using the verbal communication technique of broad opening that invites the client to take the initiative but her crossed arms lack of eye contact is incongruent with the verbal message. The nurse is non-verbally distancing herself from the client.
28. Which of the following behaviors of the nurse reflect empathy?
a. Gestures and laughs a lot
b. Shares about the self when it is appropriate
c. Listens to what is said and understands how the client feels
d. Assist the client to be specific rather that speak in generalities
Rationale: Empathy is the ability of the nurse to perceive the meanings and the feelings of the client and to communicate that understanding to the client.
29. Situation: A female client age 40, was admitted because of bouts of sweating, nervousness and selective inattention. This has progressed for the past 3 months. What is the initial responsibility of the nurse?
a. Encourage a relative to stay with her
b. Encourage her to talk about her feelings
c. Administer medication to allay her apprehension
d. Assess her level of anxiety
Rationale: The initial responsibility of the nurse is to begin an assessment of the patient’s needs. The patient’s physiologic responses, recurring thoughts, feelings and behaviors are cues to the client’s problem areas that will lead to planning appropriate interventions.
30. The client is likely manifesting what level of anxiety?
a. Mild b. Moderate c. Severe d. Panic
Rationale: The client has moderate anxiety. Other physiologic manifestations of moderate anxiety include muscle tension, pounding pulse, dry mouth, high pitch voice and faster rate of speech. Physiologic responses of moderate anxiety are increased irritability, narrowing of perceptual field, and easy distractibility but the individual can focus with assistance.
31. The nurse does the SOAP recording . The following are objective manifestations of anxiety except:
a. The client said “I can’t sleep well.”
b. The client’s blood pressure is 130/90
c. The client had sweaty palms
d. The client was noted to be pacing and can’t sit still
Rationale: The inability to sleep as claimed by the client’s is a subjective manifestation of anxiety.
32. Stress management techniques include the following except:
a. Problem solving
c. Progressive muscle relaxation
Rationale: Problem solving is a technique where a nurse helps the client explore possibilities and find solutions to his problem. The rest of the choices are explore possibilities and find solutions to his problem. The rest of the choices are techniques to reduce anxiety. Imagery is the use of fantasy to relieve anxiety. Progressive muscle relaxation uses a process of tensing and releasing groups of muscles starting from the facial muscles and moving down to the body to the muscles in the feet. Meditation involves focusing attention and self regulation.
33. The nurse engages the client in problem solving. The client says, I know that my work and family concerns upset me. The next statement the nurse makes in guiding the client do problem solving is:
a. “What have you tried to solve it.”
b. Perhaps we can discuss other things you can do to ease your work.”
c. “Engage other family members in household chores.”
d. “That is something you can discuss with your boss.”
Rationale: This attempts to assess the problem solving techniques previously tried they may help the nurse in guiding the client identify alternative solutions to the problem. Choice B helps the client identify new coping strategies after assessment is done. Choice C and D give advice and do not allow the client to have a role in the problem solving process that makes the client feel helpless and not in control.
34. Situation: A 35 year old homemaker goes to the clinic and talks about having lost everything after the husband, 42 years old, leaves her for a much younger woman. The husband’s behavior may reflect a developmental concern of:
a. Role identity vs. role confusion
b. Intimacy vs. isolation
c. Generativity vs. stagnation
d. Ego integrity vs. despair
Rationale: This stage refers to middle adulthood stage where one confronts mortality for the first time that leads to reevaluation of life’s goals and purposes in life. In generativity this individual attempts to ensure his immoratlity by transmitting his values to the next generation. Persons who had previously unexamined lives often find themselves in a state of crisis as in the case of this husband.
35. When the woman was asked to talk about her husband she remarked, “let’s talk about it later” is utilizing what defense mechanism?
a. Isolation b. denial c. repression d. suppression
Rationale: Suppression is a conscious attempt to exclude from conscious awareness unacceptable thoughts and feelings.
36. Which of the following is true of crisis?
a. Ones usual coping helps in resolving the problem
b. A crisis for one may not be a crisis for another
c. One experiences a crisis alone
d. A crisis state indicates mental illness
Rationale: Crisis is highly individualized. People vary in their appraisal of events, their ability to cope, coping resources and support system so that what maybe a crisis for one may not be a crisis for another. Crisis is a state of disequilibrium where the usual coping patterns fail in dealing with the present problem. A crisis state affecting an individual usually also affects the significant others who constitute his support system. A crisis is not seen as an illness but an upset in the steady state of the system in which there is massive amount of anxiety.
37. The following questions may be included when assessing a client in crisis:
1. “What are your feelings about the situation?”
2. “Have you experienced any similar situation in the past?”
3. “Who can be helpful to you?”
4. “What were your childhood conflicts?”
a. 1 and 2 b. 3 and 4 c. 1, 2, and 3 d. 1,2, 3, and 4
Rationale: Nursing assessment of a client in crisis includes the precipitating event and circumstances, the clients perception of the event, past experience of similar event and coping measures in the past, the client’s strength and support system. Crisis intervention does not focus on any unresolved conflicts that occurred in the past butrather on the present problem.
38. During the course of therapy, the woman agrees to join a support group. After listening to someone who talked about her marital problem during the group session she remarks “I didn’t think anyone else had a problem like mine” reflects a curative factor of group therapy:
a. Altruism b. Existential factors c. catharsis d. universality
Rationale: Universality assists participants in recognizing common experiences. Altruism is finding meaning through helping others. Existential factors refer to having control over the quality of one’s life. Catharsis is expressing openly one’s suppressed feelings.
39. Situation: Ann 23 years old is very talkative, moves about a lot and is irritable, impression. Bipolar mood disorder,manic phase. The elevated , expensive emotional response in a manic client is disturbance in:
a. Mood b. Impulse control c. Affect d. Both A and C
Rationale: Mood disorder is a disturbance in the prevailing emotional state of a client. Bipolar disorder involves extreme mood swings from episode of mania to episodes of depression. Mood refers to the client’s pervasive, enduring emotional state while affect is an outward expression of an emotional state and is temporary. Affect does not prevail an d therefore it is an inappropriate term to refer to the pervasive emotional state that occurs in mania.
40. The best primary prevention for mood disorders is:
a. Expressing of feelings
b. Suppressing one’s problems
c. Avoiding stressors
d. Taking mood stabilizers
Rationale: Depression occurs when hostility is turned towards. On the other hand mania is a defense against an underlying depression . A manic client externalizes his hostility to the environment. The best primary prevention of mood disorder is verbalization of feelings.
41. During assessment the client frequently switches topics but the nurse can still follow the client’s thought pattern is manifesting:
a. Word salad
c. Looseness of association
d. Flight of ideas
Rationale: Flight of ideas is characterized from jumping from one topic to another but the client can still be followed. Word salad is a jumble of words put together. Circumstantiality I stalking around the topic with inclusion of unnecessary details that delays the meeting of a goal. Looseness of association is fragmented though without logical sequence resulting to incoherent speech.
42. When planning a therapeutic milieu for a hyperactive client the nurse considers which of the following activities?
a. Making her bed
b. Initiate social activities in the patient group
c. Competitive sports
Rationale: Making her bed is a safe activity to dissipate the excessive energy of a manic patient. It is not therapeutic to engage the client incompetitive activities nor initiate group activities because these are stimulating activities. Bingo requires concentration which the client does not have the capability to sustain.
43. The following medications maybe given to the client except:
a. Lithium carbonate b. Epival ` c. Tegretol d. Tofranil
Rationale: Tofranil is an antidepressant. Lithium Carbonate is an antimanic drug. Epival and Tegretol are anticonvulsants but may also be used to manage mania.
44. Situation: A 30 year old woman, single is admitted to the psychiatric unit after being increasingly withdrawn and eating and sleeping poorly after she has become burdened of her family problems and demotion in her work. Relatives claimed that she attempted suicide by cutting her wrist. Which of the following has the highest priority in the nursing care of the client?
a. Assess the client’s support system
b. Monitor the client’s whereabouts
c. Reassure him of worthiness and acceptance
d. The client expresses her hostile feelings
Rationale: The highest priority is given to keeping the client safe from self harm. Monitoring the client will ensure safety as this will prevent the possibility of overlooking attempts for self harm.
45. Indecision, inability to concentrate, loss of intrrest pessimism and self depreciation noted in a depressed client are alterations in:
a. Affect b. Perception c. Cognition d. Actviity
Rationale: The indecision, inability to concentrate, loss of interest, pessimism and self depreciation are cognitive manifestations of depression. Alterations in activity among the depressed may either be psychomotor retardation or agitation. Alterations in perception include delusions and hallucinations which are congruent with the depressed mood of client. Alteration in affect include sadness, apathy, despondency, anger, guilt, helplessness and hoplessness.
46. The nurse’s initial approach in caring for a patient with major depression would be to:
a. Encourage to select her own meals
b. Actively listen to the client
c. Involve the patient in group therapy
d. Provide cheerful activities
Rationale: A depressed client needs to express her angry feelings within appropriate limits. This helps resolve anger that is turned to the self engaged in by the depressed and suicidal client. Placing demands on depressed client who has psychomotor retardation as in making decision and group activities and cheerful activities are not therapeutic.
47. In planning care for a client with endogenous depression, the nurse considers engaging the client in activities:
a. At anytime during the day
b. In themorning
c. Towards the afternoon
d. At night
Rationale: Endogenous depression is associated with alterations in the neurochemicals nor epinephrine and serotonin. Its diurnal variation indicates that clients are more depressed in the early part of the day and are more accessible for activities towards the afternoon. These clients respond well to antidepressants.
48. The client says I’m not good in anything. I’ve always been a failure.” Which of the following responses is best for the client’s statement?
a. “You’re not suppose to say that. You can function.”
b. “What’s making you good for nothing.”
c. “Let’s work on your strengths.”
d. “Can we talk about this tomorrow?”
Rationale: The clients statement indicates low esteem. Focusing on the client’s strength enhances self worth. Choice A is not therapeutic because it disapproving and gives false reassurance. Choice B explores the cleint’s negative view of himself. Choice D disregards the client’s concern
49. The client is withdrawn and spends most of the time on bed. The client refuses to join activities that require social exchange. The appropriate nursing diagnosis for this client behavior is:
a. Ineffective individual coping
b. Self esteem disturbance
c. Impaired social interaction
Rationale: A depressed client has difficulty in relationship and tend to be solitary. While this poor social skill is directly linked to the client’s feeling of worthlessness the clues indicate impaired social interaction.
50. Which nurse’s action would be therapeutic
a. Engage her in dance therapy
b. Stay at the bedside at short but frequent intervals
c. Tell her that her behavior is self-defeating
d. Inform her that from time to time the nurse will check on her
Rationale: Offering to stay with the client at short but frequent interval communicates that the patient is important. This makes the nurse available during a time when the patient feels comfortable with initiating a dialogue.
51. Which behavior would the nurse expect to see in a patient following ECT?
a. Loss of short term memory
d. Relief of delusions
Rationale: An expected outcome post ECT is short term memory impairment. The client may also be mildly confused and briefly disoriented.
52. The client asks the nurse about the purpose of ECT. The nurse responds that ECT will:
a. Relieve the symptoms of severe depression
b. Helps the client focus on a positive outlook
c. Give the patient insight into his conflict
d. Potentiate the therapeutic effect of psychotropic drugs
Rationale: ECT relieves symptoms of depression by causing changes in the monoamine neurotransmitter system similar to the changes caused by antidepressant drugs. It does not potentiate the therapeutic effects of psychotropic drugs.
53. The client who is on Tofranil (Imipramine), comments “I’ve been taking it for a week but I still feels sad and hopless.” Which statement by the nurse is correct about the medication?
a. It takes 2 to 3 weeks before the medication has its effect
b. That’s not usual. The medicine has an immediate effect
c. People respond differently to medications
d. Just be patient. It will take effect in due time
Rationale: The therapeutic effect of Trofanil, A tricyclic antidepressant, takes 3 to 4 weeks.
54. Situation: Ann, 18 years old, is admitted to the psychiatric unit because of behavioral changes. The verbalization if made by a client indicates psychosis?
a. “I just heard the voices telling me to scratch my face.”
b. “I can’t get myself to stop hand washing.”
c. I Feel hopeless about anything changing in my life
d. I have trouble with the police because of my friends
Rationale: psychosis is the inability to distinguish what is real from what is not. The cleint’s manifestation is hallucination, a false sensory perception. Choice B describes compulsion noted in Obsessive Compulsive disorder, a neurosis or abnormal anxiety. Choice C indicates hopelessness that may be noted among depressed clients. Choice D may indicate antisocial personality disorder.
55. Ann is noted to assume a far away look and mumbles to self. The nurse is likely experiencing:
a. Illusion b. Delusion c. hallucination d. depersonalization
Rationale: talking to self behavior may indicate auditory hallucination. Illusion is a misinterpretation of external stimuli. Delusion is a false fixed belief. Depersonalization is the feeling of unreality of the self.
56. Ann says “You’ll kill me. Go away” Which is a therapeutic response.
a. How can I hurt you?
b. Ann I’m your nurse
c. Tell me about your fear of being killed
d. I won come close to you.
Rationale: Presenting reality to a delusional client is the therapeutic response. Choice A is challenging. Choice C is not therapeutic because it explores the false content. Choice D reinforces the false.
57. Ann has progressively withdrawn from relationships. This reaction may be a result of the following except:
a. Self punishment c. fear of rejection
b. Inadequate confidence d. Unclear self concept
Rationale: The client with schizophrenia has difficulty in social relationship may be due to positive signs like delusions and hallucinations, loss of ego boundaries, low esteem and lack of confidence.
58. The nurse conducts remotivation therapy for the purpose of:
a. Assisting a regressed client to socialize
b. Helps the client learn to compete and compromise
c. Providing work opportunities for clients who are emotionally disturbed
d. Using reading materials to help develop emotional maturity
Rationale: remotivation also called conversation therapy is a form of socializing activity through group interaction about a topic associated with the real world. Choice B is the goal of recreational therapy. Choice C refer to vocational therapy. Choice C refers to bibliotherapy.
59. Situation: Jose 57y/o, is admitted to the psychiatric ward due to aggressive behavior. The nurse was doing an assessment when the client became agitated. Which is an appropriate documentation made by the nurse regarding the patient’s behavior?
a. The client became tense
b. When asked to talk about his family the client became agitated
c. When asked to talk about his family the client was noted to pace and with a clenched fist remarked. I’ll get back at them.
d. When asked to talk the client became tense
Rationale: Recording of the client’s behavior must be accurate, objective and describe the behavior. It should include potential triggers of aggression to alert the staff.
60. When responding to a verbally abusive client it is important for the nurse to:
a. Limit the client’s verbal expressions
b. Point out the inappropriateness of the behavior
c. Remind the client that he will be restrained if he does not stop
d. Remain calm and firm
Rationale: Remaining calm and firm when the client is verbally abusive provides a low level of stimuli to the client that provides a feeling of safety and security.
61. In encouraging verbal expression of the feelings the nurse therapeutically says:
a. What ha caused you to feel angry?
b. Don’t shout. Others will be disturbed
c. Why are you angry?
d. Stop that or you’ll be placed on restraints
Rationale: This helps the client identify the true object of his hostility. Helping the client identify this in a non threatening manner may help reveal unresolved issues so they may be confronted.
62. When he was asked to be seated for his vital signs to be checked, he threw a chair across the room. Four staff members were needed to control and restrain him. The nurse identifies which appropriate nursing diagnosis:
a. Self directed violence due to aggression
b. Potential for injury related to aggression
c. Potential for violence directed to others related to poor impulse control
d. Ineffective individual coping related to poor defensive function
Rationale: The client’s behavior indicates that he can be physically harmful to others.
63. Which goal is most appropriate for this nursing diagnosis?
a. The patient will strike out at the staff but not to patients
b. The patient will verbalize anger rather than act out
c. The patient will be placed in restraints whenever he threatens anyone
d. The patient will not talk about anger or strike out at anyone.
Rationale: The goal in dealing with a potentially violent client is to be able to express his anger/feelings in way that will not be harmful to self and others.
64. The nurse’s initial action when dealing with an assaultive client is to:
a. Keep the patient away from others and under one-to-one supervision
b. Restore the patient’s self control and prevent further loss of control
c. Allow the patient to act-out his frustrations ,then establish a line of communication
d. Use of seclusion and restraints to prevent harm to patients or others
Rationale: Restoring the client’s self control may be done initially by talking down the client. When this approach fails medications may be used. When these fail, seclusion or mechanical restraints may be necessary.
65. Situation: Carlo is diagnosed to have schizoid personality. Which of the following behaviors may be noted in the patient:
a. Seductive, dramatic, center of attention
b. Seclusive, doubts others, fears confiding in others
c. Cold, introvert, lacks desire for close relationship
d. Fantasies about success, power and intelligence
Rationale: Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationship and a restricted range emotional expression in interpersonal settings. Choice A describes histrionic personality disorder. Choice B is paranoid personality disorder while Choice D describes narcissistic personality disorder.
66. Known etiology of personality disorders include:
a. Genetic influence
b. Social learning
c. Behavioral factors
d. All of them
Rationale: The development of personality disorders is a combination of biological, psychological, behavioral and socio-cultural factor.
67. Identification is one of the defense mechanism used among clients with personality disorders. This mechanism:
a. Integrates some ways of a significant other
b. Channels unacceptable drives into socially approved behavior
c. Return to earlier less mature stage of development
d. Act in reverse something that is already done
Rationale: Persons with personality disorder may model their actions after those around them, particularly their parents. Choice B describes sublimation. Choice C is regression . Choice D is undoing.
68. The nursing diagnosis that may be identified in a client with schizoid personality disorders may include the following except:
a. Impaired social interaction
b. Ineffective individual coping
c. Altered role performance
d. Perceptual alteration
Rationale: Perceptual alteration is not noted in a client with personality disorder. Personality disorders are characterized by inflexible and dysfunctional traits that impair their social and occupational function. Clients with schizoid personality use intellectualization when these patients describe emotional and interpersonal experiences in an impersonal way.
69. Carlo withdraws from everyone. A therapeutic approach for Carlo is:
a. Escort Carlo to the activity and leave him there
b. Tell Carlo to rest in his room until he is more comfortable of joining activities
c. Include Carlo when the nurse initiates conversation with the patients
d. Suggest to the patient that he discuss this difficulty to his doctor
Rationale: The client has a pervasive lack of desire for involvement with others. The nurse should promote socialization initially by building trust then slowly involving the patient in milieu and group activities.
70. Situation 7-Vina, a 28 year old movie starlet who was caught by the narcotics coman during a shabu session. She voluntarily submitted herself for rehabilitation. The best level of prevention in dealing with problems on drug abuse is:
a. Primary b. Secondary c. Tertiary d. A and C
Rationale: Primary level of prevention includes education and information dissemination regarding the effects of dangerous drugs. This involves altering the causative factors before they have the opportunity to cause drug abuse problems.
71. Vina may tend to manipulate the nurse. Which nursing approach is appropriate in dealing with the clients tendency to manipulate:
a. Involve her in interaction for as long as she wants
b. Use a casual approach without being indifferent in dealing with her
c. Negotiable with the clients requests
d. Be flexible with rules and expectations
Rationale: A firm, casual and consistent approach is used among manipulative patients. Allowing client to negotiate, rationalize for her actions or do power struggle is useless. They should be helped to directly express their needs and feelings.
72. The nurse should observe for signs of intoxication with shabu which include one of the following:
a. Hallucinations, dilated pupils, distortion in time and space
b. Tachycardia, pupil dilatation, elevated blood pressure, euphoria
c. Reduced inhibition, red eyes, dry mouth, increased appetite
d. Anorexia, confusion, increased hilarity, ataxia
Rationale: These are manifestations of intoxification with shabu, a stimulant. Choice A are the manifestation of intoxification with hallucinogens. Choice C are the effects of marijuana. Choice C are the effects of inhalants.
73. Vina says that she takes shabu because she wants to remain sexy. Life style issues that the nurse includes in the management of the client includes in the management of the client includes:
a. Regular physical activity and exercise
b. Balanced diet and vitamin supplements
c. Learning effective coping strategies
d. A and B
Rationale: Lifestyle and personal habits may affect both physical and mental health. Teaching the client the effects of chemical abuse on the body, weight management through diet and exercise are essential parts of the treatment of the client.
74. The medication that the client maybe given during withdrawal is:
a. Antipsychotic b. Antidepressant c. antianxiety d. Stimulants
Rationale: Clients who are withdrawn from Shabu may experience a fatigability and depression. Antidepressant maybe prescribed for symptomatic management.
75. Situation 11: Mang Dading, a 77 year old retired school teacher is brought to a home for the aged. He is noted to have confusion and memory loss. He is diagnosed to have Alzheimer’s disease. Mang Dading asks the nurse “Where am I”? The most therapeutic response by the nurse is:
a. Where do you think are you?
b. Let’s sit down and find out where you are.
c. You should know better than that
d. You are in the dayroom of the home for the aged.
Rationale: Reorientation of the client to reality and his surroundings helps in maintaining a sense of security and enhances self worth. The client’s cognitive impairment can disrupt the client’s ability to communicate. Choice C is a demanding statement.
76. Mang Dading says to the nurse “I am going out with friends today” and proceeds to the door. The nurse should give priority to the client’s need for:
c. Love and belonging
Rationale: The client’s safety is compromised among clients with cognitive impairments thus this must be given priority.
77. The patient finds difficulty in pulling his pants and difficulty feeding himself. In Alzheimer’s disease, this is known as:
a. Aphasia b. Apraxia c. Amnesia d. Agnosia
Rationale: Apraxia is loss of purposeful body movement.
78. In addition to disturbance in mental awareness and disorientation, Mang Dading has difficulty in hearing. In communicating with this client. Which of the following should be avoided?
a. Speaking slowly in a face to face position
b. Using visual cues to facilitate understanding
c. Using simple and specific words
d. Increasing the pitch of your voice while talking close to the client’s ear
Rationale: Using high pitch voice causes some distortion of sound and may cause discomfort or even irritate the patient.
79. The emotional task of Mang Badong is:
a. Integrity b. Industry c. Intimacy d. Independence
Rationale: The positive task of late adulthood if integrity where the individual reviews past life realistically, accepts past failures and limitations and accepts death with dignity.
80. To prevent deterioration the following activities may be engaged in by institutionalized elderly clients but:
a. Pet therapy
b. Reminiscence therapy
c. Table tennis
Rationale: Table tennis places unnecessary demand on the limited motor capability of the elderly. Pet therapy, help fulfill the need to love and be loved. Reminiscence group can help rethink aspects of the past and enhance communication and socialization. Horticulture entails tending plants can enhance physical condition, relieve tension and provide a sense of accomplishment.
81. Situation: A client is admitted in the psychiatric ward because of repeated hand washing. The client has not eaten nor slept adequately because of her hand washing ritual. The clients inability to control her and washing is a/an:
a. Obsession b. Compulsion c. Mannerism d. Echopraxia
Rationale: Compulsion is an uncontrollable impulse to perform an act repetitively. Choice A Obsession is a repetitive though that cant be controlled. Choice C mannerism is ingrained, habitual involuntary movement. Choice D echopraxia is a pathological imitation of movements of one person by another.
82. The main goal in dealing with the client with obsessive compulsive disorder whose hand have become cracked is to:
a. Eliminate the hand washing ritual
b. To provide good hand care
c. Confront the client’s hand washing
d. Decrease the number of hand washing
Rationale: A measurable goal is to decrease the number of hand washing. Confronting and eliminating the hand washing are not therapeutic as these may further increase the client’s anxiety. Providing good hand care is not adequate in dealing with the cracked hands of the client.
83. After 2 weeks in the unit the client agrees to join art therapy. To ensure that she comes on time for the activity, the nurse does of the following:
a. Provide adequate time to complete her hand washing
b. Remind her about the activity several times
c. Tell her that she has to keep her promise to join
d. Stop her hand washing and bring her to the activity
Rationale: Rituals are used to relieve anxiety. Allowing her adequate time to complete her rituals is helpful. All the other choices can heighten the client’s tension.
84. Which of the following are the expected outcome of psychotherapy:
a. The family members will use alternative resources in and outside the family to solve their problem
b. The client’s ritual will be replaced by verbalization of anxiety
c. The client will tell herself to stop whenever compulsive thoughts occur
d. The client will gain insight into her conflict
Rationale: Psychotherapy helps in alleviating the client’s tension and problems as they are discussed with the therapist. Choice A refers to family therapy. Choice C is thought-stopping technique while Choice D refers to psychoanalysis.
85. During the interview the client acknowledge that her illness is due to her inability to cope with her problems. This reflects which aspect of her mental status?
a. Judgment b. Insight c. Sensorium d. Thought process
Rationale: Insight is the patient’s degree of awareness and understanding of her illness. Judgment is the ability to assess a situation correctly and act appropriately in relation to the situation. Sensorium refers to the level if consciousness, orientation, attention and alertness. Though process refers to the manner in which an individual connects his thoughts.
86. Situation: A nurse who deals with children and adolescent may be faces with various concerns. The nurse may suspect the possibility of abuse if the parents:
a. Belong to the low socioeconomic group
b. Have not completed their education
c. Are unmarried
d. Are socially isolated
Rationale: Abuse may occur across socioeconomic, educational, religious and cultural groups. It often occurs during pregnancy.
87. The priority nursing intervention in the care of a child victim of abuse is:
a. Asses family dysfunction
b. The child will remain safe
c. Encourage expression of feelings
d. Talk to the parents
Rationale: The primary consideration is the safety of the child. Failure to do so may put the child in further endangement. The other choices are also important but are not priority.
88. Play therapy among victims of abuse is:
a. Playing indoor games to divert attention from the abuse.
b. Drawing or playing with dolls rather than talking
c. Allowing the child to talk about hurt feelings and pain
d. Opening communication channels with the family
Rationale: Play therapy is used among children who lack the language facility to express what they feel. This may be achieved through drawing or playing dolls rather than talking.
89. A 7 year old child is accompanied by both parents for psychiatric evaluation. He was observed to be easily destructed, fidgety, unable to follow instructions nor finish school work. The child is likely suffering from:
a. Attention deficit hyperactivity disorder
b. Conduct disorder
c. Autistic disorder
d. Oppositional defiant disorder
Rationale: The manifestation indicate attention deficit hyperactivity disorder. Autistic disorder is characterized by impairment in social relatedness, delayed language and stereotypical behaviors like rocking. Conduct disorder is a characterized by persistent disregard for age-related norms. Oppositional Defiant disorder is manifested by enduring pattern of argumentativeness, explosive angry outburst and disobedience.
90. The parents of a child tells the nurse that they have tried everything to calm their child and nothing has worked. Which action is most appropriate initially?
a. Actively listen to the parents concerns
b. Encourage the parents to discuss these issues with the mental health team
c. Provide literature regarding the disorder and its management
d. Tell the parents they are overreacting to the problem
Rationale: Assessing the situation by listening to the parents description of the problem is done initially before planning nursing interventions.
91. An adolescent hospitalized in a psychiatric unit initiates frequent fights with peers. Which approach should be avoided?
a. Use exercise to channel energy for anger
b. Ignore minor infractions of rules
c. Establish firm, consistent limits
d. Intervene early for escalating behavior
Rationale: These clients will not benefit from leniency. Clear expectations and limit must be set and consistently implemented. Don’t debate, argue or rationalize with the client but he must be made to take the consequences of infractions.
92. The real issue in school phobia is not the school itself but the separation from:
a. School work b. Teacher c. classmate d. Mother
Rationale: The child experiences extreme discomfort upon separation from mother and major attachment figure.
93. The priority nursing action for a child with Separation Anxiety disorder is?
a. Assist the child to gradual exposure of experience of separation
b. Help the child express his fears through play therapy
c. Encourage family discussion of various problem areas
d. Give positive feedback for efforts to be with others
Rationale: Overwhelming feelings of anxiety can be dealt with first before attempts are made to desensitize the child to experience of separation and to conduct family therapy.
94. A 5year old child is presented to the clinic because of repeated urination on clothing referred to as:
a. Encopresis b. Enuresis c. Somnambolism d.Somniloquy
Rationale: Enuresis is bedwetting. Encopresis is soiling clothing with feces in a child 4 years or older. Somnambolism is sleep walking while somniloquy is sleep talking.
95. A child with a depressive disorder is more likely than an adult with the same disorder to exhibit:
a. Acting out
b. Sadness and crying
c. Suicidal thoughts
d. Weight gain
Rationale: Children may be less able to verbalize their feelings. Irritability and acting out may be a predominant features of depression.
96. Babe, 4 years old is diagnosed with mental retardation. Mental retardation is best described as:
a. Rapid, repetitive jerky movement of muscle groups
b. Communication deficit severe enough to hinder academic achievement
c. Achievement in reading and mathematics is below that expected for age
d. Below average intellectual functioning
Rationale: Mental retardation is a developmental disorder characterized by subaverage intellectual functioning with an I.Q below 70. This is accompanied by limitations communication skills, social skills and academic skills.
97. Babe’s I.Q is 35-40.This mental retardation is classified as:
a. Mild b. Moderate c. Severe d. Profound
Rationale: Moderate mental retardation has an I.Q ranging from 35-50. Mild has an I.Q of 50-70. Severe has a I.Q of 20-35 and profound has an I.Q less than 20.
98. The highest capability that a client with moderate mental retardation can attain is:
a. Achieve very limited self care
b. Contribute partially to self maintenance under supervision
c. Achieves self maintenance in unskilled and semi-skilled work
d. Trainable in vocational skills
Rationale: The client with moderate mental retardation has a mental age of 3 to 8 and can achieve self maintenance in unskilled and semi-skilled work. Choice A is what a profoundly mentally retarded can achieve. Choice b is the capability of a client with severe mental retardation. Choice D is associated with mild retardation.
99. To discourage purging in a client with eating disorder, the best approach is to:
a. Observe the client for at least 1 hour after meal
b. Weigh the client 3 times a day
c. Teach the client about nutrition
d. Set a contract to stop purging
Rationale: Observe the client for at least 1 hour after meals. Otherwise, this time may be used by client to discard food stashed from tray or to engage in self induced vomiting.
100. The client came late for interaction with the nurse. She claims “I feel like a bloated balloon” for having eaten a lot. A therapeutic response by the nurse is:
a. You are not going to get well if you don’t attend our sessions
b. Everybody feels upset sometimes
c. Let’s find out how much you ate
d. You must have felt upset. Let’s find out why.
Rationale: This reflects how the client feels. When nutritional status has improved, exploring the cleint’s feelings may be done so that emotional issues maybe resolved. Only then can maladaptive eating behavior can be eliminated.
1. An ICU nurse has been assigned to four (4) clients. What situation should suggest the nurse that the machine has malfunctioned?
a. A patient on a chest tube is having a serosangineous drainage
b. A patient on an IV pump having a high pressure alarm
c. A patient on a mechanical ventilation is having a high-pressure alarm
d. A patient on a partial rebreather mask inhales while the bag inflates
Answer: C – High-pressure alarm are cause by increased secretions are in the airway, wheezing or brochospasm causes decreased airway size, the endotracheal tube is displaced, the ventilator tube is obstructed because of water or a kink in the tubing, clients cough, gags, or bites on the oral endotracheal tube, and client is anxious of flights the ventilator --- Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.804
2. A client with tracheostomy is having difficulty of breathing cause by excessive mucus secretion and needs to be suction immediately. In suctioning, what should the nurse prioritize in doing first?
a. Use aseptic technique
b. Do not apply suction while inserting the catheter
c. Insert the catheter 4 inches
d. Hyperoxygenate the client by a resuscitation bag, or increase the oxygen flow rate before and after suctioning
e. Lubricate the catheter with sterile water
f. Apply suction intermittently for 10 seconds; rotate the catheter and withdraw
3. Order the above by step-by-step procedure:
Answer: ADECBF– Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.794
4. A 35 year old client is diagnosed of having hemothorax and attached in a chest tube drainage system. Which of the following are incorrect understandings on managing a chest drainage system? SATA
a. When the wall vacuum is turned off, the drainage system must be open to the atmosphere so that intrapleural air can escape from the system
b. If the chest tube and drainage system become disconnected, a temporary water seal can be established by immersing the chest tube’s open end in a bottle of tap water ---sterile water
c. Gently “milk” the tubing away from the drainage chamber ---in the direction of…; milking prevents the tubing from becoming obstructed b y clots and fibrin. Constant attention to maintaining the patency of the tube facilitates prompt expansion of the lung and minimizes complications
d. If the patient is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. Do not clamp the chest tube during transport ---the drainage apparatus must be kept at a level lower than the patient’s chest to prevent fluid from flowing backward into the pleural space. Clamping can result in a tension pneumothorax
Answer: BC – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.631-632
5. A ward nurse has been assigned to a client, diagnosed of having pneumothorax, with a chest tube drainage system. What will suggest the nurse that the system is malfunctioning?
a. Intermittent bubbling in the suction control chamber
b. Drainage in the collection chamber is 150mL every 2 hours
c. Fluctuation of the fluid level in the water seal chamber
d. Gentle bubbling in the suction control chamber
Answer: A– Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition; Linda Ann Silvestri, MSN, RN; Pg.260-261
6. A 50 year old client went to the ED with complaints of weight loss and labored breathing on exertion. The client is diagnosed of having Ephysema. Which the following statements are incorrect about the disease?
a. Recurrent inflammation is associated with the release of proteolytic enzymes from lung cells
b. Can develop pneumomediastinum cause by alveolar blebs and bullae rupture
c. Air trapping results in hypoinflated lungs, causing a “barrel chest” appearance ---hyperinflated lungs
d. There is loss of elastic recoil as a result of destruction of elastin and collagen fibers found in lungs; without this recoil, air trapped in lungs and airways collapse
Answer: C– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.5 and Expert LPN Guides Pathophysiology; ©2007 by Lippincott Williams & Wilkins; Pg.207
7. A client has been prescribed with Guaifenesin 300mg four times a day as an expectorant. The dosage strength of the liquid is 200mg/5mL. How many mL should the nurse administer for each dose?
Answer: C – 300mg/x = 200mg/5mL; x= 7.5mL --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.309 [#9]
8. A respiratory unit nurse has been assigned to four clients. Prioritize in order how the nurse would assess the clients from highest to lowest priority:
a. A 35 year old client with suspected tuberculosis who is complaining of a cough
b. An 85 year old client with bacterial pneumonia, temperature of 102.2 °F (42°C), and shortness of breath
c. A 56 year old client with emphysema who has a schedule dose of a bronchodilator due to be administered, with no report of acute respiratory distress
d. A 60 year old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain
Answer: BDCA – The elderly client with pneumonia, shortness of breath and an elevated temperature is the most acutely ill client described and should be the client with the highest priority. The shortness of breath and elevated temperature can lead to a decrease in the client’s oxygen levels, and can predispose the client to dehydration and confusion. The nurse should assess the client with thoracotomy who is requesting pain medication and administer any needed medication. The client with emphysema should be the next priority so that the bronchodilator can be administered on schedule as possible. The nurse would then assess the client with suspected tuberculosis and a cough --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.311-312 [#31]
9. The client was brought in the ED with complaints of sudden onset of shaking chill and a temperature of 102-104 °F (38.9-40°C). The client was diagnosed of having bacterial Pneumonia. Which nursing management is incorrect?
a. Sympathomimetic drugs such as albuterol sulfate (Proventil) or metaproterenol (Alupent)
b. Antibiotic therapy as indicated by culture and sensitivity within 4hours of diagnosis or admission
c. Increased fluid intake to 2.5-3L/day to help liquefy the secretion
d. Encourage the elderly and at-risk clients to have a pneumonia vaccine every 2 years ---5 years
Answer: D– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.17
10. A 55 year old client has been diagnosed of having Pulmonary Embolism. Which of the following are the signs and symptoms of this disease? SATA
c. Left-sided heart failure ---right-sided heart failure
d. Respiratory acidosis ---respiratory alkalosis
e. Friction rub
f. Increased breath sounds ---decreased breath sounds
g. Chest pain
h. Pleuritic pain
Answer: ABEGH– Other signs and symptoms include sudden acute dyspnea with extreme anxiety, abnormal lung sounds (wheezing, or crackles), hypoxia, diaphoresis, and coughing; petechiae may develop with fat emboli; large clots or more complicated situations include pulmonary hypertension, shock, or sudden respiratory arrest --- Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.25 and Expert LPN Guides Pathophysiology; ©2007 by Lippincott Williams & Wilkins; Pg.222-223
11. A 56 year old client has an arterial blood gas of pH: 7.31; PaO₂: 80 mm Hg; PaCO₂: 63mm Hg; HCO₃: 36mEq/L. The nurse would expect this sign/symptom will occur:
d. Flushed skin
Answer: D – The high PaCO₂ level causes flushing due to vasodilation. The client also becomes drowsy and lethargy because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO₂ level of 65 mm Hg but are associated with hypoxia --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.315 [#71]
12. The nurse is assigned to care for the following clients. Which client should the nurse prioritize to assess first?
a. A 51 year old client with asthma complaining of shortness of breath (SOB) after using a bronchodilator inhaler
b. A 57 year old client with COPD and pulse oximetry reading from previous shift of 90% saturation
c. A 68 year old client on ventilator who needs a sterile sputum specimen sent to the laboratory
d. A 72 year old client with pneumonia who needs to be started on intravenous antibiotics
Answer: A – The client with asthma did not achieve relief from SOB after using the bronchodilator and is at risk for respiratory complications. The client’s needs are urgent --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.178 [#15]
13. The charge nurse is making assignments for the following shift. Which client should be assigned to a nurse who has been working in the hospital for two months and was pulled from the surgical unit to the medical unit?
a. A 72 year old client who needs teaching about incentive spirometry
b. A 69 year old client with COPD who is ventilator dependent
c. A 65 year old client just returned from bronchoscopy and biopsy
d. A 58 year old client on airborne precautions for tuberculosis (TB)
Answer: A – Many surgical clients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the client with TB on isolation, the nurse must be fitted with a high-efficiency particulate (HEPA) respirator mask. The bronchoscopy client needs specialized and careful assessment and monitoring after the procedure, and ventilator-dependent client needs a nurse who is familiar with ventilator care. Both of these clients need experienced nurses --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.178 [#15]
14. A 45 year old client went to the ED with complaints of low-grade fever in the afternoon, dry cough, and blood-tinged sputum. After some laboratory test it was found out that the client has Pulmonary Tuberculosis (PTB). In caring for the client, which nursing management is incorrect?
a. Prevention of TB requires taking BCG vaccine once for TB or medication for 6-12 months for exposure and at least 1year for clients with HIV ---9 months
b. Hepatotoxicity is a common side effect for many agents, and clients should be monitored closely
c. Once positive, the purified protein derivative (PPD) will remain positive and should not be repeated
d. Place clients with active cases on airborne precautions (in negative-pressure room)
Answer: A– Prentice Hall Nursing Reviews & Rationale Pathophysiology, 2nd Edition; Mary Ann Hogan, MSN, RN; Pg.18-20
15. A 48year old miner went to the ED with complaints of chest pain and recurrent respiratory tract infection. He has been diagnosed of having Asbestosis. A nurse know that Asbestosis: SATA
a. May progress to pulmonary fibrosis
b. Has no cure
c. Is caused by prolonged inhalation of asbestos fibers
d. Has signs and symptoms of decreased lung inflation, and finger clubbing
Answer: ALL– Expert LPN Guides Pathophysiology; ©2007 by Lippincott Williams & Wilkins; Pg.192-194
16. A client with lung injuries undergoes surgery. Postoperative orders include blood transfusion of one unit of PRBC at a rate of 60mL/hr. How long will the transfusion take to infuse the entire unit?
a. 8 hours
b. 6 hours
c. 4 hours
d. 2 hours
Answer: C – One unit of PRBC is about 250mL. If the blood is delivered at a rate of 60mL/hr, it will take 4 hours to infuse the entire unit. The transfusion of a single unit of PRBC should not exceed 4 hours to prevent growth and minimize the risk of septicemia --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.319 [#113]
17. Assessment findings of a client with Pleural effusion are as follows:
a. Tactile Fremitus: Increased; Percussion: Dull; Auscultation: Bronchial breath sounds, crackles, bronchophony, egophony, whispered pectoriloquy ---Consolidation like pneumonia
b. Tactile Fremitus: Normal; Percussion: Resonant; Auscultation: Normal to decreased breath sounds, wheezes ---Bronchitis
c. Tactile Fremitus: Decreased; Percussion: Hyperresonant; Auscultation: Decreased intensity of breath sounds, usually with prolonged expiration ---Emphysema
d. Tactile Fremitus: Absent; Percussion: Dull to flat; Auscultation: Decreased to absent bronchial breath sounds and bronchophony, egophony, and whispered pectoriloquy above the effusion over the area of compressed lung
Answer: D – Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.483
18. Which of the following criteria would indicate that a nurse can start weaning the client from his mechanical ventilator? SATA
a. Vital Capacity – 10-25mL/kg
b. Maximum inspiratory pressure (MIP) at least – 20 cm H₂O
c. Tidal volume – 7-9 mL/kg
d. Minute ventilation – 6L/min
e. Rapid/shallow breathing index – below 100 breaths/minute/L
f. PaO₂ greater than 60 mm Hg with FiO₂ less than 40%
Answer: ALL – Careful assessment of multiple weaning indices helps to determine readiness for weaning. When the criteria have been met, the patient’s likelihood of successful weaning increases --- Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 10th Edition; Suzanne Smeltzer, RN, EdD, FAAN; Pg.624
19. The nursing assistant is taking the vital signs of a client who is intubated after being suctioned by the respiratory therapist. Which vital sign should she immediately report to the RN?
a. Blood pressure: 168/90
b. Heart rate: 98 beats/min
c. Tympanic temperature: 101.4°F
d. Respiratory rate: 24 breaths/min
Answer: C – Infections are always a threat for the client using a ventilator. The ET tube bypasses the body’s normal process of filtering air and provides a direct access for bacteria to the lower parts of the respiratory system --- Prioritization, Delegation, & Assignment Practice Exercise for Medical-Surgical Nursing 1st Edition; Linda LaCharity, PhD, RN; Pg.179 [#25]
20. A PTB client asks the nurse the importance of multiple drug treatment. The nurse knows that the rationale for using multiple drug treatment for PTB clients is?
a. Multiple drugs reduce development of resistant strains of the bacteria
b. Multiple drugs reduce undesirable drug side effects
c. Multiple drugs allow reduced drug dosages to be given
d. Multiple drugs potentiate the drug’s actions
Answer: A – Use of combination of anti-tuberculosis drugs slows the rate at which organisms develop drug resistance. Combination therapy also appears to be more effective than single-drug therapy. Many drugs potentiate or inhibit the actions of other drugs; however, this is not the rationale for using multiple drugs to treat tuberculosis. Treatment with multiple drugs does not reduce side effects. Combination therapy may allow some medications to be given in reduced dosages; however, reduced dosages are not prescribed for antibiotics and anti-tuberculosis drugs --- Lippincott’s Review for NCLEX-RN 8th Edition; Diane Billings, EdD, RN, FAAN; Pg.313 [#51]