Nursing Review Exam

8/13/2019 Nursing Review Exam

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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1

Fundamentals of NursingMaternity NursingPediatric Nursing

Community Health NursingMedical Surgical Nursing

Psychiatric Nursing

Professional AdjustmentLeadership and Management

Nursing Research

Compiled by:

RO!R" C# R!$A

2009

THE EVER POPULAR LAST MINUTE TIPS FOR




NURSING LICENSURE EXAMINATIONS

In NP1, Please FOCUS on the following:

1 !ypes of leade"ship: #$to%"ati%& 'aisse( fai"e& )emo%"ati%& t"ansfo"mational& t"ansa%tional et% et%

2 Patte"n of *$"sing %a"e: P"ima"y n$"sing& %ase n$"sing& f$n%tional& team et%

+ ,-panded *$"sing "ole: *$"se anesthetist& *$"se p"a%titione"& *$"se "esea"%he" et% et%

. 'e/els of p"e/ention by 'ea/ell and Cla" emembe" that %"isis is always se%onda"y

+ way bottle system: simply "e%onne%t the t$be& %ontin$o$s b$bble is a sign of leaage& no b$bbling is

obst"$%tion 3in the wate"seal4 and yo$ sho$ld palpate the s$""o$nding a"ea fo" s$b%$taneo$s emphysema

5 Ca"e of %lients with t"a%heostomy and s$%tioning a t"a%heostomy t$be 3ste"ile te%hni6$e4 now the

f$n%tions of the %$ff& obt$"ato" and the tie %a"e of %lients with pooling of se%"etions Post$"al d"ainage: dothis befo"e meals& the positioning depending on the lo%ation of se%"etion& POP,7ICO 3a""angement4 that is

positioning& pe"%$ssing& /ib"ating and %o$ghing et% st$dy s$%tioning

8 !he independent and the dependent /a"iable in "esea"%h

now yo$" PU, and #PP'I,) as well as ,;P,I<,*!#' and *O*=,;P,I<,*!#' also yo$"

>U#*!I!#!I7, and >U#'I!#!I7, designs

9 I7 fl$id toni%ity: )' is hype"toni% while ' is isotoni%

10 Compli%ation of I7 and its inte"/ention s$%h as F'UI) O7,'O#)& P?',@I!IS& I*FI'!#!IO*

11 @lood t"ansf$sion

12 Compli%ation of immobility: ),CU@I!US U'C,& ?APO P*,U<O*I#& #!,',C!#SIS& ),,P7,I* !?O<@OSIS

1+ !he 7I!U, ,!?ICS and ,!?ICS: B$sti%e& fo"tit$de& p"$den%e& tempe"an%e& %ha"a%te"& do$ble effe%t& pate"nalism et% et% and the Patients bill of "ight

1 !ea%hing and lea"ning steps: <an initially needs info"mation and <O!I7#!IO* is needed fo" adhe"en%e

to tea%hing Fi"st step in tea%hing is to #SS,SS ',#*I*D *,,)S befo"e planning what to tea%h

15 S#F,!A: Ca$ses of inE$"ies a%%o"ding to age eg: elde"ly falls& infant s$ffo%ation and aspi"ation&

adoles%en%e s$i%ide and homi%ide Inte"/ention in an elde"ly %lient who falls f"e6$ently eep the bed at

the lowest possible position et%

1 @O* ,SO'U!IO* 220 3CO), OF ,!?ICS4 # 918+ #*) 815. 3CO<P#, #*) CO*!#S!4

and the CO*!I*UI*D POF,SSIO*#' ,)UC#!IO* 3!o enhan%e nowledge with "ega"d to spe%ifi%

field of inte"est4

NP2

1 Stages of labo" !he fi"st stage $p to the fo$"th stage and the '#!,*! #C!I7, #*) !#*SI!IO* of

the fi"st stage st$dy the inte"/ention in all stages ead pillete"i fo" this

2 !he menst"$al %y%le& what glands se%"et what ho"mones !he <,*S!U#'& PO'IF,#!I7,&

S,C,!OA and ISC?,<IC phase what ho"mone is at pea d$"ing what stage et% et%

+ Ca$ses of bleeding d$"ing p"egnan%y: ,%topi%& ab"$ptio and p"e/ia pl$s thei" n$"sing inte"/ention

. ,ndomet"iosis and ,ndomet"itis

I<CI : Pne$monia& )ia""hea and )eng$e espe%ially the b"eathing %$t off 3,g 50 fo" $nde" 2 months4&

#%$teGCh"oni% %$toff 3#%$te dia""hea and ea" infe%tion $nde" 1. days4 !he inte"/entions fo" C?I') #& @

and C



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | +

5 CO<<U*I!A ?,#'!? *USI*D POC,SS: #ssessment& Planning& Implementation and ,/al$ation

"efe" to the )O? boo please "ead this one

8 <anage"ial p"in%iples PO)C !ypes of b$dgets )i"e%t& indi"e%t& %ash& %apital& ope"ational b$dgets

ead pillete"i fo" : Cha"a%te"isti% of a toddle" and p"es%hool 3 eg : asing too many 6$estions& negati/isti%

fo" toddle" P"es%hool asso%iati/e& imagina"y& see the wo"ld on his own point of /iew& s$pe"ego

de/elopment et%4

9 POISO*I*D: 'ead& aspi"in& et% et% this is the %ommon %a$se of a%%ident among toddle"s

10 'e$emia& #nemia and Si%le %ell anemia& %hemothe"apy fo" pediat"i% %lients

11 *,H@O* SC,,*I*D

12 #mnio%entesis 7OI)& Ult"asonog"aphy )I*& 'eopolds <ane$/e" 7OI)& Pa"a%entesis 7OI)

1+ Changes d$"ing p"egnan%y 3eg: 'e$o""hea& b"a-ton hi%s& anemia4 and what %hanges o%%$"s ea"ly o" late

efe" to Pillitte"i

1. P"egnan%y and n$t"ition: @alan%ed diet +00 %al fo" p"egnant 00 %al fo" b"eastfeeding

1 PI? and <#D*,SIU< SU'F#!, 3%ns down& "" down& $Go down 4 p"io"ity :

NP3 AND NP4

1 @$"ns& Classifi%ation of @$"ns and *$"sing )iagnosis fo" @$"ns& )"$g $se in b$"ns 3Sil/e" S$lfadia(ine4&

,le%t"olyte %hanges in b$"n 3?ype"alemia& ?yponate"mia4 !he H?O Pain ladde" s%ale& Pain medi%ations

espe%ially )eme"ol& <o"phine and Fentanyl emembe" that P#I* is the ha"dest pa"t fo" the n$"se in %a"ing

fo" a b$"ned /i%tim @$"n wo$nds heal by se%onda"y intention

2 *$"sing diagnosis afte" anesthesia : IS FO I*F,C!IO* o" I*,FF,C!I7, #I C',##*C,

+ P#CU <O*I!OI*D >1 & SUDIC#' F'OO <O*I!OI*D >+0

. Pan%"eatitis& Chole%ystitis& ?epatitis <o"phine %a$ses spasms in the sphin%te" of oddi ?epa @ is %a$sed by

blood e-%hange ?epa # is o"o=fe%al both ha/e /a%%ines eithe" passi/e o" a%ti/e b$t if al"eady e-posed& Di/e

P#SSI7,

)iabetes mellit$s& <etfo"min and %ont"ast medi$m 3stop metfo"min d$e to "enal to-i%ity4& Ins$lin "otation

and administ"ation& diabetes "Gt foot%a"e #/oid wea"ing %an/ass shoes& %he% fo" the sensation& do not go

o$tside witho$t slippe"s P,IP?,#' *,UOP#!?A O?# d"$gs

5 ,le%t"olytes abno"mality espe%ially ?APOC#'C,<I# and ?AP,G?APO#',<I# !he ,CD %hanges

in potassi$m alte"ation& inte"/ention and %a$ses

8 <yo%a"dial infa"%tion : ,CD %hanges as well as n$"sing inte"/ention Ca$ses and "is fa%to"s efe" to

@U**,

Pha"ma%ologi% and *onpha"ma%ologi% pain "elief : D$ided image"y& @iofeedba%& Int"athe%al 3into the

spinal %anal di"e%tly to mi- with %sf4 and epid$"al 3 into the epid$"al spa%e 4 pain management side effe%ts of

mo"phine in elde"ly PUI!US and #'',DIC ;* and ),P,SSIO* eason fo" int"athe%al

admininst"ation p"e/ent @lood b"ain ba""ie"

9 @,#S! and C,7IC#' %an%e" #ssessment& )iagnosis and !"eatment

10 <anagement fo" a %lient with CO'OS!O<A !he i""igation& diet and body image alte"ation as well as

pe"iope"ati/e management of a %lient $nde"going yo$" #@)O<I*#' P,I*,#' ,S,C!IO* with

pe"manent %olostomy )"$gs gi/en befo"e #P s$%h as neomy%in and s$lfas$(idine& )iet befo"e #P 3low

fibe"4& no"mal %olo" of the stoma E$st afte" #P 3slightly bleeding& "ed and p"ot"$ding4

11 Ins$lin administ"ation& types and "otation efe" to b"$nne" 1 in%h away f"om ea%h inEe%tion site&

administe" at "oom temp not %old to p"e/ent lipodyst"ophy& abdomen has the fastest abso"ption et% et%

12 Inte"/entions d$"ing hypo= and hype"gly%emia



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | .

1+ Ca"e of %lients with hype"= and hypothy"oidism& st$dy !#P#JO',G<,!?I<#JO', and 'UDO'S

SO'U!IO*& P!U Ca"e of %lients afte" thy"oide%tomy: <onito" fo" hypo%al%emia tea%h %lients ?,#)

SUPPO! by p$tting hands at the ba% of the ne% befo"e t"ying to mo/e the head

1. !$be"%$losis and 'ep"osy& its ea"ly G late sign and symptoms

1 #%$te and Ch"oni% "enal fail$"e Ca$ses 3PostGp"eGint"a4 and hemodialysis

15 #D*& he$mathoid and Ostea"th"itis& @ells Palsy and !"igeminal ne$"algia

18 St$dy "adiation and %hemothe"apy and thei" $s$al side effe%ts 3Sin b$"n& "edness& do not wet "adiation

ma"4 <ammog"aphy& @S,& !S,& ),& P"ostate and Colon %an%e"& Changes that o%%$"s d$"ing elde"ly&

@ladde"& Colon and Ce"/i%al %an%e" )iagnosti% e-aminationGC,#& P"o%tosigmoidos%opy& @iopsy& Pap smea"

1 'a"yngeal %an%e" and t"a%heostomy %a"e 3"efe" to o(ie" fo" t"a%heostomy %a"e4

NP5

1 In yo$" !est 7 st$dy the following: #n-iety and an-iety diso"de"s& !he le/el of an-iety and yo$"an-iolyti%s& S%hi(oph"enia: Pa"anoid type and Catatoni% type and yo$" n$"sing inte"/entions fo" these %lients

as well as yo$" p"io"ity n$"sing diagnosis

2 )ep"ession and yo$" antidep"essants& <ania& Pe"sonality diso"de"s espe%ially yo$" #ntiso%ial& @o"de"line

and Pa"anoid !he defense me%hanism $se fo" diffe"ent types of diso"de"s and the p"io"ity *USI*D

)I#D*OSIS fo" ea%h psy%hiat"i% diso"de"s& #ntipsy%hoti% d"$gs its side effe%ts and n$"sing inte"/ention fo"

ea%h side effe%ts

+ ,le%t"o%on/$lsi/e the"apy& !ho$ght p"o%ess dist$"ban%e manifestation s$%h as Clang #sso%iation&

P"ess$"ed spee%h& !ho$ght blo%ing& Ho"d salad& pe"se/e"ation et% et% #lte"ation in pe"%eption and tho$ght

lie hall$%ination and del$sion !ypes of del$sions eg "eligio$s and pe"se%$to"y #%ti/ities and diet as well as

n$"sing diagnosis fo" a %lient with <ania& )ep"essed and #l(heime"KsG)ementia patient

. ,ating diso"de"s and the t"eatments of %hoi%e 3@eha/io" the"apy fo" #no"e-ia& Psy%hothe"apy fo" the

Pe"sonality )iso"de"s& Cogniti/e the"apy fo" dep"ession 4 #lways answe" LS!#A HI!? !?, C'I,*!Lespe%ially if the 6$estion is abo$t an-iety diso"de"s and pani% atta%s #lways %hoose an option that will

en%o$"age /e"bali(ation of feelings& ne/e" answe" an option with the wo"d H?A

St$dy yo$" %o$nte" t"ansfe"en%e and yo$" t"ansfe"en%e& Dla$%oma& Cata"a%t and %"$t%hG%ane waling !he

p"in%iples of body me%hani%s& %"anial ne"/e f$n%tioning and how to assess them as well as thei" dist$"ban%es

espe%ially @ells and !"igeminal *e$"algia <enie"es disease& )eli"$m& )ementia& C7#GSt"oe

pathophysiology and Fa%to"s

5 Psy%hothe"apy : @eha/io" the"apy = a/e"sion& ope"ant %onditioning 3positi/e "einfo"%ement4 systemati%

desensiti(ation Cogniti/e the"apy is the PSAC?O!?,#PA of %hoi%e fo" dep"ession St$dy the"ape$ti%

milie$ = gene"al pt management& en/i"onmental manip$lation& $ses demo%"ati% leade"ship to test new patte"ns

of beha/io" Comm$nity meeting is the hea"t of milie$ the"apy Pha"ma%othe"apy: )"$g %lassifi%ation and

side effe%ts of #*!IPSAC?O!IC& #*;IO'A!ICS& #*!I<#*IC 3!eg"et"ol& 'ithi$m& )epaene4

8 !"ansfe" of %lients f"om @,) to C?#I as well as <O7I*D C'I,*! UP I* @,) 3,#) OJI,4

S$ppo"ting the %lient in: SUPI*, 3eg p"e/ent ne% hype"e-tension by p$tting pillow4& FOH',S

3p"e/ent poste"io" %$"/at$"e of the spine4& )OS#' ,CU<@,*! 3p"e/ent hype"e-tension of the nee4#*) SI),'AI*D position 3P"e/ent late"al fle-ion of the ste"no%leidomastoid4

9 ,6$ipments fo" immobility : !"o%hante" "ollGsandbags = p"e/ent e-te"nal "otation of the hips Pillow to

s$ppo"t ba%& head& a"ms and sho$lde"s Footboa"d to p"e/ent footd"op !"ape(e ba" to mo/e the %lient $p in

bed nee gat%h o" pillow = to slightly fle- the %lients nee

10 I*!O)UC, C?#*D, D#)U#''A = St$dy methods of implementing %hange s$%h as FOC,

FI,') #*#'ASIS = !?, )I7I*D #*) !?, ,S!#I*I*D FOC,S& FOCUS = FI*) OD#*IJ,

C'#IFA U*),S!#*) SO'U!IO* !?, P)S# CAC', = P'#* )O S!U)A #C!



COMPREHENSIVE NURSING REVIEW by R. C. REÑA |

!?, 5 !,C?*IC#' !IPS FO !?, @O#) ,;#<I*#!IO*

1 #%%ept the fa%t that yo$ %an ne/e" now e/e"ything !he"efo"e& on%e yo$ see an $nfamilia" 6$estion that

was ne/e" been ta$ght& $se yo$" test taing st"ategies

2 If yo$ a"e in !est I& II& III& and I7 and yo$ a"e being ased to p"io"iti(e& Use #@C fi"st and then <aslows

?ie"a"%hy of needs

+ !he $se of yo$" n$"sing p"o%ess is he"alded by the wo"d: L!he *$"se Ho$ld o" !he n$"ses initial a%tionL

emembe" to #ssess fi"st befo"e inte"/ening If the sit$ation and the 6$estion al"eady assessed the patient&

then p"o%eed with the ne-t step

. ,n%i"%le yo$" modifie"s Some people mae mistaes be%a$se of fail$"e to see the wo"d& L,;C,P!L o"

L*O!L o" LI*#PPOPI#!,L& et% !he magi% wo"dsM

Use yo$" 6$estionnai"es as yo$" s%"at%h Ao$ %an w"ite anything on that pape" If yo$ will sip a n$mbe"&

pla%e an aste"is o" en%i"%le the n$mbe"

5 )O *O! US, @'U*! P,*CI' #lways $se a sha"p one and

shade lightly # sha"pened pen%il will gi/e a

/e"y da" shade e/en if yo$ will shade it lightly Use the sides of the pen%il not the tip Use <O*DO' *U<@, 2 O*'A Some b"ands espe%ially those made in %hina pen%ils a"e s$bstanda"d !he ma%hine will

%he% the lead If yo$ a"e I*CO*SIS!,*! with yo$" shading lie an alte"ing da" and light shades& yo$ will

F#I' the boa"ds be%a$se of te%hni%alities

Ca"e has been taen to %onfi"m the a%%$"a%y of the info"mation p"esented *e/e"theless& it is diffi%$lt to ens$"e that all theinfo"mation p"esented is enti"ely a%%$"ate fo" all %i"%$mstan%es& and the a$tho" %annot a%%ept any "esponsibility fo" any e""o" o"

omission !he a$tho" maes no wa""anty& e-p"essed o" implied& with "espe%t to this wo"& and dis%laims any liability& loss& o" damageas a %onse6$en%e& di"e%tly o" indi"e%tly& of the $se and appli%ation of any of the %ontents of this wo"

efe"en%es:

#dele Pillitte"i <#!,*#' N C?I') ?,#'!? *USI*D: Ca"e of the Childbea"ing N Child"ea"ing Family 200

wwwn$"sing%"ib%omwwws%"ibd%om

http://www.nursingcrib.com/

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PRAYERS TO ST. JOSEPH OF CUPERTINO FOR SUCCESS IN EXAMINATIONS

First Pra!r

O D"eat St Boseph of C$pe"tino who while on ea"th did obtain f"om Dod the

g"a%e to be ased at yo$" e-amination only the 6$estions yo$ new& obtain fo"me a lie fa/o$" in the e-aminations fo" whi%h I am now p"epa"ing In "et$"n I

p"omise to mae yo$ nown and %a$se yo$ to be in/oed

!h"o$gh Ch"ist o$" 'o"d

St Boseph of C$pe"tino& P"ay fo" $s

#men

S!"#$% Pra!r

O St Boseph of C$pe"tino who by yo$" p"aye" obtained f"om Dod to be ased atyo$" e-amination& the only p"eposition yo$ new D"ant that I may lie yo$

s$%%eed in the

*$"sing 'i%ens$"e ,-amination

In "et$"n& I p"omise to mae yo$ nown and %a$se yo$ to be in/oedO St Boseph of C$pe"tino p"ay fo" me

O ?oly Dhost enlighten me

O$" 'ady of Dood St$dies p"ay fo" me

Sa%"ed ?ead of Bes$s& Seat of di/ine wisdom& enlighten me

PRAYER TO SAINT JUDE THADDEUS, PATRON OF THE IMPOSSIBLE

<ost ?oly #postle St B$de& faithf$l se"/ant and f"iend of Bes$s& the %h$"%h hono"s and

in/oes yo$ $ni/e"sally as the pat"on of diffi%$lt %ases& of things almost despai"ed of&

p"ay fo" me I am so helpless and alone Inte"%ede to Dod fo" me that ?e b"ings /isible

and speedy help whe"e help is almost despai"ed of

Come to my assistan%e in this g"eat need that I may "e%ei/e the %onsolation and help of

hea/en in all my ne%essities& t"ib$lations and s$ffe"ings pa"ti%$la"ly he"e mae yo$"

"e6$est and that I may p"aise Dod with yo$ and all the saints fo"e/e"

I p"omise& O @lessed St B$de& to be e/e" mindf$l of this g"eat fa/o" g"anted to me byDod and to always hono" yo$ as my spe%ial and powe"f$l pat"on and to g"atef$lly

en%o$"age de/otion to yo$ #men




PRINCIPLES OF TEST TA&ING

I' PRINCIPLE OF CONTRADICTION

Hhen two options %ont"adi%t ea%h othe"& the"e is a highe" %han%e of one of them being the %o""e%t answe"

,-ample: Hhi%h physiologi% effe%t sho$ld the n$"se e-pe%t in a %lient addi%ted to hall$%inogensQ# )ilated p$pils

@ Const"i%ted p$pilsC @"ady%a"dia

) @"adypnea

II' PRINCIPLE OF COMMONALIT( AND DIFFERENCE

!wo o" mo"e options that has the same essential %onfig$"ation and tho$ght is $nliely the %o""e%t answe"

,-ample: Hhen inEe%ting s$b%$taneo$s inEe%tion in an obese patient& it sho$ld be angled at a"o$nd:

# .R

@ 90R

C 10R

) Pa"allel to the sin

III' PRINCIPLE OF CENTRAL TENDENC(

Co""e%t answe"s in an all n$me"i% options is most liely lo%ated in between the e-t"emes

,-ample: Hhat is the 7O "ate of @!Q

# gttsGmin

@ 10 gttsGmin

C 1 gttsGmin

) 20 gttsGmin

IV' PRINCIPLE OF POSITIVE AND NEGATIVE HARMON(

# positi/e 6$estion will always as fo" a positi/e answe" and so is a negati/e 6$estion

FO<U'#: 3=4 3=4 >$estion34 34 >$estion

3=4 34 = >$estion

,-ample: #ll b$t one of the following is an #n-iolyti%:

34 3=4

# !"an-ene@ <iltown

C #ta"a-

) Pa"lodel

V' PRINCIPLE OF IMPRO)A)LE EXTREMES

,-t"eme modifie"s& s$%h as always& all& ne/e"& o" only mae it mo"e liely that the 6$estion is false ?e"e is amo"e %omplete list of ,;!,<, modifie"s

#ll& e/e"y& nothing& none& best& absol$tely& always& ne/e"& wo"st& absol$tely not& only& nobody& e/e"ybody&

%e"tainly& in/a"iably& no one& e/e"yone& %e"tainly not

,-ample: !he most effe%ti/e way in limiting the n$mbe" of mi%"oo"ganism in the hospital is:

# Using st"i%t asepti% te%hni6$e in all p"o%ed$"es

@ Hea"ing mas and gown in %a"e of all patients with %omm$ni%able diseases

C Ste"ili(ation of all inst"$ments

) ?andwashing

VI' PRINCIPLE OF INITIATIVE CRITICAL THIN&ING

1 Co/e" the options2 ead the 6$estion %a"ef$lly

+ !"y answe"ing the 6$estion witho$t looing at the options

. Sele%t the option that most %losely mat%hes yo$" answe"

,-ample: !he n$"se new that the no"mal %olo" of <i%hielKs stoma sho$ld be:

# @"i% ed

@ D"ay

C @l$e

) Pale Pin




VII' PRINCIPLE OF GRAMMATICAL HARMON(

Options that do not %oin%ide with the g"ammati%al %onfig$"ation of the stem is *O! the %o""e%t answe"

Choi%es that a"e g"ammati%ally in%o""e%t o" %ontain typog"aphi%al e""o"s a"e p"obably not the %o""e%t answe"

,-ample: Hhen planning a %a"e fo" a %lient who is pan%ytopeni%& !he maEo" goal sho$ld be:

CP"e/ent hemo""hage& infe%tion and de%"ease o-ygenation

@ #dministe"ing an o"al i"on p"epa"ation

C P"e/enting Fatig$e and fl$id o/e"load) ,n%o$"aging a %ons$mption of a ne$t"openi% diet

VIII' PRINCIPLE OF UM)RELLA EFFECT

# %hoi%e that is mo"e in%l$si/e is $s$ally the %o""e%t answe"

,-ample: !o /iew a pe"son holisti%ally& the n$"se sho$ld thin of him o" he" as:

# Physi%al being who e-pe"ien%es pathology and so%iologi%al %hanges

@ So%ial being who needs the dynami%s of g"o$p inte"a%tion

C Psy%hologi%al being whose mind infl$en%es his o" he" health stat$s) @iopsy%hoso%ial being who is in %onstant inte"a%tion with the en/i"onment

IX' Pri$"i*+! # A)C, Mas+#-.s Hi!rar"/ a$% N0rsi$ Pr#"!ssHhen 6$estions "e6$i"e p"io"iti(ation& these p"in%iples sho$ld apply eywo"ds that indi%ate the need to p"io"iti(e

in%l$de:

@,S! 7I!#'

,SS,*!I#' PI<#A

FIS! ?ID?,S! PIOI!A

I<<,)I#!, I*I!I#'

<OS! I<PO!#*! *,;!

,-ample: # n$"se is "e/iewing the plan of %a"e fo" a p"egant %lient with a diagnosis of si%le %ell anemia Hhi%h

n$"sing diagnosis& if stated on the plan of %a"e& wo$ld the n$"se sele%t as "e%ei/ing the highest p"io"ityQ

##n-iety

@Ineffe%ti/e %opingC)ist$"bed body image

))efi%ient fl$id /ol$me

,-ample: Hhen %a"ing fo" #ida afte" a %hest s$"ge"y& yo$" p"io"ity wo$ld be to maintain:

# S$pplementa"y o-ygen

@ Chest t$be d"ainage

C @lood "epla%ement

) 7entilation e-%hange

X' Pri$"i*+! # T!++ M! M#r!

In Psy%hiat"i% *$"sing& emembe" to fo%$s on the %lientKs feeling& %on%e"ns& an-ieties and fea"s !his is best

s$mma"i(ed by a "esponse that en%o$"ages the %lientKs /e"bali(ation of feelings

,-ample: # mothe" says to the n$"se& I am af"aid that my %hild might ha/e anothe" sei($"eT Hhi%h "esponse by

the n$"se is most the"ape$ti%Q

# Hhy wo""y abo$t something yo$ %annot %ont"olQT

@ <ost %hild"en will ne/e" e-pe"ien%e a se%ond sei($"eT

C !ell me what f"ightens yo$ the most abo$t sei($"esT

) !ylenol %an p"e/ent anothe" sei($"e f"om o%%$"ingT

XI' Pri$"i*+! # R!a**!ari$ Visa!

# wo"d o" ph"ase that appea"s in the 6$estion and then "eappea"s at one of the . %hoi%es is the most p"obable

answe"

,-ample: # %h"oni%ally ill s%hool=age %hild is most /$lne"able to whi%h st"esso"Q

# <$tilation an-iety

@ #nti%ipato"y g"ief

C #n-iety o/e" s%hool absen%es

) Fea" of hospital p"o%ed$"es




XII' T/! Dr0 T!"/$i0!

<ost d"$gs& espe%ially psy%hot"opi% medi%ations eithe" a%t as a C*S Stim$lant o" a C*S dep"essant !he st"ategy

"e/ol/es in dete"mining whi%h a"e the Cent"al ne"/o$s system e-%itations and whi%h a"e the Cent"al ne"/o$s

system inhibitions If + of the options a"e all C*S $p and 1 is C*S down& pi% the C*S down If + of the options

a"e all C*S down and 1 is C*S $p& pi% the C*S $p

,-ample: !he n$"se is assessing a %lient who has E$st been admitted to the eme"gen%y depa"tment Hhi%h signs

wo$ld s$ggest an o/e"dose of an antian-iety agentQ# Combati/eness& sweating& and %onf$sion

@ #gitation& hype"a%ti/ity& and g"andiose ideation

C S$spi%io$sness& dilated p$pils& and in%"eased blood p"ess$"e

) ,motionally bl$nt& letha"gy and impai"ed memo"y




CO*!,*!S

FU*)#<,*!#'S OF *USI*D MMMM12

<#!,*I!A *USI*D MMMMMMMMMMM ++

P,)I#!IC *USI*DMMMMMMMMMMMM8

CO<<U*I!A ?,#'!? *USI*D MMMMMMM58

<,)IC#' SUDIC#' *USI*D MMMMMMM 9PSAC?I#!IC *USI*D MMMMMMMM 118

POF,SSIO*#' #)BUS!<,*! MMMMMMM 1.1

',#),S?IP and <#*#D,<,*! MMMMMM 1..

*USI*D ,S,#C? MMMMMMMMMMM15

CO<P,?,*SI7, ,;#<I*#!IO* MMMMMM

18+







FUNDAMENTALS OF NURSING PART 1

1 Using the p"in%iples of standa"d p"e%a$tions& the n$"se wo$ld wea" glo/es in what n$"sing inte"/entionsQ

a P"o/iding a ba% massage b Feeding a %lient

% P"o/iding hai" %a"ed P"o/iding o"al hygiene

2 !he n$"se is p"epa"ing to tae /ital sign in an ale"t %lient admitted to the hospital with dehyd"ation

se%onda"y to /omiting and dia""hea Hhat is the best method $sed to assess the %lientKs tempe"at$"eQ

a O"al

b #-illa"y

% adial

d ?eat sensiti/e tape

+ # n$"se obtained a %lientKs p$lse and fo$nd the "ate to be abo/e no"mal !he n$"se do%$ment this findings

as:

a !a%hypnea

b ?ype" py"e-ia

% #""ythmiad !a%hy%a"dia

. Hhi%h of the following a%tions sho$ld the n$"se tae to $se a wide base s$ppo"t when assisting a %lient to

get $p in a %hai"Q

a @end at the waist and pla%e a"ms $nde" the %lientKs a"ms and lift b Fa%e the %lient& bend nees and pla%e hands on %lientKs fo"ea"m and lift

% Sp"ead his o" he" feet apa"t

d !ighten his o" he" pel/i% m$s%les

# %lient had o"al s$"ge"y following a moto" /ehi%le a%%ident !he n$"se assessing the %lient finds the sin

fl$shed and wa"m Hhi%h of the following wo$ld be the best method to tae the %lientKs body

tempe"at$"eQ

a O"al

b #-illa"y% #"te"ial line

d e%tal

5 # %lient who is $n%ons%io$s needs f"e6$ent mo$th %a"e Hhen pe"fo"ming a mo$th %a"e& the best position

of a %lient is:

a Fowle"Ks position

b Side lying

% S$pine

d !"endelenb$"g

8 # %lient is hospitali(ed fo" the fi"st time& whi%h of the following a%tions ens$"e the safety of the %lientQ

a eep $nne%essa"y f$"nit$"e o$t of the way b eep the lights on at all time

% eep side "ails $p at all timed eep all e6$ipment o$t of /iew

# wal=in %lient ente"s into the %lini% with a %hief %omplaint of abdominal pain and dia""hea !he n$"se

taes the %lientKs /ital sign he"eafte" Hhat ph"ase of n$"sing p"o%ess is being implemented he"e by the

n$"seQ

a #ssessment

b )iagnosis

% Planning

d Implementation

9 It is best des%"ibe as a systemati%& "ational method of planning and p"o/iding n$"sing %a"e fo" indi/id$al&

families& g"o$p and %omm$nity

a #ssessment

b *$"sing P"o%ess

% )iagnosis

d Implementation

10 ,-%hange of gases taes pla%e in whi%h of the following o"ganQ

a idney b '$ngs

% 'i/e"

d ?ea"t

11 !he Chambe" of the hea"t that "e%ei/es o-ygenated blood f"om the l$ngs is theQ

a 'eft at"i$m



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1+

b ight at"i$m

% 'eft /ent"i%le

d ight /ent"i%le

12 # m$s%$la" enla"ge po$%h o" sa% that lies slightly to the left whi%h is $sed fo" tempo"a"y sto"age of

foodM

a Dallbladde"

b U"ina"y bladde"

% Stoma%hd '$ngs

1+ !he ability of the body to defend itself against s%ientifi% in/ading agent s$%h as ba%e"ia& to-in& /i"$ses and

fo"eign body

a ?o"mones

b Se%"etion

% Imm$nity

d Dlands

1. ?o"mones se%"eted by Islets of 'ange"hans

a P"ogeste"one b !estoste"one

% Ins$lin

d ?emoglobin1 It is a t"anspa"ent memb"ane that fo%$ses the light that ente"s the eyes to the "etina

a 'ens

b S%le"a

% Co"nea

d P$pils

15 Hhi%h of the following is in%l$ded in O"emKs theo"yQ

a <aintenan%e of a s$ffi%ient intae of ai"

b Self pe"%eption

% 'o/e and belonging

d Physiologi% needs

18 Hhi%h of the following %l$ste" of data belong to <aslowKs hie"a"%hy of needs

a 'o/e and belonging b Physiologi% needs

% Self a%t$ali(ation

d #ll of the abo/e1 !his is %ha"a%te"i(ed by se/e"e symptoms "elati/ely of sho"t d$"ation

a Ch"oni% Illness

b #%$te Illness

% Pain

d Synd"ome

19 Hhi%h of the following is the n$"seKs "ole in the health p"omotion

a ?ealth "is app"aisal

b !ea%h %lient to be effe%ti/e health %ons$me"

% Ho"site wellness

d *one of the abo/e

20 It is des%"ibe as a %olle%tion of people who sha"e some att"ib$tes of thei" li/es

a Family

b Illness

% Comm$nity

d *$"sing

21 Fi/e teaspoon is e6$i/alent to how many millilite"s mlQ

a +0 ml

b 2 ml% 12 ml

d 8 ml

22 100 ml is e6$al to how many lite"sQ

a 1

b 1000

% 10

d 2002+ Hhi%h of the following is the abb"e/iation of d"opsQ

a Dtt

b Dtts

% )p

d )"



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1.

2. !he abb"e/iation fo" mi%"o d"op isM

a gtt

b gtt

% md"

d mgts

2 Hhi%h of the following is the meaning of P*Q

a Hhen ad/i%e

b Immediately% Hhen ne%essa"y

d *ow

25 Hhi%h of the following is the app"op"iate meaning of C@Q

a Ca"dia% @oa"d oom

b Complete @ath"oom

% Complete @ed est

d Complete @oa"d oom

28 1 tsp is e6$als to how many d"opsQ

a 1 b 50

% 10

d +02 20 %% is e6$al to how many mlQ

a 2

b 20

% 2000

d 20000

29 1 %$p is e6$al to how many o$n%esQ

a

b 0

% 00

d 000

+0 !he n$"se m$st /e"ify the %lientKs identity befo"e administ"ation of medi%ation Hhi%h of the following is

the safest way to identify the %lientQa #s the %lient his name

b Che% the %lientKs identifi%ation band

% State the %lientKs name alo$d and ha/e the %lient "epeat it

d Che% the "oom n$mbe"

+1 !he n$"se p"epa"es to administe" b$%%al medi%ation !he medi%ine sho$ld be pla%edM

a On the %lientKs sin

b @etween the %lientKs %hees and g$ms

% Unde" the %lientKs tong$e

d On the %lientKs %onE$%ti/a

+2 !he n$"se administe"s %leansing enema !he %ommon position fo" this p"o%ed$"e isMa Sims left late"al

b )o"sal e%$mbent% S$pine

d P"one

++ # %lient %omplains of diffi%$lty of swallowing& when the n$"se t"y to administe" %aps$le medi%ation

Hhi%h of the following meas$"es the n$"se sho$ld doQ

a )issol/e the %aps$le in a glass of wate"

b @"ea the %aps$le and gi/e the %ontent with an applesa$%e

% Che% the a/ailability of a li6$id p"epa"ation

d C"ash the %aps$le and pla%e it $nde" the tong$e

+. Hhi%h of the following is the app"op"iate "o$te of administ"ation fo" ins$linQ

a Int"am$s%$la"

b Int"ade"mal

% S$b%$taneo$s

d Int"a/eno$s

+ !he n$"se is o"de"ed to administe" ampi%illin %aps$le !IP po !he n$"se sho$d gi/e the medi%ationM

a !h"ee times a day o"ally

b !h"ee times a day afte" meals% !wo time a day by mo$th

d !wo times a day befo"e meals

+5 @a% Ca"e is best des%"ibe as:

a Ca"ing fo" the ba% by means of massage

b Hashing of the ba%




% #ppli%ation of %old %omp"ess at the ba%

d #ppli%ation of hot %omp"ess at the ba%

+8 It "efe"s to the p"epa"ation of the bed with a new set of linens

a @ed bath

b @ed maing

% @ed shampoo

d @ed lining

+ Hhi%h of the following is the most impo"tant p$"pose of handwashinga !o p"omote hand %i"%$lation

b !o p"e/ent the t"ansfe" of mi%"oo"ganism

% !o a/oid to$%hing the %lient with a di"ty hand

d !o p"o/ide %omfo"t

+9 Hhat sho$ld be done in o"de" to p"e/ent %ontaminating of the en/i"onment in bed maingQ

a #/oid f$nning soiled linens

b St"ip all linens at the same time

% Finished both sides at the time

d ,mb"a%e soiled linen.0 !he most impo"tant p$"pose of %leansing bed bath is:

a !o %leanse& "ef"esh and gi/e %omfo"t to the %lient who m$st "emain in bed

b !o e-pose the ne%essa"y pa"ts of the body% !o de/elop sills in bed bath

d !o %he% the body tempe"at$"e of the %lient in bed

.1 Hhi%h of the following te%hni6$e in/ol/es the sense of sightQ

a Inspe%tion

b Palpation

% Pe"%$ssion

d #$s%$ltation

.2 !he fi"st te%hni6$es $sed e-amining the abdomen of a %lient is:

a Palpation

b #$s%$ltation

% Pe"%$ssion

d Inspe%tion.+ # te%hni6$e in physi%al e-amination that is $se to assess the mo/ement of ai" th"o$gh the

t"a%heob"on%hial t"ee:

a Palpation b #$s%$ltation

% Inspe%tion

d Pe"%$ssion

.. #n inst"$ment $sed fo" a$s%$ltation is:

a Pe"%$ssion=hamme"

b #$diomete"

% Stethos%ope

d Sphygmomanomete"

. esonan%e is best des%"ibe as:

a So$nds %"eated by ai" filled l$ngs

b Sho"t& high pit%h and th$dding

% <ode"ately lo$d with m$si%al 6$ality

d )"$m=lie

.5 !he best position fo" e-amining the "e%t$m is:

a P"one

b SimKs

% nee=%hest

d 'ithotomy.8 It "efe"s to the manne" of waling

a Dait

b ange of motion

% Fle-ion and e-tension

d ?opping

. !he n$"se ased the %lient to "ead the Snellen %ha"t Hhi%h of the following is tested:

a Opti%

b Olfa%to"y

% O%$lomoto"

d !"o%lea"

.9 #nothe" name fo" nee=%hest position is:

a Den$=do"sal







1 !he most app"op"iate n$"sing o"de" fo" a patient who de/elops dyspnea and sho"tness of b"eath wo$ld

beM

a <aintain the patient on st"i%t bed "est at all times b <aintain the patient in an o"thopnei% position as needed

% #dministe" o-ygen by 7ent$"i mas at 2.V& as needed

d #llow a 1 ho$" "est pe"iod between a%ti/ities

2 !he n$"se obse"/es that <" #dams begins to ha/e in%"eased diffi%$lty b"eathing She ele/ates the head of

the bed to the high Fowle" position& whi%h de%"eases his "espi"ato"y dist"ess !he n$"se do%$ments this

b"eathing as:

a !a%hypnea

b ,$pn%a

% O"thopnead ?ype"/entilation

+ !he physi%ian o"de"s a platelet %o$nt to be pe"fo"med on <"s Smith afte" b"eafast !he n$"se is

"esponsible fo":a Inst"$%ting the patient abo$t this diagnosti% test

b H"iting the o"de" fo" this test

% Di/ing the patient b"eafast

d #ll of the abo/e

. <"s <it%hell has been gi/en a %opy of he" diet !he n$"se dis%$sses the foods allowed on a 00=mg low

sodi$m diet !hese in%l$de:

a # ham and Swiss %heese sandwi%h on whole wheat b"ead

b <ashed potatoes and b"oiled %hi%en

% # tossed salad with oil and /inega" and oli/es

d Chi%en bo$illon

!he physi%ian o"de"s a maintenan%e dose of &000 $nits of s$b%$taneo$s hepa"in an anti%oag$lant daily

*$"sing "esponsibilities fo" <"s <it%hell now in%l$de:a e/iewing daily a%ti/ated pa"tial th"omboplastin time #P!! and p"oth"ombin time

b epo"ting an #P!! abo/e . se%onds to the physi%ian

% #ssessing the patient fo" signs and symptoms of f"an and o%%$lt bleedingd #ll of the abo/e

5 !he fo$" main %on%epts %ommon to n$"sing that appea" in ea%h of the %$""ent %on%ept$al models a"e:

a Pe"son& n$"sing& en/i"onment& medi%ine

b Pe"son& health& n$"sing& s$ppo"t systems

% Pe"son& health& psy%hology& n$"sing

d Pe"son& en/i"onment& health& n$"sing

8 In <aslowKs hie"a"%hy of physiologi% needs& the h$man need of g"eatest p"io"ity is:

a 'o/e

b ,limination

% *$t"ition

d O-ygen

!he family of an a%%ident /i%tim who has been de%la"ed b"ain=dead seems amenable to o"gan donation

Hhat sho$ld the n$"se doQ

a )is%o$"age them f"om maing a de%ision $ntil thei" g"ief has eased

b 'isten to thei" %on%e"ns and answe" thei" 6$estions honestly

% ,n%o$"age them to sign the %onsent fo"m "ight away

d !ell them the body will not be a/ailable fo" a wae o" f$ne"al

9 # new head n$"se on a $nit is dist"essed abo$t the poo" staffing on the 11 pm to 8 am shift Hhatsho$ld she doQ

a Complain to he" fellow n$"ses

b Hait $ntil she nows mo"e abo$t the $nit

% )is%$ss the p"oblem with he" s$pe"/iso"

d Info"m the staff that they m$st /ol$ntee" to "otate

10 Hhi%h of the following p"in%iples of p"ima"y n$"sing has p"o/en the most satisfying to the patient and

n$"seQ

a Contin$ity of patient %a"e p"omotes effi%ient& %ost=effe%ti/e n$"sing %a"e

b #$tonomy and a$tho"ity fo" planning a"e best delegated to a n$"se who nows the patient well

% #%%o$ntability is %lea"est when one n$"se is "esponsible fo" the o/e"all plan and its

implementation




d !he holisti% app"oa%h p"o/ides fo" a the"ape$ti% "elationship& %ontin$ity& and effi%ient n$"sing

%a"e

11 If n$"se administe"s an inEe%tion to a patient who "ef$ses that inEe%tion& she has %ommitted:

a #ssa$lt and batte"y

b *egligen%e

% <alp"a%ti%e

d *one of the abo/e

12 If patient ass the n$"se he" opinion abo$t a pa"ti%$la" physi%ians and the n$"se "eplies that the physi%ianis in%ompetent& the n$"se %o$ld be held liable fo":

a Slande"

b 'ibel

% #ssa$lt

d espondent s$pe"io"

1+ # "egiste"ed n$"se "ea%hes to answe" the telephone on a b$sy pediat"i% $nit& momenta"ily t$"ning away

f"om a + month=old infant she has been weighing !he infant falls off the s%ale& s$ffe"ing a s$ll f"a%t$"e

!he n$"se %o$ld be %ha"ged with:

a )efamation b #ssa$lt

% @atte"y

d <alp"a%ti%e1. Hhi%h of the following is an e-ample of n$"sing malp"a%ti%eQ

a !he n$"se administe"s peni%illin to a patient with a do%$mented histo"y of alle"gy to the d"$g !he

patient e-pe"ien%es an alle"gi% "ea%tion and has %e"eb"al damage "es$lting f"om ano-ia

b !he n$"se applies a hot wate" bottle o" a heating pad to the abdomen of a patient with abdominal

%"amping

% !he n$"se assists a patient o$t of bed with the bed lo%ed in positionW the patient slips and

f"a%t$"es his "ight h$me"$s

d !he n$"se administe"s the w"ong medi%ation to a patient and the patient /omits !his info"mation

is do%$mented and "epo"ted to the physi%ian and the n$"sing s$pe"/iso"

1 Hhi%h of the following signs and symptoms wo$ld the n$"se e-pe%t to find when assessing an #sian

patient fo" postope"ati/e pain following abdominal s$"ge"yQ

a )e%"eased blood p"ess$"e and hea"t "ate and shallow "espi"ations b >$iet %"ying

% Immobility& diapho"esis& and a/oidan%e of deep b"eathing o" %o$ghing

d Changing position e/e"y 2 ho$"s15 # patient is admitted to the hospital with %omplaints of na$sea& /omiting& dia""hea& and se/e"e abdominal

pain Hhi%h of the following wo$ld immediately ale"t the n$"se that the patient has bleeding f"om the DI

t"a%tQ

a Complete blood %o$nt

b D$aia% test

% 7ital signs

d #bdominal gi"th

18 !he %o""e%t se6$en%e fo" assessing the abdomen is:

a !ympani% pe"%$ssion& meas$"ement of abdominal gi"th& and inspe%tion

b #ssessment fo" distention& tende"ness& and dis%olo"ation a"o$nd the $mbili%$s

% Pe"%$ssions& palpation& and a$s%$ltation

d #$s%$ltation& pe"%$ssion& and palpation

1 ?igh=pit%hed g$"gles head o/e" the "ight lowe" 6$ad"ant a"e:

a # sign of in%"eased bowel motility

b # sign of de%"eased bowel motility

% *o"mal bowel so$nds

d # sign of abdominal %"amping

19 # patient abo$t to $nde"go abdominal inspe%tion is best pla%ed in whi%h of the following positionsQa P"one

b !"endelenb$"g

% S$pine

d Side=lying

20 Fo" a "e%tal e-amination& the patient %an be di"e%ted to ass$me whi%h of the following positionsQ

a Den$pe%te"ol

b Sims

% ?o"i(ontal "e%$mbent

d #ll of the abo/e

21 )$"ing a ombe"g test& the n$"se ass the patient to ass$me whi%h positionQ

a Sitting

b Standing




% Den$pe%to"al

d !"endelenb$"g

22 If a patientKs blood p"ess$"e is 10G95& his p$lse p"ess$"e is:

a .

b 95

% 10

d 2.5

2+ # patient is ept off food and fl$ids fo" 10 ho$"s befo"e s$"ge"y ?is o"al tempe"at$"e at am is 99 F+88 C !his tempe"at$"e "eading p"obably indi%ates:

a Infe%tion

b ?ypothe"mia

% #n-iety

d )ehyd"ation

2. Hhi%h of the following pa"amete"s sho$ld be %he%ed when assessing "espi"ationsQ

a ate

b hythm

% Symmet"yd #ll of the abo/e

2 # +=yea" old patientKs /ital signs at am a"e a-illa"y tempe"at$"e 995 F +85 CW p$lse "ate& W

"espi"ato"y "ate& +0 Hhi%h findings sho$ld be "epo"tedQa espi"ato"y "ate only

b !empe"at$"e only

% P$lse "ate and tempe"at$"e

d !empe"at$"e and "espi"ato"y "ate

25 #ll of the following %an %a$se ta%hy%a"dia e-%ept:

a Fe/e"

b ,-e"%ise

% Sympatheti% ne"/o$s system stim$lation

d Pa"asympatheti% ne"/o$s system stim$lation

28 Palpating the mid%la/i%$la" line is the %o""e%t te%hni6$e fo" assessing

a @aseline /ital signs

b Systoli% blood p"ess$"e% espi"ato"y "ate

d #pi%al p$lse

2 !he absen%e of whi%h p$lse may not be a signifi%ant finding when a patient is admitted to the hospitalQa #pi%al

b adial

% Pedal

d Femo"al

29 Hhi%h of the following patients is at g"eatest "is fo" de/eloping p"ess$"e $l%e"sQ

a #n ale"t& %h"oni% a"th"iti% patient t"eated with ste"oids and aspi"in

b #n =yea" old in%ontinent patient with gast"i% %an%e" who is %onfined to his bed at home

% #n apatheti% 5+=yea" old COP) patient "e%ei/ing nasal o-ygen /ia %ann$la

d # %onf$sed 8=yea" old patient with %ongesti/e hea"t fail$"e C?F who "e6$i"es assistan%e to get

o$t of bed

+0 !he physi%ian o"de"s the administ"ation of high=h$midity o-ygen by fa%e mas and pla%ement of the

patient in a high Fowle"Ks position #fte" assessing <"s Pa$l& the n$"se w"ites the following n$"sing

diagnosis: Impai"ed gas e-%hange "elated to in%"eased se%"etions Hhi%h of the following n$"sing

inte"/entions has the g"eatest potential fo" imp"o/ing this sit$ationQ

a ,n%o$"age the patient to in%"ease he" fl$id intae to 200 ml e/e"y 2 ho$"s

b Pla%e a h$midifie" in the patientKs "oom

% Contin$e administe"ing o-ygen by high h$midity fa%e mas

d Pe"fo"m %hest physiothe"aphy on a "eg$la" s%hed$le+1 !he most %ommon defi%ien%y seen in al%oholi%s is:

a !hiamine

b ibofla/in

% Py"ido-ine

d Pantotheni% a%id

+2 Hhi%h of the following statement is in%o""e%t abo$t a patient with dysphagiaQ

a !he patient will find p$"eed o" soft foods& s$%h as %$sta"ds& easie" to swallow than wate"

b Fowle"Ks o" semi Fowle"Ks position "ed$%es the "is of aspi"ation d$"ing swallowing

% !he patient sho$ld always feed himself

d !he n$"se sho$ld pe"fo"m o"al hygiene befo"e assisting with feeding

++ !o assess the idney f$n%tion of a patient with an indwelling $"ina"y Foley %athete"& the n$"se meas$"es

his ho$"ly $"ine o$tp$t She sho$ld notify the physi%ian if the $"ine o$tp$t is:




a 'ess than +0 mlGho$"

b 5. ml in 2 ho$"s

% 90 ml in + ho$"s

d 12 ml in . ho$"s

+. Ce"tain s$bstan%es in%"ease the amo$nt of $"ine p"od$%ed !hese in%l$de:

a Caffeine=%ontaining d"ins& s$%h as %offee and %ola

b @eets

% U"ina"y analgesi%sd aolin with pe%tin aope%tate

+ # male patient who had s$"ge"y 2 days ago fo" head and ne% %an%e" is abo$t to mae his fi"st attempt to

amb$late o$tside his "oom !he n$"se notes that he is steady on his feet and that his /ision was $naffe%ted

by the s$"ge"y Hhi%h of the following n$"sing inte"/entions wo$ld be app"op"iateQ

a ,n%o$"age the patient to wal in the hall alone

b )is%o$"age the patient f"om waling in the hall fo" a few mo"e days

% #%%ompany the patient fo" his wal

d Cons$it a physi%al the"apist befo"e allowing the patient to amb$late

+5 # patient has e-a%e"bation of %h"oni% obst"$%ti/e p$lmona"y disease COP) manifested by sho"tness of b"eathW o"thopnea: thi%& tena%io$s se%"etionsW and a d"y ha%ing %o$gh #n app"op"iate n$"sing diagnosis

wo$ld be:

a Ineffe%ti/e ai"way %lea"an%e "elated to thi%& tena%io$s se%"etions b Ineffe%ti/e ai"way %lea"an%e "elated to d"y& ha%ing %o$gh

% Ineffe%ti/e indi/id$al %oping to COP)

d Pain "elated to immobili(ation of affe%ted leg

+8 <"s 'im begins to %"y as the n$"se dis%$sses hai" loss !he best "esponse wo$ld be:

a )onKt wo""y ItKs only tempo"a"yT

b Hhy a"e yo$ %"yingQ I didnKt get to the bad news yetT

% Ao$" hai" is "eally p"ettyT

d I now this will be diffi%$lt fo" yo$& b$t yo$" hai" will g"ow ba% afte" the %ompletion of

%hemothe"aphyT

+ #n additional 7itamin C is "e6$i"ed d$"ing all of the following pe"iods e-%ept:

a Infan%y

b Ao$ng ad$lthood% Childhood

d P"egnan%y

+9 # p"es%"ibed amo$nt of o-ygen s needed fo" a patient with COP) to p"e/ent:

a Ca"dia% a""est "elated to in%"eased pa"tial p"ess$"e of %a"bon dio-ide in a"te"ial blood PaCO2

b Ci"%$lato"y o/e"load d$e to hype"/olemia

% espi"ato"y e-%itement

d Inhibition of the "espi"ato"y hypo-i% stim$l$s

.0 #fte" 1 wee of hospitali(ation& <" D"ay de/elops hypoalemia Hhi%h of the following is the most

signifi%ant symptom of his diso"de"Q

a 'etha"gy b In%"eased p$lse "ate and blood p"ess$"e

% <$s%le weanessd <$s%le i""itability

.1 Hhi%h of the following n$"sing inte"/entions p"omotes patient safetyQ

a #sses the patientKs ability to amb$late and t"ansfe" f"om a bed to a %hai"

b )emonst"ate the signal system to the patient

% Che% to see that the patient is wea"ing his identifi%ation band

d #ll of the abo/e

.2 St$dies ha/e shown that abo$t .0V of patients fall o$t of bed despite the $se of side "ailsW this has led to

whi%h of the following %on%l$sionsQ

a Side "ails a"e ineffe%ti/e

b Side "ails sho$ld not be $sed

% Side "ails a"e a dete""ent that p"e/ent a patient f"om falling o$t of bed

d Side "ails a"e a "eminde" to a patient not to get o$t of bed

.+ ,-amples of patients s$ffe"ing f"om impai"ed awa"eness in%l$de all of the following e-%ept:

a # semi%ons%io$s o" o/e" fatig$ed patient

b # diso"iented o" %onf$sed patient

% # patient who %annot %a"e fo" himself at homed # patient demonst"ating symptoms of d"$gs o" al%ohol withd"awal

.. !he most %ommon inE$"y among elde"ly pe"sons is:

a #the"os%leoti% %hanges in the blood /essels

b In%"eased in%iden%e of gallbladde" disease

% U"ina"y !"a%t Infe%tion




d ?ip f"a%t$"e

. !he most %ommon psy%hogeni% diso"de" among elde"ly pe"son is:

a )ep"ession

b Sleep dist$"ban%es s$%h as bi(a""e d"eams

% Inability to %on%ent"ate

d )e%"eased appetite

.5 Hhi%h of the following /as%$la" system %hanges "es$lts f"om agingQ

a In%"eased pe"iphe"al "esistan%e of the blood /essels b )e%"eased blood flow

% In%"eased wo" load of the left /ent"i%le

d #ll of the abo/e

.8 Hhi%h of the following is the most %ommon %a$se of dementia among elde"ly pe"sonsQ

a Pa"insonKs disease

b <$ltiple s%le"osis

% #myot"ophi% late"al s%le"osis 'o$ De"higKs disease

d #l(heime"Ks disease

. !he n$"seKs most impo"tant legal "esponsibility afte" a patientKs death in a hospital is:a Obtaining a %onsent of an a$topsy

b *otifying the %o"one" o" medi%al e-amine"

% 'abeling the %o"pse app"op"iatelyd ,ns$"ing that the attending physi%ian iss$es the death %e"tifi%ation

.9 @efo"e "igo" mo"tis o%%$"s& the n$"se is "esponsible fo":

a P"o/iding a %omplete bath and d"essing %hange

b Pla%ing one pillow $nde" the bodyKs head and sho$lde"s

% emo/ing the bodyKs %lothing and w"apping the body in a sh"o$d

d #llowing the body to "ela- no"mally

0 Hhen a patient in the te"minal stages of l$ng %an%e" begins to e-hibit loss of %ons%io$sness& a maEo"

n$"sing p"io"ity is to:

a P"ote%t the patient f"om inE$"y

b Inse"t an ai"way

% ,le/ate the head of the bed

d Hithd"aw all pain medi%ations




ANSERS a$% RATIONALES #r FUNDAMENTALS OF NURSING PART 2

1 ) ' Hhen a patient de/elops dyspnea and sho"tness of b"eath& the o"thopnei% position en%o$"ages

ma-im$m %hest e-pansion and eeps the abdominal o"gans f"om p"essing against the diaph"agm& th$simp"o/ing /entilation @ed "est and o-ygen by 7ent$"i mas at 2.V wo$ld imp"o/e o-ygenation of the

tiss$es and %ells b$t m$st be o"de"ed by a physi%ian #llowing fo" "est pe"iods de%"eases the possibility of

hypo-ia

2 C ' O"thopnea is diffi%$lty of b"eathing e-%ept in the $p"ight position !a%hypnea is "apid "espi"ation

%ha"a%te"i(ed by 6$i%& shallow b"eaths ,$pnea is no"mal "espi"ation X 6$iet& "hythmi%& and witho$teffo"t

+ C' # platelet %o$nt e/al$ates the n$mbe" of platelets in the %i"%$lating blood /ol$me !he n$"se is

"esponsible fo" gi/ing the patient b"eafast at the s%hed$led time !he physi%ian is "esponsible fo"

inst"$%ting the patient abo$t the test and fo" w"iting the o"de" fo" the test

. )' <ashed potatoes and b"oiled %hi%en a"e low in nat$"al sodi$m %hlo"ide ?am& oli/es& and %hi%en

bo$illon %ontain la"ge amo$nts of sodi$m and a"e %ont"aindi%ated on a low sodi$m diet

D' #ll of the identified n$"sing "esponsibilities a"e pe"tinent when a patient is "e%ei/ing hepa"in !heno"mal a%ti/ated pa"tial th"omboplastin time is 15 to 2 se%onds and the no"mal p"oth"ombin time is 12 to

1 se%ondsW these le/els m$st "emain within two to two and one half the no"mal le/els #ll patients

"e%ei/ing anti%oag$lant the"apy m$st be obse"/ed fo" signs and symptoms of f"an and o%%$lt bleeding

in%l$ding hemo""hage& hypotension& ta%hy%a"dia& ta%hypnea& "estlessness& pallo"& %old and %lammy sin&

thi"st and %onf$sionW blood p"ess$"e sho$ld be meas$"ed e/e"y . ho$"s and the patient sho$ld be

inst"$%ted to "epo"t p"omptly any bleeding that o%%$"s with tooth b"$shing& bowel mo/ements& $"ination

o" hea/y p"olonged menst"$ation

5 D' !he fo%$s %on%epts that ha/e been a%%epted by all theo"ists as the fo%$s of n$"sing p"a%ti%e f"om the

time of Flo"en%e *ightingale in%l$de the pe"son "e%ei/ing n$"sing %a"e& his en/i"onment& his health on the

health illness %ontin$$m& and the n$"sing a%tions ne%essa"y to meet his needs

8 D' <aslow& who defined a need as a satisfa%tion whose absen%e %a$ses illness& %onside"ed o-ygen to be

the most impo"tant physiologi% needW witho$t it& h$man life %o$ld not e-ist #%%o"ding to this theo"y&othe" physiologi% needs in%l$ding food& wate"& elimination& shelte"& "est and sleep& a%ti/ity and

tempe"at$"e "eg$lation m$st be met befo"e p"o%eeding to the ne-t hie"a"%hi%al le/els on psy%hoso%ial

needs

)' !he b"ain=dead patientKs family needs s$ppo"t and "eass$"an%e in maing a de%ision abo$t o"gan

donation @e%a$se t"ansplants a"e done within ho$"s of death& de%isions abo$t o"gan donation m$st be

made as soon as possible ?owe/e"& the familyKs %on%e"ns m$st be add"essed befo"e membe"s a"e ased

to sign a %onsent fo"m !he body of an o"gan dono" is a/ailable fo" b$"ial

9 C' #ltho$gh a new head n$"se sho$ld initially spend time obse"/ing the $nit fo" its st"engths and

weaness& she sho$ld tae a%tion if a p"oblem th"eatens patient safety In this %ase& the s$pe"/iso" is the

"eso$"%e pe"son to app"oa%h

10 D' St$dies ha/e shown that patients and n$"ses both "espond well to p"ima"y n$"sing %a"e $nits Patients

feel less an-io$s and isolated and mo"e se%$"e be%a$se they a"e allowed to pa"ti%ipate in planning thei"

own %a"e *$"ses feel pe"sonal satisfa%tion& m$%h of it "elated to positi/e feedba% f"om the patients!hey also seem to gain a g"eate" sense of a%hie/ement and esp"it de %o"ps

11 A' #ssa$lt is the $nE$stifiable attempt o" th"eat to to$%h o" inE$"e anothe" pe"son @atte"y is the $nlawf$l

to$%hing of anothe" pe"son o" the %a""ying o$t of th"eatened physi%al ha"m !h$s& any a%t that a n$"se

pe"fo"ms on the patient against his will is %onside"ed assa$lt and batte"y

12 A' O"al %omm$ni%ation that inE$"es an indi/id$alKs "ep$tation is %onside"ed slande" H"itten

%omm$ni%ation that does the same is %onside"ed libel

1+ D' <alp"a%ti%e is defined as inE$"io$s o" $np"ofessional a%tions that ha"m anothe" It in/ol/es

p"ofessional mis%ond$%t& s$%h as omission o" %ommission of an a%t that a "easonable and p"$dent n$"se

wo$ld o" wo$ld not do In this e-ample& the standa"d of %a"e was b"ea%hedW a +=month=old infant sho$ld

ne/e" be left $nattended on a s%ale1. A' !he th"ee elements ne%essa"y to establish a n$"sing malp"a%ti%e a"e n$"sing e""o" administe"ing

peni%illin to a patient with a do%$mented alle"gy to the d"$g& inE$"y %e"eb"al damage& and p"o-imal

%a$se administe"ing the peni%illin %a$sed the %e"eb"al damage #pplying a hot wate" bottle o" heating

pad to a patient witho$t a physi%ianKs o"de" does not in%l$de the th"ee "e6$i"ed %omponents #ssisting a patient o$t of bed with the bed lo%ed in position is the %o""e%t n$"sing p"a%ti%eW the"efo"e& the f"a%t$"e

was not the "es$lt of malp"a%ti%e #dministe"ing an in%o""e%t medi%ation is a n$"sing e""o"W howe/e"& if

s$%h a%tion "es$lted in a se"io$s illness o" %h"oni% p"oblem& the n$"se %o$ld be s$ed fo" malp"a%ti%e

1 C' #n #sian patient is liely to hide his pain Conse6$ently& the n$"se m$st obse"/e fo" obEe%ti/e signs In

an abdominal s$"ge"y patient& these might in%l$de immobility& diapho"esis& and a/oidan%e of deep




b"eathing o" %o$ghing& as well as in%"eased hea"t "ate& shallow "espi"ations stemming f"om pain $pon

mo/ing the diaph"agm and "espi"ato"y m$s%les& and g$a"ding o" "igidity of the abdominal wall S$%h a

patient is $nliely to display emotion& s$%h as %"ying

15 )' !o assess fo" DI t"a%t bleeding when f"an blood is absent& the n$"se has two options: She %an test fo"

o%%$lt blood in /omit$s& if p"esent& o" in stool X th"o$gh g$aia% ?emo%%$lt test # %omplete blood %o$nt

does not p"o/ide immediate "es$lts and does not always immediately "efle%t blood loss Changes in /italsigns may be %a$se by fa%to"s othe" than blood loss #bdominal gi"th is $n"elated to blood loss

18 D' @e%a$se pe"%$ssion and palpation %an affe%t bowel motility and th$s bowel so$nds& they sho$ld followa$s%$ltation in abdominal assessment !ympani% pe"%$ssion& meas$"ement of abdominal gi"th& and

inspe%tion a"e methods of assessing the abdomen #ssessing fo" distention& tende"ness and dis%olo"ation

a"o$nd the $mbili%$s %an indi%ate /a"io$s bowel="elated %onditions& s$%h as %hole%ystitis& appendi%itis

and pe"itonitis

1 C' ?ype"a%ti/e so$nds indi%ate in%"eased bowel motilityW two o" th"ee so$nds pe" min$te indi%ate

de%"eased bowel motility #bdominal %"amping with hype"a%ti/e& high pit%hed tinling bowel so$nds %an

indi%ate a bowel obst"$%tion

19 C' !he s$pine position also %alled the do"sal position& in whi%h the patient lies on his ba% with his fa%e

$pwa"d& allows fo" easy a%%ess to the abdomen In the p"one position& the patient lies on his abdomen with

his fa%e t$"ned to the side In the !"endelenb$"g position& the head of the bed is tilted downwa"d to +0 to

.0 deg"ees so that the $ppe" body is lowe" than the legs In the late"al position& the patient lies on his side

20 D' #ll of these positions a"e app"op"iate fo" a "e%tal e-amination In the gen$pe%to"al nee=%hest position& the patient neels and "ests his %hest on the table& fo"ming a 90 deg"ee angle between the to"so

and $ppe" legs In SimsK position& the patient lies on his left side with the left a"m behind the body and his

"ight leg fle-ed In the ho"i(ontal "e%$mbent position& the patient lies on his ba% with legs e-tended and

hips "otated o$twa"d

21 )' )$"ing a ombe"g test& whi%h e/al$ates fo" senso"y o" %e"ebella" ata-ia& the patient m$st stand with

feet togethe" and a"ms "esting at the sidesYfi"st with eyes open& then with eyes %losed !he need to mo/e

the feet apa"t to maintain this stan%e is an abno"mal finding

22 A' !he p$lse p"ess$"e is the diffe"en%e between the systoli% and diastoli% blood p"ess$"e "eadings X in this

%ase& .

2+ D' # slightly ele/ated tempe"at$"e in the immediate p"eope"ati/e o" post ope"ati/e pe"iod may "es$lt f"om

the la% of fl$ids befo"e s$"ge"y "athe" than f"om infe%tion #n-iety will not %a$se an ele/ated

tempe"at$"e ?ypothe"mia is an abno"mally low body tempe"at$"e

2. D' !he 6$ality and effi%ien%y of the "espi"ato"y p"o%ess %an be dete"mined by app"aising the "ate& "hythm&

depth& ease& so$nd& and symmet"y of "espi"ations

2 D' Unde" no"mal %onditions& a healthy ad$lt b"eathes in a smooth $ninte""$pted patte"n 12 to 20 times a

min$te !h$s& a "espi"ato"y "ate of +0 wo$ld be abno"mal # no"mal ad$lt body tempe"at$"e& as meas$"ed

on an o"al the"momete"& "anges between 98R and 100RF +51R and +8RCW an a-illa"y tempe"at$"e is

app"o-imately one deg"ee lowe" and a "e%tal tempe"at$"e& one deg"ee highe" !h$s& an a-illa"y

tempe"at$"e of 995RF +85RC wo$ld be %onside"ed abno"mal !he "esting p$lse "ate in an ad$lt "anges

f"om 50 to 100 beatsGmin$te& so a "ate of is no"mal

25 D' Pa"asympatheti% ne"/o$s system stim$lation of the hea"t de%"eases the hea"t "ate as well as the fo"%e of

%ont"a%tion& "ate of imp$lse %ond$%tion and blood flow th"o$gh the %o"ona"y /essels Fe/e"& e-e"%ise& and

sympatheti% stim$lation all in%"ease the hea"t "ate

28 D' !he api%al p$lse the p$lse at the ape- of the hea"t is lo%ated on the mid%la/i%$la" line at the fo$"th&

fifth& o" si-th inte"%ostal spa%e @ase line /ital signs in%l$de p$lse "ate& tempe"at$"e& "espi"ato"y "ate& and

blood p"ess$"e @lood p"ess$"e is typi%ally assessed at the ante%$bital fossa& and "espi"ato"y "ate is

assessed best by obse"/ing %hest mo/ement with ea%h inspi"ation and e-pi"ation

2 C' @e%a$se the pedal p$lse %annot be dete%ted in 10V to 20V of the pop$lation& its absen%e is not

ne%essa"ily a signifi%ant finding ?owe/e"& the p"esen%e o" absen%e of the pedal p$lse sho$ld be

do%$mented $pon admission so that %hanges %an be identified d$"ing the hospital stay #bsen%e of the

api%al& "adial& o" femo"al p$lse is abno"mal and sho$ld be in/estigated

29 )' P"ess$"e $l%e"s a"e most liely to de/elop in patients with impai"ed mental stat$s& mobility& a%ti/ity

le/el& n$t"ition& %i"%$lation and bladde" o" bowel %ont"ol #ge is also a fa%to" !h$s& the =yea" old

in%ontinent patient who has impai"ed n$t"ition f"om gast"i% %an%e" and is %onfined to bed is at g"eate"

"is+0 A' #de6$ate hyd"ation thins and loosens p$lmona"y se%"etions and also helps to "epla%e fl$ids lost f"om

ele/ated tempe"at$"e& diapho"esis& dehyd"ation and dyspnea ?igh= h$midity ai" and %hest physiothe"apy

help li6$efy and mobili(e se%"etions

+1 A' Ch"oni% al%oholism %ommonly "es$lts in thiamine defi%ien%y and othe" symptoms of maln$t"ition

+2 C' # patient with dysphagia diffi%$lty swallowing "e6$i"es assistan%e with feeding Feeding himself is a

long="ange e-pe%ted o$t%ome Soft foods& Fowle"Ks o" semi=Fowle"Ks position& and o"al hygiene befo"e

eating sho$ld be pa"t of the feeding "egimen




++ A' # $"ine o$tp$t of less than +0mlGho$" indi%ates hypo/olemia o" olig$"ia& whi%h is "elated to idney

f$n%tion and inade6$ate fl$id intae

+. A' Fl$ids %ontaining %affeine ha/e a di$"eti% effe%t @eets and $"ina"y analgesi%s& s$%h as py"idi$m& %an

%olo" $"ine "ed aope%tate is an anti dia""heal medi%ation

+ C' # hospitali(ed s$"gi%al patient lea/ing his "oom fo" the fi"st time fea"s "eEe%tion and othe"s sta"ing at

him& so he sho$ld not wal alone #%%ompanying him will offe" mo"al s$ppo"t& enabling him to fa%e the"est of the wo"ld Patients sho$ld begin amb$lation as soon as possible afte" s$"ge"y to de%"ease

%ompli%ations and to "egain st"ength and %onfiden%e Haiting to %ons$lt a physi%al the"apist is$nne%essa"y

+5 A' !hi%& tena%io$s se%"etions& a d"y& ha%ing %o$gh& o"thopnea& and sho"tness of b"eath a"e signs of

ineffe%ti/e ai"way %lea"an%e Ineffe%ti/e ai"way %lea"an%e "elated to d"y& ha%ing %o$gh is in%o""e%t

be%a$se the %o$gh is not the "eason fo" the ineffe%ti/e ai"way %lea"an%e Ineffe%ti/e indi/id$al %oping

"elated to COP) is w"ong be%a$se the etiology fo" a n$"sing diagnosis sho$ld not be a medi%al diagnosisCOP) and be%a$se no data indi%ate that the patient is %oping ineffe%ti/ely Pain "elated to

immobili(ation of affe%ted leg wo$ld be an app"op"iate n$"sing diagnosis fo" a patient with a leg f"a%t$"e

+8 D' I now this will be diffi%$ltT a%nowledges the p"oblem and s$ggests a "esol$tion to it )onKt

wo""yT offe"s some "elief b$t doesnKt "e%ogni(e the patientKs feelings I didnKt get to the bad news

yetT wo$ld be inapp"op"iate at any time Ao$" hai" is "eally p"ettyT offe"s no %onsolation o" alte"nati/es

to the patient

+ )' #dditional 7itamin C is needed in g"owth pe"iods& s$%h as infan%y and %hildhood& and d$"ing p"egnan%y to s$pply demands fo" fetal g"owth and mate"nal tiss$es Othe" %onditions "e6$i"ing e-t"a

/itamin C in%l$de wo$nd healing& fe/e"& infe%tion and st"ess

+9 D' )eli/e"y of mo"e than 2 lite"s of o-ygen pe" min$te to a patient with %h"oni% obst"$%ti/e p$lmona"y

disease COP)& who is $s$ally in a state of %ompensated "espi"ato"y a%idosis "etaining %a"bon dio-ide

CO2& %an inhibit the hypo-i% stim$l$s fo" "espi"ation #n in%"eased pa"tial p"ess$"e of %a"bon dio-ide

in a"te"ial blood P#CO2 wo$ld not initially "es$lt in %a"dia% a""est Ci"%$lato"y o/e"load and "espi"ato"y

e-%itement ha/e no "ele/an%e to the 6$estion

.0 C' P"esenting symptoms of hypoalemia a se"$m potassi$m le/el below + m,6Glite" in%l$de m$s%le

weaness& %h"oni% fatig$e& and %a"dia% dys"hythmias !he %ombined effe%ts of inade6$ate food intae and

p"olonged dia""hea %an deplete the potassi$m sto"es of a patient with DI p"oblems

.1 D' #ssisting a patient with amb$lation and t"ansfe" f"om a bed to a %hai" allows the n$"se to e/al$ate the

patientKs ability to %a""y o$t these f$n%tions safely )emonst"ating the signal system and p"o/iding an

oppo"t$nity fo" a "et$"n demonst"ation ens$"es that the patient nows how to ope"ate the e6$ipment and

en%o$"ages him to %all fo" assistan%e when needed Che%ing the patientKs identifi%ation band /e"ifies the patientKs identity and p"e/ents identifi%ation mistaes in d"$g administ"ation

.2 D' Sin%e abo$t .0V of patients fall o$t of bed despite the $se of side "ails& side "ails %annot be said to

p"e/ent fallsW howe/e"& they do se"/e as a "eminde" that the patient sho$ld not get o$t of bed !he othe"

answe"s a"e in%o""e%t inte"p"etations of the statisti%al data

.+ C' # patient who %annot %a"e fo" himself at home does not ne%essa"ily ha/e impai"ed awa"enessW he may

simply ha/e some deg"ee of immobility

.. D' ?ip f"a%t$"e& the most %ommon inE$"y among elde"ly pe"sons& $s$ally "es$lts f"om osteopo"osis !he

othe" answe"s a"e diseases that %an o%%$" in the elde"ly f"om physiologi% %hanges

. A' Sleep dist$"ban%es& inability to %on%ent"ate and de%"eased appetite a"e symptoms of dep"ession& themost %ommon psy%hogeni% diso"de" among elde"ly pe"sons Othe" symptoms in%l$de diminished

memo"y& apathy& disinte"est in appea"an%e& withd"awal& and i""itability )ep"ession typi%ally begins

befo"e the onset of old age and $s$ally is %a$sed by psy%hoso%ial& geneti%& o" bio%hemi%al fa%to"s

.5 D' #ging de%"eases elasti%ity of the blood /essels& whi%h leads to in%"eased pe"iphe"al "esistan%e and

de%"eased blood flow !hese %hanges& in t$"n& in%"ease the wo" load of the left /ent"i%le

.8 D' #l(heime"Ws disease& sometimes nown as senile dementia of the Alzheimer’s type or primary

degenerative dementia& is an insidio$sW p"og"essi/e& i""e/e"sible& and degene"ati/e disease of the b"ain

whose etiology is still $nnown Parkinson’s disease is a ne$"ologi% diso"de" %a$sed by lesions in the

e-t"apy"amidial system and manifested by t"emo"s& m$s%le "igidity& hypoinesis& dysphagia& and

dysphonia Multiple sclerosis, a p"og"essi/e& degene"ati/e disease in/ol/ing demyelination of the ne"/e

fibe"s& $s$ally begins in yo$ng ad$lthood and is ma"ed by pe"iods of "emission and e-a%e"bation

Amyotrophic lateral sclerosis& a disease ma"ed by p"og"essi/e degene"ation of the ne$"ons& e/ent$ally"es$lts in at"ophy of all the m$s%lesW in%l$ding those ne%essa"y fo" "espi"ation

. C' !he n$"se is legally "esponsible fo" labeling the %o"pse when death o%%$"s in the hospital She may be

in/ol/ed in obtaining %onsent fo" an a$topsy o" notifying the %o"one" o" medi%al e-amine" of a patientKs

deathW howe/e"& she is not legally "esponsible fo" pe"fo"ming these f$n%tions !he attending physi%ian

may need info"mation f"om the n$"se to %omplete the death %e"tifi%ate& b$t he is "esponsible fo" iss$ing it

.9 )' !he n$"se m$st pla%e a pillow $nde" the de%"eased pe"sonKs head and sho$lde"s to p"e/ent blood f"om

settling in the fa%e and dis%olo"ing it She is "e6$i"ed to bathe only soiled a"eas of the body sin%e the




mo"ti%ian will wash the enti"e body @efo"e w"apping the body in a sh"o$d& the n$"se pla%es a %lean gown

on the body and %loses the eyes and mo$th

0 A' ,ns$"ing the patientKs safety is the most essential a%tion at this time !he othe" n$"sing a%tions may be

ne%essa"y b$t a"e not a maEo" p"io"ity


1 Hhi%h element in the %i"%$la" %hain of infe%tion %an be eliminated by p"ese"/ing sin integ"ityQ

a ?ost

b ese"/oi"

% <ode of t"ansmission

d Po"tal of ent"y

2 Hhi%h of the following will p"obably "es$lt in a b"ea in ste"ile te%hni6$e fo" "espi"ato"y isolationQ

a Opening the patientKs window to the o$tside en/i"onment

b !$"ning on the patientKs "oom /entilato"% Opening the doo" of the patientKs "oom leading into the hospital %o""ido"

d Failing to wea" glo/es when administe"ing a bed bath

+ Hhi%h of the following patients is at g"eate" "is fo" %ont"a%ting an infe%tionQ

a # patient with le$openia b # patient "e%ei/ing b"oad=spe%t"$m antibioti%s

% # postope"ati/e patient who has $nde"gone o"thopedi% s$"ge"y

d # newly diagnosed diabeti% patient

. ,ffe%ti/e hand washing "e6$i"es the $se of:

a Soap o" dete"gent to p"omote em$lsifi%ation

b ?ot wate" to dest"oy ba%te"ia

% # disinfe%tant to in%"ease s$"fa%e tension

d #ll of the abo/e #fte" "o$tine patient %onta%t& hand washing sho$ld last at least:

a +0 se%onds

b 1 min$te

% 2 min$te

d + min$tes

5 Hhi%h of the following p"o%ed$"es always "e6$i"es s$"gi%al asepsisQa 7aginal instillation of %onE$gated est"ogen

b U"ina"y %athete"i(ation

% *asogast"i% t$be inse"tion

d Colostomy i""igation

8 Ste"ile te%hni6$e is $sed whene/e":

a St"i%t isolation is "e6$i"ed b !e"minal disinfe%tion is pe"fo"med% In/asi/e p"o%ed$"es a"e pe"fo"med

d P"ote%ti/e isolation is ne%essa"y

Hhi%h of the following %onstit$tes a b"ea in ste"ile te%hni6$e while p"epa"ing a ste"ile field fo" a

d"essing %hangeQ

a Using ste"ile fo"%eps& "athe" than ste"ile glo/es& to handle a ste"ile item

b !o$%hing the o$tside w"appe" of ste"ili(ed mate"ial witho$t ste"ile glo/es

% Pla%ing a ste"ile obEe%t on the edge of the ste"ile field

d Po$"ing o$t a small amo$nt of sol$tion 1 to +0 ml befo"e po$"ing the sol$tion into a ste"ile

%ontaine"

9 # nat$"al body defense that plays an a%ti/e "ole in p"e/enting infe%tion is:

a Aawning b @ody hai"

% ?i%%$pping

d apid eye mo/ements

10 #ll of the following statement a"e t"$e abo$t donning ste"ile glo/es e-%ept:

a !he fi"st glo/e sho$ld be pi%ed $p by g"asping the inside of the %$ff

b !he se%ond glo/e sho$ld be pi%ed $p by inse"ting the glo/ed finge"s $nde" the %$ff o$tside the

glo/e

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% !he glo/es sho$ld be adE$sted by sliding the glo/ed finge"s $nde" the ste"ile %$ff and p$lling the

glo/e o/e" the w"ist

d !he inside of the glo/e is %onside"ed ste"ile

11 Hhen "emo/ing a %ontaminated gown& the n$"se sho$ld be %a"ef$l that the fi"st thing she to$%hes is the:

a Haist tie and ne% tie at the ba% of the gown

b Haist tie in f"ont of the gown

% C$ffs of the gown

d Inside of the gown12 Hhi%h of the following n$"sing inte"/entions is %onside"ed the most effe%ti/e fo"m o" $ni/e"sal

p"e%a$tionsQ

a Cap all $sed needles befo"e "emo/ing them f"om thei" sy"inges

b )is%a"d all $sed $n%apped needles and sy"inges in an impenet"able p"ote%ti/e %ontaine"

% Hea" glo/es when administe"ing I< inEe%tions

d Follow ente"i% p"e%a$tions

1+ #ll of the following meas$"es a"e "e%ommended to p"e/ent p"ess$"e $l%e"s e-%ept:

a <assaging the "eddened a"e with lotion

b Using a wate" o" ai" matt"ess% #dhe"ing to a s%hed$le fo" positioning and t$"ning

d P"o/iding meti%$lo$s sin %a"e

1. Hhi%h of the following blood tests sho$ld be pe"fo"med befo"e a blood t"ansf$sionQa P"oth"ombin and %oag$lation time

b @lood typing and %"oss=mat%hing

% @leeding and %lotting time

d Complete blood %o$nt C@C and ele%t"olyte le/els

1 !he p"ima"y p$"pose of a platelet %o$nt is to e/al$ate the:

a Potential fo" %lot fo"mation

b Potential fo" bleeding

% P"esen%e of an antigen=antibody "esponse

d P"esen%e of %a"dia% en(ymes

15 Hhi%h of the following white blood %ell H@C %o$nts %lea"ly indi%ates le$o%ytosisQ

a .&00GmmZ

b 8&000GmmZ% 10&000GmmZ

d 2&000GmmZ

18 #fte" days of di$"eti% the"apy with 20mg of f$"osemide 'asi- daily& a patient begins to e-hibit fatig$e&

m$s%le %"amping and m$s%le weaness !hese symptoms p"obably indi%ate that the patient is

e-pe"ien%ing:

a ?ypoalemia

b ?ype"alemia

% #no"e-ia

d )ysphagia

1 Hhi%h of the following statements abo$t %hest ;="ay is falseQa *o %ont"adi%tions e-ist fo" this test

b @efo"e the p"o%ed$"e& the patient sho$ld "emo/e all Eewel"y& metalli% obEe%ts& and b$ttons abo/ethe waist

% # signed %onsent is not "e6$i"ed

d ,ating& d"ining& and medi%ations a"e allowed befo"e this test

19 !he most app"op"iate time fo" the n$"se to obtain a sp$t$m spe%imen fo" %$lt$"e is:

a ,a"ly in the mo"ning

b #fte" the patient eats a light b"eafast

% #fte" ae"osol the"apy

d #fte" %hest physiothe"apy

20 # patient with no nown alle"gies is to "e%ei/e peni%illin e/e"y 5 ho$"s Hhen administe"ing the

medi%ation& the n$"se obse"/es a fine "ash on the patientKs sin !he most app"op"iate n$"sing a%tion

wo$ld be to:

a Hithhold the mode"ation and notify the physi%ian

b #dministe" the medi%ation and notify the physi%ian

% #dministe" the medi%ation with an antihistamine

d #pply %o"n sta"%h soas to the "ash

21 #ll of the following n$"sing inte"/entions a"e %o""e%t when $sing the J=t"a% method of d"$g inEe%tione-%ept:

a P"epa"e the inEe%tion site with al%ohol

b Use a needle thatKs a least 1T long

% #spi"ate fo" blood befo"e inEe%tion

d $b the site /igo"o$sly afte" the inEe%tion to p"omote abso"ption

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22 !he %o""e%t method fo" dete"mining the /ast$s late"alis site fo" I< inEe%tion is to:

a 'o%ate the $ppe" aspe%t of the $ppe" o$te" 6$ad"ant of the b$tto% abo$t to %m below the ilia%

%"est

b Palpate the lowe" edge of the a%"omion p"o%ess and the midpoint late"al aspe%t of the a"m

% Palpate a 1T %i"%$la" a"ea ante"io" to the $mbili%$s

d )i/ide the a"ea between the g"eate" femo"al t"o%hante" and the late"al femo"al %ondyle into thi"ds&

and sele%t the middle thi"d on the ante"io" of the thigh

2+ !he mid=deltoid inEe%tion site is seldom $sed fo" I< inEe%tions be%a$se it:a Can a%%ommodate only 1 ml o" less of medi%ation

b @"$ises too easily

% Can be $sed only when the patient is lying down

d )oes not "eadily pa"ente"al medi%ation

2. !he app"op"iate needle si(e fo" ins$lin inEe%tion is:

a 1D& 1 [T long

b 22D& 1T long

% 22D& 1 [T long

d 2D& GT long2 !he app"op"iate needle ga$ge fo" int"ade"mal inEe%tion is:

a 20D

b 22D% 2D

d 25D

25 Pa"ente"al peni%illin %an be administe"ed as an:

a I< inEe%tion o" an I7 sol$tion

b I7 o" an int"ade"mal inEe%tion

% Int"ade"mal o" s$b%$taneo$s inEe%tion

d I< o" a s$b%$taneo$s inEe%tion

28 !he physi%ian o"de"s g" 10 of aspi"in fo" a patient !he e6$i/alent dose in millig"ams is:

a 05 mg

b 10 mg

% 50 mg

d 500 mg2 !he physi%ian o"de"s an I7 sol$tion of de-t"ose V in wate" at 100mlGho$" Hhat wo$ld the flow "ate be

if the d"op fa%to" is 1 gtt 1 mlQ

a gttGmin$te b 1+ gttGmin$te

% 2 gttGmin$te

d 0 gttGmin$te

29 Hhi%h of the following is a sign o" symptom of a hemolyti% "ea%tion to blood t"ansf$sionQ

a ?emoglobin$"ia

b Chest pain

% U"ti%a"ia

d )istended ne% /eins

+0 Hhi%h of the following %onditions may "e6$i"e fl$id "est"i%tionQ

a Fe/e"

b Ch"oni% Obst"$%ti/e P$lmona"y )isease

% enal Fail$"e

d )ehyd"ation

+1 #ll of the following a"e %ommon signs and symptoms of phlebitis e-%ept:

a Pain o" dis%omfo"t at the I7 inse"tion site

b ,dema and wa"mth at the I7 inse"tion site

% # "ed st"ea e-iting the I7 inse"tion site

d F"an bleeding at the inse"tion site+2 !he best way of dete"mining whethe" a patient has lea"ned to instill ea" medi%ation p"ope"ly is fo" the

n$"se to:

a #s the patient if heGshe has $sed ea" d"ops befo"e

b ?a/e the patient "epeat the n$"seKs inst"$%tions $sing he" own wo"ds

% )emonst"ate the p"o%ed$"e to the patient and en%o$"age to as 6$estions

d #s the patient to demonst"ate the p"o%ed$"e

++ Hhi%h of the following types of medi%ations %an be administe"ed /ia gast"ostomy t$beQ

a #ny o"al medi%ations

b Caps$les whole %ontents a"e dissol/e in wate"

% ,nte"i%=%oated tablets that a"e tho"o$ghly dissol/ed in wate"

d <ost tablets designed fo" o"al $se& e-%ept fo" e-tended=d$"ation %ompo$nds

+. # patient who de/elops hi/es afte" "e%ei/ing an antibioti% is e-hibiting d"$g:




a !ole"an%e

b Idiosyn%"asy

% Syne"gism

d #lle"gy

+ # patient has "et$"ned to his "oom afte" femo"al a"te"iog"aphy #ll of the following a"e app"op"iate

n$"sing inte"/entions e-%ept:

a #ssess femo"al& popliteal& and pedal p$lses e/e"y 1 min$tes fo" 2 ho$"s

b Che% the p"ess$"e d"essing fo" sang$ineo$s d"ainage% #ssess a /ital signs e/e"y 1 min$tes fo" 2 ho$"s

d O"de" a hemoglobin and hemato%"it %o$nt 1 ho$" afte" the a"te"iog"aphy

+5 !he n$"se e-plains to a patient that a %o$gh:

a Is a p"ote%ti/e "esponse to %lea" the "espi"ato"y t"a%t of i""itants

b Is p"ima"ily a /ol$nta"y a%tion

% Is ind$%ed by the administ"ation of an antit$ssi/e d"$g

d Can be inhibited by splintingT the abdomen

+8 #n infe%ted patient has %hills and begins shi/e"ing !he best n$"sing inte"/ention is to:

a #pply i%ed al%ohol sponges b P"o/ide in%"eased %ool li6$ids

% P"o/ide additional bed%lothes

d P"o/ide in%"eased /entilation+ # %lini%al n$"se spe%ialist is a n$"se who has:

a @een %e"tified by the *ational 'eag$e fo" *$"sing

b e%ei/ed %"edentials f"om the Philippine *$"sesK #sso%iation

% D"ad$ated f"om an asso%iate deg"ee p"og"am and is a "egiste"ed p"ofessional n$"se

d Completed a maste"Ks deg"ee in the p"es%"ibed %lini%al a"ea and is a "egiste"ed p"ofessional n$"se

+9 !he p$"pose of in%"easing $"ine a%idity th"o$gh dieta"y means is to:

a )e%"ease b$"ning sensations

b Change the $"ineKs %olo"

% Change the $"ineKs %on%ent"ation

d Inhibit the g"owth of mi%"oo"ganisms

.0 Clay %olo"ed stools indi%ate:

a Uppe" DI bleeding b Impending %onstipation

% #n effe%t of medi%ation

d @ile obst"$%tion.1 In whi%h step of the n$"sing p"o%ess wo$ld the n$"se as a patient if the medi%ation she administe"ed

"elie/ed his painQ

a #ssessment

b #nalysis

% Planning

d ,/al$ation

.2 #ll of the following a"e good so$"%es of /itamin # e-%ept:a Hhite potatoes

b Ca""ots% #p"i%ots

d ,gg yols

.+ Hhi%h of the following is a p"ima"y n$"sing inte"/ention ne%essa"y fo" all patients with a Foley Cathete"

in pla%eQ

a <aintain the d"ainage t$bing and %olle%tion bag le/el with the patientKs bladde"

b I""igate the patient with 1V *eospo"in sol$tion th"ee times a daily

% Clamp the %athete" fo" 1 ho$" e/e"y . ho$"s to maintain the bladde"Ks elasti%ity

d <aintain the d"ainage t$bing and %olle%tion bag below bladde" le/el to fa%ilitate d"ainage by

g"a/ity

.. !he ,'IS# test is $sed to:

a S%"een blood dono"s fo" antibodies to h$man imm$nodefi%ien%y /i"$s ?I7

b !est blood to be $sed fo" t"ansf$sion fo" ?I7 antibodies% #id in diagnosing a patient with #I)S

d #ll of the abo/e

. !he two blood /essels most %ommonly $sed fo" !P* inf$sion a"e the:

a S$b%la/ian and E$g$la" /eins b @"a%hial and s$b%la/ian /eins

% Femo"al and s$b%la/ian /eins

d @"a%hial and femo"al /eins

.5 ,ffe%ti/e sin disinfe%tion befo"e a s$"gi%al p"o%ed$"e in%l$des whi%h of the following methodsQ

a Sha/ing the site on the day befo"e s$"ge"y

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b #pplying a topi%al antisepti% to the sin on the e/ening befo"e s$"ge"y

% ?a/ing the patient tae a t$b bath on the mo"ning of s$"ge"y

d ?a/ing the patient showe" with an antisepti% soap on the e/ening /befo"e and the mo"ning of

s$"ge"y

.8 Hhen t"ansfe""ing a patient f"om a bed to a %hai"& the n$"se sho$ld $se whi%h m$s%les to a/oid ba%

inE$"yQ

a #bdominal m$s%les

b @a% m$s%les% 'eg m$s%les

d Uppe" a"m m$s%les

. !h"ombophlebitis typi%ally de/elops in patients with whi%h of the following %onditionsQ

a In%"eases pa"tial th"omboplastin time

b #%$te p$ls$s pa"ado-$s

% #n impai"ed o" t"a$mati(ed blood /essel wall

d Ch"oni% Obst"$%ti/e P$lmona"y )isease COP)

.9 In a "e%$mbent& immobili(ed patient& l$ng /entilation %an be%ome alte"ed& leading to s$%h "espi"ato"y

%ompli%ations as:a espi"ato"y a%idosis& ate%le%tasis& and hypostati% pne$monia

b #ppne$sti% b"eathing& atypi%al pne$monia and "espi"ato"y alalosis

% Cheyne=St"oes "espi"ations and spontaneo$s pne$motho"a-d $ssmailKs "espi"ations and hypo/entilation

0 Immobility impai"s bladde" elimination& "es$lting in s$%h diso"de"s as

a In%"eased $"ine a%idity and "ela-ation of the pe"ineal m$s%les& %a$sing in%ontinen%e

b U"ine "etention& bladde" distention& and infe%tion

% )i$"esis& nat"i$"esis& and de%"eased $"ine spe%ifi% g"a/ity

d )e%"eased %al%i$m and phosphate le/els in the $"ine



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | +0

ANSERS a$% RATIONALES #r FUNDAMENTALS OF NURSING PART 3

1 D In the %i"%$la" %hain of infe%tion& pathogens m$st be able to lea/e thei" "ese"/oi" and be t"ansmitted to

a s$s%eptible host th"o$gh a po"tal of ent"y& s$%h as b"oen sin

2 C espi"ato"y isolation& lie st"i%t isolation& "e6$i"es that the doo" to the doo" patientKs "oom "emain

%losed ?owe/e"& the patientKs "oom sho$ld be well /entilated& so opening the window o" t$"ning on the

/ent"i%$la" is desi"able !he n$"se does not need to wea" glo/es fo" "espi"ato"y isolation& b$t good hand

washing is impo"tant fo" all types of isolation+ A 'e$openia is a de%"eased n$mbe" of le$o%ytes white blood %ells& whi%h a"e impo"tant in "esisting

infe%tion *one of the othe" sit$ations wo$ld p$t the patient at "is fo" %ont"a%ting an infe%tionW taing

b"oad=spe%t"$m antibioti%s might a%t$ally "ed$%e the infe%tion "is

. A Soaps and dete"gents a"e $sed to help "emo/e ba%te"ia be%a$se of thei" ability to lowe" the s$"fa%e

tension of wate" and a%t as em$lsifying agents ?ot wate" may lead to sin i""itation o" b$"ns

A )epending on the deg"ee of e-pos$"e to pathogens& hand washing may last f"om 10 se%onds to .

min$tes #fte" "o$tine patient %onta%t& hand washing fo" +0 se%onds effe%ti/ely minimi(es the "is of

pathogen t"ansmission

5 ) !he $"ina"y system is no"mally f"ee of mi%"oo"ganisms e-%ept at the $"ina"y meat$s #ny p"o%ed$"e

that in/ol/es ente"ing this system m$st $se s$"gi%ally asepti% meas$"es to maintain a ba%te"ia=f"ee state

8 C #ll in/asi/e p"o%ed$"es& in%l$ding s$"ge"y& %athete" inse"tion& and administ"ation of pa"ente"al the"apy&

"e6$i"e ste"ile te%hni6$e to maintain a ste"ile en/i"onment #ll e6$ipment m$st be ste"ile& and the n$"seand the physi%ian m$st wea" ste"ile glo/es and maintain s$"gi%al asepsis In the ope"ating "oom& the n$"se

and physi%ian a"e "e6$i"ed to wea" ste"ile gowns& glo/es& mass& hai" %o/e"s& and shoe %o/e"s fo" all

in/asi/e p"o%ed$"es St"i%t isolation "e6$i"es the $se of %lean glo/es& mass& gowns and e6$ipment to

p"e/ent the t"ansmission of highly %omm$ni%able diseases by %onta%t o" by ai"bo"ne "o$tes !e"minal

disinfe%tion is the disinfe%tion of all %ontaminated s$pplies and e6$ipment afte" a patient has been

dis%ha"ged to p"epa"e them fo" "e$se by anothe" patient !he p$"pose of p"ote%ti/e "e/e"se isolation is to p"e/ent a pe"son with se"io$sly impai"ed "esistan%e f"om %oming into %onta%t who potentially pathogeni%

o"ganisms

C !he edges of a ste"ile field a"e %onside"ed %ontaminated Hhen ste"ile items a"e allowed to %ome in

%onta%t with the edges of the field& the ste"ile items also be%ome %ontaminated

9 ) ?ai" on o" within body a"eas& s$%h as the nose& t"aps and holds pa"ti%les that %ontain mi%"oo"ganisms

Aawning and hi%%$pping do not p"e/ent mi%"oo"ganisms f"om ente"ing o" lea/ing the body apid eyemo/ement ma"s the stage of sleep d$"ing whi%h d"eaming o%%$"s

10 D !he inside of the glo/e is always %onside"ed to be %lean& b$t not ste"ile

11 A !he ba% of the gown is %onside"ed %lean& the f"ont is %ontaminated So& afte" "emo/ing glo/es and

washing hands& the n$"se sho$ld $ntie the ba% of the gownW slowly mo/e ba%wa"d away f"om the gown&

holding the inside of the gown and eeping the edges off the floo"W t$"n and fold the gown inside o$tW

dis%a"d it in a %ontaminated linen %ontaine"W then wash he" hands again

12 ) #%%o"ding to the Cente"s fo" )isease Cont"ol C)C& blood=to=blood %onta%t o%%$"s most %ommonly

when a health %a"e wo"e" attempts to %ap a $sed needle !he"efo"e& $sed needles sho$ld ne/e" be

"e%appedW instead they sho$ld be inse"ted in a spe%ially designed p$n%t$"e "esistant& labeled %ontaine"

Hea"ing glo/es is not always ne%essa"y when administe"ing an I< inEe%tion ,nte"i% p"e%a$tions p"e/ent

the t"ansfe" of pathogens /ia fe%es

1+ A *$"ses and othe" health %a"e p"ofessionals p"e/io$sly belie/ed that massaging a "eddened a"ea with

lotion wo$ld p"omote /eno$s "et$"n and "ed$%e edema to the a"ea ?owe/e"& "esea"%h has shown that

massage only in%"eases the lielihood of %ell$la" is%hemia and ne%"osis to the a"ea

1. ) @efo"e a blood t"ansf$sion is pe"fo"med& the blood of the dono" and "e%ipient m$st be %he%ed fo"

%ompatibility !his is done by blood typing a test that dete"mines a pe"sonKs blood type and %"oss=

mat%hing a p"o%ed$"e that dete"mines the %ompatibility of the dono"Ks and "e%ipientKs blood afte" the

blood types has been mat%hed If the blood spe%imens a"e in%ompatible& hemolysis and antigen=antibody

"ea%tions will o%%$"

http://void%280%29/

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http://void%280%29/




1 A Platelets a"e dis=shaped %ells that a"e essential fo" blood %oag$lation # platelet %o$nt dete"mines the

n$mbe" of th"ombo%ytes in blood a/ailable fo" p"omoting hemostasis and assisting with blood

%oag$lation afte" inE$"y It also is $sed to e/al$ate the patientKs potential fo" bleedingW howe/e"& this is not

its p"ima"y p$"pose !he no"mal %o$nt "anges f"om 10&000 to +0&000Gmm + # %o$nt of 100&000Gmm+ o"

less indi%ates a potential fo" bleedingW %o$nt of less than 20&000Gmm + is asso%iated with spontaneo$s

bleeding

15 D 'e$o%ytosis is any t"ansient in%"ease in the n$mbe" of white blood %ells le$o%ytes in the blood

*o"mal H@C %o$nts "ange f"om &000 to 100&000Gmm+

!h$s& a %o$nt of 2&000Gmm+

indi%atesle$o%ytosis

18 A Fatig$e& m$s%le %"amping& and m$s%le weanesses a"e symptoms of hypoalemia an inade6$ate

potassi$m le/el& whi%h is a potential side effe%t of di$"eti% the"apy !he physi%ian $s$ally o"de"s

s$pplemental potassi$m to p"e/ent hypoalemia in patients "e%ei/ing di$"eti%s #no"e-ia is anothe"

symptom of hypoalemia )ysphagia means diffi%$lty swallowing

1 A P"egnan%y o" s$spe%ted p"egnan%y is the only %ont"aindi%ation fo" a %hest ;="ay ?owe/e"& if a %hest

;="ay is ne%essa"y& the patient %an wea" a lead ap"on to p"ote%t the pel/i% "egion f"om "adiation Bewel"y&

metalli% obEe%ts& and b$ttons wo$ld inte"fe"e with the ;="ay and th$s sho$ld not be wo"n abo/e the waist

# signed %onsent is not "e6$i"ed be%a$se a %hest ;="ay is not an in/asi/e e-amination ,ating& d"ining

and medi%ations a"e allowed be%a$se the ;="ay is of the %hest& not the abdominal "egion

19 A Obtaining a sp$t$m spe%imen ea"ly in this mo"ning ens$"es an ade6$ate s$pply of ba%te"ia fo"

%$lt$"ing and de%"eases the "is of %ontamination f"om food o" medi%ation20 A Initial sensiti/ity to peni%illin is %ommonly manifested by a sin "ash& e/en in indi/id$als who ha/e

not been alle"gi% to it p"e/io$sly @e%a$se of the dange" of anaphyla%ti% sho%& he n$"se sho$ld withhold

the d"$g and notify the physi%ian& who may %hoose to s$bstit$te anothe" d"$g #dministe"ing an

antihistamine is a dependent n$"sing inte"/ention that "e6$i"es a w"itten physi%ianKs o"de" #ltho$gh

applying %o"n sta"%h to the "ash may "elie/e dis%omfo"t& it is not the n$"seKs top p"io"ity in s$%h a

potentially life=th"eatening sit$ation

21 D !he J=t"a% method is an I< inEe%tion te%hni6$e in whi%h the patientKs sin is p$lled in s$%h a way

that the needle t"a% is sealed off afte" the inEe%tion !his p"o%ed$"e seals medi%ation deep into the

m$s%le& the"eby minimi(ing sin staining and i""itation $bbing the inEe%tion site is %ont"aindi%ated

be%a$se it may %a$se the medi%ation to e-t"a/asate into the sin

22 D !he /ast$s late"alis& a long& thi% m$s%le that e-tends the f$ll length of the thigh& is /iewed by many

%lini%ians as the site of %hoi%e fo" I< inEe%tions be%a$se it has "elati/ely few maEo" ne"/es and blood/essels !he middle thi"d of the m$s%le is "e%ommended as the inEe%tion site !he patient %an be in a

s$pine o" sitting position fo" an inEe%tion into this site

2+ A !he mid=deltoid inEe%tion site %an a%%ommodate only 1 ml o" less of medi%ation be%a$se of its si(e and

lo%ation on the deltoid m$s%le of the a"m& %lose to the b"a%hial a"te"y and "adial ne"/e

2. D # 2D& GT needle is the "e%ommended si(e fo" ins$lin inEe%tion be%a$se ins$lin is administe"ed by

the s$b%$taneo$s "o$te #n 1D& 1 [T needle is $s$ally $sed fo" I< inEe%tions in %hild"en& typi%ally in

the /ast$s late"alis # 22D& 1 [T needle is $s$ally $sed fo" ad$lt I< inEe%tions& whi%h a"e typi%ally

administe"ed in the /ast$s late"alis o" /ent"ogl$teal site

2 D @e%a$se an int"ade"mal inEe%tion does not penet"ate deeply into the sin& a small=bo"e 2D needle is

"e%ommended !his type of inEe%tion is $sed p"ima"ily to administe" antigens to e/al$ate "ea%tions fo"

alle"gy o" sensiti/ity st$dies # 20D needle is $s$ally $sed fo" I< inEe%tions of oil=based medi%ationsW a

22D needle fo" I< inEe%tionsW and a 2D needle& fo" I< inEe%tionsW and a 2D needle& fo" s$b%$taneo$s

ins$lin inEe%tions

25 A Pa"ente"al peni%illin %an be administe"ed I< o" added to a sol$tion and gi/en I7 It %annot be

administe"ed s$b%$taneo$sly o" int"ade"mally

28 D g" 10 - 50mgGg" 1 500 mg

2 C 100mlG50 min ; 1 gttG 1 ml 2 gttGmin$te

29 A ?emoglobin$"ia& the abno"mal p"esen%e of hemoglobin in the $"ine& indi%ates a hemolyti% "ea%tion

in%ompatibility of the dono"Ks and "e%ipientKs blood In this "ea%tion& antibodies in the "e%ipientKs plasma

%ombine "apidly with dono" @CKsW the %ells a"e hemoly(ed in eithe" %i"%$lato"y o" "eti%$loendothelial

system ?emolysis o%%$"s mo"e "apidly in #@O in%ompatibilities than in h in%ompatibilities Chest pain

and $"ti%a"ia may be symptoms of impending anaphyla-is )istended ne% /eins a"e an indi%ation of

hype"/olemia+0 C In "eal fail$"e& the idney loses thei" ability to effe%ti/ely eliminate wastes and fl$ids @e%a$se of this&

limiting the patientKs intae of o"al and I7 fl$ids may be ne%essa"y Fe/e"& %h"oni% obst"$%ti/e

p$lmona"y disease& and dehyd"ation a"e %onditions fo" whi%h fl$ids sho$ld be en%o$"aged

+1 D Phlebitis& the inflammation of a /ein& %an be %a$sed by %hemi%al i""itants I7 sol$tions o"

medi%ations& me%hani%al i""itants the needle o" %athete" $sed d$"ing /enip$n%t$"e o" %ann$lation& o" a

lo%ali(ed alle"gi% "ea%tion to the needle o" %athete" Signs and symptoms of phlebitis in%l$de pain o"

dis%omfo"t& edema and heat at the I7 inse"tion site& and a "ed st"ea going $p the a"m o" leg f"om theI7 inse"tion site




+2 D et$"n demonst"ation p"o/ides the most %e"tain e/iden%e fo" e/al$ating the effe%ti/eness of patient

tea%hing

++ D Caps$les& ente"i%=%oated tablets& and most e-tended d$"ation o" s$stained "elease p"od$%ts sho$ld not

be dissol/ed fo" $se in a gast"ostomy t$be !hey a"e pha"ma%e$ti%ally man$fa%t$"ed in these fo"ms fo"

/alid "easons& and alte"ing them dest"oys thei" p$"pose !he n$"se sho$ld see an alte"nate physi%ianKs

o"de" when an o"de"ed medi%ation is inapp"op"iate fo" deli/e"y by t$be

+. D # d"$g=alle"gy is an ad/e"se "ea%tion "es$lting f"om an imm$nologi% "esponse following a p"e/io$s

sensiti(ing e-pos$"e to the d"$g !he "ea%tion %an "ange f"om a "ash o" hi/es to anaphyla%ti% sho%Tolerance to a d"$g means that the patient e-pe"ien%es a de%"easing physiologi% "esponse to "epeated

administ"ation of the d"$g in the same dosage Idiosyncrasy is an indi/id$alKs $ni6$e hype"sensiti/ity to a

d"$g& food& o" othe" s$bstan%eW it appea"s to be geneti%ally dete"mined Synergism& is a d"$g inte"a%tion in

whi%h the s$m of the d"$gKs %ombined effe%ts is g"eate" than that of thei" sepa"ate effe%ts

+ D # hemoglobin and hemato%"it %o$nt wo$ld be o"de"ed by the physi%ian if bleeding we"e s$spe%ted

!he othe" answe"s a"e app"op"iate n$"sing inte"/entions fo" a patient who has $nde"gone femo"al

a"te"iog"aphy

+5 A Co$ghing& a p"ote%ti/e "esponse that %lea"s the "espi"ato"y t"a%t of i""itants& $s$ally is in/ol$nta"yW

howe/e" it %an be /ol$nta"y& as when a patient is ta$ght to pe"fo"m %o$ghing e-e"%ises #n antit$ssi/e

d"$g inhibits %o$ghing Splinting the abdomen s$ppo"ts the abdominal m$s%les when a patient %o$ghs

+8 C In an infe%ted patient& shi/e"ing "es$lts f"om the bodyKs attempt to in%"ease heat p"od$%tion and the

p"od$%tion of ne$t"ophils and phago%ytoti% a%tion th"o$gh in%"eased seletal m$s%le tension and%ont"a%tions Initial /aso%onst"i%tion may %a$se sin to feel %old to the to$%h #pplying additional bed

%lothes helps to e6$ali(e the body tempe"at$"e and stop the %hills #ttempts to %ool the body "es$lt in

f$"the" shi/e"ing& in%"eased metabloism& and th$s in%"eased heat p"od$%tion

+ D # %lini%al n$"se spe%ialist m$st ha/e %ompleted a maste"Ks deg"ee in a %lini%al spe%ialty and be a

"egiste"ed p"ofessional n$"se !he *ational 'eag$e of *$"sing a%%"edits ed$%ational p"og"ams in n$"sing

and p"o/ides a testing se"/i%e to e/al$ate st$dent n$"sing %ompeten%e b$t it does not %e"tify n$"ses !he

#me"i%an *$"ses #sso%iation identifies "e6$i"ements fo" %e"tifi%ation and offe"s e-aminations fo"

%e"tifi%ation in many a"eas of n$"sing& s$%h as medi%al s$"gi%al n$"sing !hese %e"tifi%ation

%"edentialing demonst"ates that the n$"se has the nowledge and the ability to p"o/ide high 6$ality

n$"sing %a"e in the a"ea of he" %e"tifi%ation # g"ad$ate of an asso%iate deg"ee p"og"am is not a %lini%al

n$"se spe%ialist: howe/e"& she is p"epa"ed to p"o/ide bed side n$"sing with a high deg"ee of nowledge

and sill She m$st s$%%essf$lly %omplete the li%ensing e-amination to be%ome a "egiste"ed p"ofessionaln$"se

+9 D <i%"oo"ganisms $s$ally do not g"ow in an a%idi% en/i"onment

.0 D @ile %olo"s the stool b"own #ny inflammation o" obst"$%tion that impai"s bile flow will affe%t the

stool pigment& yielding light& %lay=%olo"ed stool Uppe" DI bleeding "es$lts in bla% o" ta""y stool

Constipation is %ha"a%te"i(ed by small& ha"d masses <any medi%ations and foods will dis%olo" stool X fo"

e-ample& d"$gs %ontaining i"on t$"n stool bla%W beets t$"n stool "ed

.1 D In the e/al$ation step of the n$"sing p"o%ess& the n$"se m$st de%ide whethe" the patient has a%hie/ed

the e-pe%ted o$t%ome that was identified in the planning phase

.2 A !he main so$"%es of /itamin # a"e yellow and g"een /egetables s$%h as %a""ots& sweet potatoes&

s6$ash& spina%h& %olla"d g"eens& b"o%%oli& and %abbage and yellow f"$its s$%h as ap"i%ots& and

%antalo$pe #nimal so$"%es in%l$de li/e"& idneys& %"eam& b$tte"& and egg yols

.+ D <aintaing the d"ainage t$bing and %olle%tion bag le/el with the patientKs bladde" %o$ld "es$lt in "efl$-

of $"ine into the idney I""igating the bladde" with *eospo"in and %lamping the %athete" fo" 1 ho$" e/e"y

. ho$"s m$st be p"es%"ibed by a physi%ian

.. D !he ,'IS# test of /eno$s blood is $sed to assess blood and potential blood dono"s to h$man

imm$nodefi%ien%y /i"$s ?I7 # positi/e ,'IS# test %ombined with /a"io$s signs and symptoms helpsto diagnose a%6$i"ed imm$nodefi%ien%y synd"ome #I)S

. D !a%hypnea an abno"mally "apid "ate of b"eathing wo$ld indi%ate that the patient was still hypo-i%

defi%ient in o-ygen!he pa"tial p"ess$"es of a"te"ial o-ygen and %a"bon dio-ide listed a"e within the

no"mal "ange ,$pnea "efe"s to no"mal "espi"ation

.5 D St$dies ha/e shown that showe"ing with an antisepti% soap befo"e s$"ge"y is the most effe%ti/e method

of "emo/ing mi%"oo"ganisms f"om the sin Sha/ing the site of the intended s$"ge"y might %a$se b"eas in

the sin& the"eby in%"easing the "is of infe%tionW howe/e"& if indi%ated& sha/ing& sho$ld be doneimmediately befo"e s$"ge"y& not the day befo"e # topi%al antisepti% wo$ld not "emo/e mi%"oo"ganisms

and wo$ld be benefi%ial only afte" p"ope" %leaning and "insing !$b bathing might t"ansfe" o"ganisms to

anothe" body site "athe" than "inse them away

.8 C !he leg m$s%les a"e the st"ongest m$s%les in the body and sho$ld bea" the g"eatest st"ess when lifting

<$s%les of the abdomen& ba%& and $ppe" a"ms may be easily inE$"ed

. C !he fa%to"s& nown as 7i"%howKs t"iad& %olle%ti/ely p"edispose a patient to th"omboplebitisW impai"ed

/eno$s "et$"n to the hea"t& blood hype"%oag$lability& and inE$"y to a blood /essel wall In%"eased pa"tialth"omboplastin time indi%ates a p"olonged bleeding time d$"ing fib"in %lot fo"mation& %ommonly the





COMPREHENSIVE NURSING REVIEW by R. C. REÑA | +.

MATERNIT( NURSING Part 1

1 Hhen assessing the ade6$a%y of spe"m fo" %on%eption to o%%$"& whi%h of the following is the most $sef$l%"ite"ionQ

a Spe"m %o$nt

b Spe"m motility

% Spe"m mat$"ity

d Semen /ol$me

2 # %o$ple who wants to %on%ei/e b$t has been $ns$%%essf$l d$"ing the last 2 yea"s has $nde"gone many

diagnosti% p"o%ed$"es Hhen dis%$ssing the sit$ation with the n$"se& one pa"tne" states& He now se/e"al

f"iends in o$" age g"o$p and all of them ha/e thei" own %hild al"eady& Hhy %anKt we ha/e oneQT Hhi%h

of the following wo$ld be the most pe"tinent n$"sing diagnosis fo" this %o$pleQ

a Fea" "elated to the $nnown

b Pain "elated to n$me"o$s p"o%ed$"es

% Ineffe%ti/e family %oping "elated to infe"tilityd Self=esteem dist$"ban%e "elated to infe"tility

+ Hhi%h of the following $"ina"y symptoms does the p"egnant woman most f"e6$ently e-pe"ien%e d$"ing

the fi"st t"imeste"Q

a )ys$"ia

b F"e6$en%y

% In%ontinen%e

d @$"ning

. ?ea"tb$"n and flat$len%e& %ommon in the se%ond t"imeste"& a"e most liely the "es$lt of whi%h of the

followingQ

a In%"eased plasma ?CD le/els

b )e%"eased intestinal motility

% )e%"eased gast"i% a%idityd ,le/ated est"ogen le/els

On whi%h of the following a"eas wo$ld the n$"se e-pe%t to obse"/e %hloasmaQ

a @"east& a"eola& and nipples

b Chest& ne%& a"ms& and legs

% #bdomen& b"east& and thighsd Chees& fo"ehead& and nose

5 # p"egnant %lient states that she waddlesT when she wals !he n$"seKs e-planation is based on whi%h of

the following as the %a$seQ

a !he la"ge si(e of the newbo"n

b P"ess$"e on the pel/i% m$s%les

% ela-ation of the pel/i% Eoints

d ,-%essi/e weight gain8 Hhi%h of the following "ep"esents the a/e"age amo$nt of weight gained d$"ing p"egnan%yQ

a 12 to 22 lb

b 1 to 2 lb

% 2. to +0 lb

d 2 to .0 lb

Hhen taling with a p"egnant %lient who is e-pe"ien%ing a%hing swollen& leg /eins& the n$"se wo$ld

e-plain that this is most p"obably the "es$lt of whi%h of the followingQa !h"ombophlebitis

b P"egnan%y=ind$%ed hype"tension

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http://nursingcrib.com/hypertension/




% P"ess$"e on blood /essels f"om the enla"ging $te"$s

d !he fo"%e of g"a/ity p$lling down on the $te"$s

9 Ce"/i%al softening and $te"ine so$ffle a"e %lassified as whi%h of the followingQ

a )iagnosti% signs

b P"es$mpti/e signs

% P"obable signs

d Positi/e signs

10 Hhi%h of the following wo$ld the n$"se identify as a p"es$mpti/e sign of p"egnan%yQa ?ega" sign

b *a$sea and /omiting

% Sin pigmentation %hanges

d Positi/e se"$m p"egnan%y test

11 Hhi%h of the following %ommon emotional "ea%tions to p"egnan%y wo$ld the n$"se e-pe%t to o%%$" d$"ing

the fi"st t"imeste"Q

a Int"o/e"sion& ego%ent"ism& na"%issism

b #wwa"dness& %l$msiness& and $natt"a%ti/eness

% #n-iety& passi/ity& e-t"o/e"siond #mbi/alen%e& fea"& fantasies

12 )$"ing whi%h of the following wo$ld the fo%$s of %lasses be mainly on physiologi% %hanges& fetal

de/elopment& se-$ality& d$"ing p"egnan%y& and n$t"itionQa P"ep"egnant pe"iod

b Fi"st t"imeste"

% Se%ond t"imeste"

d !hi"d t"imeste"1+ Hhi%h of the following wo$ld be disad/antage of b"east feedingQ

a In/ol$tion o%%$"s mo"e "apidly

b !he in%iden%e of alle"gies in%"eases d$e to mate"nal antibodies

% !he fathe" may "esent the infantKs demands on the mothe"Ks body

d !he"e is a g"eate" %han%e fo" e""o" d$"ing p"epa"ation

1. Hhi%h of the following wo$ld %a$se a false=positi/e "es$lt on a p"egnan%y testQ

a !he test was pe"fo"med less than 10 days afte" an abo"tion

b !he test was pe"fo"med too ea"ly o" too late in the p"egnan%y% !he $"ine sample was sto"ed too long at "oom tempe"at$"e

d # spontaneo$s abo"tion o" a missed abo"tion is impending

1 F? %an be a$s%$ltated with a fetos%ope as ea"ly as whi%h of the followingQ

a wees gestation

b 10 wees gestation

% 1 wees gestation

d 20 wees gestation

15 # %lient '<P began B$ly ?e" ,)) sho$ld be whi%h of the followingQ

a Ban$a"y 2

b <a"%h 2% #p"il 12

d O%tobe" 1218 Hhi%h of the following f$ndal heights indi%ates less than 12 weesK gestation when the date of the '<P

is $nnownQ

a Ute"$s in the pel/is

b Ute"$s at the -iphoid

% Ute"$s in the abdomen

d Ute"$s at the $mbili%$s

1 Hhi%h of the following dange" signs sho$ld be "epo"ted p"omptly d$"ing the antepa"t$m pe"iodQ

a Constipation

b @"east tende"ness

% *asal st$ffiness

d 'eaing amnioti% fl$id

19 Hhi%h of the following p"enatal labo"ato"y test /al$es wo$ld the n$"se %onside" as signifi%antQ

a ?emato%"it ++V

b $bella tite" less than 1:

% Hhite blood %ells &000Gmm+

d One ho$" gl$%ose %hallenge test 110 gGd'20 Hhi%h of the following %ha"a%te"isti%s of %ont"a%tions wo$ld the n$"se e-pe%t to find in a %lient

e-pe"ien%ing t"$e labo"Q

a O%%$""ing at i""eg$la" inte"/als

b Sta"ting mainly in the abdomen

% D"ad$ally in%"easing inte"/als

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d In%"easing intensity with waling

21 )$"ing whi%h of the following stages of labo" wo$ld the n$"se assess %"owningTQ

a Fi"st stage

b Se%ond stage

% !hi"d stage

d Fo$"th stage

22 @a"bit$"ates a"e $s$ally not gi/en fo" pain "elief d$"ing a%ti/e labo" fo" whi%h of the following "easonsQ

a !he neonatal effe%ts in%l$de hypotonia& hypothe"mia& gene"ali(ed d"owsiness& and "el$%tan%e tofeed fo" the fi"st few days

b !hese d"$gs "eadily %"oss the pla%ental ba""ie"& %a$sing dep"essi/e effe%ts in the newbo"n 2 to +

ho$"s afte" int"am$s%$la" inEe%tion

% !hey "apidly t"ansfe" a%"oss the pla%enta& and la% of an antagonist mae them gene"ally

inapp"op"iate d$"ing labo"

d #d/e"se "ea%tions may in%l$de mate"nal hypotension& alle"gi% o" to-i% "ea%tion o" pa"tial o" total

"espi"ato"y fail$"e

2+ Hhi%h of the following n$"sing inte"/entions wo$ld the n$"se pe"fo"m d$"ing the thi"d stage of labo"Q

a Obtain a $"ine spe%imen and othe" labo"ato"y tests

b #ssess $te"ine %ont"a%tions e/e"y +0 min$tes

% Coa%h fo" effe%ti/e %lient p$shing

d P"omote pa"ent=newbo"n inte"a%tion2. Hhi%h of the following a%tions demonst"ates the n$"seKs $nde"standing abo$t the newbo"nKs

the"mo"eg$lato"y abilityQ

a Pla%ing the newbo"n $nde" a "adiant wa"me"

b S$%tioning with a b$lb sy"inge% Obtaining an #pga" s%o"e

d Inspe%ting the newbo"nKs $mbili%al %o"d

2 Immediately befo"e e-p$lsion& whi%h of the following %a"dinal mo/ements o%%$"Q

a )es%ent

b Fle-ion

% ,-tension

d ,-te"nal "otation

25 @efo"e bi"th& whi%h of the following st"$%t$"es %onne%ts the "ight and left a$"i%les of the hea"tQa Umbili%al /ein

b Fo"amen o/ale

% )$%t$s a"te"ios$s

d )$%t$s /enos$s

28 Hhi%h of the following when p"esent in the $"ine may %a$se a "eddish stain on the diape" of a newbo"nQ

a <$%$s

b U"i% a%id %"ystals

% @ili"$bin

d ,-%ess i"on

2 Hhen assessing the newbo"nKs hea"t "ate& whi%h of the following "anges wo$ld be %onside"ed no"mal ifthe newbo"n we"e sleepingQ

a 0 beats pe" min$te b 100 beats pe" min$te

% 120 beats pe" min$te

d 1.0 beats pe" min$te

29 Hhi%h of the following is t"$e "ega"ding the fontanels of the newbo"nQ

a !he ante"io" is t"iang$la" shapedW the poste"io" is diamond shaped

b !he poste"io" %loses at 1 monthsW the ante"io" %loses at to 12 wees

% !he ante"io" is la"ge in si(e when %ompa"ed to the poste"io" fontanel

d !he ante"io" is b$lgingW the poste"io" appea"s s$nen

+0 Hhi%h of the following g"o$ps of newbo"n "efle-es below a"e p"esent at bi"th and "emain $n%hanged

th"o$gh ad$lthoodQ

a @lin& %o$gh& "ooting& and gag

b @lin& %o$gh& snee(e& gag

% ooting& snee(e& swallowing& and %o$gh

d Stepping& blin& %o$gh& and snee(e

+1 Hhi%h of the following des%"ibes the @abinsi "efle-Q

a !he newbo"nKs toes will hype"e-tend and fan apa"t f"om do"sifle-ion of the big toe when one sideof foot is st"oed $pwa"d f"om the ball of the heel and a%"oss the ball of the foot

b !he newbo"n abd$%ts and fle-es all e-t"emities and may begin to %"y when e-posed to s$dden

mo/ement o" lo$d noise

% !he newbo"n t$"ns the head in the di"e%tion of stim$l$s& opens the mo$th& and begins to s$%

when %hee& lip& o" %o"ne" of mo$th is to$%hed

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d !he newbo"n will attempt to %"awl fo"wa"d with both a"ms and legs when he is pla%ed on his

abdomen on a flat s$"fa%e

+2 Hhi%h of the following statements best des%"ibes hype"emesis g"a/ida"$mQ

a Se/e"e anemia leading to ele%t"olyte& metaboli%& and n$t"itional imbalan%es in the absen%e of

othe" medi%al p"oblems

b Se/e"e na$sea and /omiting leading to ele%t"olyte& metaboli%& and n$t"itional imbalan%es in the

absen%e of othe" medi%al p"oblems

% 'oss of appetite and %ontin$o$s /omiting that %ommonly "es$lts in dehyd"ation and $ltimatelyde%"easing mate"nal n$t"ients

d Se/e"e na$sea and dia""hea that %an %a$se gast"ointestinal i""itation and possibly inte"nal bleeding

++ Hhi%h of the following wo$ld the n$"se identify as a %lassi% sign of PI?Q

a ,dema of the feet and anles

b ,dema of the hands and fa%e

% Height gain of 1 lbGwee

d ,a"ly mo"ning heada%he

+. In whi%h of the following types of spontaneo$s abo"tions wo$ld the n$"se assess da" b"own /aginal

dis%ha"ge and a negati/e p"egnan%y testsQa !h"eatened

b Imminent

% <issedd In%omplete

+ Hhi%h of the following fa%to"s wo$ld the n$"se s$spe%t as p"edisposing a %lient to pla%enta p"e/iaQ

a <$ltiple gestation

b Ute"ine anomalies

% #bdominal t"a$ma

d enal o" /as%$la" disease

+5 Hhi%h of the following wo$ld the n$"se assess in a %lient e-pe"ien%ing ab"$ptio pla%entaQ

a @"ight "ed& painless /aginal bleeding

b Con%ealed o" e-te"nal da" "ed bleeding

% Palpable fetal o$tline

d Soft and nontende" abdomen

+8 Hhi%h of the following is des%"ibed as p"emat$"e sepa"ation of a no"mally implanted pla%enta d$"ing these%ond half of p"egnan%y& $s$ally with se/e"e hemo""hageQ

a Pla%enta p"e/ia

b ,%topi% p"egnan%y% In%ompetent %e"/i-

d #b"$ptio pla%entae

+ Hhi%h of the following may happen if the $te"$s be%omes o/e"stim$lated by o-yto%in d$"ing the

ind$%tion of labo"Q

a Hea %ont"a%tion p"olonged to mo"e than 80 se%onds

b !etani% %ont"a%tions p"olonged to mo"e than 90 se%onds

% In%"eased pain with b"ight "ed /aginal bleeding

d In%"eased "estlessness and an-iety

+9 Hhen p"epa"ing a %lient fo" %esa"ean deli/e"y& whi%h of the following ey %on%epts sho$ld be %onside"ed

when implementing n$"sing %a"eQ

a Inst"$%t the mothe"Ks s$ppo"t pe"son to "emain in the family lo$nge $ntil afte" the deli/e"y

b #""ange fo" a staff membe" of the anesthesia depa"tment to e-plain what to e-pe%t

postope"ati/ely

% <odify p"eope"ati/e tea%hing to meet the needs of eithe" a planned o" eme"gen%y %esa"ean bi"th

d ,-plain the s$"ge"y& e-pe%ted o$t%ome& and ind of anestheti%s

.0 Hhi%h of the following best des%"ibes p"ete"m labo"Q

a 'abo" that begins afte" 20 wees gestation and befo"e +8 wees gestation

b 'abo" that begins afte" 1 wees gestation and befo"e +8 wees gestation% 'abo" that begins afte" 2. wees gestation and befo"e 2 wees gestation

d 'abo" that begins afte" 2 wees gestation and befo"e .0 wees gestation

.1 Hhen PO< o%%$"s& whi%h of the following p"o/ides e/iden%e of the n$"seKs $nde"standing of the

%lientKs immediate needsQ

a !he %ho"ion and amnion "$pt$"e . ho$"s befo"e the onset of labo"

b PO< "emo/es the fet$s most effe%ti/e defense against infe%tion

% *$"sing %a"e is based on fetal /iability and gestational age

d PO< is asso%iated with malp"esentation and possibly in%ompetent %e"/i-

.2 Hhi%h of the following fa%to"s is the $nde"lying %a$se of dysto%iaQ

a *$"tional

b <e%hani%al

% ,n/i"onmental




d <edi%al

.+ Hhen $te"ine "$pt$"e o%%$"s& whi%h of the following wo$ld be the p"io"ityQ

a 'imiting hypo/olemi% sho%

b Obtaining blood spe%imens

% Instit$ting %omplete bed "est

d Inse"ting a $"ina"y %athete"

.. Hhi%h of the following is the n$"seKs initial a%tion when $mbili%al %o"d p"olapse o%%$"sQ

a @egin monito"ing mate"nal /ital signs and F? b Pla%e the %lient in a nee=%hest position in bed

% *otify the physi%ian and p"epa"e the %lient fo" deli/e"y

d #pply a ste"ile wa"m saline d"essing to the e-posed %o"d

. Hhi%h of the following amo$nts of blood loss following bi"th ma"s the %"ite"ion fo" des%"ibing

postpa"t$m hemo""hageQ

a <o"e than 200 ml

b <o"e than +00 ml

% <o"e than .00 ml

d <o"e than 00 ml.5 Hhi%h of the following is the p"ima"y p"edisposing fa%to" "elated to mastitisQ

a ,pidemi% infe%tion f"om noso%omial so$"%es lo%ali(ing in the la%tife"o$s glands and d$%ts

b ,ndemi% infe%tion o%%$""ing "andomly and lo%ali(ing in the pe"igland$la" %onne%ti/e tiss$e% !empo"a"y $"ina"y "etention d$e to de%"eased pe"%eption of the $"ge to a/oid

d @"east inE$"y %a$sed by o/e"distention& stasis& and %"a%ing of the nipples

.8 Hhi%h of the following best des%"ibes th"ombophlebitisQ

a Inflammation and %lot fo"mation that "es$lt when blood %omponents %ombine to fo"m an

agg"egate body

b Inflammation and blood %lots that e/ent$ally be%ome lodged within the p$lmona"y blood /essels

% Inflammation and blood %lots that e/ent$ally be%ome lodged within the femo"al /ein

d Inflammation of the /as%$la" endotheli$m with %lot fo"mation on the /essel wall

. Hhi%h of the following assessment findings wo$ld the n$"se e-pe%t if the %lient de/elops )7!Q

a <id%alf pain& tende"ness and "edness along the /ein

b Chills& fe/e"& malaise& o%%$""ing 2 wees afte" deli/e"y

% <$s%le pain the p"esen%e of ?omans sign& and swelling in the affe%ted limbd Chills& fe/e"& stiffness& and pain o%%$""ing 10 to 1. days afte" deli/e"y

.9 Hhi%h of the following a"e the most %ommonly assessed findings in %ystitisQ

a F"e6$en%y& $"gen%y& dehyd"ation& na$sea& %hills& and flan pain b *o%t$"ia& f"e6$en%y& $"gen%y dys$"ia& hemat$"ia& fe/e" and s$p"ap$bi% pain

% )ehyd"ation& hype"tension& dys$"ia& s$p"ap$bi% pain& %hills& and fe/e"

d ?igh fe/e"& %hills& flan pain na$sea& /omiting& dys$"ia& and f"e6$en%y

0 Hhi%h of the following best "efle%ts the f"e6$en%y of "epo"ted postpa"t$m bl$esTQ

a @etween 10V and .0V of all new mothe"s "epo"t some fo"m of postpa"t$m bl$es

b @etween +0V and 0V of all new mothe"s "epo"t some fo"m of postpa"t$m bl$es

% @etween 0V and 0V of all new mothe"s "epo"t some fo"m of postpa"t$m bl$es

d @etween 2V and 80V of all new mothe"s "epo"t some fo"m of postpa"t$m bl$es

1 Fo" the %lient who is $sing o"al %ont"a%epti/es& the n$"se info"ms the %lient abo$t the need to tae the pill

at the same time ea%h day to a%%omplish whi%h of the followingQ

a )e%"ease the in%iden%e of na$sea

b <aintain ho"monal le/els

% ed$%e side effe%ts

d P"e/ent d"$g inte"a%tions

2 Hhen tea%hing a %lient abo$t %ont"a%eption Hhi%h of the following wo$ld the n$"se in%l$de as the most

effe%ti/e method fo" p"e/enting se-$ally t"ansmitted infe%tionsQ

a Spe"mi%ides

b )iaph"agm% Condoms

d 7ase%tomy

+ Hhen p"epa"ing a woman who is 2 days postpa"t$m fo" dis%ha"ge& "e%ommendations fo" whi%h of the

following %ont"a%epti/e methods wo$ld be a/oidedQ

a )iaph"agm

b Female %ondom

% O"al %ont"a%epti/es

d hythm method

. Fo" whi%h of the following %lients wo$ld the n$"se e-pe%t that an int"a$te"ine de/i%e wo$ld $#t be

"e%ommendedQ

a Homan o/e" age +

b *$llipa"o$s woman




% P"omis%$o$s yo$ng ad$lt

d Postpa"t$m %lient

# %lient in he" thi"d t"imeste" tells the n$"se& IKm %onstipated all the time\T Hhi%h of the following

sho$ld the n$"se "e%ommendQ

a )aily enemas

b 'a-ati/es

% In%"eased fibe" intae

d )e%"eased fl$id intae5 Hhi%h of the following wo$ld the n$"se $se as the basis fo" the tea%hing plan when %a"ing fo" a p"egnant

teenage" %on%e"ned abo$t gaining too m$%h weight d$"ing p"egnan%yQ

a 10 po$nds pe" t"imeste"

b 1 po$nd pe" wee fo" .0 wees

% [ po$nd pe" wee fo" .0 wees

d # total gain of 2 to +0 po$nds

8 !he %lient tells the n$"se that he" last menst"$al pe"iod sta"ted on Ban$a"y 1. and ended on Ban$a"y 20

Using *ageleKs "$le& the n$"se dete"mines he" ,)) to be whi%h of the followingQ

a Septembe" 28 b O%tobe" 21

% *o/embe" 8

d )e%embe" 28 Hhen taing an obstet"i%al histo"y on a p"egnant %lient who states& I had a son bo"n at + wees

gestation& a da$ghte" bo"n at +0 wees gestation and I lost a baby at abo$t wees&T the n$"se sho$ld

"e%o"d he" obstet"i%al histo"y as whi%h of the followingQ

a D2 !2 P0 #0 '2

b D+ !1 P1 #0 '2

% D+ !2 P0 #0 '2

d D. !2 P1 #1 '2

9 Hhen p"epa"ing to listen to the fetal hea"t "ate at 12 weesK gestation& the n$"se wo$ld $se whi%h of the

followingQ

a Stethos%ope pla%ed midline at the $mbili%$s

b )opple" pla%ed midline at the s$p"ap$bi% "egion

% Fetos%ope pla%ed midway between the $mbili%$s and the -iphoid p"o%essd ,-te"nal ele%t"oni% fetal monito" pla%ed at the $mbili%$s

50 Hhen de/eloping a plan of %a"e fo" a %lient newly diagnosed with gestational diabetes& whi%h of the

following inst"$%tions wo$ld be the p"io"ityQa )ieta"y intae

b <edi%ation

% ,-e"%ise

d Dl$%ose monito"ing

51 # %lient at 2. wees gestation has gained 5 po$nds in . wees Hhi%h of the following wo$ld be the

p"io"ity when assessing the %lientQ

a Dl$%os$"ia

b )ep"ession

% ?andGfa%e edema

d )ieta"y intae

52 # %lient 12 weesK p"egnant %ome to the eme"gen%y depa"tment with abdominal %"amping and mode"ate

/aginal bleeding Spe%$l$m e-amination "e/eals 2 to + %ms %e"/i%al dilation !he n$"se wo$ld do%$ment

these findings as whi%h of the followingQ

a !h"eatened abo"tion

b Imminent abo"tion

% Complete abo"tion

d <issed abo"tion

5+ Hhi%h of the following wo$ld be the p"io"ity n$"sing diagnosis fo" a %lient with an e%topi% p"egnan%yQ

a is fo" infe%tion

b Pain

% nowledge )efi%it

d #nti%ipato"y D"ie/ing

5. @efo"e assessing the postpa"t$m %lientKs $te"$s fo" fi"mness and position in "elation to the $mbili%$s and

midline& whi%h of the following sho$ld the n$"se do fi"stQ

a #ssess the /ital signs b #dministe" analgesia

% #mb$late he" in the hall

d #ssist he" to $"inate

5 Hhi%h of the following sho$ld the n$"se do when a p"imipa"a who is la%tating tells the n$"se that she has

so"e nipplesQ

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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | .0

a !ell he" to b"east feed mo"e f"e6$ently

b #dministe" a na"%oti% befo"e b"east feeding

% ,n%o$"age he" to wea" a n$"sing b"assie"e

d Use soap and wate" to %lean the nipples

55 !he n$"se assesses the /ital signs of a %lient& . ho$"sK postpa"t$m that a"e as follows: @P 90G50W

tempe"at$"e 100.]FW p$lse 100 wea& th"eadyW 20 pe" min$te Hhi%h of the following sho$ld the n$"se

do fi"stQ

a epo"t the tempe"at$"e to the physi%ian b e%he% the blood p"ess$"e with anothe" %$ff

% #ssess the $te"$s fo" fi"mness and position

d )ete"mine the amo$nt of lo%hia

58 !he n$"se assesses the postpa"t$m /aginal dis%ha"ge lo%hia on fo$" %lients Hhi%h of the following

assessments wo$ld wa""ant notifi%ation of the physi%ianQ

a # da" "ed dis%ha"ge on a 2=day postpa"t$m %lient

b # pin to b"ownish dis%ha"ge on a %lient who is days postpa"t$m

% #lmost %olo"less to %"eamy dis%ha"ge on a %lient 2 wees afte" deli/e"y

d # b"ight "ed dis%ha"ge days afte" deli/e"y5 # postpa"t$m %lient has a tempe"at$"e of 101.]F& with a $te"$s that is tende" when palpated& "emains

$n$s$ally la"ge& and not des%ending as no"mally e-pe%ted Hhi%h of the following sho$ld the n$"se assess

ne-tQa 'o%hia

b @"easts

% In%ision

d U"ine

59 Hhi%h of the following is the p"io"ity fo%$s of n$"sing p"a%ti%e with the %$""ent ea"ly postpa"t$m

dis%ha"geQ

a P"omoting %omfo"t and "esto"ation of health

b ,-plo"ing the emotional stat$s of the family

% Fa%ilitating safe and effe%ti/e self=and newbo"n %a"e

d !ea%hing abo$t the impo"tan%e of family planning

80 Hhi%h of the following a%tions wo$ld be least effe%ti/e in maintaining a ne$t"al the"mal en/i"onment fo"

the newbo"nQa Pla%ing infant $nde" "adiant wa"me" afte" bathing

b Co/e"ing the s%ale with a wa"med blanet p"io" to weighing

% Pla%ing %"ib %lose to n$"se"y window fo" family /iewing

d Co/e"ing the infantKs head with a nit sto%inette

81 # newbo"n who has an asymmet"i%al <o"o "efle- "esponse sho$ld be f$"the" assessed fo" whi%h of the

followingQ

a !alipes e6$ino/a"$s

b F"a%t$"ed %la/i%le

% Congenital hypothy"oidism

d In%"eased int"a%"anial p"ess$"e

82 )$"ing the fi"st . ho$"s afte" a male %i"%$m%ision& assessing fo" whi%h of the following is the p"io"ityQ

a Infe%tion b ?emo""hage

% )is%omfo"t

d )ehyd"ation

8+ !he mothe" ass the n$"se HhatKs w"ong with my sonKs b"eastsQ Hhy a"e they so enla"gedQT Hhish of

the following wo$ld be the best "esponse by the n$"seQa !he b"east tiss$e is inflamed f"om the t"a$ma e-pe"ien%ed with bi"thT

b # de%"ease in mate"ial ho"mones p"esent befo"e bi"th %a$ses enla"gement&T

% Ao$ sho$ld dis%$ss this with yo$" do%to" It %o$ld be a malignan%yT

d !he tiss$e has hype"t"ophied while the baby was in the $te"$sT

8. Immediately afte" bi"th the n$"se notes the following on a male newbo"n: "espi"ations 8W api%al hea"th

"ate 150 @P<& nost"il fla"ingW mild inte"%ostal "et"a%tionsW and g"$nting at the end of e-pi"ation Hhi%h of

the following sho$ld the n$"se doQa Call the assessment data to the physi%ianKs attention

b Sta"t o-ygen pe" nasal %ann$la at 2 'Gmin

% S$%tion the infantKs mo$th and na"es

d e%ogni(e this as no"mal fi"st pe"iod of "ea%ti/ity

8 !he n$"se hea"s a mothe" telling a f"iend on the telephone abo$t $mbili%al %o"d %a"e Hhi%h of the

following statements by the mothe" indi%ates effe%ti/e tea%hingQ

a )aily soap and wate" %leansing is bestT

b ^#l%ohol helps it d"y and ills ge"msT

% #n antibioti% ointment applied daily p"e/ents infe%tionT






d ?e %an ha/e a t$b bath ea%h dayT

85 # newbo"n weighing +000 g"ams and feeding e/e"y . ho$"s needs 120 %alo"iesGg of body weight e/e"y

2. ho$"s fo" p"ope" g"owth and de/elopment ?ow many o$n%es of 20 %alGo( fo"m$la sho$ld this

newbo"n "e%ei/e at ea%h feeding to meet n$t"itional needsQ

a 2 o$n%es

b + o$n%es

% . o$n%es

d 5 o$n%es88 !he postte"m neonate with me%oni$m=stained amnioti% fl$id needs %a"e designed to espe%ially monito"

fo" whi%h of the followingQ

a espi"ato"y p"oblems

b Dast"ointestinal p"oblems

% Integ$menta"y p"oblems

d ,limination p"oblems

8 Hhen meas$"ing a %lientKs f$ndal height& whi%h of the following te%hni6$es denotes the %o""e%t method

of meas$"ement $sed by the n$"seQ

a F"om the -iphoid p"o%ess to the $mbili%$s b F"om the symphysis p$bis to the -iphoid p"o%ess

% F"om the symphysis p$bis to the f$nd$s

d F"om the f$nd$s to the $mbili%$s89 # %lient with se/e"e p"ee%lampsia is admitted with of @P 150G110& p"otein$"ia& and se/e"e pitting edema

Hhi%h of the following wo$ld be most impo"tant to in%l$de in the %lientKs plan of %a"eQ

a )aily weights

b Sei($"e p"e%a$tions

% ight late"al positioning

d St"ess "ed$%tion

0 # postpa"t$m p"imipa"a ass the n$"se& Hhen %an we ha/e se-$al inte"%o$"se againQT Hhi%h of the

following wo$ld be the n$"seKs best "esponseQ

a #nytime yo$ both want toT

b #s soon as %hoose a %ont"a%epti/e methodT

% Hhen the dis%ha"ge has stopped and the in%ision is healedT

d #fte" yo$" 5 wees e-aminationT1 Hhen p"epa"ing to administe" the /itamin inEe%tion to a neonate& the n$"se wo$ld sele%t whi%h of the

following sites as app"op"iate fo" the inEe%tionQ

a )eltoid m$s%le

b #nte"io" femo"is m$s%le

% 7ast$s late"alis m$s%le

d Dl$te$s ma-im$s m$s%le

2 Hhen pe"fo"ming a pel/i% e-amination& the n$"se obse"/es a "ed swollen a"ea on the "ight side of the

/aginal o"ifi%e !he n$"se wo$ld do%$ment this as enla"gement of whi%h of the followingQ

a Clito"is

b Pa"otid gland% SeneKs gland

d @a"tholinKs gland+ !o diffe"entiate as a female& the ho"monal stim$lation of the emb"yo that m$st o%%$" in/ol/es whi%h of

the followingQ

a In%"ease in mate"nal est"ogen se%"etion

b )e%"ease in mate"nal and"ogen se%"etion

% Se%"etion of and"ogen by the fetal gonad

d Se%"etion of est"ogen by the fetal gonad

. # %lient at weesK gestation %alls %omplaining of slight na$sea in the mo"ning ho$"s Hhi%h of the

following %lient inte"/entions sho$ld the n$"se 6$estionQ

a !aing 1 teaspoon of bi%a"bonate of soda in an =o$n%e glass of wate"

b ,ating a few low=sodi$m %"a%e"s befo"e getting o$t of bed

% #/oiding the intae of li6$ids in the mo"ning ho$"s

d ,ating si- small meals a day instead of thee la"ge meals

!he n$"se do%$ments positi/e ballottement in the %lientKs p"enatal "e%o"d !he n$"se $nde"stands that this

indi%ates whi%h of the followingQ

a Palpable %ont"a%tions on the abdomen

b Passi/e mo/ement of the $nengaged fet$s% Fetal i%ing felt by the %lient

d ,nla"gement and softening of the $te"$s

5 )$"ing a pel/i% e-am the n$"se notes a p$"ple=bl$e tinge of the %e"/i- !he n$"se do%$ments this as whi%h

of the followingQ

a @"a-ton=?i%s sign






b Chadwi%Ks sign

% DoodellKs sign

d <%)onaldKs sign

8 )$"ing a p"enatal %lass& the n$"se e-plains the "ationale fo" b"eathing te%hni6$es d$"ing p"epa"ation fo"

labo" based on the $nde"standing that b"eathing te%hni6$es a"e most impo"tant in a%hie/ing whi%h of the

followingQ

a ,liminate pain and gi/e the e-pe%tant pa"ents something to do

b ed$%e the "is of fetal dist"ess by in%"easing $te"opla%ental pe"f$sion% Fa%ilitate "ela-ation& possibly "ed$%ing the pe"%eption of pain

d ,liminate pain so that less analgesia and anesthesia a"e needed

#fte" . ho$"s of a%ti/e labo"& the n$"se notes that the %ont"a%tions of a p"imig"a/ida %lient a"e not st"ong

eno$gh to dilate the %e"/i- Hhi%h of the following wo$ld the n$"se anti%ipate doingQ

a Obtaining an o"de" to begin I7 o-yto%in inf$sion

b #dministe"ing a light sedati/e to allow the patient to "est fo" se/e"al ho$"

% P"epa"ing fo" a %esa"ean se%tion fo" fail$"e to p"og"ess

d In%"easing the en%o$"agement to the patient when p$shing begins

9 # m$ltig"a/ida at + weesK gestation is admitted with painless& b"ight "ed bleeding and mild %ont"a%tionse/e"y 8 to 10 min$tes Hhi%h of the following assessments sho$ld be a/oidedQ

a <ate"nal /ital sign

b Fetal hea"t "ate% Cont"a%tion monito"ing

d Ce"/i%al dilation

90 Hhi%h of the following wo$ld be the n$"seKs most app"op"iate "esponse to a %lient who ass why she

m$st ha/e a %esa"ean deli/e"y if she has a %omplete pla%enta p"e/iaQ

a Ao$ will ha/e to as yo$" physi%ian when he "et$"nsT

b Ao$ need a %esa"ean to p"e/ent hemo""hageT

% !he pla%enta is %o/e"ing most of yo$" %e"/i-T

d !he pla%enta is %o/e"ing the opening of the $te"$s and blo%ing yo$" babyT

91 !he n$"se $nde"stands that the fetal head is in whi%h of the following positions with a fa%e p"esentationQ

a Completely fle-ed

b Completely e-tended

% Pa"tially e-tendedd Pa"tially fle-ed

92 Hith a fet$s in the left=ante"io" b"ee%h p"esentation& the n$"se wo$ld e-pe%t the fetal hea"t "ate wo$ld be

most a$dible in whi%h of the following a"easQa #bo/e the mate"nal $mbili%$s and to the "ight of midline

b In the lowe"=left mate"nal abdominal 6$ad"ant

% In the lowe"="ight mate"nal abdominal 6$ad"ant

d #bo/e the mate"nal $mbili%$s and to the left of midline

9+ !he amnioti% fl$id of a %lient has a g"eenish tint !he n$"se inte"p"ets this to be the "es$lt of whi%h of the

followingQ

a 'an$go

b ?yd"amnio

% <e%oni$m

d 7e"ni-

9. # patient is in labo" and has E$st been told she has a b"ee%h p"esentation !he n$"se sho$ld be pa"ti%$la"ly

ale"t fo" whi%h of the followingQ

a >$i%ening

b Ophthalmia neonato"$m

% Pi%a

d P"olapsed $mbili%al %o"d

9 Hhen des%"ibing di(ygoti% twins to a %o$ple& on whi%h of the following wo$ld the n$"se base the

e-planationQa !wo o/a fe"tili(ed by sepa"ate spe"m

b Sha"ing of a %ommon pla%enta

% ,a%h o/a with the same genotype

d Sha"ing of a %ommon %ho"ion

95 Hhi%h of the following "efe"s to the single %ell that "ep"od$%es itself afte" %on%eptionQ

a Ch"omosome

b @lasto%yst

% Jygote

d !"ophoblast

98 In the late 190s& %ons$me"s and health %a"e p"ofessionals began %hallenging the "o$tine $se of analgesi%s

and anestheti%s d$"ing %hildbi"th Hhi%h of the following was an o$tg"owth of this %on%eptQ

a 'abo"& deli/e"y& "e%o/e"y& postpa"t$m ')P



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | .+

b *$"se=midwife"y

% Clini%al n$"se spe%ialist

d P"epa"ed %hildbi"th

9 # %lient has a midpel/i% %ont"a%t$"e f"om a p"e/io$s pel/i% inE$"y d$e to a moto" /ehi%le a%%ident as a

teenage" !he n$"se is awa"e that this %o$ld p"e/ent a fet$s f"om passing th"o$gh o" a"o$nd whi%h

st"$%t$"e d$"ing %hildbi"thQ

a Symphysis p$bis

b Sa%"al p"omonto"y% Is%hial spines

d P$bi% a"%h

99 Hhen tea%hing a g"o$p of adoles%ents abo$t /a"iations in the length of the menst"$al %y%le& the n$"se

$nde"stands that the $nde"lying me%hanism is d$e to /a"iations in whi%h of the following phasesQ

a <enst"$al phase

b P"olife"ati/e phase

% Se%"eto"y phase

d Is%hemi% phase

100 Hhen tea%hing a g"o$p of adoles%ents abo$t male ho"mone p"od$%tion& whi%h of the following wo$ldthe n$"se in%l$de as being p"od$%ed by the 'eydig %ellsQ

a Folli%le=stim$lating ho"mone

b !estoste"one% 'e$teini(ing ho"mone

d Donadot"opin "eleasing ho"mone






1+ C Hith b"east feeding& the fathe"Ks body is not %apable of p"o/iding the mil fo" the newbo"n& whi%h may

inte"fe"e with feeding the newbo"n& p"o/iding fewe" %han%es fo" bonding& o" he may be Eealo$s of the

infantKs demands on his wifeKs time and body @"east feeding is ad/antageo$s be%a$se $te"ine in/ol$tion

o%%$"s mo"e "apidly& th$s minimi(ing blood loss !he p"esen%e of mate"nal antibodies in b"east mil helps

de%"ease the in%iden%e of alle"gies in the newbo"n # g"eate" %han%e fo" e""o" is asso%iated with bottle

feeding *o p"epa"ation is "e6$i"ed fo" b"east feeding

1. A # false=positi/e "ea%tion %an o%%$" if the p"egnan%y test is pe"fo"med less than 10 days afte" an

abo"tion Pe"fo"ming the tests too ea"ly o" too late in the p"egnan%y& sto"ing the $"ine sample too long at"oom tempe"at$"e& o" ha/ing a spontaneo$s o" missed abo"tion impending %an all p"od$%e false=negati/e

"es$lts

1 D !he F? %an be a$s%$ltated with a fetos%ope at abo$t 20 weeKs gestation F? $s$ally is

a$s%$latated at the midline s$p"ap$bi% "egion with )opple" $lt"aso$nd t"ansd$%e" at 10 to 12 weeKs

gestation F?& %annot be hea"d any ea"lie" than 10 weesK gestation

15 C' !o dete"mine the ,)) when the date of the %lientKs '<P is nown $se *agele "$le !o the fi"st day of

the '<P& add 8 days& s$bt"a%t + months& and add 1 yea" if appli%able to a""i/e at the ,)) as follows:

8 12 B$ly min$s + . #p"il !he"efo"e& the %lientKs ,)) is #p"il 12

18 A' Hhen the '<P is $nnown& the gestational age of the fet$s is estimated by $te"ine si(e o" position

f$ndal height !he p"esen%e of the $te"$s in the pel/is indi%ates less than 12 weesK gestation #t

app"o-imately 12 to 1. wees& the f$nd$s is o$t of the pel/is abo/e the symphysis p$bis !he f$nd$s is at

the le/el of the $mbili%$s at app"o-imately 20 weesK gestation and "ea%hes the -iphoid at te"m o" .0wees

1 D )ange" signs that "e6$i"e p"ompt "epo"ting leaing of amnioti% fl$id& /aginal bleeding& bl$""ed /ision&

"apid weight gain& and ele/ated blood p"ess$"e Constipation& b"east tende"ness& and nasal st$ffiness a"e

%ommon dis%omfo"ts asso%iated with p"egnan%y

19 ) # "$bella tite" sho$ld be 1: o" g"eate" !h$"s& a finding of a tite" less than 1: is signifi%ant& indi%ating

that the %lient may not possess imm$nity to "$bella # hemato%"it of ++V a white blood %ell %o$nt of

&000Gmm+& and a 1 ho$" gl$%ose %hallenge test of 110 gGdl a"e with no"mal pa"amete"s

20 D Hith t"$e labo"& %ont"a%tions in%"ease in intensity with waling In addition& t"$e labo" %ont"a%tions

o%%$" at "eg$la" inte"/als& $s$ally sta"ting in the ba% and sweeping a"o$nd to the abdomen !he inte"/al

of t"$e labo" %ont"a%tions g"ad$ally sho"tens

21 ) C"owing& whi%h o%%$"s when the newbo"nKs head o" p"esenting pa"t appea"s at the /aginal opening&

o%%$"s d$"ing the se%ond stage of labo" )$"ing the fi"st stage of labo"& %e"/i%al dilation and effa%ement

o%%$" )$"ing the thi"d stage of labo"& the newbo"n and pla%enta a"e deli/e"ed !he fo$"th stage of labo"

lasts f"om 1 to . ho$"s afte" bi"th& d$"ing whi%h time the mothe" and newbo"n "e%o/e" f"om the physi%al p"o%ess of bi"th and the mothe"Ks o"gans $nde"go the initial "eadE$stment to the nonp"egnant state

22 C @a"bit$"ates a"e "apidly t"ansfe""ed a%"oss the pla%ental ba""ie"& and la% of an antagonist maes them

gene"ally inapp"op"iate d$"ing a%ti/e labo" *eonatal side effe%ts of ba"bit$"ates in%l$de %ent"al ne"/o$s

system dep"ession& p"olonged d"owsiness& delayed establishment of feeding eg d$e to poo" s$%ing

"efle- o" poo" s$%ing p"ess$"e !"an6$ili(e"s a"e asso%iated with neonatal effe%ts s$%h as hypotonia&

hypothe"mia& gene"ali(ed d"owsiness& and "el$%tan%e to feed fo" the fi"st few days *a"%oti% analgesi%

"eadily %"oss the pla%ental ba""ie"& %a$sing dep"essi/e effe%ts in the newbo"n 2 to + ho$"s afte"int"am$s%$la" inEe%tion egional anesthesia is asso%iated with ad/e"se "ea%tions s$%h as mate"nal

hypotension& alle"gi% o" to-i% "ea%tion& o" pa"tial o" total "espi"ato"y fail$"e

2+ D )$"ing the thi"d stage of labo"& whi%h begins with the deli/e"y of the newbo"n& the n$"se wo$ld

p"omote pa"ent=newbo"n inte"a%tion by pla%ing the newbo"n on the mothe"Ks abdomen and en%o$"aging

the pa"ents to to$%h the newbo"n Colle%ting a $"ine spe%imen and othe" labo"ato"y tests is done on

admission d$"ing the fi"st stage of labo" #ssessing $te"ine %ont"a%tions e/e"y +0 min$tes is pe"fo"med

d$"ing the latent phase of the fi"st stage of labo" Coa%hing the %lient to p$sh effe%ti/ely is app"op"iate

d$"ing the se%ond stage of labo"

2. A' !he newbo"nKs ability to "eg$late body tempe"at$"e is poo" !he"efo"e& pla%ing the newbo"n $nde" a

"adiant wa"me" aids in maintaining his o" he" body tempe"at$"e S$%tioning with a b$lb sy"inge helps

maintain a patent ai"way Obtaining an #pga" s%o"e meas$"es the newbo"nKs immediate adE$stment to

e-t"a$te"ine life Inspe%ting the $mbili%al %o"d aids in dete%ting %o"d anomalies

2 D' Immediately befo"e e-p$lsion o" bi"th of the "est of the body& the %a"dinal mo/ement of e-te"nal

"otation o%%$"s )es%ent fle-ion& inte"nal "otation& e-tension& and "estit$tion in this o"de" o%%$" befo"ee-te"nal "otation

25 )' !he fo"amen o/ale is an opening between the "ight and left a$"i%les at"ia that sho$ld %lose sho"tly

afte" bi"th so the newbo"n will not ha/e a m$"m$" o" mi-ed blood t"a/eling th"o$gh the /as%$la" system

!he $mbili%al /ein& d$%t$s a"te"ios$s& and d$%t$s /enos$s a"e oblite"ated at bi"th

28 )' U"i% a%id %"ystals in the $"ine may p"od$%e the "eddish b"i% d$stT stain on the diape" <$%$s wo$ld

not p"od$%e a stain @ili"$bin and i"on a"e f"om hepati% adaptation

2 ) !he no"mal hea"t "ate fo" a newbo"n that is sleeping is app"o-imately 100 beats pe" min$te If the

newbo"n was awae& the no"mal hea"t "ate wo$ld "ange f"om 120 to 150 beats pe" min$te






29 C !he ante"io" fontanel is la"ge" in si(e than the poste"io" fontanel #dditionally& the ante"io" fontanel&

whi%h is diamond shaped& %loses at 1 months& whe"eas the poste"io" fontanel& whi%h is t"iang$la" shaped&

%loses at to 12 wees *eithe" fontanel sho$ld appea" b$lging& whi%h may indi%ate in%"eased

int"a%"anial p"ess$"e& o" s$nen& whi%h may indi%ate dehyd"ation

+0 ) @lin& %o$gh& snee(e& swallowing and gag "efle-es a"e all p"esent at bi"th and "emain $n%hanged

th"o$gh ad$lthood efle-es s$%h as "ooting and stepping s$bside within the fi"st yea"

+1 A Hith the babinsi "efle-& the newbo"nKs toes hype"e-tend and fan apa"t f"om do"sifle-ion of the big toe

when one side of foot is st"oed $pwa"d fo"m the heel and a%"oss the ball of the foot Hith the sta"tle"efle-& the newbo"n abd$%ts and fle-es all e-t"emities and may begin to %"y when e-posed to s$dden

mo/ement of lo$d noise Hith the "ooting and s$%ing "efle-& the newbo"n t$"ns his head in the di"e%tion

of stim$l$s& opens the mo$th& and begins to s$% when the %hees& lip& o" %o"ne" of mo$th is to$%hed

Hith the %"awl "efle-& the newbo"n will attempt to %"awl fo"wa"d with both a"ms and legs when he is

pla%ed on his abdomen on a flat s$"fa%e

+2 ) !he des%"iption of hype"emesis g"a/ida"$m in%l$des se/e"e na$sea and /omiting& leading to

ele%t"olyte& metaboli%& and n$t"itional imbalan%es in the absen%e of othe" medi%al p"oblems ?ype"emesis

is not a fo"m of anemia 'oss of appetite may o%%$" se%onda"y to the na$sea and /omiting of

hype"emesis& whi%h& if it %ontin$es& %an deplete the n$t"ients t"anspo"ted to the fet$s )ia""hea does not

o%%$" with hype"emesis

++ )' ,dema of the hands and fa%e is a %lassi% sign of PI? <any healthy p"egnant woman e-pe"ien%e foot

and anle edema # weight gain of 2 lb o" mo"e pe" wee indi%ates a p"oblem ,a"ly mo"ning heada%he isnot a %lassi% sign of PI?

+. C' In a missed abo"tion& the"e is ea"ly fetal int"a$te"ine death& and p"od$%ts of %on%eption a"e not

e-pelled !he %e"/i- "emains %losedW the"e may be a da" b"own /aginal dis%ha"ge& negati/e p"egnan%y

test& and %essation of $te"ine g"owth and b"east tende"ness # th"eatened abo"tion is e/iden%ed with

%"amping and /aginal bleeding in ea"ly p"egnan%y& with no %e"/i%al dilation #n in%omplete abo"tion

p"esents with bleeding& %"amping& and %e"/i%al dilation #n in%omplete abo"tion in/ol/es only e-p$lsion

of pa"t of the p"od$%ts of %on%eption and bleeding o%%$"s with %e"/i%al dilation

+ A' <$ltiple gestation is one of the p"edisposing fa%to"s that may %a$se pla%enta p"e/ia Ute"ine anomalies

abdominal t"a$ma& and "enal o" /as%$la" disease may p"edispose a %lient to ab"$ptio pla%entae

+5 )' # %lient with ab"$ptio pla%entae may e-hibit %on%ealed o" da" "ed bleeding& possibly "epo"ting s$dden

intense lo%ali(ed $te"ine pain !he $te"$s is typi%ally fi"m to boa"dlie& and the fetal p"esenting pa"t may

be engaged @"ight "ed& painless /aginal bleeding& a palpable fetal o$tline and a soft nontende" abdomena"e manifestations of pla%enta p"e/ia

+8 D' #b"$ptio pla%entae is des%"ibed as p"emat$"e sepa"ation of a no"mally implanted pla%enta d$"ing the

se%ond half of p"egnan%y& $s$ally with se/e"e hemo""hage Pla%enta p"e/ia "efe"s to implantation of the

pla%enta in the lowe" $te"ine segment& %a$sing painless bleeding in the thi"d t"imeste" of p"egnan%y

,%topi% p"egnan%y "efe"s to the implantation of the p"od$%ts of %on%eption in a site othe" than the

endomet"i$m In%ompetent %e"/i- is a %ond$%tion %ha"a%te"i(ed by painf$l dilation of the %e"/i%al os

witho$t $te"ine %ont"a%tions

+ )' ?ype"stim$lation of the $te"$s s$%h as with o-yto%in d$"ing the ind$%tion of labo" may "es$lt in tetani%

%ont"a%tions p"olonged to mo"e than 90se%onds& whi%h %o$ld lead to s$%h %ompli%ations as fetal dist"ess&ab"$ptio pla%entae& amnioti% fl$id embolism& la%e"ation of the %e"/i-& and $te"ine "$pt$"e Hea

%ont"a%tions wo$ld not o%%$" Pain& b"ight "ed /aginal bleeding& and in%"eased "estlessness and an-iety a"e

not asso%iated with hype"stim$lation

+9 C' # ey point to %onside" when p"epa"ing the %lient fo" a %esa"ean deli/e"y is to modify the p"eope"ati/e

tea%hing to meet the needs of eithe" a planned o" eme"gen%y %esa"ean bi"th& the depth and b"eadth of

inst"$%tion will depend on %i"%$mstan%es and time a/ailable #llowing the mothe"Ks s$ppo"t pe"son to

"emain with he" as m$%h as possible is an impo"tant %on%ept& altho$gh doing so depends on many

/a"iables #""anging fo" ne%essa"y e-planations by /a"io$s staff membe"s to be in/ol/ed with the %lientKs

%a"e is a n$"sing "esponsibility !he n$"se is "esponsible fo" "einfo"%ing the e-planations abo$t the

s$"ge"y& e-pe%ted o$t%ome& and type of anestheti% to be $sed !he obstet"i%ian is "esponsible fo"

e-plaining abo$t the s$"ge"y and o$t%ome and the anesthesiology staff is "esponsible fo" e-planationsabo$t the type of anesthesia to be $sed

.0 A' P"ete"m labo" is best des%"ibed as labo" that begins afte" 20 weesK gestation and befo"e +8 weesK

gestation !he othe" time pe"iods a"e ina%%$"ate

.1 )' PO< %an p"e%ipitate many potential and a%t$al p"oblemsW one of the most se"io$s is the fet$s loss of

an effe%ti/e defense against infe%tion !his is the %lientKs most immediate need at this time !ypi%ally&

PO< o%%$"s abo$t 1 ho$"& not . ho$"s& befo"e labo" begins Fetal /iability and gestational age a"e less

immediate %onside"ations that affe%t the plan of %a"e <alp"esentation and an in%ompetent %e"/i- may be

%a$ses of PO<

.2 )' )ysto%ia is diffi%$lt& painf$l& p"olonged labo" d$e to me%hani%al fa%to"s in/ol/ing the fet$s

passenge"& $te"$s powe"s& pel/is passage& o" psy%he *$t"itional& en/i"onment& and medi%al fa%to"s

may %ont"ib$te to the me%hani%al fa%to"s that %a$se dysto%ia




.+ A' Hith $te"ine "$pt$"e& the %lient is at "is fo" hypo/olemi% sho% !he"efo"e& the p"io"ity is to p"e/ent

and limit hypo/olemi% sho% Immediate steps sho$ld in%l$de gi/ing o-ygen& "epla%ing lost fl$ids&

p"o/iding d"$g the"apy as needed& e/al$ating fetal "esponses and p"epa"ing fo" s$"ge"y Obtaining blood

spe%imens& instit$ting %omplete bed "est& and inse"ting a $"ina"y %athete" a"e ne%essa"y in p"epa"ation fo"

s$"ge"y to "emedy the "$pt$"e

.. )' !he immediate p"io"ity is to minimi(e p"ess$"e on the %o"d !h$s the n$"seKs initial a%tion in/ol/es

pla%ing the %lient on bed "est and then pla%ing the %lient in a nee=%hest position o" lowe"ing the head of

the bed& and ele/ating the mate"nal hips on a pillow to minimi(e the p"ess$"e on the %o"d <onito"ingmate"nal /ital signs and F?& notifying the physi%ian and p"epa"ing the %lient fo" deli/e"y& and w"apping

the %o"d with ste"ile saline soaed wa"m ga$(e a"e impo"tant @$t these a%tions ha/e no effe%t on

minimi(ing the p"ess$"e on the %o"d

. D' Postpa"t$m hemo""hage is defined as blood loss of mo"e than 00 ml following bi"th #ny amo$nt less

than this not %onside"ed postpa"t$m hemo""hage

.5 D' Hith mastitis& inE$"y to the b"east& s$%h as o/e"distention& stasis& and %"a%ing of the nipples& is the

p"ima"y p"edisposing fa%to" ,pidemi% and endemi% infe%tions a"e p"obable so$"%es of infe%tion fo"

mastitis !empo"a"y $"ina"y "etention d$e to de%"eased pe"%eption of the $"ge to /oid is a %ont"ib$to"y

fa%to" to the de/elopment of $"ina"y t"a%t infe%tion& not mastitis

.8 D' !h"ombophlebitis "efe"s to an inflammation of the /as%$la" endotheli$m with %lot fo"mation on the

wall of the /essel @lood %omponents %ombining to fo"m an agg"egate body des%"ibe a th"omb$s o"

th"ombosis Clots lodging in the p$lmona"y /as%$lat$"e "efe"s to p$lmona"y embolismW in the femo"al/ein& femo"al th"ombophlebitis

. C' Classi% symptoms of )7! in%l$de m$s%le pain& the p"esen%e of ?omans sign& and swelling of the

affe%ted limb <id%alf pain& tende"ness& and "edness& along the /ein "efle%t s$pe"fi%ial th"ombophlebitis

Chills& fe/e" and malaise o%%$""ing 2 wees afte" deli/e"y "efle%t pel/i% th"ombophlebitis Chills& fe/e"&

stiffness and pain o%%$""ing 10 to 1. days afte" deli/e"y s$ggest femo"al th"ombophlebitis

.9 )' <anifestations of %ystitis in%l$de& f"e6$en%y& $"gen%y& dys$"ia& hemat$"ia no%t$"ia& fe/e"& and

s$p"ap$bi% pain )ehyd"ation& hype"tension& and %hills a"e not typi%ally asso%iated with %ystitis ?igh

fe/e" %hills& flan pain& na$sea& /omiting& dys$"ia& and f"e6$en%y a"e asso%iated with p/eloneph"itis

0 C' #%%o"ding to statisti%al "epo"ts& between 0V and 0V of all new mothe"s "epo"t some fo"m of

postpa"t$m bl$es !he "anges of 10V to .0V& +0V to 0V& and 2V to 80V a"e in%o""e%t

1 ) eg$la" timely ingestion of o"al %ont"a%epti/es is ne%essa"y to maintain ho"monal le/els of the d"$gs to

s$pp"ess the a%tion of the hypothalam$s and ante"io" pit$ita"y leading to inapp"op"iate se%"etion of FS?

and '? !he"efo"e& folli%les do not mat$"e& o/$lation is inhibited& and p"egnan%y is p"e/ented !he

est"ogen %ontent of the o"al site %ont"a%epti/e may %a$se the na$sea& "ega"dless of when the pill is taenSide effe%ts and d"$g inte"a%tions may o%%$" with o"al %ont"a%epti/es "ega"dless of the time the pill is

taen

2 C Condoms& when $sed %o""e%tly and %onsistently& a"e the most effe%ti/e %ont"a%epti/e method o" ba""ie"

against ba%te"ial and /i"al se-$ally t"ansmitted infe%tions #ltho$gh spe"mi%ides ill spe"m& they do not

p"o/ide "eliable p"ote%tion against the sp"ead of se-$ally t"ansmitted infe%tions& espe%ially int"a%ell$la"

o"ganisms s$%h as ?I7 Inse"tion and "emo/al of the diaph"agm along with the $se of the spe"mi%ides

may %a$se /aginal i""itations& whi%h %o$ld pla%e the %lient at "is fo" infe%tion t"ansmission <aleste"ili(ation eliminates spe"mato(oa f"om the eEa%$late& b$t it does not eliminate ba%te"ial andGo" /i"al

mi%"oo"ganisms that %an %a$se se-$ally t"ansmitted infe%tions

+ A !he diaph"agm m$st be fitted indi/id$ally to ens$"e effe%ti/eness @e%a$se of the %hanges to the

"ep"od$%ti/e st"$%t$"es d$"ing p"egnan%y and following deli/e"y& the diaph"agm m$st be "efitted& $s$ally

at the 5 weesK e-amination following %hildbi"th o" afte" a weight loss of 1 lbs o" mo"e In addition& fo"

ma-im$m effe%ti/eness& spe"mi%idal Eelly sho$ld be pla%ed in the dome and a"o$nd the "im ?owe/e"&

spe"mi%idal Eelly sho$ld not be inse"ted into the /agina $ntil in/ol$tion is %ompleted at app"o-imately 5

wees Use of a female %ondom p"ote%ts the "ep"od$%ti/e system f"om the int"od$%tion of semen o"

spe"mi%ides into the /agina and may be $sed afte" %hildbi"th O"al %ont"a%epti/es may be sta"ted within

the fi"st postpa"t$m wee to ens$"e s$pp"ession of o/$lation Fo" the %o$ple who has dete"mined the

femaleKs fe"tile pe"iod& $sing the "hythm method& a/oidan%e of inte"%o$"se d$"ing this pe"iod& is safe andeffe%ti/e

. C #n IU) may in%"ease the "is of pel/i% inflammato"y disease& espe%ially in women with mo"e than one

se-$al pa"tne"& be%a$se of the in%"eased "is of se-$ally t"ansmitted infe%tions #n UI) sho$ld not be

$sed if the woman has an a%ti/e o" %h"oni% pel/i% infe%tion& postpa"t$m infe%tion& endomet"ial

hype"plasia o" %a"%inoma& o" $te"ine abno"malities #ge is not a fa%to" in dete"mining the "iss asso%iated

with IU) $se <ost IU) $se"s a"e o/e" the age of +0 #ltho$gh the"e is a slightly highe" "is fo"

infe"tility in women who ha/e ne/e" been p"egnant& the IU) is an a%%eptable option as long as the "is= benefit "atio is dis%$ssed IU)s may be inse"ted immediately afte" deli/e"y& b$t this is not "e%ommended

be%a$se of the in%"eased "is and "ate of e-p$lsion at this time

C )$"ing the thi"d t"imeste"& the enla"ging $te"$s pla%es p"ess$"e on the intestines !his %o$pled with the

effe%t of ho"mones on smooth m$s%le "ela-ation %a$ses de%"eased intestinal motility pe"istalsis

In%"easing fibe" in the diet will help fe%al matte" pass mo"e 6$i%ly th"o$gh the intestinal t"a%t& th$s






fo" feeding *a"%oti%s administe"ed p"io" to b"east feeding a"e passed th"o$gh the b"east mil to the

infant& %a$sing e-%essi/e sleepiness *ipple so"eness is not se/e"e eno$gh to wa""ant na"%oti% analgesia

#ll postpa"t$m %lients& espe%ially la%tating mothe"s& sho$ld wea" a s$ppo"ti/e b"assie"e with wide %otton

st"aps !his does not& howe/e"& p"e/ent o" "ed$%e nipple so"eness Soaps a"e d"ying to the sin of the

nipples and sho$ld not be $sed on the b"easts of la%tating mothe"s )"y nipple sin p"edisposes to %"a%s

and fiss$"es& whi%h %an be%ome so"e and painf$l

55 D' # wea& th"eady p$lse ele/ated to 100 @P< may indi%ate impending hemo""hagi% sho% #n in%"eased

p$lse is a %ompensato"y me%hanism of the body in "esponse to de%"eased fl$id /ol$me !h$s& the n$"sesho$ld %he% the amo$nt of lo%hia p"esent !empe"at$"es $p to 100.F in the fi"st 2. ho$"s afte" bi"th a"e

"elated to the dehyd"ating effe%ts of labo" and a"e %onside"ed no"mal #ltho$gh "e%he%ing the blood

p"ess$"e may be a %o""e%t %hoi%e of a%tion& it is not the fi"st a%tion that sho$ld be implemented in light of

the othe" data !he data indi%ate a potential impending hemo""hage #ssessing the $te"$s fo" fi"mness and

position in "elation to the $mbili%$s and midline is impo"tant& b$t the n$"se sho$ld %he% the e-tent of

/aginal bleeding fi"st !hen it wo$ld be app"op"iate to %he% the $te"$s& whi%h may be a possible %a$se of

the hemo""hage

58 D' #ny b"ight "ed /aginal dis%ha"ge wo$ld be %onside"ed abno"mal& b$t espe%ially days afte" deli/e"y&

when the lo%hia is typi%ally pin to b"ownish 'o%hia "$b"a& a da" "ed dis%ha"ge& is p"esent fo" 2 to +days afte" deli/e"y @"ight "ed /aginal bleeding at this time s$ggests late postpa"t$m hemo""hage& whi%h

o%%$"s afte" the fi"st 2. ho$"s following deli/e"y and is gene"ally %a$sed by "etained pla%ental f"agments

o" bleeding diso"de"s 'o%hia "$b"a is the no"mal da" "ed dis%ha"ge o%%$""ing in the fi"st 2 to + days afte"deli/e"y& %ontaining epithelial %ells& e"yth"o%yes& le$o%ytes and de%id$a 'o%hia se"osa is a pin to

b"ownish se"osang$ineo$s dis%ha"ge o%%$""ing f"om + to 10 days afte" deli/e"y that %ontains de%id$a&

e"yth"o%ytes& le$o%ytes& %e"/i%al m$%$s& and mi%"oo"ganisms 'o%hia alba is an almost %olo"less to

yellowish dis%ha"ge o%%$""ing f"om 10 days to + wees afte" deli/e"y and %ontaining le$o%ytes& de%id$a&

epithelial %ells& fat& %e"/i%al m$%$s& %holeste"ol %"ystals& and ba%te"ia

5 A' !he data s$ggests an infe%tion of the endomet"ial lining of the $te"$s !he lo%hia may be de%"eased o"

%opio$s& da" b"own in appea"an%e& and fo$l smelling& p"o/iding f$"the" e/iden%e of a possible infe%tion

#ll the %lientKs data indi%ate a $te"ine p"oblem& not a b"east p"oblem !ypi%ally& t"ansient fe/e"& $s$ally

101]F& may be p"esent with b"east engo"gement Symptoms of mastitis in%l$de infl$en(a=lie

manifestations 'o%ali(ed infe%tion of an episiotomy o" C=se%tion in%ision "a"ely %a$ses systemi%

symptoms& and $te"ine in/ol$tion wo$ld not be affe%ted !he %lient data do not in%l$de dys$"ia&

f"e6$en%y& o" $"gen%y& symptoms of $"ina"y t"a%t infe%tions& whi%h wo$ld ne%essitate assessing the%lientKs $"ine

59 C' @e%a$se of ea"ly postpa"t$m dis%ha"ge and limited time fo" tea%hing& the n$"seKs p"io"ity is to fa%ilitate

the safe and effe%ti/e %a"e of the %lient and newbo"n #ltho$gh p"omoting %omfo"t and "esto"ation of

health& e-plo"ing the familyKs emotional stat$s& and tea%hing abo$t family planning a"e impo"tant in

postpa"t$mGnewbo"n n$"sing %a"e& they a"e not the p"io"ity fo%$s in the limited time p"esented by ea"ly

post=pa"t$m dis%ha"ge

80 C' ?eat loss by "adiation o%%$"s when the infantKs %"ib is pla%ed too nea" %old walls o" windows !h$s

pla%ing the newbo"nKs %"ib %lose to the /iewing window wo$ld be least effe%ti/e @ody heat is lost

th"o$gh e/apo"ation d$"ing bathing Pla%ing the infant $nde" the "adiant wa"me" afte" bathing will assist

the infant to be "ewa"med Co/e"ing the s%ale with a wa"med blanet p"io" to weighing p"e/ents heat loss

th"o$gh %ond$%tion # nit %ap p"e/ents heat loss f"om the head a la"ge head& a la"ge body s$"fa%e a"ea of

the newbo"nKs body81 )' # f"a%t$"ed %la/i%le wo$ld p"e/ent the no"mal <o"o "esponse of symmet"i%al se6$ential e-tension and

abd$%tion of the a"ms followed by fle-ion and add$%tion In talipes e6$ino/a"$s %l$bfoot the foot is

t$"ned medially& and in planta" fle-ion& with the heel ele/ated !he feet a"e not in/ol/ed with the <o"o

"efle- ?ypothy"oiddism has no effe%t on the p"imiti/e "efle-es #bsen%e of the <o"o" "efle- is the most

signifi%ant single indi%ato" of %ent"al ne"/o$s system stat$s& b$t it is not a sign of in%"eased int"a%"anial

p"ess$"e

82 )' ?emo""hage is a potential "is following any s$"gi%al p"o%ed$"e #ltho$gh the infant has been gi/en

/itamin to fa%ilitate %lotting& the p"ophyla%ti% dose is often not s$ffi%ient to p"e/ent bleeding #ltho$ghinfe%tion is a possibility& signs will not appea" within . ho$"s afte" the s$"gi%al p"o%ed$"e !he p"ima"y

dis%omfo"t of %i"%$m%ision o%%$"s d$"ing the s$"gi%al p"o%ed$"e& not afte"wa"d #ltho$gh feedings a"e

withheld p"io" to the %i"%$m%ision& the %han%es of dehyd"ation a"e minimal

8+ )' !he p"esen%e of e-%essi/e est"ogen and p"ogeste"one in the mate"nal=fetal blood followed by p"omptwithd"awal at bi"th p"e%ipitates b"east engo"gement& whi%h will spontaneo$sly "esol/e in . to days afte"

bi"th !he t"a$ma of the bi"th p"o%ess does not %a$se inflammation of the newbo"nKs b"east tiss$e

*ewbo"ns do not ha/e b"east malignan%y !his "eply by the n$"se wo$ld %a$se the mothe" to ha/e $nd$e

an-iety @"east tiss$e does not hype"t"ophy in the fet$s o" newbo"ns

8. D' !he fi"st 1 min$tes to 1 ho$" afte" bi"th is the fi"st pe"iod of "ea%ti/ity in/ol/ing "espi"ato"y and

%i"%$lato"y adaptation to e-t"a$te"ine life !he data gi/en "efle%t the no"mal %hanges d$"ing this time

pe"iod !he infantKs assessment data "efle%t no"mal adaptation !h$s& the physi%ian does not need to be




notified and o-ygen is not needed !he data do not indi%ate the p"esen%e of %hoing& gagging o" %o$ghing&

whi%h a"e signs of e-%essi/e se%"etions S$%tioning is not ne%essa"y

8 )' #ppli%ation of 80V isop"opyl al%ohol to the %o"d minimi(es mi%"oo"ganisms ge"mi%idal and

p"omotes d"ying !he %o"d sho$ld be ept d"y $ntil it falls off and the st$mp has healed #ntibioti%

ointment sho$ld only be $sed to t"eat an infe%tion& not as a p"ophyla-is Infants sho$ld not be s$bme"ged

in a t$b of wate" $ntil the %o"d falls off and the st$mp has %ompletely healed

85 )' !o dete"mine the amo$nt of fo"m$la needed& do the following mathemati%al %al%$lation + g - 120

%alGg pe" day +50 %alo"iesGday feeding 6 . ho$"s 5 feedings pe" day 50 %alo"ies pe" feeding: 50%alo"ies pe" feedingW 50 %alo"ies pe" feeding with fo"m$la 20 %alGo( + o$n%es pe" feeding @ased on the

%al%$lation 2& . o" 5 o$n%es a"e in%o""e%t

88 A' Int"a$te"ine ano-ia may %a$se "ela-ation of the anal sphin%te" and emptying of me%oni$m into the

amnioti% fl$id #t bi"th some of the me%oni$m fl$id may be aspi"ated& %a$sing me%hani%al obst"$%tion o"

%hemi%al pne$monitis !he infant is not at in%"eased "is fo" gast"ointestinal p"oblems ,/en tho$gh the

sin is stained with me%oni$m& it is noninfe%tio$s ste"ile and noni""itating !he postte"m me%oni$m=

stained infant is not at additional "is fo" bowel o" $"ina"y p"oblems

8 C' !he n$"se sho$ld $se a nonelasti%& fle-ible& pape" meas$"ing tape& pla%ing the (e"o point on the

s$pe"io" bo"de" of the symphysis p$bis and st"et%hing the tape a%"oss the abdomen at the midline to the

top of the f$nd$s !he -iphoid and $mbili%$s a"e not app"op"iate landma"s to $se when meas$"ing the

height of the f$nd$s <%)onaldKs meas$"ement

89 )' Homen hospitali(ed with se/e"e p"ee%lampsia need de%"eased C*S stim$lation to p"e/ent a sei($"eSei($"e p"e%a$tions p"o/ide en/i"onmental safety sho$ld a sei($"e o%%$" @e%a$se of edema& daily weight

is impo"tant b$t not the p"io"ity P"e%lampsia %a$ses /asospasm and the"efo"e %an "ed$%e $te"o=pla%ental

pe"f$sion !he %lient sho$ld be pla%ed on he" left side to ma-imi(e blood flow& "ed$%e blood p"ess$"e&

and p"omote di$"esis Inte"/entions to "ed$%e st"ess and an-iety a"e /e"y impo"tant to fa%ilitate %oping

and a sense of %ont"ol& b$t sei($"e p"e%a$tions a"e the p"io"ity

0 C' Cessation of the lo%hial dis%ha"ge signifies healing of the endomet"i$m is of hemo""hage and

infe%tion a"e minimal + wees afte" a no"mal /aginal deli/e"y !elling the %lient anytime is inapp"op"iate be%a$se this "esponse does not p"o/ide the %lient with the spe%ifi% info"mation she is "e6$esting Choi%e

of a %ont"a%epti/e method is impo"tant& b$t not the spe%ifi% %"ite"ia fo" safe "es$mption of se-$al a%ti/ity

C$lt$"ally& the 5=weesK e-amination has been $sed as the time f"ame fo" "es$ming se-$al a%ti/ity& b$t it

may be "es$med ea"lie"

1 C !he middle thi"d of the /ast$s late"alis is the p"efe""ed inEe%tion site fo" /itamin administ"ation be%a$se it is f"ee of blood /essels and ne"/es and is la"ge eno$gh to abso"b the medi%ation !he deltoid

m$s%le of a newbo"n is not la"ge eno$gh fo" a newbo"n I< inEe%tion InEe%tions into this m$s%le in a small

%hild might %a$se damage to the "adial ne"/e !he ante"io" femo"is m$s%le is the ne-t safest m$s%le to $se

in a newbo"n b$t is not the safest @e%a$se of the p"o-imity of the s%iati% ne"/e& the gl$te$s ma-im$s

m$s%le sho$ld not be $ntil the %hild has been waling 2 yea"s

2 D @a"tholinKs glands a"e the glands on eithe" side of the /aginal o"ifi%e !he %lito"is is female e"e%tile

tiss$e fo$nd in the pe"ineal a"ea abo/e the $"eth"a !he pa"otid glands a"e open into the mo$th SeneKs

glands open into the poste"io" wall of the female $"ina"y meat$s

+ D !he fetal gonad m$st se%"ete est"ogen fo" the emb"yo to diffe"entiate as a female #n in%"ease in

mate"nal est"ogen se%"etion does not effe%t diffe"entiation of the emb"yo& and mate"nal est"ogen se%"etion

o%%$"s in e/e"y p"egnan%y <ate"nal and"ogen se%"etion "emains the same as befo"e p"egnan%y and does

not effe%t diffe"entiation Se%"etion of and"ogen by the fetal gonad wo$ld p"od$%e a male fet$s

. A Using bi%a"bonate wo$ld in%"ease the amo$nt of sodi$m ingested& whi%h %an %a$se %ompli%ations

,ating low=sodi$m %"a%e"s wo$ld be app"op"iate Sin%e li6$ids %an in%"ease na$sea a/oiding them in the

mo"ning ho$"s when na$sea is $s$ally the st"ongest is app"op"iate ,ating si- small meals a day wo$ld

eep the stoma%h f$ll& whi%h often de%"ease na$sea

) @allottement indi%ates passi/e mo/ement of the $nengaged fet$s @allottement is not a %ont"a%tion

Fetal i%ing felt by the %lient "ep"esents 6$i%ening ,nla"gement and softening of the $te"$s is nown as

Pisa%eKs sign

5 ) Chadwi%Ks sign "efe"s to the p$"ple=bl$e tinge of the %e"/i- @"a-ton ?i%s %ont"a%tions a"e painless

%ont"a%tions beginning a"o$nd the .th month DoodellKs sign indi%ates softening of the %e"/i- Fle-ibility

of the $te"$s against the %e"/i- is nown as <%)onaldKs sign

8 C @"eathing te%hni6$es %an "aise the pain th"eshold and "ed$%e the pe"%eption of pain !hey also p"omote"ela-ation @"eathing te%hni6$es do not eliminate pain& b$t they %an "ed$%e it Positioning& not b"eathing&

in%"eases $te"opla%ental pe"f$sion

A !he %lientKs labo" is hypotoni% !he n$"se sho$ld %all the physi%al and obtain an o"de" fo" an inf$sion

of o-yto%in& whi%h will assist the $te"$s to %onta%t mo"e fo"%ef$lly in an attempt to dilate the %e"/i-#dministe"ing light sedati/e wo$ld be done fo" hype"toni% $te"ine %ont"a%tions P"epa"ing fo" %esa"ean

se%tion is $nne%essa"y at this time O-yto%in wo$ld in%"ease the $te"ine %ont"a%tions and hopef$lly

p"og"ess labo" befo"e a %esa"ean wo$ld be ne%essa"y It is too ea"ly to anti%ipate %lient p$shing with

%ont"a%tions






9 D !he signs indi%ate pla%enta p"e/ia and /aginal e-am to dete"mine %e"/i%al dilation wo$ld not be done

be%a$se it %o$ld %a$se hemo""hage #ssessing mate"nal /ital signs %an help dete"mine mate"nal

physiologi% stat$s Fetal hea"t "ate is impo"tant to assess fetal well=being and sho$ld be done <onito"ing

the %ont"a%tions will help e/al$ate the p"og"ess of labo"

90 D # %omplete pla%enta p"e/ia o%%$"s when the pla%enta %o/e"s the opening of the $te"$s& th$s blo%ing

the passageway fo" the baby !his "esponse e-plains what a %omplete p"e/ia is and the "eason the baby

%annot %ome o$t e-%ept by %esa"ean deli/e"y !elling the %lient to as the physi%ian is a poo" "esponse

and wo$ld in%"ease the patientKs an-iety #ltho$gh a %esa"ean wo$ld help to p"e/ent hemo""hage& thestatement does not e-plain why the hemo""hage %o$ld o%%$" Hith a %omplete p"e/ia& the pla%enta is

%o/e"ing all the %e"/i-& not E$st most of it

91 ) Hith a fa%e p"esentation& the head is %ompletely e-tended Hith a /e"te- p"esentation& the head is

%ompletely o" pa"tially fle-ed Hith a b"ow fo"ehead p"esentation& the head wo$ld be pa"tially e-tended

92 D Hith this p"esentation& the fetal $ppe" to"so and ba% fa%e the left $ppe" mate"nal abdominal wall !he

fetal hea"t "ate wo$ld be most a$dible abo/e the mate"nal $mbili%$s and to the left of the middle !he

othe" positions wo$ld be in%o""e%t

9+ C' !he g"eenish tint is d$e to the p"esen%e of me%oni$m 'an$go is the soft& downy hai" on the sho$lde"s

and ba% of the fet$s ?yd"amnios "ep"esents e-%essi/e amnioti% fl$id 7e"ni- is the white& %heesy

s$bstan%e %o/e"ing the fet$s

9. D' In a b"ee%h position& be%a$se of the spa%e between the p"esenting pa"t and the %e"/i-& p"olapse of the

$mbili%al %o"d is %ommon >$i%ening is the womanKs fi"st pe"%eption of fetal mo/ement Ophthalmianeonato"$m $s$ally "es$lts f"om mate"nal gono""hea and is %onE$n%ti/itis Pi%a "efe"s to the o"al intae of

nonfood s$bstan%es

9 A' )i(ygoti% f"ate"nal twins in/ol/e two o/a fe"tili(ed by sepa"ate spe"m <ono(ygoti% identi%al twins

in/ol/e a %ommon pla%enta& same genotype& and %ommon %ho"ion

95 C' !he (ygote is the single %ell that "ep"od$%es itself afte" %on%eption !he %h"omosome is the mate"ial

that maes $p the %ell and is gained f"om ea%h pa"ent @lasto%yst and t"ophoblast a"e late" te"ms fo" the

emb"yo afte" (ygote

98 D' P"epa"ed %hildbi"th was the di"e%t "es$lt of the 190Ks %hallenging of the "o$tine $se of analgesi% and

anestheti%s d$"ing %hildbi"th !he ')P was a m$%h late" %on%ept and was not a di"e%t "es$lt of the

%hallenging of "o$tine $se of analgesi%s and anestheti%s d$"ing %hildbi"th oles fo" n$"se midwi/es and

%lini%al n$"se spe%ialists did not de/elop f"om this %hallenge

9 C' !he is%hial spines a"e lo%ated in the mid=pel/i% "egion and %o$ld be na""owed d$e to the p"e/io$s

pel/i% inE$"y !he symphysis p$bis& sa%"al p"omonto"y& and p$bi% a"%h a"e not pa"t of the mid=pel/is

99 )' 7a"iations in the length of the menst"$al %y%le a"e d$e to /a"iations in the p"olife"ati/e phase !he

menst"$al& se%"eto"y and is%hemi% phases do not %ont"ib$te to this /a"iation

100 ) !estoste"one is p"od$%ed by the 'eyding %ells in the seminife"o$s t$b$les Folli%le=stim$lating

ho"mone and le$tein(ing ho"mone a"e "eleased by the ante"io" pit$ita"y gland !he hypothalam$s is

"esponsible fo" "eleasing gonadot"opin="eleasing ho"mone




MATERNIT( NURSING Part 2

1 S$ppose <elissa Ch$ng ass yo$ whethe" mate"nal %hild health n$"sing is a p"ofession Hhat 6$alifies an

a%ti/ity as a p"ofessionQ

a <embe"s s$pe"/ise othe" people

b <embe"s $se a distin%t body of nowledge

% <embe"s enEoy good wo"ing %onditionsd <embe"s "e%ei/e "elati/ely high pay

2 *$"sing is %hanging be%a$se so%ial %hange affe%ts %a"e Hhi%h of the following is a t"end that is o%%$""ingin n$"sing be%a$se of so%ial %hangeQ

a So many %hild"en a"e t"eated in amb$lato"y $nits that n$"ses a"e ha"dly needed

b Imm$ni(ations a"e no longe" needed fo" infe%tio$s diseases

% !he $se of silled te%hnology has made n$"sing %a"e mo"e %omple-

d P"egnant women a"e so healthy today that they "a"ely need p"enatal %a"e

+ !he best des%"iption if the family n$"se p"a%titione" "ole is

a !o gi/e bedside %a"e to %"iti%ally ill family membe"s

b !o s$pe"/ise the health of %hild"en $p to age 1 yea"s

% !o p"o/ide health s$pe"/ision fo" families

d !o s$pe"/ise women d$"ing p"egnan%y

. !he )elos eyes family was a single=pa"ent one befo"e <"s )elos eyes "ema""ied Hhat is a %ommon

%on%e"n of single=pa"ent familiesQ

a !oo many people gi/e ad/i%e

b Finan%es a"e inade6$ate

% Child"en miss many days of s%hool

d Child"en donKt now any othe" family lie thei"s

<"s )elos eyes se"/es many "oles in he" family If& when yo$ tal to 7e"oni%a& he" da$ghte"& she

inte""$pts to say& )onKt tell o$" family se%"ets&T she is f$lfilling what family "oleQ

a )e%ision=mae"

b Dateeepe"

% P"oblem=sol/e"

d @"ead=ea"ne"

5 !he )elos eyes family %onsists of two pa"entsW 7e"oni%a& 12W and Paolo& 2 <"s )elos eyes is

months p"egnant Hhi%h of )$/allKs family life stages is the family %$""ently e-pe"ien%ingQ

a P"egnan%y stage

b P"es%hool stage




% S%hool=age stage

d 'a$n%hing stage

8 Hhile she is in the hospital& Ca"mela maes the following statements Hhi%h is the best e-ample of

ste"eotypingQ

a <y do%to" is f$nnyW he tells Eoes and maes me la$gh

b IKm glad IKm @atang$eò be%a$se all @atang$eòs a"e sma"t

% IKm s$"e my leg will heal 6$i%lyW IKm o/e"all healthyd I lie foods in @atangas& altho$gh not if it tastes too spi%y

<onet i/e"a tells yo$ she $sed to w""y be%a$se she de/eloped b"easts late" than most of he" f"iends

@"east de/elopment is te"med:

a #d"ena"%he

b <ama"%he

% !hela"%he

d <ena"%he

9 S$ppose Baypee <analo tells yo$ that he is %onside"ing a /ase%tomy afte" the bi"th of his new %hild

7ase%tomy is the in%ision of whi%h o"ganQ

a !estes b 7as defe"ens

% Fallopian t$be

d ,pididymis

10 On physi%al e-amination& <onet i/e"a is fo$nd to ha/e %ysto%ele # %ysto%ele is:

a # seba%eo$s %yst a"ising f"om a /$l/a" fold

b P"ot"$sion of the intestine into the /agina

% P"olapse of the $te"$s and %e"/i- into the /agina

d ?e"niation of the bladde" into the /aginal wall

11 <onet i/e"a typi%ally has a menst"$al %y%le of +. days She tells yo$ she had %oit$s on days & 10& 1&

and 20 of he" last %y%le Hhi%h is the day on whi%h she most liely %on%ei/edQa# !he th day

%# !he 10th day

% )ay 1

d )ay 20

12 !he <analoKs neighbo" Cah"ell is a woman who has se- with women #nothe" te"m fo" this se-$al

o"ientation is

a 'esbian

b Celibate

% Day

d 7oye$"

1+ S$ppose oseann& 18 yea"s old& tells yo$ that she wants to $se fe"tility awa"eness method of

%ont"a%eption ?ow will she dete"mine he" fe"tile daysQ

a She will noti%e that she feels hot& as if she has an ele/ated tempe"at$"e

b She sho$ld assess whethe" he" %e"/i%al m$%$s is thin and wate"y

% She sho$ld monito" he" emotions fo" s$dden ange" o" %"yingd She sho$ld assess whethe" he" b"easts feels sensiti/e to %ool ai"

1. S$ppose oseann& 18 yea"s old& %hooses to $se a %ombination o"al %ont"a%epti/e COC as he" family

planning method Hhat is a dange" sign of COCs yo$ wo$ld as he" to "epo"tQ

a # st$ffy o" "$nny nose

b #"th"itis=lie symptoms

% Slight weight gain

d <ig"aine heada%he

1 S$ppose oseann& 18 yea"s old& %hooses s$b%$taneo$s implants *o"plant as he" method of "ep"od$%ti/e

life planning ?ow long will these implants be effe%ti/eQ

a One month

b 12 months

% Fi/e yea"s

d 10 yea"s




15 oseann& 18 yea"s old& wants to t"y female %ondoms as he" "ep"od$%ti/e life planning method Hhi%h

inst"$%tion wo$ld yo$ gi/e he"Q

a !he ho"mone the %ondom "eleases may %a$se mild weight gain

b She sho$ld inse"t the %ondom befo"e any penile penet"ation

% She sho$ld %oat the %ondom with a spe"mi%ide befo"e $se

d Female %ondoms& $nlie male %ondoms& %an be "e$sed

18 oseann& 18 yea"s old& ass yo$ how a t$bal ligation p"e/ents p"egnan%y Hhi%h wo$ld be the bestanswe"Q

a Spe"m %an no longe" "ea%h the o/a be%a$se fallopian t$bes a"e blo%ed

b Spe"m %an not ente" the $te"$s be%a$se the %e"/i%al ent"an%e is blo%ed

% P"ostaglandins "eleased f"om the %$t fallopian t$bes %an ill spe"m

d !he o/a"y no longe" "eleases o/a as the"e is no whe"e fo" them to go

1 !he #tien(as a"e a %o$ple $nde"going testing fo" infe"tility Infe"tility is said to e-ist when:

a # %o$ple has been t"ying to %on%ei/e fo" 1 yea"

b # woman has no %hild"en% # woman has no $te"$s

d # %o$ple has wanted a %hild fo" 5 months

19 D$adal$pe #tien(a is diagnosed as ha/ing endomet"iosis !his %ondition inte"fe"es with fe"tility be%a$se:

a !he o/a"ies stop p"od$%ing ade6$ate est"ogen

b !he $te"ine %e"/i- be%omes inflamed and swollen

% P"ess$"e on the pit$ita"y leads to de%"eased FS? le/els

d ,ndomet"ial implants %an blo% the fallopian t$bes

20 D$adal$pe #tien(a is s%hed$led to ha/e a hyste"osalpingog"am Hhi%h of the following inst"$%tions

wo$ld yo$ gi/e he" "ega"ding this p"o%ed$"eQ

a She may feel some mild %"amping when the dye is inse"ted

b !he sonog"am of the $te"$s will "e/eal any t$mo"s p"esent

% She will not be able to %on%ei/e fo" th"ee months afte" the p"o%ed$"e

d <ay women e-pe"ien%e mild bleeding as an afte"effe%t

21 $el <a"asigan ass yo$ what a"tifi%ial insemination by dono" entails Hhi%h wo$ld be yo$" best

answe"Qa #"tifi%ial spe"m a"e inEe%ted /aginally to test t$bal paten%y

b )ono" spe"m a"e int"od$%ed /aginally into the $te"$s of the %e"/i-

% !he h$sbandKs spe"m is administe"ed int"a/eno$sly weely

d )ono" spe"m a"e inEe%ted int"aabdominally into ea%h o/a"y

22 D$adal$pe #tien(a is ha/ing a gamete int"afallopian t"ansfe" DIF! p"o%ed$"e Hhat maes he" a good

%andidate fo" this p"o%ed$"eQ

a She has patent fallopian t$bes& so fe"tili(ed o/a %an be implanted into them

b She is h negati/e& a ne%essa"y stip$lation to "$le o$t h in%ompatibility

% She has a no"mal $te"$s& so spe"m %an be inEe%ted th"o$gh the %e"/i- into it

d ?e" h$sband is taing sildenafil 7iag"a& so all his pe"m will be motile

2+ Bean S$a"e( is p"egnant with he" fi"st %hild ?e" phenotype "efe"s to:

a ?e" %on%ept of he"self as male o" female

b Hhethe" she has .5 %h"omosomes o" not

% ?e" a%t$al geneti% %omposition

d ?e" o$twa"d appea"an%e

2. Bean S$a"e( is a balan%ed t"anslo%ation %a""ie" fo" )own synd"ome !his te"m means that:

a #ll of he" %hild"en will be bo"n with some aspe%ts of )own synd"ome

b #ll of he" female and none of he" male %hild"en will ha/e )own synd"ome

% She has a g"eate" than a/e"age %han%e a %hild will ha/e )own synd"ome

d It is impossible fo" any of he" %hild"en to be bo"n with )own synd"ome

2 Bean S$a"e( was told at a geneti% %o$nseling session tat she is a balan%ed t"anslo%ation %a""ie" fo" )own

synd"ome Hhat wo$ld be yo$" best a%tion "ega"ding this info"mationQ

a @e %e"tain all of he" family $nde"stand what this means

b )is%$ss the %ost of /a"io$s abo"tion te%hni6$es with Bean

% @e s$"e Bean nows she sho$ld not ha/e any mo"e %hild"en

d #s Bean is she has any 6$estions that yo$ %o$ld answe" fo" he"






+ @e"nadetteKs do%to" told he" she had a positi/e Chadwi%Ks sign She ass yo$ what this means& and yo$

tell he" that:

a ?e" abdomen is soft and tende"

b ?e" $te"$s has tipped fo"wa"d

% Ce"/i%al m$%$s is %lea" and sti%y

d ?e" /agina has da"ened in %olo"

+5 @e"nadette o/e"hea"d he" do%to" say that ins$lin is not as effe%ti/e d$"ing p"egnan%y as $s$al !hat madehe" wo""y that she is de/eloping diabetes& lie he" a$nt ?ow wo$ld yo$ e-plain how de%"eased ins$lin

effe%ti/eness safeg$a"ds the fet$sQ

a )e%"eased effe%ti/eness p"e/ents the fet$s f"om being hypogly%emi%

b If ins$lin is ineffe%ti/e it %annot %"oss the pla%enta and ha"m the fet$s

% !he lessened a%tion p"e/ents the fet$s f"om gaining too m$%h weight

d !he mothe"& not the fet$s& is g$a"ded by this de%"eased ins$lin a%tion

+8 i(a C$a feels well She ass yo$ why she needs to %ome fo" p"enatal %a"e !he best "eason fo" he" to

"e%ei/e "eg$la" %a"e is:a )is%o/e"ing alle"gies %an help eliminate ea"ly bi"th

b It helps do%$ment how many p"egnan%ies o%%$" ea%h yea"

% It p"o/ides time fo" ed$%ation abo$t p"egnan%y and bi"thd It dete"mines whethe" p"egnan%ies today a"e planned o" not

+ Hhy is it impo"tant to as i(a abo$t past s$"ge"y on a p"egnan%y health histo"yQ

a !o test he" "e%ent and long=te"m memo"y

b #dhesions f"om s$"ge"y %o$ld limit $te"ine g"owth

% !o assess she %o$ld be alle"gi% to any medi%ation

d !o dete"mine if she has effe%ti/e heath ins$"an%e

+9 i(a "epo"ts that the palms of he" hands a"e always it%hy Ao$ noti%e s%"at%hes on them when yo$ do a

physi%al e-am Hhat is the most liely %a$se of this finding d$"ing p"egnan%yQ

a She m$st ha/e be%ome alle"gi% to dishwashing soap

b She has an alle"gy to he" fet$s and will p"obably abo"t% ?e" weight gain has st"et%hed the sin o/e" he" hands

d !his is a %ommon "ea%tion to in%"easing est"ogen le/els

.0 i(a has not had a pel/i% e-am sin%e she was in highs%hool Hhat ad/i%e wo$ld yo$ gi/e he" to help he"

"ela- d$"ing he" fi"st p"enatal pel/i% e-amQ

a ?a/e he" tae a deep b"eath and hold it d$"ing the e-am

b !ell he" to bea" down slightly as the spe%$l$m is inse"ted

% Singing o$t lo$d helps& be%a$se this p$shes down the diaph"agm

d She sho$ld b"eathe slowly and e/enly d$"ing the e-am

.1 i(a has pel/i% meas$"ements taen Hhat si(e sho$ld the is%hial t$be"osity diamete" be to be %onside"ed

ade6$ateQ

a 5 %m

b !wi%e the width of the %onE$gate diamete"

% 11 %m

d ?alf the width of the symphysis p$bis

Sit$ation: One of the n$"sing "oles in %a"ing fo" the p"egnant family is p"omoting fetal and mate"nal health

.2 Hhi%h statement by 7anna )elgado wo$ld ale"t yo$ that she needs mo"e tea%hing abo$t safe p"a%ti%es

d$"ing p"egnan%yQa I tae eithe" a showe" o" t$b bath& be%a$se I now both a"e safeT

b I wash my b"easts with %lea" wate"& not with soap dailyT

% IKm glad I donKt ha/e to as my boyf"iend to $se %ondoms anymo"eT

d IKm wea"ing low=heeled shoes to t"y and a/oid ba%a%heT

.+ 7anna des%"ibes he" typi%al day to yo$ Hhat wo$ld ale"t yo$ that she may need f$"the" p"egnan%y

ad/i%eQ

a I Eog "athe" than wal e/e"y time I %an fo" e-e"%iseT

b I always go to sleep on my side& not on my ba%T

% I pa% my l$n%h in the mo"ning when IKm not so ti"edT

d I wal a"o$nd my des e/e"y ho$" to p"e/ent /a"i%ositiesT






PEDIATRIC NURSING

1 Hhile pe"fo"ming physi%al assessment of a 12 month=old& the n$"se notes that the infantKs ante"io"fontanelle is still slightly open Hhi%h of the following is the n$"seKs most app"op"iate a%tionQ

a *otify the physi%ian immediately be%a$se the"e is a p"oblem

b Pe"fo"m an intensi/e ne$"ologi% e-amination% Pe"fo"m an intensi/e de/elopmental e-amination

d )o nothing be%a$se this is a no"mal finding fo" the age

2 Hhen tea%hing a mothe" abo$t int"od$%ing solid foods to he" %hild& whi%h of the following indi%ates the

ea"liest age at whi%h this sho$ld be doneQ

a 1 month

b 2 months

% + months

d . months

+ !he infant of a s$bstan%e=ab$sing mothe" is at "is fo" de/eloping a sense of whi%h of the followingQ

a <ist"$st

b Shame

% D$ilt

d Infe"io"ity

. Hhi%h of the following toys sho$ld the n$"se "e%ommend fo" a =month=oldQ

a # big "ed balloon

b # teddy bea" with b$tton eyes

% # p$sh=p$ll wooden t"$%

d # %olo"f$l b$sy bo- !he mothe" of a 2=month=old is %on%e"ned that she may be spoiling he" baby by pi%ing he" $p when she

%"ies Hhi%h of the following wo$ld be the n$"seKs best "esponseQ

a 'et he" %"y fo" a while befo"e pi%ing he" $p& so yo$ donKt spoil he"T

b @abies need to be held and %$ddledW yo$ wonKt spoil he" this wayT

% C"ying at this age means the baby is h$ng"yW gi/e he" a bottleT

d If yo$ lea/e he" alone she will lea"n how to %"y he"self to sleepT

5 Hhen assessing an 1=month=old& the n$"se notes a %ha"a%te"isti% p"ot"$ding abdomen Hhi%h of the

following wo$ld e-plain the "ationale fo" this findingQ

a In%"eased food intae owing to age

b Unde"de/eloped abdominal m$s%les

% @owlegged post$"e

d 'inea" g"owth %$"/e






a Shame

b D$ilt

% Infe"io"ity

d ole diff$sion

19 Hhi%h of the following wo$ld be most app"op"iate fo" a n$"se to $se when des%"ibing mena"%he to a 1+=

yea"=oldQ

a # femaleKs fi"st menst"$ation o" menst"$al pe"iodsT

b !he fi"st yea" of menst"$ation o" pe"iodT% !he enti"e menst"$al %y%le o" f"om one pe"iodT to anothe"

d !he onset of $te"ine mat$"ation o" pea g"owth

20 # 1.=yea"=old boy has a%ne and a%%o"ding to his pa"ents& dominates the bath"oom by $sing the mi""o" all

the time Hhi%h of the following "ema"s by the n$"se wo$ld be least helpf$l in taling to the boy and his

pa"entsQ

a !his is p"obably the only %on%e"n he has abo$t his body So donKt wo""y abo$t it o" the time he

spends on itT

b !eenage"s a"e an-io$s abo$t how thei" pee"s pe"%ei/e them So they spend a lot of time

g"oomingT% # teen may de/elop a poo" self=image when e-pe"ien%ing a%ne )o yo$ feel this way

sometimesQT

d Ao$ appea" to be eeping yo$" fa%e well washed Ho$ld yo$ feel %omfo"table dis%$ssing yo$"%leansing methodQT

21 Hhi%h of the following sho$ld the n$"se s$spe%t when noting that a +=yea"=old is engaging in e-pli%it

se-$al beha/io" d$"ing doll playQ

a !he %hild is e-hibiting no"mal p"e=s%hool %$"iosity

b !he %hild is a%ting o$t pe"sonal e-pe"ien%es

% !he %hild does not now how to play with dolls

d !he %hild is p"obably de/elopmentally delayed

22 Hhi%h of the following statements by the pa"ents of a %hild with s%hool phobia wo$ld indi%ate the need

fo" f$"the" tea%hingQ

a HeKll eep him at home $ntil phobia s$bsidesT

b HeKll wo" with his tea%he"s and %o$nselo"s at s%hoolT

% HeKll t"y to en%o$"age him to tal abo$t his p"oblemTd HeKll dis%$ss possible sol$tions with him and his %o$nselo"T

2+ Hhen de/eloping a tea%hing plan fo" a g"o$p of high s%hool st$dents abo$t teenage p"egnan%y& the n$"se

wo$ld eep in mind whi%h of the followingQa !he in%iden%e of teenage p"egnan%ies is in%"easing

b <ost teenage p"egnan%ies a"e planned

% )enial of the p"egnan%y is %ommon ea"ly on

d !he "is fo" %ompli%ations d$"ing p"egnan%y is "a"e

2. Hhen assessing a %hild with a %left palate& the n$"se is awa"e that the %hild is at "is fo" mo"e f"e6$ent

episodes of otitis media d$e to whi%h of the followingQ

a 'owe"ed "esistan%e f"om maln$t"ition

b Ineffe%ti/e f$n%tioning of the ,$sta%hian t$bes

% Pl$gging of the ,$sta%hian t$bes with food pa"ti%les

d #sso%iated %ongenital defe%ts of the middle ea"

2 Hhile pe"fo"ming a ne$"ode/elopmental assessment on a +=month=old infant& whi%h of the following

%ha"a%te"isti%s wo$ld be e-pe%tedQ

a # st"ong <o"o "efle-

b # st"ong pa"a%h$te "efle-

% olling f"om f"ont to ba%

d 'ifting of head and %hest when p"one

25 @y the end of whi%h of the following wo$ld the n$"se most %ommonly e-pe%t a %hildKs bi"th weight to

t"ipleQa . months

b 8 months

% 9 months

d 12 months

28 Hhi%h of the following best des%"ibes pa"allel play between two toddle"sQ

a Sha"ing %"ayons to %olo" sepa"ate pi%t$"es

b Playing a boa"d game with a n$"se

% Sitting nea" ea%h othe" while playing with sepa"ate dolls

d Sha"ing thei" dolls with two diffe"ent n$"ses

2 Hhi%h of the following wo$ld the n$"se identify as the initial p"io"ity fo" a %hild with a%$te lympho%yti%

le$emiaQ

a Instit$ting infe%tion %ont"ol p"e%a$tions




b ,n%o$"aging ade6$ate intae of i"on="i%h foods

% #ssisting with %oping with %h"oni% illness

d #dministe"ing medi%ations /ia I< inEe%tions

29 Hhi%h of the following info"mation& when /oi%ed by the mothe"& wo$ld indi%ate to the n$"se that she

$nde"stands home %a"e inst"$%tions following the administ"ation of a diphthe"ia& tetan$s& and pe"t$ssis

inEe%tionQ

a <eas$"es to "ed$%e fe/e"

b *eed fo" dieta"y "est"i%tions% easons fo" s$bse6$ent "ash

d <eas$"es to %ont"ol s$bse6$ent dia""hea

+0 Hhi%h of the following a%tions by a %omm$nity health n$"se is most app"op"iate when noting m$ltiple

b"$ises and b$"ns on the poste"io" t"$n of an 1=month=old %hild d$"ing a home /isitQ

a epo"t the %hildKs %ondition to P"ote%ti/e Se"/i%es immediately

b S%hed$le a follow=$p /isit to %he% fo" mo"e b"$ises

% *otify the %hildKs physi%ian immediately

d )on nothing be%a$se this is a no"mal finding in a toddle"

+1 Hhi%h of the following is being $sed when the mothe" of a hospitali(ed %hild %alls the st$dent n$"se andstates& Ao$ idiot& yo$ ha/e no idea how to %a"e fo" my si% %hildTQ

a )ispla%ement

b P"oEe%tion% ep"ession

d Psy%hosis

+2 Hhi%h of the following sho$ld the n$"se e-pe%t to note as a f"e6$ent %ompli%ation fo" a %hild with

%ongenital hea"t diseaseQ

a S$s%eptibility to "espi"ato"y infe%tion

b @leeding tenden%ies

% F"e6$ent /omiting and dia""hea

d Sei($"e diso"de"

++ Hhi%h of the following wo$ld the n$"se do fi"st fo" a +=yea"=old boy who a""i/es in the eme"gen%y "oom

with a tempe"at$"e of 10 deg"ees& inspi"ato"y st"ido"& and "estlessness& who is lea"ning fo"wa"d and

d"oolingQ

a #$s%$ltate his l$ngs and pla%e him in a mist tent b ?a/e him lie down and "est afte" en%o$"aging fl$ids

% ,-amine his th"oat and pe"fo"m a th"oat %$lt$"e

d *otify the physi%ian immediately and p"epa"e fo" int$bation+. Hhi%h of the following wo$ld the n$"se need to eep in mind as a p"edisposing fa%to" when fo"m$lating a

tea%hing plan fo" %hild with a $"ina"y t"a%t infe%tionQ

a # sho"te" $"eth"a in females

b F"e6$ent emptying of the bladde"

% In%"eased fl$id intae

d Ingestion of a%idi% E$i%es

+ Hhi%h of the following sho$ld the n$"se do fi"st fo" a 1=yea"=old boy with a f$ll leg %ast who is

s%"eaming in $n"elenting pain and e-hibiting "ight foot pallo" signifying %ompa"tment synd"omeQ

a <edi%ate him with a%etaminophen

b *otify the physi%ian immediately

% elease the t"a%tion

d <onito" him e/e"y min$tes

+5 #t whi%h of the following ages wo$ld the n$"se e-pe%t to administe" the /a"i%ella (oste" /a%%ine to %hildQ

a #t bi"th

b 2 months

% 5 months

d 12 months

+8 Hhen dis%$ssing no"mal infant g"owth and de/elopment with pa"ents& whi%h of the following toys wo$ldthe n$"se s$ggest as most app"op"iate fo" an =month=oldQ

a P$sh=p$ll toys

b attle

% 'a"ge blo%s

d <obile

+ Hhi%h of the following aspe%ts of psy%hoso%ial de/elopment is ne%essa"y fo" the n$"se to eep in mind

when p"o/iding %a"e fo" the p"es%hool %hildQ

a !he %hild %an $se %omple- "easoning to thin o$t sit$ations

b Fea" of body m$tilation is a %ommon p"es%hool fea"

% !he %hild engages in %ompetiti/e types of play

d Immediate g"atifi%ation is ne%essa"y to de/elop initiati/e

+9 Hhi%h of the following is %ha"a%te"isti% of a p"es%hoole" with mid mental "eta"dationQ




a Slow to feed self

b 'a% of spee%h

% <a"ed moto" delays

d Dait disability

.0 Hhi%h of the following assessment findings wo$ld lead the n$"se to s$spe%t )own synd"ome in an infantQ

a Small tong$e

b !"ans/e"se palma" %"ease

% 'a"ge nosed est"i%ted Eoint mo/ement

.1 Hhile assessing a newbo"n with %left lip& the n$"se wo$ld be ale"t that whi%h of the following will most

liely be %omp"omisedQ

a S$%ing ability

b espi"ato"y stat$s

% 'o%omotion

d DI f$n%tion

.2 Hhen p"o/iding postope"ati/e %a"e fo" the %hild with a %left palate& the n$"se sho$ld position the %hild in

whi%h of the following positionsQa S$pine

b P"one

% In an infant seatd On the side

.+ Hhile assessing a %hild with pylo"i% stenosis& the n$"se is liely to note whi%h of the followingQ

a eg$"gitation

b Steato""hea

% P"oEe%tile /omiting

d C$""ant EellyT stools

.. Hhi%h of the following n$"sing diagnoses wo$ld be inapp"op"iate fo" the infant with gast"oesophageal

"efl$- D,Q

a Fl$id /ol$me defi%it

b is fo" aspi"ation

% #lte"ed n$t"ition: less than body "e6$i"ements

d #lte"ed o"al m$%o$s memb"anes. Hhi%h of the following pa"amete"s wo$ld the n$"se monito" to e/al$ate the effe%ti/eness of thi%ened

feedings fo" an infant with gast"oesophageal "efl$- D,Q

a 7omiting b Stools

% Ute"ine

d Height

.5 )is%ha"ge tea%hing fo" a %hild with %elia% disease wo$ld in%l$de inst"$%tions abo$t a/oiding whi%h of the

followingQ

a i%e

b <il

% Hheat

d Chi%en

.8 Hhi%h of the following wo$ld the n$"se e-pe%t to assess in a %hild with %elia% disease ha/ing a %elia%

%"isis se%onda"y to an $ppe" "espi"ato"y infe%tionQ

a espi"ato"y dist"ess

b 'etha"gy

% Hate"y dia""hea

d Height gain

. Hhi%h of the following sho$ld the n$"se do fi"st afte" noting that a %hild with ?i"s%hsp"$ng disease has a

fe/e" and wate"y e-plosi/e dia""heaQ

a *otify the physi%ian immediately b #dministe" antidia""heal medi%ations

% <onito" %hild e/e" +0 min$tes

d *othing& this is %ha"a%te"isti% of ?i"s%hsp"$ng disease

.9 # newbo"nKs fail$"e to pass me%oni$m within the fi"st 2. ho$"s afte" bi"th may indi%ate whi%h of the

followingQ

a ?i"s%hsp"$ng disease

b Celia% disease

% Int$ss$s%eption

d #bdominal wall defe%t

0 Hhen assessing a %hild fo" possible int$ss$s%eption& whi%h of the following wo$ld be least liely to

p"o/ide /al$able info"mationQ

a Stool inspe%tion




b Pain patte"n

% Family histo"y

d #bdominal palpation

ANSERS a$% RATIONALES #r PEDIATRIC NURSING

1 D' !he ante"io" fontanelle typi%ally %loses anywhe"e between 12 to 1 months of age !h$s& assessing the

ante"io" fontanelle as still being slightly open is a no"mal finding "e6$i"ing no f$"the" a%tion @e%a$se it is

no"mal finding fo" this age& notifying he physi%ian o" pe"fo"ming additional e-aminations a"e

inapp"op"iate2 D' Solid foods a"e not "e%ommended befo"e age . to 5 months be%a$se of the s$%ing "efle- and the

immat$"ity of the gast"ointestinal t"a%t and imm$ne system !he"efo"e& the ea"liest age at whi%h to

int"od$%e foods is . months #ny time ea"lie" wo$ld be inapp"op"iate

+ A' #%%o"ding to ,"ison& infants need to ha/e thei" needs met %onsistently and effe%ti/ely to de/elop a

sense of t"$st #n infant whose needs a"e %onsistently $nmet o" who e-pe"ien%es signifi%ant delays in

ha/ing them met& s$%h as in the %ase of the infant of a s$bstan%e=ab$sing mothe"& will de/elop a sense of

$n%e"tainty& leading to mist"$st of %a"egi/e"s and the en/i"onment !oddle"s de/elop a sense of shame

when thei" a$tonomy needs a"e not met %onsistently P"es%hoole"s de/elop a sense of g$ilt when thei"

sense of initiati/e is thwa"ted S%hoolage"s de/elop a sense of infe"io"ity when they do not de/elop a

sense of ind$st"y

. D' # b$sy bo- fa%ilitates the fine moto" de/elopment that o%%$"s between . and 5 months @alloons a"e

%ont"aindi%ated be%a$se small %hild"en may aspi"ate balloons @e%a$se the b$tton eyes of a teddy bea"may deta%h and be aspi"ated& this toy is $nsafe fo" %hild"en yo$nge" than + yea"s # =month=old is too

yo$ng to $se a p$sh=p$ll toy

)' Infants need to ha/e thei" se%$"ity needs met by being held and %$ddled #t 2 months of age& they a"e

$nable to mae the %onne%tion between %"ying and attention !his asso%iation does not o%%$" $ntil late

infan%y o" ea"ly toddle"hood 'etting the infant %"y fo" a time befo"e pi%ing $p the infant o" lea/ing the

infant alone to %"y he"self to sleep inte"fe"es with meeting the infantKs need fo" se%$"ity at this /e"y yo$ng

age Infants %"y fo" many "easons #ss$ming that the %hild s h$ng"y may %a$se o/e"feeding p"oblems

s$%h as obesity

5 )' Unde"de/eloped abdominal m$s%$lat$"e gi/es the toddle" a %ha"a%te"isti%ally p"ot"$ding abdomen

)$"ing toddle"hood& food intae de%"eases& not in%"eases !oddle"s a"e %ha"a%te"isti%ally bowlegged

be%a$se the leg m$s%les m$st bea" the weight of the "elati/ely la"ge t"$n !oddle" g"owth patte"ns o%%$"

in a steplie& not linea" patte"n8 )' #%%o"ding to ,"ison& toddle"s e-pe"ien%e a sense of shame when they a"e not allowed to de/elop

app"op"iate independen%e and a$tonomy Infants de/elop mist"$st when thei" needs a"e not %onsistentlyg"atified P"es%hoole"s de/elop g$ilt when thei" initiati/e needs a"e not met while s%hoolage"s de/elop a

sense of infe"io"ity when thei" ind$st"y needs a"e not met

C' Ao$ng toddle"s a"e still senso"imoto" lea"ne"s and they enEoy the e-pe"ien%e of feeling diffe"ent

te-t$"es !h$s& finge" paints wo$ld be an app"op"iate toy %hoi%e <$ltiple=pie%e toys& s$%h as p$((le& a"e

too diffi%$lt to manip$late and may be ha(a"do$s if the pie%es a"e small eno$gh to be aspi"ated <iniat$"e




%a"s also ha/e a high potential fo" aspi"ation Comi% boos a"e on too high a le/el fo" toddle"s #ltho$gh

they may enEoy looing at some of the pi%t$"es& toddle"s a"e mo"e liely to "ip a %omi% boo apa"t

9 D' !he %hild m$st be able to sate the need to go to the bath"oom to initiate toilet t"aining Us$ally& a %hild

needs to be d"y fo" only 2 ho$"s& not . ho$"s !he %hild also m$st be able to sit& wal& and s6$at # new

sibling wo$ld most liely hinde" toilet t"aining

10 A' !oddle"s be%ome pi%y eate"s& e-pe"ien%ing food Eags and eating la"ge amo$nts one day and /e"y little

the ne-t # toddle"Ks food gags e-p"ess a p"efe"en%e fo" the "it$alism of eating one type of food fo"

se/e"al days at a time !oddle"s typi%ally enEoy so%iali(ation and limiting othe"s at meal time !oddle"s p"efe" to feed themsel/es and th$s a"e too yo$ng to ha/e table manne"s # toddle"Ks appetite and need fo"

%alo"ies& p"otein& and fl$id de%"ease d$e to the d"amati% slowing of g"owth "ate

11 D' P"es%hoole"s %ommonly ha/e fea"s of the da"& being left alone espe%ially at bedtime& and ghosts&

whi%h may affe%t the %hildKs going to bed at night >$iet play and time with pa"ents is a positi/e bedtime

"o$tine that p"o/ides se%$"ity and also "eadies the %hild fo" sleep !he %hild sho$ld sleep in his own bed

!elling the %hild abo$t lo%ing him in his "oom will /iewed by the %hild as a th"eat #dditionally& a

lo%ed doo" is f"ightening and potentially ha(a"do$s 7igo"o$s a%ti/ity at bedtime sti"s $p the %hild and

maes mo"e diffi%$lt to fall asleep

12 )' )"ess=$p %lothes enhan%e imaginati/e play and imagination& allowing p"es%hoole"s to engage in "i%h

fantasy play @$ilding blo%s and wooden p$((les a"e app"op"iate fo" en%o$"aging fine moto"

de/elopment @ig wheels and t"i%y%les en%o$"age g"oss moto" de/elopment

1+ D' !he s%hool=aged %hild is in the stage of %on%"ete ope"ations& ma"ed by ind$%ti/e "easoning& logi%alope"ations& and "e/e"sible %on%"ete tho$ght !he ability to %onside" the f$t$"e "e6$i"es fo"mal tho$ght

ope"ations& whi%h a"e not de/eloped $ntil adoles%en%e Colle%ting baseball %a"ds and ma"bles& o"de"ing

dolls by si(e& and simple p"oblem=sol/ing options a"e e-amples of the %on%"ete ope"ational thining of the

s%hoolage"

1. C' ea%tion fo"mation is the s%hoolage"Ks typi%al defensi/e "esponse when hospitali(ed In "ea%tion

fo"mation& e-p"ession of $na%%eptable tho$ghts o" beha/io"s is p"e/ented o" o/e""idden by the

e-agge"ated e-p"ession of opposite tho$ghts o" types of beha/io"s eg"ession is seen in toddle"s and p"esh%oole"s when they "et"eat o" "et$"n to an ea"lie" le/el of de/elopment ep"ession "efe"s to the

in/ol$nta"y blo%ing of $npleasant feelings and e-pe"ien%es f"om oneKs awa"eness ationali(ation is the

attempt to mae e-%$ses to E$stify $na%%eptable feelings o" beha/io"s

1 C' !he s%hoolage"Ks %ogniti/e le/el is s$ffi%iently de/eloped to enable good $nde"standing of and

adhe"en%e to "$les !h$s& s%hoolage"s sho$ld be able to $nde"stand the potential dange"s a"o$nd themHith g"owth %omes g"eate" f"eedom and %hild"en be%ome mo"e ad/ent$"o$s and da"ing !he s%hool=aged

%hild is also still p"one to a%%idents and home ha(a"ds& espe%ially be%a$se of in%"eased moto" abilities and

independen%e Pl$s the home ha(a"ds diffe" f"om othe" age g"o$ps !hese ha(a"ds& whi%h a"e potentially

lethal b$t tempting& may in%l$de fi"ea"ms& al%ohol& and medi%ations S%hool=age %hild"en begin to

inte"nali(e thei" own %ont"ols and need less o$tside di"e%tion Pl$s the %hild is away f"om home mo"e

often Some pa"ental o" %a"egi/e" assistan%e is still needed to answe" 6$estions and p"o/ide g$idan%e fo"de%isions and "esponsibilities

15 C' !he most signifi%ant sill lea"ned d$"ing the s%hool=age pe"iod is "eading )$"ing this time the %hild

de/elops fo"mal ad$lt a"ti%$lation patte"ns and lea"ns that wo"ds %an be a""anged in st"$%t$"e Colle%ti/e&

o"de"ing& and so"ting& altho$gh impo"tant& a"e not most signifi%ant sills lea"ned

18 C' @ased on the "e%ommendations of the #me"i%an #%ademy of Family Physi%ians and the #me"i%an

#%ademy of Pediat"i%s& the << /a%%ine sho$ld be gi/en at the age of 10 if the %hild did not "e%ei/e it between the ages of . to 5 yea"s as "e%ommended Imm$ni(ation fo" diphthe"ia and tetan$s is "e6$i"ed at

age 1+

1 D' #%%o"ding to ,"ison& "ole diff$sion de/elops when the adoles%ent does not de/elop a sense of identity

and a sense o" whe"e he fits in !oddle"s de/elop a sense of shame when they do not a%hie/e a$tonomy

P"es%hoole"s de/elop a sense of g$ilt when they do not de/elop a sense of initiati/e S%hool=age %hild"en

de/elop a sense of infe"io"ity when they do not de/elop a sense of ind$st"y

19 A' <ena"%he "efe"s to the onset of the fi"st menst"$ation o" menst"$al pe"iod and "efe"s only to the fi"st

%y%le Ute"ine g"owth and b"oadening of the pel/i% gi"dle o%%$"s befo"e mena"%he

20 A' Stating that this is p"obably the only %on%e"n the adoles%ent has and telling the pa"ents not to wo""y

abo$t it o" the time he" spends on it sh$ts off f$"the" in/estigation and is liely to mae the adoles%ent and

his pa"ents feel defensi/e !he statement abo$t pee" a%%eptan%e and time spent in f"ont of the mi""o" fo"

the de/elopment of self image p"o/ides info"mation abo$t the adoles%entKs needs to the pa"ents and may

help to gain t"$st with the adoles%ent #sing the adoles%ent how he feels abo$t the a%ne will en%o$"age

the adoles%ent to sha"e his feelings )is%$ssing the %leansing method shows inte"est and %on%e"n fo" the

adoles%ent and also %an help to identify any patient=tea%hing needs fo" the adoles%ent "ega"ding %leansing

21 )' P"es%hoole"s sho$ld be de/elopmentally in%apable of demonst"ating e-pli%it se-$al beha/io" If a %hild

does so& the %hild has been e-posed to s$%h beha/io"& and se-$al ab$se sho$ld be s$spe%ted ,-pli%it

se-$al beha/io" d$"ing doll play is not a %ha"a%te"isti% of p"es%hool de/elopment no" symptomati% of

de/elopmental delay Hhethe" o" no" the %hild nows how to play with dolls is i""ele/ant




22 A' !he pa"ents need mo"e tea%hing if they state that they will eep the %hild home $ntil the phobia

s$bsides )oing so "einfo"%es the %hildKs feelings of wo"thlessness and dependen%y !he %hild sho$ld

attend s%hool e/en d$"ing "esol$tion of the p"oblem #llowing the %hild to /e"bali(e helps the %hild to

/entilate feelings and may help to $n%o/e" %a$ses and sol$tions Collabo"ation with the tea%he"s and

%o$nselo"s at s%hool may lead to $n%o/e"ing the %a$se of the phobia and to the de/elopment of sol$tions

!he %hild sho$ld pa"ti%ipate and play an a%ti/e "ole in de/eloping possible sol$tions

2+ C' !he adoles%ent who be%omes p"egnant typi%ally denies the p"egnan%y ea"ly on ,a"ly "e%ognition by a

pa"ent o" health %a"e p"o/ide" may be %"$%ial to timely initiation of p"enatal %a"e !he in%iden%e ofadoles%ent p"egnan%y has de%lined sin%e 1991& yet mo"bidity "emains high <ost teenage p"egnan%ies a"e

$nplanned and o%%$" o$t of wedlo% !he p"egnant adoles%ent is at high "is fo" physi%al %ompli%ations

in%l$ding p"emat$"e labo" and low=bi"th=weight infants& high neonatal mo"tality& i"on defi%ien%y anemia&

p"olonged labo"& and fetopel/i% disp"opo"tion as well as n$me"o$s psy%hologi%al %"ises

2. )' @e%a$se of the st"$%t$"al defe%t& %hild"en with %left palate may ha/e ineffe%ti/e f$n%tioning of thei"

,$sta%hian t$bes %"eating f"e6$ent bo$ts of otitis media <ost %hild"en with %left palate "emain well=

no$"ished and maintain ade6$ate n$t"ition th"o$gh the $se of p"ope" feeding te%hni6$es Food pa"ti%les do

not pass th"o$gh the %left and into the ,$sta%hian t$bes !he"e is no asso%iation between %left palate and

%ongenial ea" defo"mities

2 D' # +=month=old infant sho$ld be able to lift the head and %hest when p"one !he <o"o "efle- typi%ally

diminishes o" s$bsides by + months !he pa"a%h$te "efle- appea"s at 9 months olling f"om f"ont to ba%

$s$ally is a%%omplished at abo$t months25 D' # %hildKs bi"th weight $s$ally t"iples by 12 months and do$bles by . months *o spe%ifi% bi"th weight

pa"amete"s a"e established fo" 8 o" 9 months

28 C' !oddle"s engaging in pa"allel play will play nea" ea%h othe"& b$t not with ea%h othe" !h$s& when two

toddle"s sit nea" ea%h othe" b$t play with sepa"ate dolls& they a"e e-hibiting pa"allel play Sha"ing %"ayons&

playing a boa"d game with a n$"se& o" sha"ing dolls with two diffe"ent n$"ses a"e all e-amples of

%oope"ati/e play

2 A' #%$te lympho%yti% le$emia #'' %a$ses le$openia& "es$lting in imm$nos$pp"ession and in%"easing

the "is of infe%tion& a leading %a$se of death in %hild"en with #'' !he"efo"e& the initial p"io"ity n$"sing

inte"/ention wo$ld be to instit$te infe%tion %ont"ol p"e%a$tions to de%"ease the "is of infe%tion I"on="i%h

foods help with anemia& b$t dieta"y i"on is not an initial inte"/ention !he p"ognosis of #'' $s$ally is

good ?owe/e"& late" on& the n$"se may need to assist the %hild and family with %oping sin%e death and

dying may still be an iss$e in need of dis%$ssion InEe%tions sho$ld be dis%o$"aged& owing to in%"eased"is f"om bleeding d$e to th"ombo%ytopenia

29 A' !he pe"t$sis %omponent may "es$lt in fe/e" and the tetan$s %omponent may "es$lt in inEe%tion

so"eness !he"efo"e& the mothe"Ks /e"bali(ation of info"mation abo$t meas$"es to "ed$%e fe/e" indi%ates

$nde"standing *o dieta"y "est"i%tions a"e ne%essa"y afte" this inEe%tion is gi/en # s$bse6$ent "ash is

mo"e liely to be seen to 10 days afte" "e%ei/ing the << /a%%ine& not the diphthe"ia& pe"t$ssis& and

tetan$s /a%%ine )ia""hea is not asso%iated with this /a%%ine

+0 A' <$ltiple b"$ises and b$"ns on a toddle" a"e signs %hild ab$se !he"efo"e& the n$"se is "esponsible fo"

"epo"ting the %ase to P"ote%ti/e Se"/i%es immediately to p"ote%t the %hild f"om f$"the" ha"m S%hed$ling a

follow=$p /isit is inapp"op"iate be%a$se additional ha"m may %ome to the %hild if the n$"se waits fo"

f$"the" assessment data #ltho$gh the n$"se sho$ld notify the physi%ian& the goal is to initiate meas$"es to

p"ote%t the %hildKs safety *otifying the physi%ian immediately does not initiate the "emo/al of the %hild

f"om ha"m no" does it absol/e the n$"se f"om "esponsibility <$ltiple b"$ises and b$"ns a"e not no"maltoddle" inE$"ies

+1 )' !he mothe" is $sing p"oEe%tion& the defense me%hanism $sed when a pe"son att"ib$tes his o" he" own

$ndesi"able t"aits to anothe" )ispla%ement is the t"ansfe" of emotion onto an $n"elated obEe%t& s$%h as

when the mothe" wo$ld i% a %hai" o" bang the doo" sh$t ep"ession is the s$bme"ging of painf$l ideas

into the $n%ons%io$s Psy%hosis is a state of being o$t of to$%h with "eality

+2 A' Child"en with %ongenital hea"t disease a"e mo"e p"one to "espi"ato"y infe%tions @leeding tenden%ies&

f"e6$ent /omiting& and dia""hea and sei($"e diso"de"s a"e not asso%iated with %ongenital hea"t disease

++ D' !he %hild is e-hibiting %lassi% signs of epiglottitis& always a pediat"i% eme"gen%y !he physi%ian m$st

be notified immediately and the n$"se m$st be p"epa"ed fo" an eme"gen%y int$bation o" t"a%heostomy

F$"the" assessment with a$s%$ltating l$ngs and pla%ing the %hild in a mist tent wastes /al$able time !he

sit$ation is a possible life=th"eatening eme"gen%y ?a/ing the %hild lie down wo$ld %a$se additional

dist"ess and may "es$lt in "espi"ato"y a""est !h"oat e-amination may "es$lt in la"yngospasm that %o$ld be

fatal

+. A' In females& the $"eth"a is sho"te" than in males !his de%"eases the distan%e fo" o"ganisms to t"a/el&

the"eby in%"easing the %han%e of the %hild de/eloping a $"ina"y t"a%t infe%tion F"e6$ent emptying of the

bladde" wo$ld help to de%"ease $"ina"y t"a%t infe%tions by a/oiding sphin%te" st"ess In%"eased fl$id intae

enables the bladde" to be %lea"ed mo"e f"e6$ently& th$s helping to p"e/ent $"ina"y t"a%t infe%tions !he

intae of a%idi% E$i%es helps to eep the $"ine p? a%idi% and th$s de%"ease the %han%e of flo"a

de/elopment




+ )' Compa"tment synd"ome is an eme"gent sit$ation and the physi%ian needs to be notified immediately so

that inte"/entions %an be initiated to "elie/e the in%"easing p"ess$"e and "esto"e %i"%$lation

#%etaminophen !ylenol will be ineffe%ti/e sin%e the pain is "elated to the in%"easing p"ess$"e and tiss$e

is%hemia !he %ast& not t"a%tion& is being $sed in this sit$ation fo" immobili(ation& so "eleasing the t"a%tion

wo$ld be inapp"op"iate In this sit$ation& spe%ifi% a%tion not %ontin$ed monito"ing is indi%ated

+5 D' !he /a"i%ella (oste" /a%%ine 7J7 is a li/e /a%%ine gi/en afte" age 12 months !he fi"st dose of

hepatitis @ /a%%ine is gi/en at bi"th to 2 months& then at 1 to . months& and then again at 5 to 1 months

)taP is "o$tinely gi/en at 2& .& 5& and 1 to 1 months and a booste" at . to 5 yea"s+8 C' @e%a$se the =month=old is "efining his g"oss moto" sills& being able to sit $ns$ppo"ted and also

imp"o/ing his fine moto" sills& p"obably %apable of maing hand=to=hand t"ansfe"s& la"ge blo%s wo$ld

be the most app"op"iate toy sele%tion P$sh=p$ll toys wo$ld be mo"e app"op"iate fo" the 10 to 12=month=

old as he o" she begins to %"$ise the en/i"onment attles and mobiles a"e mo"e app"op"iate fo" infants in

the 1 to + month age "ange <obiles pose a dange" to olde" infants be%a$se of possible st"ang$lation

+ )' )$"ing the p"es%hool pe"iod& the %hild has maste"ed a sense of a$tonomy and goes on to maste" a sense

of initiati/e )$"ing this pe"iod& the %hild %ommonly e-pe"ien%es mo"e fea"s than at any othe" time One

%ommon fea" is fea" of the body m$tilation& espe%ially asso%iated with painf$l e-pe"ien%es !he p"es%hool

%hild $ses simple& not %omple-& "easoning& engages in asso%iati/e& not %ompetiti/e& play inte"a%ti/e and

%oope"ati/e play with sha"ing& and is able to tole"ate longe" pe"iods of delayed g"atifi%ation

+9 A' <ild mental "eta"dation "efe"s to de/elopment disability in/ol/ing an I> 0 to 80 !ypi%ally& the %hild

is not noted as being "eta"ded& b$t e-hibits slowness in pe"fo"ming tass& s$%h as self=feeding& waling&and taing 'ittle o" no spee%h& ma"ed moto" delays& and gait disabilities wo$ld be seen in mo"e se/e"e

fo"ms mental "eta"dation

.0 ) )own synd"ome is %ha"a%te"i(ed by the following a t"ans/e"se palma" %"ease simian %"ease&

sepa"ated sagittal s$t$"e& obli6$e palpeb"al fiss$"es& small nose& dep"essed nasal b"idge& high=a"%hed

palate& e-%ess and la- sin& wide spa%ing and planta" %"ease between the se%ond and big toes&

hype"e-tensible and la- Eoints& la"ge p"ot"$ding tong$e& and m$s%le weaness

.1 A' @e%a$se of the defe%t& the %hild will be $nable to f"om the mo$th ade6$ately a"o$nd nipple& the"eby

"e6$i"ing spe%ial de/i%es to allow fo" feeding and s$%ing g"atifi%ation espi"ato"y stat$s may be

%omp"omised if the %hild is fed imp"ope"ly o" d$"ing postope"ati/e pe"iod& 'o%omotion wo$ld be a

p"oblem fo" the olde" infant be%a$se of the $se of "est"aints DI f$n%tioning is not %omp"omised in the

%hild with a %left lip

.2 )' Postope"ati/ely %hild"en with %left palate sho$ld be pla%ed on thei" abdomens to fa%ilitate d"ainage Ifthe %hild is pla%ed in the s$pine position& he o" she may aspi"ate Using an infant seat does not fa%ilitate

d"ainage Side=lying does not fa%ilitate d"ainage as well as the p"one position

.+ C' P"oEe%tile /omiting is a ey symptom of pylo"i% stenosis eg$"gitation is seen mo"e %ommonly with

D, Steato""hea o%%$"s in malabso"ption diso"de"s s$%h as %elia% disease C$""ant EellyT stools a"e

%ha"a%te"isti% of int$ss$s%eption

.. D' D, is the ba%flow of gast"i% %ontents into the esophag$s "es$lting f"om "ela-ation o" in%ompeten%e

of the lowe" esophageal %a"dia% sphin%te" *o alte"ation in the o"al m$%o$s memb"anes o%%$"s with this

diso"de" Fl$id /ol$me defi%it& "is fo" aspi"ation& and alte"ed n$t"ition a"e app"op"iate n$"sing diagnoses

. A' !hi%ened feedings a"e $sed with D, to stop the /omiting !he"efo"e& the n$"se wo$ld monito" the

%hildKs /omiting to e/al$ate the effe%ti/eness of $sing the thi%ened feedings *o "elationship e-ists

between feedings and %ha"a%te"isti%s of stools and $te"ine If feedings a"e ineffe%ti/e& this sho$ld be noted

befo"e the"e is any %hange in the %hildKs weight

.5 C' Child"en with %elia% disease %annot tole"ate o" digest gl$ten !he"efo"e& be%a$se of its gl$ten %ontent&

wheat and wheat=%ontaining p"od$%ts m$st be a/oided i%e& mil& and %hi%en do not %ontain gl$ten and

need not be a/oided

.8 C' ,pisodes of %elia% %"ises a"e p"e%ipitated by infe%tions& ingestion of gl$ten& p"olonged fasting& o"

e-pos$"e to anti%holine"gi% d"$gs Celia% %"isis is typi%ally %ha"a%te"i(ed by se/e"e wate"y dia""hea

espi"ato"y dist"ess is $nliely in a "o$tine $ppe" "espi"ato"y infe%tion I""itability& "athe" than letha"gy& is

mo"e liely @e%a$se of the fl$id loss asso%iated with the se/e"e wate"y dia""hea& the %hildKs weight is

mo"e liely to be de%"eased

. A' Fo" the %hild with ?i"s%hsp"$ng disease& fe/e" and e-plosi/e dia""hea indi%ate ente"o%olitis& a life=

th"eatening sit$ation !he"efo"e& the physi%ian sho$ld be notified immediately Dene"ally& be%a$se of the

intestinal obst"$%tion and inade6$ate p"op$lsi/e intestinal mo/ement& antidia""heals a"e not $sed to t"eat?i"s%hsp"$ng disease !he %hild is a%$tely ill and "e6$i"es inte"/ention& with monito"ing mo"e f"e6$ently

than e/e"y +0 min$tes ?i"s%hsp"$ng disease typi%ally p"esents with %h"oni% %onstipation

.9 A Fail$"e to pass me%oni$m within the fi"st 2. ho$"s afte" bi"th may be an indi%ation of ?i"s%hsp"$ng

disease& a %ongenital anomaly "es$lting in me%hani%al obst"$%tion d$e to inade6$ate motility in an

intestinal segment Fail$"e to pass me%oni$m is not asso%iated with %elia% disease& int$ss$s%eption& o"

abdominal wall defe%t

0 C @e%a$se int$ss$s%eption is not belie/ed to ha/e a familial tenden%y& obtaining a family histo"y wo$ld

p"o/ide the least amo$nt of info"mation Stool inspe%tion& pain patte"n& and abdominal palpation wo$ld

"e/eal possible indi%ato"s of int$ss$s%eption C$""ent& Eelly=lie stools %ontaining blood and m$%$s a"e an




indi%ation of int$ss$s%eption #%$te& episodi% abdominal pain is %ha"a%te"isti%s of int$ss$s%eption #

sa$sage=shaped mass may be palpated in the "ight $ppe" 6$ad"ant




COMMUNIT( HEALTH NURSING Part 1

SI!U#!IO* : ,pidemiology and 7ital statisti%sis a /e"y impo"tant tool that a n$"se %o$ld $se in

%ont"olling the sp"ead of disease in the

%omm$nity and at the same time& s$"/eying the

impa%t of the disease on the pop$lation and

p"e/ent itKs f$t$"e o%%$""en%e

1 It is %on%e"ned with the st$dy of fa%to"s that

infl$en%e the o%%$""en%e and dist"ib$tion of

diseases& defe%ts& disability o" death whi%h

o%%$"s in g"o$ps o" agg"egation of indi/id$als

A' E*i%!6i#+#

@ )emog"aphi%s

C 7ital Statisti%s

) ?ealth Statisti%s

2 Hhi%h of the following is the ba%bone in

disease p"e/entionQ

A' E*i%!6i#+#

@ )emog"aphi%s

C 7ital Statisti%s

) ?ealth Statisti%s

+ Hhi%h of the following type of "esea"%h %o$ld

show how %omm$nity e-pe%tations %an "es$lt in

the a%t$al p"o/ision of se"/i%esQ

# @asi% esea"%h

)' O*!rati#$a+ R!s!ar"/

C #%tion esea"%h) #pplied esea"%h

. #n o$tb"ea of measles has been "epo"ted in

Comm$nity # #s a n$"se& whi%h of the

following is yo$" fi"st a%tion fo" an

,pidemiologi%al in/estigationQ

# Classify if the o$tb"ea of measles is

epidemi% o" E$st spo"adi%

@ epo"t the in%iden%e into the ?U

C )ete"mine the fi"st day when the o$tb"ea

o%%$""ed

D' I%!$ti i it is t/! %is!as! -/i"/ it is

r!*#rt!% t# 7!

#fte" the epidemiologi%al in/estigation

p"od$%ed final %on%l$sions& whi%h of the

following is yo$" initial step in yo$" ope"ational p"o%ed$"e d$"ing disease o$tb"eaQ

A' C##r%i$at! *!rs#$$!+ r#6 M0$i"i*a+ t#

t/! Nati#$a+ +!8!+

@ Colle%t pe"tinent labo"ato"y spe%imen to

%onfi"m disease %a$sation

C Imm$ni(e nea"by %omm$nities with <easles

) ,d$%ate the %omm$nity in f$t$"e p"e/ention

of simila" o$tb"eas

5 !he main %on%e"n of a p$bli% health n$"se is

the p"e/ention of disease& p"olonging of life and




p"omoting physi%al health and effi%ien%y

th"o$gh whi%h of the followingQ

# Use of epidemiologi%al tools and /ital health

statisti%s

@ )ete"mine the sp"ead and o%%$""en%e of the

disease

C Politi%al empowe"ment and So%io ,%onomi%#ssistan%e

D' Ora$i9!% C#660$it E#rts

8 In o"de" to %ont"ol a disease effe%ti/ely& whi%h

of the following m$st fi"st be nownQ

1 !he %onditions s$""o$nding its o%%$""en%e

2 Fa%to"s that do not fa/o" its de/elopment

+ !he %ondition that do not s$""o$nd itso%%$""en%e

. Fa%to"s that fa/o"s its de/elopment

# 1 and +

)' 1 a$% 4

C 2 and +

) 2 and .

#ll of the following a"e $ses of epidemiology

e-%ept:

# !o st$dy the histo"y of health pop$lation and

the "ise and fall of disease

@ !o diagnose the health of the %omm$nity and

the %ondition of the peopleC' T# *r#8i%! s066ar %ata #$ /!a+t/

s!r8i"! %!+i8!r

) !o identify g"o$ps needing spe%ial attention

9 @efo"e "epo"ting the fa%t of p"esen%e of an

epidemi%& whi%h of the following is of most

impo"tan%e to dete"mineQ

A' Ar! t/! a"ts "#6*+!t!:

@ Is the disease "ealQ

C Is the disease tangibleQ

) Is it epidemi% o" endemi%Q

10 #n $nnown epidemi% has E$st been "epo"ted

in @a"angay )eb$deb$ People said that

affe%ted pe"son demonst"ates hemo""hagi% type

of fe/e" Ao$ a"e designated now to plan fo"

epidemiologi%al in/estigation #""ange the

se6$en%e of e/ents in a%%o"dan%e with the

%o""e%t o$tline plan fo" epidemiologi%al

in/estigation

1 epo"t the p"esen%e of deng$e

2 S$mma"i(e data and %on%l$de the final pi%t$"e

of epidemi%

+ elate the o%%$""en%e to the pop$lation g"o$p&

fa%ilities& food s$pply and %a""ie"s

. )ete"mine if the disease is fa%t$al o" "eal

)ete"mine any $n$s$al p"e/alen%e of the

disease and its nat$"eW is it epidemi%& spo"adi%&

endemi% o" pandemi%Q

5 )ete"mine onset and the geog"aphi%al

limitation of the disease

# .&1&+&&2&5

)' 4,1,5,;,3,2

C &.&5&2&1&+

) &.&5&1&2&+

, 1&2&+&.&&5

11 In the o%%$""en%e of S#S and othe" pandemi%s& whi%h of the following is the most

/ital "ole of a n$"se in epidemiologyQ

# ?ealth p"omotion

@ )isease p"e/ention

C' S0r8!i++a$"!

) Casefinding

12 <easles o$tb"ea has been "epo"ted in@a"angay @ahay !o"o& #fte" %ond$%ting an

epidemiologi%al in/estigation yo$ ha/e

%onfi"med that the o$tb"ea is fa%t$al Ao$ a"etased to lead a team of medi%al wo"e"s fo"

ope"ational p"o%ed$"e in disease o$tb"ea

#""ange the %o""e%t se6$en%e of e/ents that yo$

m$st do to effe%ti/ely %ontain the disease

1 C"eate a final "epo"t and "e%ommendation

2 Pe"fo"m nasopha"yngeal swabbing to infe%ted

indi/id$als

+ Pe"fo"m mass measles imm$ni(ation to

/$lne"able g"o$ps

. Pe"fo"m an en/i"onmental sanitation s$"/ey

on the immediate en/i"onment O"gani(e yo$" team and Coo"dinate the

pe"sonnels

5 ,d$%ate the %omm$nity on diseaset"ansmission

# 1&2&+&.&&5

@ 5&&.&+&2&1

C &5&.&2&+&1

D' 5,2,3,4,;,1

1+ #ll of the following a"e f$n%tion of *$"se

@$de in epidemiology e-%ept

A' La7#rat#r Dia$#sis

@ S$"/eillan%e of disease o%%$""en%e

C Follow $p %ases and %onta%ts

) efe" %ases to hospitals if ne%essa"y

, Isolate %ases of %omm$ni%able disease

1. #ll of the following a"e pe"fo"med in team

o"gani(ation e-%ept

# O"ientation and demonst"ation of

methodology to be employed

@ #"ea assignments of team membe"s

C Che% teamKs e6$ipments and pa"aphe"nalia

D' A"ti8! "as! i$%i$ a$% S0r8!i++a$"!

1 Hhi%h of the following is the final o$tp$t of

data "epo"ting in epidemiologi%al ope"ational

p"o%ed$"eQ

A' R!"#66!$%ati#$




@ ,/al$ation

C Final epo"t

) P"elimina"y "epo"t

15 !he offi%e in %ha"ge with "egiste"ing /ital

fa%ts in the Philippines is none othe" than the

# PCSO@ P#DCO

C )O?

D' NSO

18 !he following a"e possible so$"%es of )ata

e-%ept:

A' E<*!ri!$"!

@ Cens$sC S$"/eys

) esea"%h

1 !his "efe"s to systemati% st$dy of /ital

e/ents s$%h as bi"ths& illnesses& ma""iages&

di/o"%es and deaths

# ,pidemiology

@ )emog"aphi%s

C' Vita+ Statisti"s

) ?ealth Statisti%s

19 In %ase of %le"i%al e""o"s in yo$" bi"th

%e"tifi%ate& Hhe"e sho$ld yo$ go to ha/e it

%o""e%tedQ

# *SO

@ Co$"t of #ppealsC <$ni%ipal !"ial Co$"t

D' L#"a+ Ci8i+ R!istrar

20 #%asia E$st ga/e bi"th to 'estat& # healthy

baby boy Hho a"e going to "epo"t the bi"th of

@aby 'estatQ

# *$"se

@ <idwife

C O@ Dyne

D' )irt/ Att!$%a$t

21 In "epo"ting the bi"th of @aby 'estat& whe"e

will he be "egiste"edQ

A' At t/! L#"a+ Ci8i+ R!istrar

@ In the *ational Statisti%s Offi%e

C In the City ?ealth )epa"tment) In the Field ?ealth Se"/i%es and Info"mation

System <ain Offi%e

22 )eeEay& !he bi"th attendant noti%ed that

'estat has low set of ea"s& <i%"ognathia&

<i%"o%ephaly and a typi%al %at lie %"y Hhat

sho$ld )eeEay doQ

# @"ing 'estat immediately to the nea"est

hospital

@ #s his assistant to %all the nea"by

pediat"i%ian

C @"ing 'estat to the nea"est pediat"i% %lini%

D' Ca++ a Ta<i a$% t#!t/!r -it/ A"asia,

)ri$ L!stat t# t/! $!ar!st /#s*ita+

2+ )eeEay wo$ld s$spe%t whi%h diso"de"Q

# !"isomy 21

@ !$"ne"s Synd"omeC' Cri D0 C/at

) linefelte"s Synd"ome

2. )eeEay %o$ld e-pe%t whi%h of the following

%ongenital anomaly that wo$ld a%%ompany this

diso"de"Q

A' AVSD

@ P)#C !OF

) !OD7

25 Hhi%h p"esidential de%"ee o"de"s "epo"ting

of bi"ths within +0 days afte" its o%%$""en%eQ

A' ;51

@ .1

C 995

) 2

2 !hese "ates a"e "efe""ed to the total li/ing

pop$lation& It m$st be p"es$med that the total

pop$lation was e-posed to the "is of o%%$""en%e

of the e/ent

# ate

@ atio

C' Cr0%!=G!$!ra+ Rat!s

) Spe%ifi% ate

25 !hese a"e $sed to des%"ibe the "elationship

between two n$me"i%al 6$antities o" meas$"es of

e/ents witho$t taing pa"ti%$la" %onside"ations

to the time o" pla%e

# ate

)' Rati#s

C C"$deGDene"al ate

) Spe%ifi% ate

28 !his is the most sensiti/e inde- in

dete"mining the gene"al health %ondition of a

%omm$nity sin%e it "efle%ts the %hanges in the

en/i"onment and medi%al %onditions of a

%omm$nity

# C"$de death "ate

)' I$a$t 6#rta+it rat!

C <ate"nal mo"tality "ate

) Fetal death "ate

2 #%%o"ding to the H?O& whi%h of the

following is the most f"e6$ent %a$se of death in

%hild"en $nde"fi/e wo"ldwide in the 200+ H?O

S$"/eyQ

A' N!#$ata+




@ Pne$monia

C )ia""hea

) ?I7G#I)S

29 In the Philippines& what is the most %ommon

%a$se of death of infants a%%o"ding to the latest

s$"/eyQ

# Pne$monia

@ )ia""hea

C' Ot/!r *!ri$ata+ "#$%iti#$

) espi"ato"y %ondition of fet$s and newbo"n

+0 !he maEo" %a$se of mo"tality f"om 1999 $p

to 2002 in the Philippines a"e

A' Dis!as!s # t/! /!art

@ )iseases of the /as%$la" system

C Pne$monias

) !$be"%$losis

+1 #li%ia& a 9 yea" old %hild ased yo$ Hhat

is the %ommon %a$se of death in my age g"o$p

he"e in the PhilippinesQ !he n$"se is %o""e%t if

he will answe"

# Pne$monia is the top leading %a$se of death

in %hild"en age to 9

@ <alignant neoplasm if %ommon in yo$" age

g"o$p

C' Pr#7a7i+it -is!, (#0 6i/t %i! %0! t#

a""i%!$ts) )iseases of the "espi"ato"y system is the most

%ommon %a$se of death in %hild"en

+2 In %hild"en 1 to . yea"s old& whi%h is the

most %ommon %a$se of deathQ

# )ia""hea

@ #%%idents

C' P$!06#$ia

) )iseases of the hea"t

++ Ho"ing in the %omm$nity as a P?* fo"

almost 10 yea"s& #ida new the fl$%t$ation in

/ital statisti%s She new that the most %ommon

%a$se of mo"bidity among the Filipinos is

# )iseases of the hea"t

@ )ia""hea

C' P$!06#$ia

) 7as%$la" system diseases

+. *$"se #ida also new that most mate"nal

deaths a"e %a$sed by

# ?emo""hage

)' Ot/!r C#6*+i"ati#$s r!+at!% t# *r!$a$"

#""0rri$ i$ t/! "#0rs! # +a7#r, %!+i8!r a$%

*0!r*!ri06

C ?ype"tension %ompli%ating p"egnan%y&

%hildbi"th and p$e"pe"i$m

) #bo"tion

SI!U#!IO* : @a"angay Pinoy@S* has the

following data in yea" 2005

1 B$ly 1 pop$lation : 2.&+15

2 'i/ebi"ths : 2&29

+ )eaths f"om mate"nal %a$se : 1

. )eath f"om C7) : +&029

)eaths $nde" 1 yea" of age : 2+

5 Fetal deaths : 8 )eaths $nde" 2 days :

)eath d$e to "abies : .

9 egiste"ed %ases of "abies : .

10 People with pne$monia : 89

11 People e-posed with pne$monia : 2&9+

12 !otal n$mbe" of deaths f"om all %a$ses :

10&99

!he following 6$estions "efe" to these data

+ Hhat is the %"$de bi"th "ate of @a"angay

Pinoy@S*Q

# 90G100&000

@ 9G100

C 90G1000

D' >=1???

+5 Hhat is the %a$se spe%ifi% death "ate f"om

%a"dio/as%$la" diseasesQ

# 28G100

)' 11>1=1??,???

C 28G100&000) 11G1000

+8 Hhat is the <ate"nal <o"tality "ate of this ba"angayQ

A' ;'55=1???

@ 9G1000

C 1+5G1000

) +58G1000

+ Hhat is the fetal death "ateQ

A' 3'4>=1???

@ 100.G1000

C +1.G1000

) +1.G100&000

+9 Hhat is the atta% "ate of pne$moniaQ

# +0.G1000

@ 81G1000C +22G100

D' 3'?4=1??

.0 )ete"mine the Case fatality "atio of "abies in

this @a"angay

# 1G100

)' 1??@

C 1V

) 100G1000

.1 !he following a"e all f$n%tions of the n$"se




in /ital statisti%s& whi%h of the following is notQ

A' C#$s#+i%at! Data

@ Colle%ts )ata

C #naly(e )ata

) !ab$late )ata

.2 !he following a"e *otifiable diseases thatneeds to ha/e a tally sheet in data "epo"ting&

Hhi%h one is notQ

# ?ype"tension

@ @"on%hiolitis

C Chemi%al Poisoning

D' A""i%!$ts

.+ Hhi%h of the following "e6$i"es "epo"tingwithin 2. ho$"sQ

# *eonatal tetan$s)' M!as+!s

C ?ype"tension

) !etan$s

.. Hhi%h #%t de%la"ed that all %omm$ni%able

disease be "epo"ted to the nea"est health stationQ

# 102

@ 191

C' 353

) 558

. In the ?U !eam& Hhi%h p"ofessional is

di"e%tly "esponsible in %a"ing a si% pe"son who

is homebo$ndQ

A' Mi%-i!

@ *$"se

C @?H

) Physi%ian

.5 )$"ing epidemi%s& whi%h of the following

epidemiologi%al f$n%tion will yo$ ha/e to

pe"fo"m fi"stQ

# !ea%hing the %omm$nity on disease

p"e/ention

@ #ssessment on s$spe%ted %ases

C <onito" the %ondition of people affe%ted

D' D!t!r6i$i$ t/! s#0r"! a$% $at0r! # t/!

!*i%!6i"

.8 Hhi%h of the following is a POI*!SOUC, epidemi%Q

# )eng$e ?F

@ <ala"ia

C' C#$ta6i$at!% at!r S#0r"!

) !$be"%$losis

. #ll b$t one is a %ha"a%te"isti% of a point

so$"%e epidemi%& whi%h one is notQ

# !he sp"ead of the disease is %a$sed by a

%ommon /ehi%le

@ !he disease is $s$ally %a$sed by

%ontaminated food

C' T/!r! is a ra%0a+ i$"r!as! # "as!s

) ,pidemi% is $s$ally s$dden

.9 !he only <i%"oo"ganism monito"ed in %ases

of %ontaminated wate" is

# 7ib"io Chole"a

)' Es"/!ri"/ia C#+i

C ,ntamoeba ?istolyti%a

) Colifo"m !est

0 )eng$e in%"ease in n$mbe" d$"ing B$ne& B$ly

and #$g$st !his patte"n is %alled

# ,pidemi%@ ,ndemi%

C' C"+i"a+

) Se%$la"

SI!U#!IO* : Field health se"/i%es and

info"mation system p"o/ides s$mma"y data on

health se"/i%e deli/e"y and sele%ted p"og"am

f"om the ba"angay le/el $p to the national le/el

#s a n$"se& yo$ sho$ld now the p"o%ess on how

these info"mation be%ame p"o%essed and

%onsolidated

1 #ll of the following a"e obEe%ti/es of F?SIS

,-%ept

A' T# "#6*+!t! t/! "+i$i"a+ *i"t0r! # "/r#$i"

%is!as! a$% %!s"ri7! t/!ir $at0ra+ /ist#r

@ !o p"o/ide standa"di(ed& fa%ility le/el data base whi%h %an be a%%essed fo" mo"e in depth

st$dies

C !o minimi(e "e%o"ding and "epo"ting b$"den

allowing mo"e time fo" patient %a"e and

p"omoti/e a%ti/ities

) !o ens$"e that data "epo"ted a"e $sef$l and

a%%$"ate and a"e disseminated in a timely and

easy to $se fashion

2 Hhat is the f$ndamental blo% o" fo$ndation

of the field health se"/i%e info"mation systemQ

A' Fa6i+ tr!at6!$t r!"#r%

@ !a"get Client list

C epo"ting fo"ms

) O$tp$t "e%o"d

+ Hhat is the p"ima"y ad/antage of ha/ing ata"get %lient listQ

A' N0rs!s $!!% $#t t# # 7a"B t# FTR t#

6#$it#r tr!at6!$t a$% s!r8i"!s t#

7!$!i"iari!s t/0s sa8i$ ti6! a$% !#rt

@ ?elp monito" se"/i%e "ende"ed to %lients in

gene"al

C Fa%ilitate monito"ing and s$pe"/ision of

se"/i%es

) Fa%ilitates easie" "epo"ting

. Hhi%h of the following is $sed to monito"




pa"ti%$la" g"o$ps that a"e 6$alified as eligible to

a %e"tain p"og"am of the )O?Q

# Family t"eatment "e%o"d

)' Tar!t C+i!$t +ist

C epo"ting fo"ms

) O$tp$t "e%o"d

In $sing the tally sheet& what is the

"e%ommended f"e6$en%y in tallying a%ti/ities

and se"/i%esQ

A' Dai+

@ Heely

C <onthly

) >$a"te"ly

5 Hhen is the %o$nting of the tally sheet doneQ

# #t the end of the day@ #t the end of the wee

C' At t/! !$% # t/! 6#$t/

) #t the end of the yea"

8 !a"get %lient list will be t"ansmitted to the

ne-t fa%ility in the fo"m of



C' R!*#rti$ #r6s

) O$tp$t "e%o"d

#ll b$t one of the following a"e eligible

ta"get %lient list

# 'ep"osy %ases

@ !@ %ases

C P"enatal %a"e

D' Diarr/!a "as!s

9 !his is the only me%hanism th"o$gh whi%h

data a"e "o$tinely t"ansmitted f"om on%e fa%ility

to anothe"



C' R!*#rti$ #r6s

) O$tp$t "e%o"d

50 F?SISG>=+ O" the "epo"t fo" en/i"onmental

health a%ti/ities is p"epa"ed how f"e6$entlyQ

# )aily@ Heely

C' 0art!r+

) Aea"ly

51 *$"se @$de is p"epa"ing the "epo"ting fo"m

fo" weely notifiable diseases ?e new that he

will %ode the "epo"t fo"m as

# F?SISG,=1

@ F?SISG,=2

C F?SISG,=+

D' FHSIS=M1

52 In p"epa"ing the mate"nal death "epo"t& whi%h

of the following %o""e%tly %odes this o%%$""en%eQ

# F?SISG,=1

)' FHSIS=E2

C F?SISG,=+

) F?SISG<=1

5+ Hhe"e sho$ld *$"se @$de b"ing the

"epo"ting fo"ms if he is in the @?U Fa%ilityQ

# $"al health offi%e

@ F?SIS <ain offi%e

C' Pr#8i$"ia+ /!a+t/ #i"!

) egional health offi%e

5. #fte" b"inging the "epo"ting fo"ms in the

"ight fa%ility fo" p"o%essing& *$"se @$de new

that the o$tp$t "epo"ts a"e solely p"od$%ed bywhat offi%eQ

# $"al health offi%e

@ F?SIS <ain offi%e

C' Pr#8i$"ia+ /!a+t/ #i"!

) egional health offi%e

5 <ang a$l ente"ed the health %ente"

%omplaining of fatig$e and f"e6$ent syn%ope

Ao$ assessed <ang a$l and fo$nd o$t that he

is se/e"ely malno$"ished and anemi% Hhat

"e%o"d sho$ld yo$ get fi"st to do%$ment thesefindingsQ



C epo"ting fo"ms

) O$tp$t "e%o"d

55 !he info"mation abo$t <ang a$lKs add"ess&

f$ll name& age& symptoms and diagnosis is

"e%o"ded in



C epo"ting fo"ms

) O$tp$t "e%o"d

58 #nothe" ent"y is to be made fo" <ang a$l

be%a$se he is in the ta"get %lientKs list& In what

!C' sho$ld <ang a$lKs ent"y be do%$mentedQ

# !C' ,ligible Pop$lation@ !C' Family Planning

C' TCL N0triti#$

) !C' P"e *atal

5 !he n$"se $ses the F?SIS e%o"d system

in%o""e%tly when she fo$nd o$t that

# She go to the indi/id$al o" F! fo" ent"y

%onfi"mation in the !allyGepo"t S$mma"y

)' S/! r!!r t# #t/!r s#0r"!s #r "#6*+!ti$

6#$t/+ a$% 0art!r+ r!*#rts

C She "e%o"ds dia""hea in the !ally sheetGepo"t






1 *$"se @$de w"ote a lette" to PCSO asing

them fo" assistan%e in thei" feeding p"og"ams fo"

the %omm$nityKs n$t"ition and health p"oEe%ts

PCSO then app"o/ed the "e6$est and ga/e

@$de 0&000 Pesos and a t"$%load of "i%e&

f"$its and /egetables Hhi%h phase of COP#

did @$de $tili(edQ

# P"epa"ato"y

@ O"gani(ational

C ,d$%ation and !"aining

D' I$t!rs!"t#ra+ C#++a7#rati#$

, Phase o$t

2 Ideally& ?ow many yea"s sho$ld the *$"se

stay in the %omm$nity befo"e he %an phase o$t

and be ass$"ed of a Self eliant %omm$nityQ

A' 5 !ars

@ 10 yea"sC 1 yea"

) 5 months

+ <aEo" dis%$ssion in %omm$nity o"gani(ation

a"e made by

# !he n$"se

@ !he leade"s of ea%h %ommittee

C' T/! !$tir! r#0*

) Collabo"ating #gen%ies

. !he n$"se sho$ld now that O"gani(ational plan best s$%%eeds when

1 People sees its /al$es2 People thin its antagonisti% p"ofessionally

+ It is in%ompatible with thei" pe"sonal beliefs

. It is %ompatible with thei" pe"sonal beliefs

# 1 and +

@ 2 and .

C 1 and 2

D' 1 a$% 4

*$"se @$de made a p"oposal that people

sho$ld t$"n thei" ba%ya"d into small fa"ming

lots to plant /egetables and f"$its ?e spe%ified

that the obEe%ti/e is to sa/e money in b$ying

/egetables and f"$its that tend to ha/e a

fl$%t$ating and %y%li%al p"i%e Hhi%h step in

Comm$nity o"gani(ing p"o%ess did he $tili(edQ

# Fa%t finding@ )ete"mination of needs

C' Pr#ra6 #r6ati#$

) ,d$%ation and Inte"p"etation

5 One of the %"iti%al steps in COP# is

be%oming one with the people and

$nde"standing thei" %$lt$"e and lifestyle Hhi%h

%"iti%al step in COP# will the *$"se t"y to

imme"se himself in the %omm$nityQ

A' I$t!rati#$

@ So%ial <obili(ation

C D"o$nd Ho"

) <obili(ation

8 !he #%t$al e-e"%ise of people powe" o%%$"s

d$"ing whenQ

# Integ"ation

@ So%ial <obili(ationC D"o$nd Ho"

D' M#7i+i9ati#$

Hhi%h steps in COP# t"ains indigeno$s

and info"mal leade"sQ

# D"o$nd Ho"

@ <obili(ation

C' C#r! Gr#0* #r6ati#$

) Integ"ation

9 #s a P?*& One of yo$" "ole is to o"gani(ethe %omm$nity *$"se @$de nows that the

p$"poses of %omm$nity o"gani(ing a"e

1 <o/e the %omm$nity to a%t on thei" own p"oblems

2 <ae people awa"e of thei" own p"oblems

+ ,nable the n$"se to sol/e the %omm$nity

p"oblems

. Offe" people means of sol/ing thei" own

p"oblems

# 1&2&+

@ 1&2&+&.C 1&2

D' 1,2,4

90 !his is %onside"ed the fi"st a%t of integ"ating

with the people !his gi/es an in depth

pa"ti%ipation in %omm$nity health p"oblems and

needs

A' R!si%i$ i$ t/! ar!a # assi$6!$t

@ 'isting down the name of pe"son to %onta%t fo"

%o$"tesy %all

C Dathe"ing initial info"mation abo$t the%omm$nity

) P"epa"ing #genda fo" the fi"st meeting

SI!U#!IO* : ?ealth ed$%ation is the p"o%ess

whe"eby nowledge& attit$de and p"a%ti%e of

people a"e %hanged to imp"o/e indi/id$al& family

and %omm$nity health

91 Hhi%h of the following is the %o""e%t se6$en%e

in health ed$%ationQ

1 Info"mation

2 Comm$ni%ation+ ,d$%ation

A' 1,2,3

@ +&2&1

C 1&+&2

) +&1&2

92 !he health stat$s of the people is g"eatly

affe%ted and dete"mined by whi%h of the






COMMUNIT( HEALTH NURSING Part 2

1 Hhi%h is the p"ima"y goal of %omm$nity

health n$"singQ

# !o s$ppo"t and s$pplement the effo"ts of the

medi%al p"ofession in the p"omotion of health

and p"e/ention of illness@ !o enhan%e the %apa%ity of indi/id$als&

families and %omm$nities to %ope with thei"

health needs

C !o in%"ease the p"od$%ti/ity of the people by

p"o/iding them with se"/i%es that will in%"ease

thei" le/el of health) !o %ont"ib$te to national de/elopment

th"o$gh p"omotion of family welfa"e& fo%$sing

pa"ti%$la"ly on mothe"s and %hild"en

A$s-!r ) T# !$/a$"! t/! "a*a"it #

i$%i8i%0a+s, a6i+i!s a$% "#660$iti!s t# "#*!

-it/ t/!ir /!a+t/ $!!%s

!o %ont"ib$te to national de/elopment th"o$gh p"omotion of family welfa"e& fo%$sing

pa"ti%$la"ly on mothe"s and %hild"en

2 C?* is a %omm$nity=based p"a%ti%e Hhi%h best e-plains this statementQ

# !he se"/i%e is p"o/ided in the nat$"al

en/i"onment of people

@ !he n$"se has to %ond$%t %omm$nity

diagnosis to dete"mine n$"sing needs and

p"oblems

C !he se"/i%es a"e based on the a/ailable

"eso$"%es within the %omm$nity

) P"io"ity setting is based on the magnit$de of

the health p"oblems identified

A$s-!r ) T/! $0rs! /as t# "#$%0"t

"#660$it %ia$#sis t# %!t!r6i$! $0rsi$

$!!%s a$% *r#7+!6s'

Comm$nity=based p"a%ti%e means p"o/iding

%a"e to people in thei" own nat$"al

en/i"onments: the home& s%hool and wo"pla%e&

fo" e-ample

+ Pop$lation=fo%$sed n$"sing p"a%ti%e "e6$i"es

whi%h of the following p"o%essesQ

# Comm$nity o"gani(ing

@ *$"sing p"o%ess

C Comm$nity diagnosis

) ,pidemiologi% p"o%ess

A$s-!r C C#660$it %ia$#sis

Pop$lation=fo%$sed n$"sing %a"e means

p"o/iding %a"e based on the g"eate" need of the

maEo"ity of the pop$lation !he g"eate" need is

identified th"o$gh %omm$nity diagnosis

. # 10. is also nown as the O%%$pational

?ealth #%t #side f"om n$mbe" of employees&

what othe" fa%to" m$st be %onside"ed in

dete"mining the o%%$pational health p"i/ileges to

whi%h the wo"e"s will be entitledQ

# !ype of o%%$pation: ag"i%$lt$"al& %omme"%ial&

ind$st"ial




@ 'o%ation of the wo"pla%e in "elation to

health fa%ilities

C Classifi%ation of the b$siness ente"p"ise based

on net p"ofit

) Se- and age %omposition of employees

A$s-!r ) L#"ati#$ # t/! -#rB*+a"! i$

r!+ati#$ t# /!a+t/ a"i+iti!s@ased on # 10.& an o%%$pational n$"se m$st

be employed when the"e a"e +0 to 100

employees and the wo"pla%e is mo"e than 1 m

away f"om the nea"est health %ente"

# b$siness fi"m m$st employ an o%%$pational

health n$"se when it has at least how many

employeesQ

# 21@ 101

C 201

) +01

A$s-!r ) 1?1

#gain& this is based on # 10.

5 Hhen the o%%$pational health n$"se employs

e"gonomi% p"in%iples& she is pe"fo"ming whi%h

of he" "olesQ

# ?ealth %a"e p"o/ide"

@ ?ealth ed$%ato"

C ?ealth %a"e %oo"dinato"

) ,n/i"onmental manage"

A$s-!r D E$8ir#$6!$ta+ 6a$a!r

,"gonomi%s is imp"o/ing effi%ien%y of wo"e"s

by imp"o/ing the wo"e"Ks en/i"onment th"o$ghapp"op"iately designed f$"nit$"e& fo" e-ample

8 # ga"ment fa%to"y does not ha/e an

o%%$pational n$"se Hho shall p"o/ide the

o%%$pational health needs of the fa%to"y

wo"e"sQ

# O%%$pational health n$"se at the P"o/in%ial

?ealth Offi%e

@ Physi%ian employed by the fa%to"y

C P$bli% health n$"se of the ?U of thei"

m$ni%ipality

) $"al sanita"y inspe%to" of the ?U of thei"

m$ni%ipality

A$s-!r C P07+i" /!a+t/ $0rs! # t/! RHU

# t/!ir 60$i"i*a+it

Ao$K"e "ight\ !his 6$estion is based on

#10.

P$bli% health se"/i%es a"e gi/en f"ee of

%ha"geT Is this statement t"$e o" falseQ

# !he statement is t"$eW it is the "esponsibility

of go/e"nment to p"o/ide basi% se"/i%es

@ !he statement is falseW people pay indi"e%tly

fo" p$bli% health se"/i%es

C !he statement may be t"$e o" false&

depending on the spe%ifi% se"/i%e "e6$i"ed

) !he statement may be t"$e o" false&

depending on poli%ies of the go/e"nment

%on%e"ned

A$s-!r ) T/! stat!6!$t is a+s! *!#*+!

*a i$%ir!"t+ #r *07+i" /!a+t/ s!r8i"!s'

Comm$nity health se"/i%es& in%l$ding p$bli%

health se"/i%es& a"e p"e=paid se"/i%es& tho$gh

ta-ation& fo" e-ample

9 #%%o"ding to C,Hinslow& whi%h of thefollowing is the goal of P$bli% ?ealthQ

# Fo" people to attain thei" bi"th"ights of health

and longe/ity

@ Fo" p"omotion of health and p"e/ention of

disease

C Fo" people to ha/e a%%ess to basi% health

se"/i%es

) Fo" people to be o"gani(ed in thei" health

effo"ts

A$s-!r A F#r *!#*+! t# attai$ t/!ir

7irt/ri/ts # /!a+t/ a$% +#$!8it#%%o"ding to Hinslow& all p$bli% health effo"ts

a"e fo" people to "eali(e thei" bi"th"ights of

health and longe/ity

10 He say that a Filipino has attained longe/ity

when he is able to "ea%h the a/e"age lifespan of

Filipinos Hhat othe" statisti% may be $sed to

dete"mine attainment of longe/ityQ

# #ge=spe%ifi% mo"tality "ate

@ P"opo"tionate mo"tality "ate

C Swa"oopKs inde-

) Case fatality "ate

A$s-!r C S-ar##*.s i$%!<

Swa"oopKs inde- is the pe"%entage of the deathsaged 0 yea"s o" olde" Its in/e"se "ep"esents the

pe"%entage of $ntimely deaths those who died

yo$nge" than 0 yea"s

11 Hhi%h of the following is the most

p"ominent feat$"e of p$bli% health n$"singQ

# It in/ol/es p"o/iding home %a"e to si%

people who a"e not %onfined in the hospital

@ Se"/i%es a"e p"o/ided f"ee of %ha"ge to people

within the %at%hment a"ea

C !he p$bli% health n$"se f$n%tions as pa"t of a

team p"o/iding a p$bli% health n$"sing se"/i%es

) P$bli% health n$"sing fo%$ses on p"e/enti/e&

not %$"ati/e& se"/i%es

A$s-!r D P07+i" /!a+t/ $0rsi$ #"0s!s #$

*r!8!$ti8!, $#t "0rati8!, s!r8i"!s'

!he %at%hment a"ea in P?* %onsists of a"esidential %omm$nity& many of whom a"e well

indi/id$als who ha/e g"eate" need fo" p"e/enti/e

"athe" than %$"ati/e se"/i%es

12 #%%o"ding to <a"ga"et Shetland& the

philosophy of p$bli% health n$"sing is based on

whi%h of the followingQ

# ?ealth and longe/ity as bi"th"ights

@ !he mandate of the state to p"ote%t the

bi"th"ights of its %iti(ens

C P$bli% health n$"sing as a spe%iali(ed field of

n$"sing




) !he wo"th and dignity of man

A$s-!r D T/! -#rt/ a$% %i$it # 6a$

!his is a di"e%t 6$ote f"om )" <a"ga"et

ShetlandKs statements on P$bli% ?ealth *$"sing

1+ Hhi%h of the following is the mission of the

)epa"tment of ?ealthQ# ?ealth fo" all Filipinos

@ ,ns$"e the a%%essibility and 6$ality of health

%a"e

C Imp"o/e the gene"al health stat$s of the

pop$lation

) ?ealth in the hands of the Filipino people by

the yea" 2020

A$s-!r ) E$s0r! t/! a""!ssi7i+it a$%

0a+it # /!a+t/ "ar!

none

1. egion I7 ?ospital is %lassified as what

le/el of fa%ilityQ

# P"ima"y

@ Se%onda"y

C Inte"mediate

) !e"tia"y

A$s-!r D T!rtiar

egional hospitals a"e te"tia"y fa%ilities be%a$se

they se"/e as t"aining hospitals fo" the "egion

1 Hhi%h is t"$e of p"ima"y fa%ilitiesQ# !hey a"e $s$ally go/e"nment="$n

@ !hei" se"/i%es a"e p"o/ided on an o$t=patient

basisC !hey a"e t"aining fa%ilities fo" health

p"ofessionals

) # %omm$nity hospital is an e-ample of this

le/el of health fa%ilities

A$s-!r ) T/!ir s!r8i"!s ar! *r#8i%!% #$

a$ #0t*ati!$t 7asis'

P"ima"y fa%ilities go/e"nment and non=

go/e"nment fa%ilities that p"o/ide basi% o$t=

patient se"/i%es

15 Hhi%h is an e-ample of the s%hool n$"seKs

health %a"e p"o/ide" f$n%tionsQ

# e6$esting fo" @CD f"om the ?U fo"

s%hool ent"ant imm$ni(ation

@ Cond$%ting "andom %lass"oom inspe%tion

d$"ing a measles epidemi%

C !aing "emedial a%tion on an a%%ident ha(a"din the s%hool playg"o$nd

) Obse"/ing pla%es in the s%hool whe"e p$pils

spend thei" f"ee time

A$s-!r ) C#$%0"ti$ ra$%#6 "+assr##6

i$s*!"ti#$ %0ri$ a 6!as+!s !*i%!6i"

andom %lass"oom inspe%tion is assessment of

p$pilsGst$dents and tea%he"s fo" signs of a health

p"oblem p"e/alent in the %omm$nity

18 Hhen the n$"se dete"mines whethe"

"eso$"%es we"e ma-imi(ed in implementing

'igtas !igdas& she is e/al$ating

# ,ffe%ti/eness

@ ,ffi%ien%y

C #de6$a%y

) #pp"op"iateness

A$s-!r ) Ei"i!$"

,ffi%ien%y is dete"mining whethe" the goalswe"e attained at the least possible %ost

1 Ao$ a"e a new @S* g"ad$ate Ao$ want to

be%ome a P$bli% ?ealth *$"se Hhe"e will yo$

applyQ

# )epa"tment of ?ealth

@ P"o/in%ial ?ealth Offi%e

C egional ?ealth Offi%e

) $"al ?ealth Unit

A$s-!r D R0ra+ H!a+t/ U$it

# 8150 de/ol/ed basi% health se"/i%es tolo%al go/e"nment $nits 'DUKs !he p$bli%

health n$"se is an employee of the 'DU

19 # 8150 mandates de/ol$tion of basi%

se"/i%es f"om the national go/e"nment to lo%al

go/e"nment $nits Hhi%h of the following is the

maEo" goal of de/ol$tionQ

# !o st"engthen lo%al go/e"nment $nits

@ !o allow g"eate" a$tonomy to lo%al

go/e"nment $nits

C !o empowe" the people and p"omote thei"

self="elian%e) !o mae basi% se"/i%es mo"e a%%essible to the

people

A$s-!r C T# !6*#-!r t/! *!#*+! a$%

*r#6#t! t/!ir s!+r!+ia$"!

People empowe"ment is the basi% moti/ation

behind de/ol$tion of basi% se"/i%es to 'DUKs

20 Hho is the Chai"man of the <$ni%ipal

?ealth @oa"dQ

# <ayo"

@ <$ni%ipal ?ealth Offi%e"

C P$bli% ?ealth *$"se

) #ny 6$alified physi%ian

A$s-!r A Ma#r

!he lo%al e-e%$ti/e se"/es as the %hai"man of

the <$ni%ipal ?ealth @oa"d

21 Hhi%h le/el of health fa%ility is the $s$al

point of ent"y of a %lient into the health %a"edeli/e"y systemQ

# P"ima"y

@ Se%onda"y

C Inte"mediate

) !e"tia"y

A$s-!r A Pri6ar

!he ent"y of a pe"son into the health %a"e

deli/e"y system is $s$ally th"o$gh a %ons$ltation

in o$t=patient se"/i%es




22 !he p$bli% health n$"se is the s$pe"/iso" of

"$"al health midwi/es Hhi%h of the following is

a s$pe"/iso"y f$n%tion of the p$bli% health

n$"seQ

# efe""ing %ases o" patients to the midwife

@ P"o/iding te%hni%al g$idan%e to the midwife

C P"o/iding n$"sing %a"e to %ases "efe""ed by

the midwife) Fo"m$lating and implementing t"aining

p"og"ams fo" midwi/es

A$s-!r ) Pr#8i%i$ t!"/$i"a+ 0i%a$"! t#

t/! 6i%-i!

!he n$"se p"o/ides te%hni%al g$idan%e to the

midwife in the %a"e of %lients& pa"ti%$la"ly in the

implementation of management g$idelines& as in

Integ"ated <anagement of Childhood Illness

2+ One of the pa"ti%ipants in a hilot t"aining

%lass ased yo$ to whom she sho$ld "efe" a patient in labo" who de/elops a %ompli%ation

Ao$ will answe"& to the

# P$bli% ?ealth *$"se

@ $"al ?ealth <idwife

C <$ni%ipal ?ealth Offi%e"

) #ny of these health p"ofessionals

A$s-!r C M0$i"i*a+ H!a+t/ Oi"!r

# p$bli% health n$"se and "$"al health midwife

%an p"o/ide %a"e d$"ing no"mal %hildbi"th #

physi%ian sho$ld attend to a woman with a

%ompli%ation d$"ing labo"

2. Ao$ a"e the p$bli% health n$"se in a

m$ni%ipality with a total pop$lation of abo$t20&000 !he"e a"e + "$"al health midwi/es

among the ?U pe"sonnel ?ow many mo"e

midwife items will the ?U needQ

# 1

@ 2

C +

) !he ?U does not need any mo"e midwife

item

A$s-!r A 1

,a%h "$"al health midwife is gi/en a pop$lation

assignment of abo$t &000

2 If the ?U needs additional midwife items&

yo$ will s$bmit the "e6$est fo" additional

midwife items fo" app"o/al to the

# $"al ?ealth Unit

@ )ist"i%t ?ealth Offi%eC P"o/in%ial ?ealth Offi%e

) <$ni%ipal ?ealth @oa"d

A$s-!r D M0$i"i*a+ H!a+t/ )#ar%

#s mandated by # 8150& basi% health se"/i%es

ha/e been de/ol/ed f"om the national

go/e"nment to lo%al go/e"nment $nits

25 #s an epidemiologist& the n$"se is

"esponsible fo" "epo"ting %ases of notifiable

diseases Hhat law mandates "epo"ting of %ases

of notifiable diseasesQ

# #%t +8+

@ # +8+

C # 10.

) # 102

A$s-!r A A"t 353

#%t +8+& the 'aw on epo"ting of

Comm$ni%able )iseases& ena%ted in 1929&mandated the "epo"ting of diseases listed in the

law to the nea"est health station

28 #%%o"ding to F"eeman and ?ein"i%h&

%omm$nity health n$"sing is a de/elopmental

se"/i%e Hhi%h of the following best ill$st"ates

this statementQ

# !he %omm$nity health n$"se %ontin$o$sly

de/elops himself pe"sonally and p"ofessionally@ ?ealth ed$%ation and %omm$nity o"gani(ing

a"e ne%essa"y in p"o/iding %omm$nity health

se"/i%esC Comm$nity health n$"sing is intended

p"ima"ily fo" health p"omotion and p"e/ention

and t"eatment of disease

) !he goal of %omm$nity health n$"sing is to

p"o/ide n$"sing se"/i%es to people in thei" own

pla%es of "esiden%e

A$s-!r ) H!a+t/ !%0"ati#$ a$%

"#660$it #ra$i9i$ ar! $!"!ssar i$

*r#8i%i$ "#660$it /!a+t/ s!r8i"!s'

!he %omm$nity health n$"se de/elops the health

%apability of people th"o$gh health ed$%ationand %omm$nity o"gani(ing a%ti/ities

2 Hhi%h disease was de%la"ed th"o$ghP"esidential P"o%lamation *o . as a ta"get fo"

e"adi%ation in the PhilippinesQ

# Poliomyelitis

@ <easles

C abies

) *eonatal tetan$s

A$s-!r ) M!as+!s

P"esidential P"o%lamation *o . is on the 'igtas

!igdas P"og"am

29 !he p$bli% health n$"se is "esponsible fo"

p"esenting the m$ni%ipal health statisti%s $sing

g"aphs and tables !o %ompa"e the f"e6$en%y of

the leading %a$ses of mo"tality in the

m$ni%ipality& whi%h g"aph will yo$ p"epa"eQ

# 'ine

@ @a"C Pie

) S%atte" diag"am

A$s-!r ) )ar

# ba" g"aph is $sed to p"esent %ompa"ison of

/al$es& a line g"aph fo" t"ends o/e" time o" age& a

pie g"aph fo" pop$lation %omposition o"

dist"ib$tion& and a s%atte" diag"am fo"

%o""elation of two /a"iables

+0 Hhi%h step in %omm$nity o"gani(ing

in/ol/es t"aining of potential leade"s in the




%omm$nityQ

# Integ"ation

@ Comm$nity o"gani(ation

C Comm$nity st$dy

) Co"e g"o$p fo"mation

A$s-!r D C#r! r#0* #r6ati#$

In %o"e g"o$p fo"mation& the n$"se is able tot"ansfe" the te%hnology of %omm$nity

o"gani(ing to the potential o" info"mal

%omm$nity leade"s th"o$gh a t"aining p"og"am

+1 In whi%h step a"e plans fo"m$lated fo"

sol/ing %omm$nity p"oblemsQ

# <obili(ation

@ Comm$nity o"gani(ation

C Follow=$pGe-tension) Co"e g"o$p fo"mation

A$s-!r ) C#660$it #ra$i9ati#$Comm$nity o"gani(ation is the step when

%omm$nity assemblies tae pla%e )$"ing the

%omm$nity assembly& the people may opt to

fo"mali(e the %omm$nity o"gani(ation and mae

plans fo" %omm$nity a%tion to "esol/e a

%omm$nity health p"oblem

+2 !he p$bli% health n$"se taes an a%ti/e "ole

in %omm$nity pa"ti%ipation Hhat is the p"ima"y

goal of %omm$nity o"gani(ingQ

# !o ed$%ate the people "ega"ding %omm$nity

health p"oblems@ !o mobili(e the people to "esol/e %omm$nity

health p"oblems

C !o ma-imi(e the %omm$nityKs "eso$"%es indealing with health p"oblems

) !o ma-imi(e the %omm$nityKs "eso$"%es in

dealing with health p"oblems

A$s-!r D T# 6a<i6i9! t/! "#660$it.s

r!s#0r"!s i$ %!a+i$ -it/ /!a+t/ *r#7+!6s

Comm$nity o"gani(ing is a de/elopmental

se"/i%e& with the goal of de/eloping the peopleKs

self="elian%e in dealing with %omm$nity health

p"oblems #& @ and C a"e obEe%ti/es of

%ont"ib$to"y obEe%ti/es to this goal

++ #n indi%ato" of s$%%ess in %omm$nity

o"gani(ing is when people a"e able to

# Pa"ti%ipate in %omm$nity a%ti/ities fo" the

sol$tion of a %omm$nity p"oblem

@ Implement a%ti/ities fo" the sol$tion of the

%omm$nity p"oblemC Plan a%ti/ities fo" the sol$tion of the

%omm$nity p"oblem

) Identify the health p"oblem as a %ommon

%on%e"n

A$s-!r A Parti"i*at! i$ "#660$it

a"ti8iti!s #r t/! s#+0ti#$ # a "#660$it

*r#7+!6

Pa"ti%ipation in %omm$nity a%ti/ities in

"esol/ing a %omm$nity p"oblem may be in any

of the p"o%esses mentioned in the othe" %hoi%es

+. !e"tia"y p"e/ention is needed in whi%h stage

of the nat$"al histo"y of diseaseQ

# P"e=pathogenesis

@ Pathogenesis

C P"od"omal

) !e"minal

A$s-!r D T!r6i$a+!e"tia"y p"e/ention in/ol/es "ehabilitation&

p"e/ention of pe"manent disability and disability

limitation app"op"iate fo" %on/ales%ents& the

disabled& %ompli%ated %ases and the te"minally

ill those in the te"minal stage of a disease

+ Isolation of a %hild with measles belongs to

what le/el of p"e/entionQ

# P"ima"y@ Se%onda"y

C Inte"mediate

) !e"tia"y

A$s-!r A Pri6ar

!he p$"pose of isolating a %lient with a

%omm$ni%able disease is to p"ote%t those who

a"e not si% spe%ifi% disease p"e/ention

+5 On the othe" hand& Ope"ation !imbang is

p"e/ention

# P"ima"y

@ Se%onda"y

C Inte"mediate

) !e"tia"y

A$s-!r ) S!"#$%ar

Ope"ation !imbang is done to identify membe"sof the s$s%eptible pop$lation who a"e

malno$"ished Its p$"pose is ea"ly diagnosis and&

s$bse6$ently& p"ompt t"eatment

+8 Hhi%h type of family=n$"se %onta%t will

p"o/ide yo$ with the best oppo"t$nity to obse"/e

family dynami%sQ

# Clini% %ons$ltation

@ D"o$p %onfe"en%e

C ?ome /isit

) H"itten %omm$ni%ation

A$s-!r C H#6! 8isit

)ynami%s of family "elationships %an best be

obse"/ed in the familyKs nat$"al en/i"onment&

whi%h is the home

+ !he typology of family n$"sing p"oblems is$sed in the statement of n$"sing diagnosis in the

%a"e of families !he yo$ngest %hild of the de los

eyes family has been diagnosed as mentally

"eta"ded !his is %lassified as a

# ?ealth th"eat

@ ?ealth defi%it

C Fo"eseeable %"isis

) St"ess point

A$s-!r ) H!a+t/ %!i"it

Fail$"e of a family membe" to de/elop




a%%o"ding to what is e-pe%ted& as in mental

"eta"dation& is a health defi%it

+9 !he de los eyes %o$ple ha/e a 5=yea" old

%hild ente"ing s%hool fo" the fi"st time !he de

los eyes family has a

# ?ealth th"eat

@ ?ealth defi%itC Fo"eseeable %"isis

) St"ess point

A$s-!r C F#r!s!!a7+! "risis

,nt"y of the 5=yea" old into s%hool is an

anti%ipated pe"iod of $n$s$al demand on the

family

.0 Hhi%h of the following is an ad/antage of ahome /isitQ

# It allows the n$"se to p"o/ide n$"sing %a"e to

a g"eate" n$mbe" of people@ It p"o/ides an oppo"t$nity to do fi"st hand

app"aisal of the home sit$ation

C It allows sha"ing of e-pe"ien%es among

people with simila" health p"oblems

) It de/elops the familyKs initiati/e in

p"o/iding fo" health needs of its membe"s

A$s-!r ) It *r#8i%!s a$ #**#rt0$it t# %#

irst /a$% a**raisa+ # t/! /#6! sit0ati#$'

Choi%e # is not %o""e%t sin%e a home /isit

"e6$i"es that the n$"se spend so m$%h time with

the family Choi%e C is an ad/antage of a g"o$p%onfe"en%e& while %hoi%e ) is t"$e of a %lini%

%ons$ltation

.1 Hhi%h is CO*!#A to the p"in%iples in

planning a home /isitQ

# # home /isit sho$ld ha/e a p$"pose o"

obEe%ti/e

@ !he plan sho$ld "e/ol/e a"o$nd family health

needs

C # home /isit sho$ld be %ond$%ted in the

manne" p"es%"ibed by the ?U

) Planning of %ontin$ing %a"e sho$ld in/ol/e a

"esponsible family membe"

A$s-!r C A /#6! 8isit s/#0+% 7!

"#$%0"t!% i$ t/! 6a$$!r *r!s"ri7!% 7 t/!

RHU'

!he home /isit plan sho$ld be fle-ible and

p"a%ti%al& depending on fa%to"s& s$%h as the

familyKs needs and the "eso$"%es a/ailable to the

n$"se and the family

.2 !he P?* bag is an impo"tant tool in

p"o/iding n$"sing %a"e d$"ing a home /isit !he

most impo"tant p"in%iple of bag te%hni6$e states

that it

# Sho$ld sa/e time and effo"t

@ Sho$ld minimi(e if not totally p"e/ent the

sp"ead of infe%tion

C Sho$ld not o/e"shadow %on%e"n fo" the

patient and his family

) <ay be done in a /a"iety of ways depending

on the home sit$ation& et%

A$s-!r ) S/#0+% 6i$i6i9! i $#t t#ta++

*r!8!$t t/! s*r!a% # i$!"ti#$'

@ag te%hni6$e is pe"fo"med befo"e and afte"

handling a %lient in the home to p"e/ent

t"ansmission of infe%tion to and f"om the %lient

.+ !o maintain the %leanliness of the bag and its%ontents& whi%h of the following m$st the n$"se

doQ

# Hash hisGhe" hands befo"e and afte"

p"o/iding n$"sing %a"e to the family membe"s

@ In the %a"e of family membe"s& as m$%h as

possible& $se only a"ti%les taen f"om the bag

C P$t on an ap"on to p"ote%t he" $nifo"m and

fold it with the "ight side o$t befo"e p$tting it

ba% into the bag) #t the end of the /isit& fold the lining on

whi%h the bag was pla%ed& ens$"ing that the

%ontaminated side is on the o$tside

A$s-!r A as/ /is=/!r /a$%s 7!#r! a$%

at!r *r#8i%i$ $0rsi$ "ar! t# t/! a6i+

6!67!rs'

Choi%e @ goes against the idea of $tili(ing the

familyKs "eso$"%es& whi%h is en%o$"aged in

C?* Choi%es C and ) goes against the

p"in%iple of asepsis of %onfining the

%ontaminated s$"fa%e of obEe%ts

.. !he p$bli% health n$"se %ond$%ts a st$dy on

the fa%to"s %ont"ib$ting to the high mo"tality "ated$e to hea"t disease in the m$ni%ipality whe"e

she wo"s Hhi%h b"an%h of epidemiology does

the n$"se p"a%ti%e in this sit$ationQ# )es%"ipti/e

@ #nalyti%al

C !he"ape$ti%

) ,/al$ation

A$s-!r ) A$a+ti"a+

#nalyti%al epidemiology is the st$dy of fa%to"s

o" dete"minants affe%ting the patte"ns of

o%%$""en%e and dist"ib$tion of disease in a

%omm$nity

. Hhi%h of the following is a f$n%tion of

epidemiologyQ

# Identifying the disease %ondition based on

manifestations p"esented by a %lient

@ )ete"mining fa%to"s that %ont"ib$ted to the

o%%$""en%e of pne$monia in a + yea" old

C )ete"mining the effi%a%y of the antibioti%$sed in the t"eatment of the + yea" old %lient

with pne$monia

) ,/al$ating the effe%ti/eness of the

implementation of the Integ"ated <anagement

of Childhood Illness

A$s-!r D E8a+0ati$ t/! !!"ti8!$!ss #

t/! i6*+!6!$tati#$ # t/! I$t!rat!%

Ma$a!6!$t # C/i+%/##% I++$!ss

,pidemiology is $sed in the assessment of a

%omm$nity o" e/al$ation of inte"/entions in

%omm$nity health p"a%ti%e




.5 Hhi%h of the following is an epidemiologi%

f$n%tion of the n$"se d$"ing an epidemi%Q

# Cond$%ting assessment of s$spe%ted %ases to

dete%t the %omm$ni%able disease

@ <onito"ing the %ondition of the %ases affe%ted

by the %omm$ni%able disease

C Pa"ti%ipating in the in/estigation to dete"minethe so$"%e of the epidemi%

) !ea%hing the %omm$nity on p"e/enti/e

meas$"es against the disease

A$s-!r C Parti"i*ati$ i$ t/! i$8!stiati#$

t# %!t!r6i$! t/! s#0r"! # t/! !*i%!6i"

,pidemiology is the st$dy of patte"ns of

o%%$""en%e and dist"ib$tion of disease in the

%omm$nity& as well as the fa%to"s that affe%tdisease patte"ns !he p$"pose of an

epidemiologi% in/estigation is to identify the

so$"%e of an epidemi%& ie& what b"o$ght abo$tthe epidemi%

.8 !he p"ima"y p$"pose of %ond$%ting an

epidemiologi% in/estigation is to

# )elineate the etiology of the epidemi%

@ ,n%o$"age %oope"ation and s$ppo"t of the

%omm$nity

C Identify g"o$ps who a"e at "is of %ont"a%ting

the disease

) Identify geog"aphi%al lo%ation of %ases of the

disease in the %omm$nity

A$s-!r A D!+i$!at! t/! !ti#+# # t/!

!*i%!6i"

)elineating the etiology of an epidemi% isidentifying its so$"%e

. Hhi%h is a %ha"a%te"isti% of pe"son=to=pe"son

p"opagated epidemi%sQ

# !he"e a"e mo"e %ases of the disease than

e-pe%ted

@ !he disease m$st ne%essa"ily be t"ansmitted

th"o$gh a /e%to"

C !he sp"ead of the disease %an be att"ib$ted to

a %ommon /ehi%le

) !he"e is a g"ad$al b$ild $p of %ases befo"e

the epidemi% be%omes easily noti%eable

A$s-!r D T/!r! is a ra%0a+ 70i+% 0* #

"as!s 7!#r! t/! !*i%!6i" 7!"#6!s !asi+

$#ti"!a7+!'

# g"ad$al o" insidio$s onset of the epidemi% is

$s$ally obse"/able in pe"son=to=pe"son p"opagated epidemi%s

.9 In the in/estigation of an epidemi%& yo$

%ompa"e the p"esent f"e6$en%y of the disease

with the $s$al f"e6$en%y at this time of the yea"

in this %omm$nity !his is done d$"ing whi%h

stage of the in/estigationQ

# ,stablishing the epidemi%

@ !esting the hypothesis

C Fo"m$lation of the hypothesis

) #pp"aisal of fa%ts

A$s-!r A Esta7+is/i$ t/! !*i%!6i"

,stablishing the epidemi% is dete"mining

whethe" the"e is an epidemi% o" not !his is done

by %ompa"ing the p"esent n$mbe" of %ases with

the $s$al n$mbe" of %ases of the disease at the

same time of the yea"& as well as establishing the

"elatedness of the %ases of the disease

0 !he n$mbe" of %ases of )eng$e fe/e"

$s$ally in%"eases towa"ds the end of the "ainy

season !his patte"n of o%%$""en%e of )eng$e

fe/e" is best des%"ibed as

# ,pidemi% o%%$""en%e

@ Cy%li%al /a"iation

C Spo"adi% o%%$""en%e

) Se%$la" /a"iation

A$s-!r ) C"+i"a+ 8ariati#$

# %y%li%al /a"iation is a pe"iodi% fl$%t$ation in

the n$mbe" of %ases of a disease in the%omm$nity

1 In the yea" 190& the Ho"ld ?ealth

O"gani(ation de%la"ed the Philippines& togethe"

with some othe" %o$nt"ies in the Heste"n Pa%ifi%

egion& f"eeT of whi%h diseaseQ

# Pne$moni% plag$e

@ Poliomyelitis

C Small po-

) #nth"a-

A$s-!r C S6a++ *#<!he last do%$mented %ase of Small po- was in

1988 at Somalia

2 In the %ens$s of the Philippines in 199&

the"e we"e abo$t +&299&000 males and abo$t

+.&95&000 females Hhat is the se- "atioQ

# 9905:100

@ 1009.:100

C 02+V

) .985V

A$s-!r ) 1??'>41??

Se- "atio is the n$mbe" of males fo" e/e"y 100

females in the pop$lation

+ P"ima"y health %a"e is a total app"oa%h to

%omm$nity de/elopment Hhi%h of the

following is an indi%ato" of s$%%ess in the $se of

the p"ima"y health %a"e app"oa%hQ

# ?ealth se"/i%es a"e p"o/ided f"ee of %ha"ge to

indi/id$als and families@ 'o%al offi%ials a"e empowe"ed as the maEo"

de%ision mae"s in matte"s of health

C ?ealth wo"e"s a"e able to p"o/ide %a"e based

on identified health needs of the people

) ?ealth p"og"ams a"e s$stained a%%o"ding to

the le/el of de/elopment of the %omm$nity

A$s-!r D H!a+t/ *r#ra6s ar! s0stai$!%

a""#r%i$ t# t/! +!8!+ # %!8!+#*6!$t # t/!

"#660$it'

P"ima"y health %a"e is essential health %a"e that




%an be s$stained in all stages of de/elopment of

the %omm$nity

. Sp$t$m e-amination is the maEo" s%"eening

tool fo" p$lmona"y t$be"%$losis Clients wo$ld

sometimes get false negati/e "es$lts in this

e-am !his means that the test is not pe"fe%t in

te"ms of whi%h %ha"a%te"isti% of a diagnosti%e-aminationQ

# ,ffe%ti/eness

@ ,ffi%a%y

C Spe%ifi%ity

) Sensiti/ity

A$s-!r D S!$siti8it

Sensiti/ity is the %apa%ity of a diagnosti%

e-amination to dete%t %ases of the disease If atest is 100V sensiti/e& all the %ases tested will

ha/e a positi/e "es$lt& ie& the"e will be no false

negati/e "es$lts

Use of app"op"iate te%hnology "e6$i"es

nowledge of indigeno$s te%hnology Hhi%h

medi%inal he"b is gi/en fo" fe/e"& heada%he and

%o$ghQ

# Sambong

@ !saang g$bat

C #ap$lo

) 'ag$ndi

A$s-!r D La0$%i

Sambong is $sed as a di$"eti% !saang g$bat is$sed to "elie/e dia""hea #ap$lo is $sed fo" its

antif$ngal p"ope"ty

5 Hhat law %"eated the Philippine Instit$te of

!"aditional and #lte"nati/e ?ealth Ca"eQ

# # .2+

@ # .2+

C # 2.+

) # +.2

A$s-!r A R'A' 423

none

8 In t"aditional Chinese medi%ine& the yielding&

negati/e and feminine fo"%e is te"med

# Ain

@ Aang

C >i

) Chai

A$s-!r A (i$

Aang is the male dominating& positi/e and

mas%$line fo"%e

Hhat is the legal basis fo" P"ima"y ?ealth

Ca"e app"oa%h in the PhilippinesQ

# #lma #ta )e%la"ation on P?C

@ 'ette" of Inst"$%tion *o 9.9

C P"esidential )e%"ee *o 1.8

) P"esidential )e%"ee 995

A$s-!r ) L!tt!r # I$str0"ti#$ N#' >4>

'ette" of Inst"$%tion 9.9 was iss$ed by then

P"esident Fe"dinand <a"%os& di"e%ting the

fo"me"ly %alled <inist"y of ?ealth& now the

)epa"tment of ?ealth& to $tili(e P"ima"y ?ealth

Ca"e app"oa%h in planning and implementing

health p"og"ams

9 Hhi%h of the following demonst"ates

inte"se%to"al linagesQ# !wo=way "efe""al system

@ !eam app"oa%h

C ,ndo"sement done by a midwife to anothe"

midwife

) Coope"ation between the P?* and p$bli%

s%hool tea%he"

A$s-!r D C##*!rati#$ 7!t-!!$ t/! PHN

a$% *07+i" s"/##+ t!a"/!r

Inte"se%to"al linages "efe" to wo"ing

"elationships between the health se%to" and othe"

se%to"s in/ol/ed in %omm$nity de/elopment

50 !he m$ni%ipality assigned to yo$ has a

pop$lation of abo$t 20&000 ,stimate the n$mbe"

of 1=. yea" old %hild"en who will be gi/en

etinol %aps$le 200&000 IU e/e"y 5 months

# 1&00

@ 1&00

C 2&000

) 2&+00

A$s-!r D 2,3??

@ased on the Philippine pop$lation %omposition&to estimate the n$mbe" of 1=. yea" old %hild"en&

m$ltiply total pop$lation by 11V

51 ,stimate the n$mbe" of p"egnant women

who will be gi/en tetan$s to-oid d$"ing an

imm$ni(ation o$t"ea%h a%ti/ity in a ba"angay

with a pop$lation of abo$t 1&00

# 25

@ +00

C +8

) .00

A$s-!r A 2;5

!o estimate the n$mbe" of p"egnant women&

m$ltiply the total pop$lation by +V

52 !o des%"ibe the se- %omposition of the

pop$lation& whi%h demog"aphi% tool may be

$sedQ

# Se- "atio

@ Se- p"opo"tionC Pop$lation py"amid

) #ny of these may be $sed

A$s-!r D A$ # t/!s! 6a 7! 0s!%'

Se- "atio and se- p"opo"tion a"e $sed to

dete"mine the se- %omposition of a pop$lation

# pop$lation py"amid is $sed to p"esent the

%omposition of a pop$lation by age and se-

5+ Hhi%h of the following is a natality "ateQ

# C"$de bi"th "ate

@ *eonatal mo"tality "ate




C Infant mo"tality "ate

) Dene"al fe"tility "ate

A$s-!r A Cr0%! 7irt/ rat!

*atality means bi"th # natality "ate is a bi"th

"ate

5. Ao$ a"e %omp$ting the %"$de death "ate ofyo$" m$ni%ipality& with a total pop$lation of

abo$t 1&000& fo" last yea" !he"e we"e 9.

deaths #mong those who died& 20 died be%a$se

of diseases of the hea"t and +2 we"e aged 0

yea"s o" olde" Hhat is the %"$de death "ateQ

# .2G1&000

@ 2G1&000

C 5+G1&000

) 8+G1&000

A$s-!r ) 5'2=1,???

!o %omp$te %"$de death "ate di/ide total n$mbe"of deaths 9. by total pop$lation 1&000 and

m$ltiply by 1&000

5 nowing that maln$t"ition is a f"e6$ent

%omm$nity health p"oblem& yo$ de%ided to

%ond$%t n$t"itional assessment Hhat pop$lation

is pa"ti%$la"ly s$s%eptible to p"otein ene"gy

maln$t"ition P,<Q

# P"egnant women and the elde"ly

@ Unde"= yea" old %hild"en

C 1=. yea" old %hild"en

) S%hool age %hild"en

A$s-!r C 14 !ar #+% "/i+%r!$

P"es%hoole"s a"e the most s$s%eptible to P,< be%a$se they ha/e gene"ally been weaned #lso&

this is the pop$lation who& $nable to feed

themsel/es& a"e often the /i%tims of poo"

int"afamilial food dist"ib$tion

55 Hhi%h statisti% %an gi/e the most a%%$"ate

"efle%tion of the health stat$s of a %omm$nityQ

# 1=. yea" old age=spe%ifi% mo"tality "ate

@ Infant mo"tality "ate

C Swa"oopKs inde-

) C"$de death "ate

A$s-!r C S-ar##*.s i$%!<

Swa"oopKs inde- is the p"opo"tion of deaths

aged 0 yea"s and abo/e !he highe" the

Swa"oopKs inde- of a pop$lation& the g"eate" the

p"opo"tion of the deaths who we"e able to "ea%h

the age of at least 0 yea"s& ie& mo"e peopleg"ew old befo"e they died

58 In the past yea"& @a"angay # had an a/e"age

pop$lation of 15 .5 babies we"e bo"n in that

yea"& 2 of whom died less than . wees afte"

they we"e bo"n !he"e we"e . "e%o"ded

stillbi"ths Hhat is the neonatal mo"tality "ateQ

# 28G1&000

@ .+G1&000

C 59G1&000

) 1+0.G1&000

A$s-!r ) 43'5=1,???

!o %omp$te fo" neonatal mo"tality "ate& di/ide

the n$mbe" of babies who died befo"e "ea%hing

the age of 2 days by the total n$mbe" of li/e

bi"ths& then m$ltiply by 1&000

5 Hhi%h statisti% best "efle%ts the n$t"itional

stat$s of a pop$lationQ

# 1=. yea" old age=spe%ifi% mo"tality "ate@ P"opo"tionate mo"tality "ate

C Infant mo"tality "ate

) Swa"oopKs inde-

A$s-!r A 14 !ar #+% a!s*!"ii"

6#rta+it rat!

Sin%e p"es%hoole"s a"e the most s$s%eptible to

the effe%ts of maln$t"ition& a pop$lation with

poo" n$t"itional stat$s will most liely ha/e ahigh 1=. yea" old age=spe%ifi% mo"tality "ate&

also nown as %hild mo"tality "ate

59 Hhat n$me"ato" is $sed in %omp$ting

gene"al fe"tility "ateQ

# ,stimated midyea" pop$lation

@ *$mbe" of "egiste"ed li/e bi"ths

C *$mbe" of p"egnan%ies in the yea"

) *$mbe" of females of "ep"od$%ti/e age

A$s-!r ) N067!r # r!ist!r!% +i8! 7irt/s

!o %omp$te fo" gene"al o" total fe"tility "ate&

di/ide the n$mbe" of "egiste"ed li/e bi"ths by the

n$mbe" of females of "ep"od$%ti/e age 1=.

yea"s& then m$ltiply by 1&000

80 Ao$ will gathe" data fo" n$t"itional

assessment of a p$"o Ao$ will gathe"info"mation only f"om families with membe"s

who belong to the ta"get pop$lation fo" P,<

Hhat method of data gathe"ing is best fo" this

p$"poseQ

# Cens$s

@ S$"/ey

C e%o"d "e/iew

) e/iew of %i/il "egist"y

A$s-!r ) S0r8!

# s$"/ey& also %alled sample s$"/ey& is data

gathe"ing abo$t a sample of the pop$lation

81 In the %ond$%t of a %ens$s& the method of

pop$lation assignment based on the a%t$al

physi%al lo%ation of the people is te"med

# )e E$"e

@ )e lo%$sC )e fa%to

) )e no/o

A$s-!r C D! a"t#

!he othe" method of pop$lation assignment& de

E$"e& is based on the $s$al pla%e of "esiden%e of

the people

82 !he Field ?ealth Se"/i%es and Info"mation

System F?SIS is the "e%o"ding and "epo"ting

system in p$bli% health %a"e in the Philippines

!he <onthly Field ?ealth Se"/i%e #%ti/ity




epo"t is a fo"m $sed in whi%h of the

%omponents of the F?SISQ

# !ally "epo"t

@ O$tp$t "epo"t

C !a"getG%lient list

) Indi/id$al health "e%o"d

A$s-!r A Ta++ r!*#rt# tally "epo"t is p"epa"ed monthly o" 6$a"te"ly

by the ?U pe"sonnel and t"ansmitted to the

P"o/in%ial ?ealth Offi%e

8+ !o monito" %lients "egiste"ed in long=te"m

"egimens& s$%h as the <$lti=)"$g !he"apy&

whi%h %omponent will be most $sef$lQ

# !ally "epo"t

@ O$tp$t "epo"tC !a"getG%lient list

) Indi/id$al health "e%o"d

A$s-!r C Tar!t="+i!$t +ist

!he <)! Client 'ist is a "e%o"d of %lients

en"olled in <)! and othe" "ele/ant data& s$%h as

dates when %lients %olle%ted thei" monthly

s$pply of d"$gs

8. Ci/il "egist"ies a"e impo"tant so$"%es of data

Hhi%h law "e6$i"es "egist"ation of bi"ths within

+0 days f"om the o%%$""en%e of the bi"thQ

# P) 51

@ #%t +8+

C # +8+) # ++8

A$s-!r A P'D' ;51

P) 51 amended # +8+& "e6$i"ing the

"egist"y of bi"ths within +0 days f"om thei"

o%%$""en%e

8 Hhi%h of the following p"ofessionals %an

sign the bi"th %e"tifi%ateQ

# P$bli% health n$"se

@ $"al health midwife

C <$ni%ipal health offi%e"

) #ny of these health p"ofessionals

A$s-!r D A$ # t/!s! /!a+t/ *r#!ssi#$a+s

) # +8+ states that any bi"th attendant may

sign the %e"tifi%ate of li/e bi"th

85 Hhi%h %"ite"ion in p"io"ity setting of health

p"oblems is $sed only in %omm$nity health%a"eQ

# <odifiability of the p"oblem

@ *at$"e of the p"oblem p"esented

C <agnit$de of the health p"oblem

) P"e/enti/e potential of the health p"oblem

A$s-!r C Ma$it0%! # t/! /!a+t/ *r#7+!6

<agnit$de of the p"oblem "efe"s to the

pe"%entage of the pop$lation affe%ted by a health

p"oblem !he othe" %hoi%es a"e %"ite"ia

%onside"ed in both family and %omm$nity health

%a"e

88 !he Sent"ong Sigla <o/ement has been

la$n%hed to imp"o/e health se"/i%e deli/e"y

Hhi%h of the following isGa"e t"$e of this

mo/ementQ

# !his is a p"oEe%t spea"headed by lo%algo/e"nment $nits

@ It is a basis fo" in%"easing f$nding f"om lo%al

go/e"nment $nits

C It en%o$"ages health %ente"s to fo%$s on

disease p"e/ention and %ont"ol

) Its main st"ategy is %e"tifi%ation of health

%ente"s able to %omply with standa"ds

A$s-!r D Its 6ai$ strat! is "!rtii"ati#$

# /!a+t/ "!$t!rs a7+! t# "#6*+ -it/

sta$%ar%s'

Sent"ong Sigla <o/ement is a Eoint p"oEe%t ofthe )O? and lo%al go/e"nment $nits Its main

st"ategy is %e"tifi%ation of health %ente"s that a"e

able to %omply with standa"ds set by the )O?

8 Hhi%h of the following women sho$ld be

%onside"ed as spe%ial ta"gets fo" family

planningQ

# !hose who ha/e two %hild"en o" mo"e

@ !hose with medi%al %onditions s$%h as

anemia

C !hose yo$nge" than 20 yea"s and olde" than

+ yea"s) !hose who E$st had a deli/e"y within the past

1 months

A$s-!r D T/#s! -/# J0st /a% a %!+i8!r

-it/i$ t/! *ast 15 6#$t/s

!he ideal bi"th spa%ing is at least two yea"s 1

months pl$s 9 months of p"egnan%y 2 yea"s

89 F"eedom of %hoi%e is one of the poli%ies of

the Family Planning P"og"am of the Philippines

Hhi%h of the following ill$st"ates this p"in%ipleQ

# Info"mation dissemination abo$t the need fo"

family planning

@ S$ppo"t of "esea"%h and de/elopment in

family planning methods

C #de6$ate info"mation fo" %o$ples "ega"ding

the diffe"ent methods

) ,n%o$"agement of %o$ples to tae family

planning as a Eoint "esponsibility

A$s-!r C A%!0at! i$#r6ati#$ #r

"#0*+!s r!ar%i$ t/! %i!r!$t 6!t/#%s

!o enable the %o$ple to %hoose f"eely among

diffe"ent methods of family planning& they m$st

be gi/en f$ll info"mation "ega"ding the diffe"ent

methods that a"e a/ailable to them& %onside"ing

the a/ailability of 6$ality se"/i%es that %an

s$ppo"t thei" %hoi%e

0 # woman& 5 months p"egnant& %ame to the

%ente" fo" %ons$ltation Hhi%h of the following

s$bstan%es is %ont"aindi%atedQ




# !etan$s to-oid

@ etinol 200&000 IU

C Fe""o$s s$lfate 200 mg

) Potassi$m iodate 200 mg %aps$le

A$s-!r ) R!ti$#+ 2??,??? IU

etinol 200&000 IU is a fo"m of megadose

7itamin # !his may ha/e a te"atogeni% effe%t

1 )$"ing p"enatal %ons$ltation& a %lient ased

yo$ if she %an ha/e he" deli/e"y at home #fte"

histo"y taing and physi%al e-amination& yo$

ad/ised he" against a home deli/e"y Hhi%h of

the following findings dis6$alifies he" fo" a

home deli/e"yQ

# ?e" O@ s%o"e is DP+

@ She has some palma" pallo"C ?e" blood p"ess$"e is 1+0G0

) ?e" baby is in %ephali% p"esentation

A$s-!r A H!r O) s"#r! is G5P3'

Only women with less than p"egnan%ies a"e

6$alified fo" a home deli/e"y It is also ad/isable

fo" a p"imig"a/ida to ha/e deli/e"y at a

%hildbi"th fa%ility

2 Inade6$ate intae by the p"egnant woman of

whi%h /itamin may %a$se ne$"al t$be defe%tsQ

# *ia%in

@ ibofla/in

C Foli% a%id

) !hiamine

A$s-!r C F#+i" a"i%

It is estimated that the in%iden%e of ne$"al t$bedefe%ts %an be "ed$%ed d"asti%ally if p"egnant

women ha/e an ade6$ate intae of foli% a%id

+ Ao$ a"e in a %lientKs home to attend to a

deli/e"y Hhi%h of the following will yo$ do

fi"stQ

# Set $p the ste"ile a"ea

@ P$t on a %lean gown o" ap"on

C Cleanse the %lientKs /$l/a with soap and

wate"

) *ote the inte"/al& d$"ation and intensity of

labo" %ont"a%tions

A$s-!r D N#t! t/! i$t!r8a+, %0rati#$ a$%

i$t!$sit # +a7#r "#$tra"ti#$s'

#ssessment of the woman sho$ld be done fi"st

to dete"mine whethe" she is ha/ing t"$e labo"

and& if so& what stage of labo" she is in

. In p"epa"ing a p"imig"a/ida fo"

b"eastfeeding& whi%h of the following will yo$

doQ

# !ell he" that la%tation begins within a day

afte" deli/e"y

@ !ea%h he" nipple st"et%hing e-e"%ises if he"

nipples a"e e/e"ted

C Inst"$%t he" to wash he" nipples befo"e and

afte" ea%h b"eastfeeding

) ,-plain to he" that p$tting the baby to b"east

will lessen blood loss afte" deli/e"y

A$s-!r D E<*+ai$ t# /!r t/at *0tti$ t/!

7a7 t# 7r!ast -i++ +!ss!$ 7+##% +#ss at!r

%!+i8!r'

S$%ling of the nipple stim$lates the "elease of

o-yto%in by the poste"io" pit$ita"y gland& whi%h

%a$ses $te"ine %ont"a%tion 'a%tation begins 1 to

+ days afte" deli/e"y *ipple st"et%hing e-e"%isesa"e done when the nipples a"e flat o" in/e"ted

F"e6$ent washing d"ies $p the nipples& maing

them p"one to the fo"mation of fiss$"es

# p"imig"a/ida is inst"$%ted to offe" he"

b"east to the baby fo" the fi"st time within +0

min$tes afte" deli/e"y Hhat is the p$"pose of

offe"ing the b"east this ea"lyQ

# !o initiate the o%%$""en%e of mil letdown@ !o stim$late mil p"od$%tion by the

mamma"y a%ini

C !o mae s$"e that the baby is able to get the%olost"$m

) !o allow the woman to p"a%ti%e b"eastfeeding

in the p"esen%e of the health wo"e"

A$s-!r ) T# sti60+at! 6i+B *r#%0"ti#$ 7

t/! 6a66ar a"i$i

S$%ling of the nipple stim$lates p"ola%tin "efle-

the "elease of p"ola%tin by the ante"io" pit$ita"y

gland& whi%h initiates la%tation

5 In a mothe"sK %lass& yo$ dis%$ss p"ope"

b"eastfeeding te%hni6$e Hhi%h is of these is asign that the baby has lat%hed onT to the b"east

p"ope"lyQ

# !he baby taes shallow& "apid s$%s@ !he mothe" does not feel nipple pain

C !he babyKs mo$th is only pa"tly open

) Only the mothe"Ks nipple is inside the babyKs

mo$th

A$s-!r ) T/! 6#t/!r %#!s $#t !!+ $i**+!

*ai$'

Hhen the baby has p"ope"ly lat%hed on to the

b"east& he taes deep& slow s$%sW his mo$th is

wide openW and m$%h of the a"eola is inside his

mo$th #nd& yo$K"e "ight\ !he mothe" does not

feel nipple pain

8 Ao$ e-plain to a b"eastfeeding mothe" that

b"east mil is s$ffi%ient fo" all of the babyKs

n$t"ient needs only $p to

# + months

@ 5 monthsC 1 yea"

) 2 yea"s

A$s-!r ) ; 6#$t/s

#fte" 5 months& the babyKs n$t"ient needs&

espe%ially the babyKs i"on "e6$i"ement& %an no

longe" be p"o/ided by mothe"Ks mil alone

Hhat is gi/en to a woman within a month

afte" the deli/e"y of a babyQ

# <al$nggay %aps$le

@ Fe""o$s s$lfate 100 mg O)




C etinol 200&000 IU& 1 %aps$le

) Potassi$m iodate 200 mg& 1 %aps$le

A$s-!r C R!ti$#+ 2??,??? I'U', 1 "a*s0+!

# %aps$le of etinol 200&000 IU is gi/en within

1 month afte" deli/e"y Potassi$m iodate is gi/en

d$"ing p"egnan%yW mal$nggay %aps$le is not

"o$tinely administe"ed afte" deli/e"yW andfe""o$s s$lfate is taen fo" two months afte"

deli/e"y

9 Hhi%h biologi%al $sed in ,-panded P"og"am

on Imm$ni(ation ,PI is sto"ed in the f"ee(e"Q

# )P!

@ !etan$s to-oid

C <easles /a%%ine

) ?epatitis @ /a%%ine

A$s-!r C M!as+!s 8a""i$!

#mong the biologi%als $sed in the ,-pandedP"og"am on Imm$ni(ation& measles /a%%ine and

OP7 a"e highly sensiti/e to heat& "e6$i"ing

sto"age in the f"ee(e"

90 Un$sed @CD sho$ld be dis%a"ded how many

ho$"s afte" "e%onstit$tionQ

# 2

@ .

C 5

) #t the end of the day

A$s-!r ) 4Hhile the $n$sed po"tion of othe" biologi%als in

,PI may be gi/en $ntil the end of the day& only

@CD is dis%a"ded . ho$"s afte" "e%onstit$tion!his is why @CD imm$ni(ation is s%hed$led

only in the mo"ning

91 In imm$ni(ing s%hool ent"ants with @CD&

yo$ a"e not obliged to se%$"e pa"ental %onsent

!his is be%a$se of whi%h legal do%$mentQ

# P) 995

@ # 8.5

C P"esidential P"o%lamation *o 5

) P"esidential P"o%lamation *o .5

A$s-!r A P'D' >>;

P"esidential )e%"ee 995& ena%ted in 1985& made

imm$ni(ation in the ,PI %omp$lso"y fo"

%hild"en $nde" yea"s of age ?epatitis @

/a%%ination was made %omp$lso"y fo" the same

age g"o$p by # 8.5

92 Hhi%h imm$ni(ation p"od$%es a pe"manent

s%a"Q

# )P!

@ @CD

C <easles /a%%ination

) ?epatitis @ /a%%ination

A$s-!r ) )CG

@CD %a$ses the fo"mation of a s$pe"fi%ial

abs%ess& whi%h begins 2 wees afte"

imm$ni(ation !he abs%ess heals witho$t

t"eatment& with the fo"mation of a pe"manent

s%a"

9+ # .=wee old baby was b"o$ght to the health

%ente" fo" his fi"st imm$ni(ation Hhi%h %an be

gi/en to himQ

# )P!1

@ OP71C Infant @CD

) ?epatitis @ /a%%ine 1

A$s-!r C I$a$t )CG

Infant @CD may be gi/en at bi"th #ll the othe"

imm$ni(ations mentioned %an be gi/en at 5

wees of age

9. Ao$ will not gi/e )P! 2 if the mothe" saysthat the infant had

# Sei($"es a day afte" )P! 1

@ Fe/e" fo" + days afte" )P! 1C #bs%ess fo"mation afte" )P! 1

) 'o%al tende"ness fo" + days afte" )P! 1

A$s-!r A S!i90r!s a %a at!r DPT 1'

Sei($"es within + days afte" administ"ation of

)P! is an indi%ation of hype"sensiti/ity to

pe"t$ssis /a%%ine& a %omponent of )P! !his is

%onside"ed a spe%ifi% %ont"aindi%ation to

s$bse6$ent doses of )P!

9 # 2=month old infant was b"o$ght to the

health %ente" fo" imm$ni(ation )$"ingassessment& the infantKs tempe"at$"e "egiste"ed

at +1RC Hhi%h is the best %o$"se of a%tion that

yo$ will taeQ# Do on with the infantKs imm$ni(ations

@ Di/e Pa"a%etamol and wait fo" his fe/e" to

s$bside

C efe" the infant to the physi%ian fo" f$"the"

assessment

) #d/ise the infantKs mothe" to b"ing him ba%

fo" imm$ni(ation when he is well

A$s-!r A G# #$ -it/ t/! i$a$t.s

i660$i9ati#$s'

In the ,PI& fe/e" $p to +RC is not a

%ont"aindi%ation to imm$ni(ation <ild a%$te

"espi"ato"y t"a%t infe%tion& simple dia""hea and

maln$t"ition a"e not %ont"aindi%ations eithe"

95 # p"egnant woman had E$st "e%ei/ed he" .th

dose of tetan$s to-oid S$bse6$ently& he" baby

will ha/e p"ote%tion against tetan$s fo" howlongQ

# 1 yea"

@ + yea"s

C 10 yea"s

) 'ifetime

A$s-!r A 1 !ar

!he baby will ha/e passi/e nat$"al imm$nity by

pla%ental t"ansfe" of antibodies !he mothe" will

ha/e a%ti/e a"tifi%ial imm$nity lasting fo" abo$t

10 yea"s doses will gi/e the mothe" lifetime

p"ote%tion




98 # .=month old infant was b"o$ght to the

health %ente" be%a$se of %o$gh ?e" "espi"ato"y

"ate is .2Gmin$te Using the Integ"ated

<anagement of Child Illness I<CI g$idelines

of assessment& he" b"eathing is %onside"ed

# Fast

@ SlowC *o"mal

) Insignifi%ant

A$s-!r C N#r6a+

In I<CI& a "espi"ato"y "ate of 0Gmin$te o" mo"e

is fast b"eathing fo" an infant aged 2 to 12

months

9 Hhi%h of the following signs will indi%atethat a yo$ng %hild is s$ffe"ing f"om se/e"e

pne$moniaQ

# )yspnea@ Hhee(ing

C Fast b"eathing

) Chest ind"awing

A$s-!r D C/!st i$%ra-i$

In I<CI& %hest ind"awing is $sed as the positi/e

sign of dyspnea& indi%ating se/e"e pne$monia

99 Using I<CI g$idelines& yo$ %lassify a %hild

as ha/ing se/e"e pne$monia Hhat is the best

management fo" the %hildQ

# P"es%"ibe an antibioti%@ efe" him $"gently to the hospital

C Inst"$%t the mothe" to in%"ease fl$id intae

) Inst"$%t the mothe" to %ontin$e b"eastfeeding

A$s-!r ) R!!r /i6 0r!$t+ t# t/!

/#s*ita+'

Se/e"e pne$monia "e6$i"es $"gent "efe""al to a

hospital #nswe"s #& C and ) a"e done fo" a

%lient %lassified as ha/ing pne$monia

100 # =month old infant was b"o$ght by his

mothe" to the health %ente" be%a$se of dia""hea

o%%$""ing . to times a day ?is sin goes ba%

slowly afte" a sin pin%h and his eyes a"e

s$nen Using the I<CI g$idelines& yo$ will

%lassify this infant in whi%h %atego"yQ

# *o signs of dehyd"ation

@ Some dehyd"ation

C Se/e"e dehyd"ation

) !he data is ins$ffi%ient

A$s-!r ) S#6! %!/%rati#$

Using the assessment g$idelines of I<CI& a

%hild 2 months to yea"s old with dia""hea is

%lassified as ha/ing SO<, ),?A)#!IO* if

he shows 2 o" mo"e of the following signs:

"estless o" i""itable& s$nen eyes& the sin goes

ba% slow afte" a sin pin%h

101 @ased on assessment& yo$ %lassified a +=

month old infant with the %hief %omplaint of

dia""hea in the %atego"y of SO<,

),?A)#!IO* @ased on I<CI management

g$idelines& whi%h of the following will yo$ doQ

# @"ing the infant to the nea"est fa%ility whe"e

I7 fl$ids %an be gi/en

@ S$pe"/ise the mothe" in gi/ing 200 to .00 ml

of O"esol in . ho$"s

C Di/e the infantKs mothe" inst"$%tions on home

management) eep the infant in yo$" health %ente" fo" %lose

obse"/ation

A$s-!r ) S0*!r8is! t/! 6#t/!r i$ i8i$

2?? t# 4?? 6+' # Or!s#+ i$ 4 /#0rs'

In the I<CI management g$idelines& SO<,

),?A)#!IO* is t"eated with the

administ"ation of O"esol within a pe"iod of .

ho$"s !he amo$nt of O"esol is best %omp$ted

on the basis of the %hildKs weight 8 mlGg body weight If the weight is $nnown& the

amo$nt of O"esol is based on the %hildKs age

102 # mothe" is $sing O"esol in the

management of dia""hea of he" +=yea" old %hild

She ased yo$ what to do if he" %hild /omits

Ao$ will tell he" to

# @"ing the %hild to the nea"est hospital fo"

f$"the" assessment

@ @"ing the %hild to the health %ente" fo"

int"a/eno$s fl$id the"apy

C @"ing the %hild to the health %ente" fo"

assessment by the physi%ian

) 'et the %hild "est fo" 10 min$tes then

%ontin$e gi/ing O"esol mo"e slowly

A$s-!r D L!t t/! "/i+% r!st #r 1? 6i$0t!s

t/!$ "#$ti$0! i8i$ Or!s#+ 6#r! s+#-+'

If the %hild /omits pe"sistently& that is& he /omits

e/e"ything that he taes in& he has to be "efe""ed

$"gently to a hospital Othe"wise& /omiting is

managed by letting the %hild "est fo" 10 min$tes

and then %ontin$ing with O"esol administ"ation

!ea%h the mothe" to gi/e O"esol mo"e slowly

10+ # 1 [ yea" old %hild was %lassified as

ha/ing +"d deg"ee p"otein ene"gy maln$t"ition&

washio"o" Hhi%h of the following signs will

be most appa"ent in this %hildQ

# 7o"a%io$s appetite

@ Hasting

C #pathy

) ,dema

A$s-!r D E%!6a

,dema& a maEo" sign of washio"o"& is %a$sed by de%"eased %olloidal osmoti% p"ess$"e of the

blood b"o$ght abo$t by hypoalb$minemia

)e%"eased blood alb$min le/el is d$e a p"otein=

defi%ient diet

10. #ssessment of a 2=yea" old %hild "e/ealed

baggy pantsT Using the I<CI g$idelines& how

will yo$ manage this %hildQ

# efe" the %hild $"gently to a hospital fo"

%onfinement

@ Coo"dinate with the so%ial wo"e" to en"oll

the %hild in a feeding p"og"am






) #s if the fe/e" is p"esent e/e"yday

A$s-!r ) AsB -/!r! t/! a6i+ r!si%!s'

@e%a$se mala"ia is endemi%& the fi"st 6$estion to

dete"mine mala"ia "is is whe"e the %lientKs

family "esides If the a"ea of "esiden%e is not a

nown endemi% a"ea& as if the %hild had

t"a/eled within the past 5 months& whe"e heGshewas b"o$ght and whethe" heGshe stayed

o/e"night in that a"ea

11+ !he following a"e st"ategies implemented

by the )epa"tment of ?ealth to p"e/ent

mos6$ito=bo"ne diseases Hhi%h of these is most

effe%ti/e in the %ont"ol of )eng$e fe/e"Q

# St"eam seeding with la"/a=eating fish

@ )est"oying b"eeding pla%es of mos6$itoesC Chemop"ophyla-is of non=imm$ne pe"sons

going to endemi% a"eas

) !ea%hing people in endemi% a"eas to $se%hemi%ally t"eated mos6$ito nets

A$s-!r ) D!str#i$ 7r!!%i$ *+a"!s #

6#s0it#!s

#edes aegypti& the /e%to" of )eng$e fe/e"&

b"eeds in stagnant& %lea" wate" Its feeding time

is $s$ally d$"ing the daytime It has a %y%li%al

patte"n of o%%$""en%e& $nlie mala"ia whi%h is

endemi% in %e"tain pa"ts of the %o$nt"y

11. Se%onda"y p"e/ention fo" mala"ia in%l$des

# Planting of neem o" e$%alypt$s t"ees@ esid$al sp"aying of inse%ti%ides at night

C )ete"mining whethe" a pla%e is endemi% o"

not) D"owing la"/a=eating fish in mos6$ito

b"eeding pla%es

A$s-!r C D!t!r6i$i$ -/!t/!r a *+a"! is

!$%!6i" #r $#t

!his is diagnosti% and the"efo"e se%onda"y le/el

p"e/ention !he othe" %hoi%es a"e fo" p"ima"y

p"e/ention

11 S%ot%h tape swab is done to %he% fo"

whi%h intestinal pa"asiteQ

# #s%a"is

@ Pinwo"m

C ?oowo"m

) S%histosoma

A$s-!r ) Pi$-#r6

Pinwo"m o/a a"e deposited a"o$nd the analo"ifi%e

115 Hhi%h of the following signs indi%ates the

need fo" sp$t$m e-amination fo" #F@Q

# ?ematemesis

@ Fe/e" fo" 1 wee

C Co$gh fo" + wees

) Chest pain fo" 1 wee

A$s-!r C C#0/ #r 3 -!!Bs

# %lient is %onside"ed a P!@ s$spe%t when he

has %o$gh fo" 2 wees o" mo"e& pl$s one o" mo"e

of the following signs: fe/e" fo" 1 month o"

mo"eW %hest pain lasting fo" 2 wees o" mo"e not

att"ib$ted to othe" %onditionsW p"og"essi/e&

$ne-plained weight lossW night sweatsW and

hemoptysis

118 Hhi%h %lients a"e %onside"ed ta"gets fo"

)O!S Catego"y IQ# Sp$t$m negati/e %a/ita"y %ases

@ Clients "et$"ning afte" a defa$lt

C elapses and fail$"es of p"e/io$s P!@

t"eatment "egimens

) Clients diagnosed fo" the fi"st time th"o$gh a

positi/e sp$t$m e-am

A$s-!r D C+i!$ts %ia$#s!% #r t/! irst

ti6! t/r#0/ a *#siti8! s*0t06 !<a6

Catego"y I is fo" new %lients diagnosed by

sp$t$m e-amination and %lients diagnosed to

ha/e a se"io$s fo"m of e-t"ap$lmona"yt$be"%$losis& s$%h as !@ osteomyelitis

11 !o imp"o/e %omplian%e to t"eatment& what

inno/ation is being implemented in )O!SQ

# ?a/ing the health wo"e" follow $p the %lient

at home

@ ?a/ing the health wo"e" o" a "esponsible

family membe" monito" d"$g intae

C ?a/ing the patient %ome to the health %ente"

e/e"y month to get his medi%ations

) ?a/ing a ta"get list to %he% on whethe" the

patient has %olle%ted his monthly s$pply ofd"$gs

A$s-!r ) Ha8i$ t/! /!a+t/ -#rB!r #r a

r!s*#$si7+! a6i+ 6!67!r 6#$it#r %r0

i$taB!

)i"e%tly Obse"/ed !"eatment Sho"t Co$"se is so=

%alled be%a$se a t"eatment pa"tne"& p"efe"ably a

health wo"e" a%%essible to the %lient& monito"s

the %lientKs %omplian%e to the t"eatment

119 )iagnosis of lep"osy is highly dependent on

"e%ognition of symptoms Hhi%h of the

following is an ea"ly sign of lep"osyQ

# <a%$la" lesions

@ Inability to %lose eyelids

C !hi%ened painf$l ne"/es

) Sining of the noseb"idge

A$s-!r C T/i"B!$!% *ai$0+ $!r8!s

!he lesion of lep"osy is not ma%$la" It is

%ha"a%te"i(ed by a %hange in sin %olo" eithe""eddish o" whitish and loss of sensation&

sweating and hai" g"owth o/e" the lesion

Inability to %lose the eyelids lagophthalmos

and sining of the noseb"idge a"e late symptoms

120 Hhi%h of the following %lients sho$ld be

%lassified as a %ase of m$ltiba%illa"y lep"osyQ

# + sin lesions& negati/e slit sin smea"

@ + sin lesions& positi/e slit sin smea"

C sin lesions& negati/e slit sin smea"

) sin lesions& positi/e slit sin smea"




A$s-!r D 5 sBi$ +!si#$s, *#siti8! s+it sBi$

s6!ar

# m$ltiba%illa"y lep"osy %ase is one who has a

positi/e slit sin smea" and at least sin

lesions

121 In the Philippines& whi%h %ondition is the

most f"e6$ent %a$se of death asso%iated withs%histosomiasisQ

# 'i/e" %an%e"

@ 'i/e" %i""hosis

C @ladde" %an%e"

) Intestinal pe"fo"ation

A$s-!r ) Li8!r "irr/#sis

!he etiologi% agent of s%histosomiasis in the

Philippines is S%histosoma Eaponi%$m& whi%haffe%ts the small intestine and the li/e" 'i/e"

damage is a %onse6$en%e of fib"oti% "ea%tions to

s%histosoma eggs in the li/e"

122 Hhat is the most effe%ti/e way of

%ont"olling s%histosomiasis in an endemi% a"eaQ

# Use of moll$s%i%ides

@ @$ilding of foot b"idges

C P"ope" $se of sanita"y toilets

) Use of p"ote%ti/e footwea"& s$%h as "$bbe"

boots

A$s-!r C Pr#*!r 0s! # sa$itar t#i+!ts

!he o/a of the pa"asite get o$t of the h$man

body togethe" with fe%es C$tting the %y%le atthis stage is the most effe%ti/e way of p"e/enting

the sp"ead of the disease to s$s%eptible hosts

12+ Hhen "esidents obtain wate" f"om an

a"tesian well in the neighbo"hood& the le/el of

this app"o/ed type of wate" fa%ility is

# I

@ II

C III

) I7

A$s-!r ) II

# %omm$nal fa$%et o" wate" standpost is

%lassified as 'e/el II

12. Fo" p"e/ention of hepatitis #& yo$ de%ided

to %ond$%t health ed$%ation a%ti/ities Hhi%h of

the following is I,',7#*!Q

# Use of ste"ile sy"inges and needles

@ Safe food p"epa"ation and food handling by

/endo"sC P"ope" disposal of h$man e-%"eta and

pe"sonal hygiene

) Immediate "epo"ting of wate" pipe leas and

illegal wate" %onne%tions

A$s-!r A Us! # st!ri+! sri$!s a$%

$!!%+!s

?epatitis # is t"ansmitted th"o$gh the fe%al o"al

"o$te ?epatitis @ is t"ansmitted th"o$gh infe%ted

body se%"etions lie blood and semen

125 Hhi%h biologi%al $sed in ,-panded

P"og"am on Imm$ni(ation ,PI sho$ld *O! be

sto"ed in the f"ee(e"Q

# )P!

@ O"al polio /a%%ine

C <easles /a%%ine

) <<

A$s-!r A DPT

)P! is sensiti/e to f"ee(ing !he app"op"iate

sto"age tempe"at$"e of )P! is 2 to R C only

OP7 and measles /a%%ine a"e highly sensiti/e to

heat and "e6$i"e f"ee(ing << is not an

imm$ni(ation in the ,-panded P"og"am on

Imm$ni(ation

128 Ao$ will %ond$%t o$t"ea%h imm$ni(ation ina ba"angay with a pop$lation of abo$t 100

,stimate the n$mbe" of infants in the ba"angay

# .@ 0

C

) 50

A$s-!r A 45

!o estimate the n$mbe" of infants& m$ltiply total

pop$lation by +V

12 In Integ"ated <anagement of Childhood

Illness& se/e"e %onditions gene"ally "e6$i"e

$"gent "efe""al to a hospital Hhi%h of the

following se/e"e %onditions )O,S *O! always"e6$i"e $"gent "efe""al to a hospitalQ

# <astoiditis

@ Se/e"e dehyd"ationC Se/e"e pne$monia

) Se/e"e feb"ile disease

A$s-!r ) S!8!r! %!/%rati#$

!he o"de" of p"io"ity in the management of

se/e"e dehyd"ation is as follows: int"a/eno$s

fl$id the"apy& "efe""al to a fa%ility whe"e I7

fl$ids %an be initiated within +0 min$tes&

O"esolGnasogast"i% t$be& O"esolGo"em Hhen the

fo"egoing meas$"es a"e not possible o" effe%ti/e&

tehn $"gent "efe""al to the hospital is done

129 # %lient was diagnosed as ha/ing )eng$e

fe/e" Ao$ will say that the"e is slow %apilla"y

"efill when the %olo" of the nailbed that yo$

p"essed does not "et$"n within how many

se%ondsQ

# +@

C

) 10

A$s-!r A 3

#de6$ate blood s$pply to the a"ea allows the

"et$"n of the %olo" of the nailbed within +

se%onds

1+0 # +=yea" old %hild was b"o$ght by his

mothe" to the health %ente" be%a$se of fe/e" of

.=day d$"ation !he %hild had a positi/e




to$"ni6$et test "es$lt In the absen%e of othe"

signs& whi%h is the most app"op"iate meas$"e

that the P?* may %a""y o$t to p"e/ent )eng$e

sho% synd"omeQ

# Inse"t an *D! and gi/e fl$ids pe" *D!

@ Inst"$%t the mothe" to gi/e the %hild O"esol

C Sta"t the patient on int"a/eno$s fl$ids S!#!

) efe" the %lient to the physi%ian fo"app"op"iate management

A$s-!r ) I$str0"t t/! 6#t/!r t# i8! t/!

"/i+% Or!s#+'

Sin%e the %hild does not manifest any othe"

dange" sign& maintenan%e of fl$id balan%e and

"epla%ement of fl$id loss may be done by gi/ing

the %lient O"esol

1+1 !he pathognomoni% sign of measles is

opliKs spot Ao$ may see opliKs spot by

inspe%ting the # *asal m$%osa

@ @$%%al m$%osa

C Sin on the abdomen

) Sin on the ante%$bital s$"fa%e

A$s-!r ) )0""a+ 60"#sa

opliKs spot may be seen on the m$%osa of the

mo$th o" the th"oat

1+2 #mong the following diseases& whi%h is

ai"bo"neQ

# 7i"al %onE$n%ti/itis@ #%$te poliomyelitis

C )iphthe"ia

) <easles

A$s-!r D M!as+!s

7i"al %onE$n%ti/itis is t"ansmitted by di"e%t o"

indi"e%t %onta%t with dis%ha"ges f"om infe%ted

eyes #%$te poliomyelitis is sp"ead th"o$gh the

fe%al=o"al "o$te and %onta%t with th"oat

se%"etions& whe"eas diphthe"ia is th"o$gh di"e%t

and indi"e%t %onta%t with "espi"ato"y se%"etions

1++ #mong %hild"en aged 2 months to + yea"s&

the most p"e/alent fo"m of meningitis is %a$sed

by whi%h mi%"oo"ganismQ

# ?emophil$s infl$en(ae

@ <o"billi/i"$s

C Stepto%o%%$s pne$moniae

) *eisse"ia meningitidis

A$s-!r A H!6#*/i+0s i$+0!$9a!

?emophil$s meningitis is $n$s$al o/e" the age

of yea"s In de/eloping %o$nt"ies& the pea

in%iden%e is in %hild"en less than 5 months of

age <o"billi/i"$s is the etiology of measles

St"epto%o%%$s pne$moniae and *eisse"ia

meningitidis may %a$se meningitis& b$t age

dist"ib$tion is not spe%ifi% in yo$ng %hild"en

1+. ?$man beings a"e the maEo" "ese"/oi" of

mala"ia Hhi%h of the following st"ategies in

mala"ia %ont"ol is based on this fa%tQ

# St"eam seeding

@ St"eam %lea"ing

C )est"$%tion of b"eeding pla%es

) Joop"ophyla-is

A$s-!r D K##*r#*/+a<is

Joop"ophyla-is is done by p$tting animals lie

%attle o" dogs %lose to windows o" doo"ways E$st

befo"e nightfall !he #nopheles mos6$ito taeshis blood meal f"om the animal and goes ba% to

its b"eeding pla%e& the"eby p"e/enting infe%tion

of h$mans

1+ !he $se of la"/i/o"o$s fish in mala"ia

%ont"ol is the basis fo" whi%h st"ategy of mala"ia

%ont"olQ

# St"eam seeding

@ St"eam %lea"ingC )est"$%tion of b"eeding pla%es

) Joop"ophyla-is

A$s-!r A Str!a6 s!!%i$

St"eam seeding is done by p$tting tilapia f"y in

st"eams o" othe" bodies of wate" identified as

b"eeding pla%es of the #nopheles mos6$ito

1+5 <os6$ito=bo"ne diseases a"e p"e/ented

mostly with the $se of mos6$ito %ont"ol

meas$"es Hhi%h of the following is *O!

app"op"iate fo" mala"ia %ont"olQ

# Use of %hemi%ally t"eated mos6$ito nets

@ Seeding of b"eeding pla%es with la"/a=eating

fishC )est"$%tion of b"eeding pla%es of the

mos6$ito /e%to"

) Use of mos6$ito="epelling soaps& s$%h asthose with basil o" %it"onella

A$s-!r C D!str0"ti#$ # 7r!!%i$ *+a"!s #

t/! 6#s0it# 8!"t#r

#nopheles mos6$itoes b"eed in slow=mo/ing&

%lea" wate"& s$%h as mo$ntain st"eams

1+8 # .=yea" old %lient was b"o$ght to the

health %ente" with the %hief %omplaint of se/e"e

dia""hea and the passage of "i%e wate"T stools

!he %lient is most p"obably s$ffe"ing f"om

whi%h %onditionQ

# Dia"diasis

@ Chole"a

C #mebiasis

) )ysente"y

A$s-!r ) C/#+!ra

Passage of p"of$se wate"y stools is the maEo"

symptom of %hole"a @oth amebi% and ba%illa"y

dysente"y a"e %ha"a%te"i(ed by the p"esen%e of

blood andGo" m$%$s in the stools Dia"diasis is

%ha"a%te"i(ed by fat malabso"ption and&

the"efo"e& steato""hea

1+ In the Philippines& whi%h spe%ie of

s%histosoma is endemi% in %e"tain "egionsQ

# S mansoni

@ S Eaponi%$m

C S malayensis




) S haematobi$m

A$s-!r ) S' Ja*#$i"06

S mansoni is fo$nd mostly in #f"i%a and So$th

#me"i%aW S haematobi$m in #f"i%a and the

<iddle ,astW and S malayensis only in

penins$la" <alaysia

1+9 # +2=yea" old %lient %ame fo" %ons$ltation

at the health %ente" with the %hief %omplaint of

fe/e" fo" a wee #%%ompanying symptoms

we"e m$s%le pains and body malaise # wee

afte" the sta"t of fe/e"& the %lient noted yellowish

dis%olo"ation of his s%le"a ?isto"y showed that

he waded in flood wate"s abo$t 2 wees befo"e

the onset of symptoms @ased on his histo"y&

whi%h disease %ondition will yo$ s$spe%tQ# ?epatitis #

@ ?epatitis @

C !etan$s) 'eptospi"osis

A$s-!r D L!*t#s*ir#sis

'eptospi"osis is t"ansmitted th"o$gh %onta%t with

the sin o" m$%o$s memb"ane with wate" o"

moist soil %ontaminated with $"ine of infe%ted

animals& lie "ats

1.0 <HSS p"o/ides wate" to <anila and othe"

%ities in <et"o <anila !his is an e-ample of

whi%h le/el of wate" fa%ilityQ

# I@ II

C III

) I7

A$s-!r C III

Hate"wo"s systems& s$%h as <HSS& a"e

%lassified as le/el III

1.1 Ao$ a"e the P?* in the %ity health %ente"

# %lient $nde"went s%"eening fo" #I)S $sing

,'IS# ?is "es$lt was positi/e Hhat is the best

%o$"se of a%tion that yo$ may taeQ

# Det a tho"o$gh histo"y of the %lient& fo%$sing

on the p"a%ti%e of high "is beha/io"s

@ #s the %lient to be a%%ompanied by a

signifi%ant pe"son befo"e "e/ealing the "es$lt

C efe" the %lient to the physi%ian sin%e he is

the best pe"son to "e/eal the "es$lt to the %lient

) efe" the %lient fo" a s$pplementa"y test& s$%h

as Heste"n blot& sin%e the ,'IS# "es$lt may be

false

A$s-!r D R!!r t/! "+i!$t #r a

s0**+!6!$tar t!st, s0"/ as !st!r$ 7+#t,

si$"! t/! ELISA r!s0+t 6a 7! a+s!'

# %lient ha/ing a "ea%ti/e ,'IS# "es$lt m$st

$nde"go a mo"e spe%ifi% test& s$%h as Heste"n

blot # negati/e s$pplementa"y test "es$lt means

that the ,'IS# "es$lt was false and that& most

p"obably& the %lient is not infe%ted

1.2 Hhi%h is the @,S! %ont"ol meas$"e fo"

#I)SQ

# @eing faithf$l to a single se-$al pa"tne"

@ Using a %ondom d$"ing ea%h se-$al %onta%t

C #/oiding se-$al %onta%t with %omme"%ial se-

wo"e"s

) <aing s$"e that oneKs se-$al pa"tne" does

not ha/e signs of #I)S

A$s-!r A )!i$ ait/0+ t# a si$+! s!<0a+*art$!r

Se-$al fidelity "$les o$t the possibility of getting

the disease by se-$al %onta%t with anothe" infe%ted

pe"son !"ansmission o%%$"s mostly th"o$gh se-$al

inte"%o$"se and e-pos$"e to blood o" tiss$es

1.+ !he most f"e6$ent %a$ses of death among

%lients with #I)S a"e oppo"t$nisti% diseases

Hhi%h of the following oppo"t$nisti% infe%tions is

%ha"a%te"i(ed by tonsillopha"yngitisQ

# espi"ato"y %andidiasis

@ Infe%tio$s monon$%leosis

C Cytomegalo/i"$s disease) Pne$mo%ystis %a"inii pne$monia

A$s-!r ) I$!"ti#0s 6#$#$0"+!#sis

Cytomegalo/i"$s disease is an a%$te /i"al disease

%ha"a%te"i(ed by fe/e"& so"e th"oat and

lymphadenopathy

1.. !o dete"mine possible so$"%es of se-$ally

t"ansmitted infe%tions& whi%h is the @,S! method

that may be $nde"taen by the p$bli% health n$"seQ

# Conta%t t"a%ing

@ Comm$nity s$"/ey

C <ass s%"eening tests

) Inte"/iew of s$spe%ts

A$s-!r A C#$ta"t tra"i$

Conta%t t"a%ing is the most p"a%ti%al and "eliable

method of finding possible so$"%es of pe"son=to=

pe"son t"ansmitted infe%tions& s$%h as se-$ally

t"ansmitted diseases

1. #nti"et"o/i"al agents& s$%h as #J!& a"e $sed

in the management of #I)S Hhi%h of the

following is *O! an a%tion e-pe%ted of thesed"$gs

# !hey p"olong the life of the %lient with #I)S

@ !hey "ed$%e the "is of oppo"t$nisti% infe%tions

C !hey sho"ten the pe"iod of %omm$ni%ability of

the disease

) !hey a"e able to b"ing abo$t a %$"e of the

disease %ondition

A$s-!r D T/! ar! a7+! t# 7ri$ a7#0t a

"0r! # t/! %is!as! "#$%iti#$'

!he"e is no nown t"eatment fo" #I)S

#nti"et"o/i"al agents "ed$%e the "is of

oppo"t$nisti% infe%tions and p"olong life& b$t doesnot %$"e the $nde"lying imm$nodefi%ien%y

1.5 # ba"angay had an o$tb"ea of De"man

measles !o p"e/ent %ongenital "$bella& what is the

@,S! ad/i%e that yo$ %an gi/e to women in the

fi"st t"imeste" of p"egnan%y in the ba"angayQ

# #d/i%e them on the signs of De"man measles

@ #/oid %"owded pla%es& s$%h as ma"ets and

mo/ieho$ses




C Cons$lt at the health %ente" whe"e "$bella

/a%%ine may be gi/en

) Cons$lt a physi%ian who may gi/e them "$bella

imm$noglob$lin

A$s-!r D C#$s0+t a */si"ia$ -/# 6a i8!

t/!6 r07!++a i660$#+#70+i$'

$bella /a%%ine is made $p of atten$ated De"man

measles /i"$ses !his is %ont"aindi%ated in

p"egnan%y Imm$ne glob$lin& a spe%ifi%

p"ophyla%ti% against De"man measles& may be

gi/en to p"egnant women

1.8 Ao$ we"e in/ited to be the "eso$"%e pe"son in

a t"aining %lass fo" food handle"s Hhi%h of the

following wo$ld yo$ emphasi(e "ega"ding

p"e/ention of staphylo%o%%al food poisoningQ

# #ll %ooing and eating $tensils m$st be

tho"o$ghly washed

@ Food m$st be %ooed p"ope"ly to dest"oy

staphylo%o%%al mi%"oo"ganismsC Food handle"s and food se"/e"s m$st ha/e a

negati/e stool e-amination "es$lt

) P"ope" handwashing d$"ing food p"epa"ation is

the best way of p"e/enting the %ondition

A$s-!r D Pr#*!r /a$%-as/i$ %0ri$ ##%

*r!*arati#$ is t/! 7!st -a # *r!8!$ti$ t/!

"#$%iti#$'

Symptoms of this food poisoning a"e d$e to

staphylo%o%%al ente"oto-in& not the

mi%"oo"ganisms themsel/es Contamination is by

food handling by pe"sons with staphylo%o%%al sin

o" eye infe%tions

1. In a mothe"sK %lass& yo$ dis%$ssed %hildhood

diseases s$%h as %hi%en po- Hhi%h of the

following statements abo$t %hi%en po- is %o""e%tQ

# !he olde" one gets& the mo"e s$s%eptible he

be%omes to the %ompli%ations of %hi%en po-

@ # single atta% of %hi%en po- will p"e/ent

f$t$"e episodes& in%l$ding %onditions s$%h as

shingles

C !o p"e/ent an o$tb"ea in the %omm$nity&

6$a"antine may be imposed by health a$tho"ities

) Chi%en po- /a%%ine is best gi/en when the"e is

an impending o$tb"ea in the %omm$nity

A$s-!r A T/! #+%!r #$! !ts, t/! 6#r!

s0s"!*ti7+! /! 7!"#6!s t# t/! "#6*+i"ati#$s #

"/i"B!$ *#<'

Chi%en po- is $s$ally mo"e se/e"e in ad$lts than

in %hild"en Compli%ations& s$%h as pne$monia& a"e

highe" in in%iden%e in ad$lts

1.9 Compli%ations to infe%tio$s pa"otitis m$mps

may be se"io$s in whi%h type of %lientsQ

# P"egnant women

@ ,lde"ly %lients

C Ao$ng ad$lt males

) Ao$ng infants

A$s-!r C (#0$ a%0+t 6a+!s

,pididymitis and o"%hitis a"e possible

%ompli%ations of m$mps In post=adoles%ent males&

bilate"al inflammation of the testes and epididymis

may %a$se ste"ility




MEDICAL SURGICAL NURSING Part 1

1 <"s Ch$a a 8 yea" old %lient is admitted with the diagnosis of mild %h"oni% hea"t fail$"e !he n$"se e-pe%ts to

hea" when listening to %lientKs l$ngs indi%ati/e of %h"oni% hea"t fail$"e wo$ld be:

a St"ido"

b C"a%les

% Hhee(es

d F"i%tion "$bs

2 Pat"i% who is hospitali(ed following a myo%a"dial infa"%tion ass the n$"se why he is taing mo"phine !he

n$"se e-plains that mo"phine:

a )e%"ease an-iety and "estlessness

b P"e/ents sho% and "elie/es pain

% )ilates %o"ona"y blood /essels

d ?elps p"e/ent fib"illation of the hea"t

+ Hhi%h of the following sho$ld the n$"se tea%h the %lient abo$t the signs of digitalis to-i%ityQa In%"eased appetite

b ,le/ated blood p"ess$"e

% Sin "ash o/e" the %hest and ba%

d 7is$al dist$"ban%es s$%h as seeing yellow spots

. *$"se !"isha tea%hes a %lient with hea"t fail$"e to tae o"al F$"osemide in the mo"ning !he "eason fo" this is to

helpM

a eta"d "apid d"$g abso"ption

b ,-%"ete e-%essi/e fl$ids a%%$m$lated at night

% P"e/ents sleep dist$"ban%es d$"ing night

d P"e/ention of ele%t"olyte imbalan%e

Hhat wo$ld be the p"ima"y goal of the"apy fo" a %lient with p$lmona"y edema and hea"t fail$"eQ

a ,nhan%e %omfo"t




b In%"ease %a"dia% o$tp$t

% Imp"o/e "espi"ato"y stat$s

d Pe"iphe"al edema de%"eased

5 *$"se 'inda is %a"ing fo" a %lient with head inE$"y and monito"ing the %lient with de%e"eb"ate post$"ing Hhi%h

of the following is a %ha"a%te"isti% of this type of post$"ingQ

a Uppe" e-t"emity fle-ion with lowe" e-t"emity fle-ion

b Uppe" e-t"emity fle-ion with lowe" e-t"emity e-tension

% ,-tension of the e-t"emities afte" a stim$l$sd Fle-ion of the e-t"emities afte" stim$l$s

8 # female %lient is taing Cas%a"a Sag"ada *$"se @etty info"ms the %lient that the following maybe e-pe"ien%ed

as side effe%ts of this medi%ation:

a DI bleeding

b Pepti% $l%e" disease

% #bdominal %"amps

d Pa"tial bowel obst"$%tion

)" <a"6$e( o"de"s a %ontin$o$s int"a/eno$s nit"ogly%e"in inf$sion fo" the %lient s$ffe"ing f"om myo%a"dial

infa"%tion Hhi%h of the following is the most essential n$"sing a%tionQa <onito"ing $"ine o$tp$t f"e6$ently

b <onito"ing blood p"ess$"e e/e"y . ho$"s

% Obtaining se"$m potassi$m le/els dailyd Obtaining inf$sion p$mp fo" the medi%ation

9 )$"ing the se%ond day of hospitali(ation of the %lient afte" a <yo%a"dial Infa"%tion Hhi%h of the following is

an e-pe%ted o$t%omeQ

a #ble to pe"fo"m self=%a"e a%ti/ities witho$t pain

b Se/e"e %hest pain

% Can "e%ogni(e the "is fa%to"s of <yo%a"dial Infa"%tion

d Can Pa"ti%ipate in %a"dia% "ehabilitation waling p"og"am

10 # 5 yea" old %lient is diagnosed with a "ight=sided b"ain atta% and is admitted to the hospital In %a"ing fo"

this %lient& the n$"se sho$ld plan to:

a #ppli%ation of elasti% sto%ings to p"e/ent fla%%id by m$s%le

b Use hand "oll and e-tend the left $ppe" e-t"emity on a pillow to p"e/ent %ont"a%tions

% Use a bed %"adle to p"e/ent do"sifle-ion of feetd )o passi/e "ange of motion e-e"%ise

11 *$"se 'i(a is assigned to %a"e fo" a %lient who has "et$"ned to the n$"sing $nit afte" left neph"e%tomy *$"se

'i(aKs highest p"io"ity wo$ld beMa ?o$"ly $"ine o$tp$t

b !empe"at$"e

% #ble to t$"n side to side

d #ble to sips %lea" li6$id

12 # 5. yea" old male %lient with a long histo"y of %a"dio/as%$la" p"oblem in%l$ding hype"tension and angina is

to be s%hed$led fo" %a"dia% %athete"i(ation )$"ing p"e %a"dia% %athete"i(ation tea%hing& *$"se Che""y sho$ld

info"m the %lient that the p"ima"y p$"pose of the p"o%ed$"e isM

a !o dete"mine the e-isten%e of C?)

b !o /is$ali(e the disease p"o%ess in the %o"ona"y a"te"ies

% !o obtain the hea"t %hambe"s p"ess$"e

d !o meas$"e o-ygen %ontent of diffe"ent hea"t %hambe"s

1+ )$"ing the fi"st se/e"al ho$"s afte" a %a"dia% %athete"i(ation& it wo$ld be most essential fo" n$"se Che""y toM

a ,le/ate %lients bed at .R

b Inst"$%t the %lient to %o$gh and deep b"eathe e/e"y 2 ho$"s

% F"e6$ently monito" %lientKs api%al p$lse and blood p"ess$"e

d <onito" %lients tempe"at$"e e/e"y ho$"

1. ate who has $nde"gone mit"al /al/e "epla%ement s$ddenly e-pe"ien%es %ontin$o$s bleeding f"om the

s$"gi%al in%ision d$"ing postope"ati/e pe"iod Hhi%h of the following pha"ma%e$ti%al agents sho$ld *$"se#i(a p"epa"e to administe" to ateQ

a P"otamine S$lfate

b >$inidine S$lfate

% 7itamin C

d Co$madin

1 In "ed$%ing the "is of endo%a"ditis& good dental %a"e is an impo"tant meas$"e !o p"omote good dental %a"e in

%lient with mit"al stenosis in tea%hing plan sho$ld in%l$de p"ope" $se ofM

a )ental floss

b ,le%t"i% toothb"$sh

% <an$al toothb"$sh

d I""igation de/i%e




15 #mong the following signs and symptoms& whi%h wo$ld most liely be p"esent in a %lient with mit"al

g$"gitationQ

a #lte"ed le/el of %ons%io$sness

b ,-%eptional )yspnea

% In%"ease %"eatine phospholinase %on%ent"ation

d Chest pain

18 "is with a histo"y of %h"oni% infe%tion of the $"ina"y system %omplains of $"ina"y f"e6$en%y and b$"ning

sensation !o fig$"e o$t whethe" the %$""ent p"oblem is in "enal o"igin& the n$"se sho$ld assess whethe" the%lient has dis%omfo"t o" pain in theM

a U"ina"y meat$s

b Pain in the 'abi$m

% S$p"ap$bi% a"ea

d ight o" left %osto/e"teb"al angle

1 *$"se Pe""y is e/al$ating the "enal f$n%tion of a male %lient #fte" do%$menting $"ine /ol$me and

%ha"a%te"isti%s& *$"se Pe""y assesses whi%h signs as the best indi%ato" of "enal f$n%tion

a @lood p"ess$"e

b Cons%io$sness% )istension of the bladde"

d P$lse "ate

19 Bohn s$ddenly e-pe"ien%es a sei($"e& and *$"se Dina noti%e that Bohn e-hibits $n%ont"ollable Ee"ingmo/ements *$"se Dina do%$ments that Bohn e-pe"ien%ed whi%h type of sei($"eQ

a !oni% sei($"e

b #bsen%e sei($"e

% <yo%loni% sei($"e

d Cloni% sei($"e

20 Smoing %essation is %"iti%al st"ategy fo" the %lient with @$"ghe"Ks disease& *$"se Basmin anti%ipates that the

male %lient will go home with a p"es%"iption fo" whi%h medi%ationQ

a Pa"a%etamol

b Ib$p"ofen

% *it"ogly%e"in

d *i%otine *i%ot"ol

21 *$"se 'illy has been assigned to a %lient with ayna$dKs disease *$"se 'illy "eali(es that the etiology of thedisease is $nnown b$t it is %ha"a%te"i(ed by:

a ,pisodi% /asospasti% diso"de" of %apilla"ies

b ,pisodi% /asospasti% diso"de" of small /eins% ,pisodi% /asospasti% diso"de" of the ao"ta

d ,pisodi% /asospasti% diso"de" of the small a"te"ies

22 *$"se Bamie sho$ld e-plain to male %lient with diabetes that self=monito"ing of blood gl$%ose is p"efe""ed to

$"ine gl$%ose testing be%a$seM

a <o"e a%%$"ate

b Can be done by the %lient

% It is easy to pe"fo"m

d It is not infl$en%ed by d"$gs

2+ Bessie weighed 210 po$nds on admission to the hospital #fte" 2 days of di$"eti% the"apy& Bessie weighs 20

po$nds !he n$"se %o$ld estimate the amo$nt of fl$id Bessie has lostM

a 0+ '

b 1 '

% 20 '

d + '

2. *$"se )onna is awa"e that the shift of body fl$ids asso%iated with Int"a/eno$s administ"ation of alb$min

o%%$"s in the p"o%ess of:

a Osmosis

b )iff$sion% #%ti/e t"anspo"t

d Filt"ation

2 <y"na a 2 yea" old %lient with a f"a%t$"ed left tibia has a long leg %ast and she is $sing %"$t%hes to amb$late

*$"se Boy assesses fo" whi%h sign and symptom that indi%ates %ompli%ation asso%iated with %"$t%h walingQ

a 'eft leg dis%omfo"t

b Hea bi%eps b"a%hii

% !"i%eps m$s%le spasm

d Fo"ea"m weaness

25 Hhi%h of the following statements sho$ld the n$"se tea%h the ne$t"openi% %lient and his family to a/oidQ

a Pe"fo"ming o"al hygiene afte" e/e"y meal

b Using s$pposito"ies o" enemas

% Pe"fo"ming pe"ineal hygiene afte" ea%h bowel mo/ement




d Using a filte" mas

28 # female %lient is e-pe"ien%ing painf$l and "igid abdomen and is diagnosed with pe"fo"ated pepti% $l%e" #

s$"ge"y has been s%hed$led and a nasogast"i% t$be is inse"ted !he n$"se sho$ld pla%e the %lient befo"e s$"ge"y

in

a Sims position

b S$pine position

% Semi=fowle"s position

d )o"sal "e%$mbent position2 Hhi%h n$"sing inte"/ention ens$"es ade6$ate /entilating e-%hange afte" s$"ge"yQ

a emo/e the ai"way only when %lient is f$lly %ons%io$s

b #ssess fo" hypo/entilation by a$s%$ltating the l$ngs

% Position %lient late"ally with the ne% e-tended

d <aintain h$midified o-ygen /ia nasal %an$la

29 Deo"ge who has $nde"gone tho"a%i% s$"ge"y has %hest t$be %onne%ted to a wate"=seal d"ainage system atta%hed

to s$%tion P"esen%e of e-%essi/e b$bbling is identified in wate"=seal %hambe"& the n$"se sho$ldM

a St"ipT the %hest t$be %athete"

b Che% the system fo" ai" leas% e%ogni(e the system is f$n%tioning %o""e%tly

d )e%"ease the amo$nt of s$%tion p"ess$"e

+0 # %lient who has been diagnosed of hype"tension is being ta$ght to "est"i%t intae of sodi$m !he n$"se wo$ldnow that the tea%hings a"e effe%ti/e if the %lient states thatM

a I %an eat %ele"y sti%s and %a""ots

b I %an eat b"oiled s%allops

% I %an eat sh"edded wheat %e"eal

d I %an eat spaghetti on "ye b"ead

+1 # male %lient with a histo"y of %i""hosis and al%oholism is admitted with se/e"e dyspnea "es$lted to as%ites

!he n$"se sho$ld be awa"e that the as%ites is most liely the "es$lt of in%"easedM

a P"ess$"e in the po"tal /ein

b P"od$%tion of se"$m alb$min

% Se%"etion of bile salts

d Inte"stitial osmoti% p"ess$"e

+2 # newly admitted %lient is diagnosed with ?odginKs disease $nde"goes an e-%isional %e"/i%al lymph node biopsy $nde" lo%al anesthesia Hhat does the n$"se assess fi"st afte" the p"o%ed$"eQ

a 7ital signs

b In%ision site% #i"way

d 'e/el of %ons%io$sness

++ # %lient has 1V blood loss Hhi%h of the following n$"sing assessment findings indi%ates hypo/olemi%

sho%Q

a Systoli% blood p"ess$"e less than 90mm ?g

b P$pils $ne6$ally dilated

% espi"ato"y "ate of . b"eathGmin

d P$lse "ate less than 50bpm

+. *$"se '$%y is planning to gi/e p"e ope"ati/e tea%hing to a %lient who will be $nde"going "hinoplasty Hhi%h

of the following sho$ld be in%l$dedQ

a es$lts of the s$"ge"y will be immediately noti%eable postope"ati/ely

b *o"mal saline nose d"ops will need to be administe"ed p"eope"ati/ely

% #fte" s$"ge"y& nasal pa%ing will be in pla%e to 10 days

d #spi"in %ontaining medi%ations sho$ld not be taen 1. days befo"e s$"ge"y

+ Pa$l is admitted to the hospital d$e to metaboli% a%idosis %a$sed by )iabeti% etoa%idosis )# !he n$"se

p"epa"es whi%h of the following medi%ations as an initial t"eatment fo" this p"oblemQ

a eg$la" ins$lin

b Potassi$m% Sodi$m bi%a"bonate

d Cal%i$m gl$%onate

+5 )" <a"6$e( tells a %lient that an in%"ease intae of foods that a"e "i%h in 7itamin , and beta=%a"otene a"e

impo"tant fo" healthie" sin !he n$"se tea%hes the %lient that e-%ellent food so$"%es of both of these

s$bstan%es a"e:

a Fish and f"$it Eam

b O"anges and g"apef"$it

% Ca""ots and potatoes

d Spina%h and mangoes

+8 # %lient has Dast"oesophageal efl$- )isease D,) !he n$"se sho$ld tea%h the %lient that afte" e/e"y

meals& the %lient sho$ldM

a est in sitting position




b !ae a sho"t wal

% )"in plenty of wate"

d 'ie down at least +0 min$tes

+ #fte" gast"os%opy& an adaptation that indi%ates maEo" %ompli%ation wo$ld be:

a *a$sea and /omiting

b #bdominal distention

% In%"eased DI motility

d )iffi%$lty in swallowing+9 # %lient who has $nde"gone a %hole%yste%tomy ass the n$"se whethe" the"e a"e any dieta"y "est"i%tions that

m$st be followed *$"se ?ila"y wo$ld "e%ogni(e that the dieta"y tea%hing was well $nde"stood when the

%lient tells a family membe" that:

a <ost people need to eat a high p"otein diet fo" 12 months afte" s$"ge"yT

b I sho$ld not eat those foods that $pset me befo"e the s$"ge"yT

% I sho$ld a/oid fatty foods as long as I li/eT

d <ost people %an tole"ate "eg$la" diet afte" this type of s$"ge"yT

.0 *$"se a%hel tea%hes a %lient who has been "e%ently diagnosed with hepatitis # abo$t $ntowa"d signs and

symptoms "elated to ?epatitis that may de/elop !he one that sho$ld be "epo"ted immediately to the physi%ianis:

a estlessness

b Aellow $"ine% *a$sea

d Clay= %olo"ed stools

.1 Hhi%h of the following antit$be"%$losis d"$gs %an damage the th %"anial ne"/eQ

a Isonia(id I*?

b Pa"aoaminosali%yli% a%id P#S

% ,thamb$tol hyd"o%hlo"ide myamb$tol

d St"eptomy%in

.2 !he %lient ass *$"se #nnie the %a$ses of pepti% $l%e" *$"se #nnie "esponds that "e%ent "esea"%h indi%ates

that pepti% $l%e"s a"e the "es$lt of whi%h of the following:

a Deneti% defe%t in gast"i% m$%osa

b St"ess

% )iet high in fatd ?eli%oba%te" pylo"i infe%tion

.+ yan has $nde"gone s$btotal gast"e%tomy !he n$"se sho$ld e-pe%t that nasogast"i% t$be d"ainage will be

what %olo" fo" abo$t 12 to 2. ho$"s afte" s$"ge"yQa @ile g"een

b @"ight "ed

% Clo$dy white

d )a" b"own

.. *$"se Boan is assigned to %ome fo" %lient who has E$st $nde"gone eye s$"ge"y *$"se Boan plans to tea%h the

%lient a%ti/ities that a"e pe"mitted d$"ing the post ope"ati/e pe"iod Hhi%h of the following is best

"e%ommended fo" the %lientQ

a Hat%hing %i"%$s

b @ending o/e"

% Hat%hing !7

d 'ifting obEe%ts

. # %lient s$ffe"ed f"om a lowe" leg inE$"y and sees t"eatment in the eme"gen%y "oom !he"e is a p"ominent

defo"mity to the lowe" aspe%t of the leg& and the inE$"ed leg appea"s sho"te" that the othe" leg !he affe%ted leg

is painf$l& swollen and beginning to be%ome e%%hymoti% !he n$"se inte"p"ets that the %lient is e-pe"ien%ing:

a F"a%t$"e

b St"ain

% Sp"ain

d Cont$sion.5 *$"se Benny is instilling an oti% sol$tion into an ad$lt male %lient left ea" *$"se Benny a/oids doing whi%h of

the following as pa"t of the p"o%ed$"e

a P$lling the a$"i%le ba%wa"d and $pwa"d

b Ha"ming the sol$tion to "oom tempe"at$"e

% Pa%ing the tip of the d"oppe" on the edge of ea" %anal

d Pla%ing %lient in side lying position

.8 *$"se @ea sho$ld inst"$%t the male %lient with an ileostomy to "epo"t immediately whi%h of the following

symptomQ

a #bsen%e of d"ainage f"om the ileostomy fo" 5 o" mo"e ho$"s

b Passage of li6$id stool in the stoma

% O%%asional p"esen%e of $ndigested food

d # tempe"at$"e of +85 RC






1. A P"otamine S$lfate is $sed to p"e/ent %ontin$o$s bleeding in %lient who has $nde"gone open hea"t

s$"ge"y

1 C !he $se of ele%t"oni% toothb"$sh& i""igation de/i%e o" dental floss may %a$se bleeding of g$ms&

allowing ba%te"ia to ente" and in%"easing the "is of endo%a"ditis

15 ) Height gain d$e to "etention of fl$ids and wo"sening hea"t fail$"e %a$ses e-e"tional dyspnea in %lients

with mit"al "eg$"gitation

18 D )is%omfo"t o" pain is a p"oblem that o"iginates in the idney It is felt at the %osto/e"teb"al angle on

the affe%ted side1 A Pe"f$sion %an be best estimated by blood p"ess$"e& whi%h is an indi"e%t "efle%tion of the ade6$a%y of

%a"dia% o$tp$t

19 C <yo%loni% sei($"e is %ha"a%te"i(ed by s$dden $n%ont"ollable Ee"ing mo/ements of a single o" m$ltiple

m$s%le g"o$p

20 D *i%otine *i%ot"ol is gi/en in %ont"olled and de%"easing doses fo" the management of ni%otine

withd"awal synd"ome

21 D ayna$dKs disease is %ha"a%te"i(ed by /asospasms of the small %$taneo$s a"te"ies that in/ol/es finge"s

and toes

22 A U"ine testing p"o/ides an indi"e%t meas$"e that maybe infl$en%ed by idney f$n%tion while blood

gl$%ose testing is a mo"e di"e%t and a%%$"ate meas$"e

2+ C One lite" of fl$id app"o-imately weighs 22 po$nds # . po$nd weight loss e6$als to app"o-imately

2'

2. A Osmosis is the mo/ement of fl$id f"om an a"ea of lesse" sol$te %on%ent"ation to an a"ea of g"eate"

sol$te %on%ent"ation

2 D Fo"ea"m m$s%le weaness is a p"obable sign of "adial ne"/e inE$"y %a$sed by %"$t%h p"ess$"e on the

a-illae

25 ) *e$t"openi% %lient is at "is fo" infe%tion espe%ially ba%te"ial infe%tion of the gast"ointestinal and

"espi"ato"y t"a%t

28 C Semi=fowle"s position will lo%ali(e the spilled stoma%h %ontents in the lowe" pa"t of the abdominal

%a/ity

2 C Positioning the %lient late"ally with the ne% e-tended does not obst"$%t the ai"way so that d"ainage of

se%"etions and o-ygen and %a"bon dio-ide e-%hange %an o%%$"

29 ) ,-%essi/e b$bbling indi%ates an ai" lea whi%h m$st be eliminated to pe"mit l$ng e-pansion+0 C Hheat %e"eal has a low sodi$m %ontent

+1 A ,nla"ged %i""hoti% li/e" impinges the po"tal system %a$sing in%"eased hyd"ostati% p"ess$"e "es$lting to

as%ites

+2 C #ssessing fo" an open ai"way is the p"io"ity !he p"o%ed$"e in/ol/es the ne%& the anesthesia may ha/e

affe%ted the swallowing "efle- o" the inflammation may ha/e %losed in on the ai"way leading to

ineffe%ti/e ai" e-%hange

++ A !ypi%al signs and symptoms of hypo/olemi% sho% in%l$des systoli% blood p"ess$"e of less than 90

mm ?g

+. D #spi"in %ontaining medi%ations sho$ld not be taen 1. days befo"e s$"ge"y to de%"ease the "is of

bleeding

+ A <etaboli% a%idosis is anae"obi% metabolism %a$sed by la% of ability of the body to $se %i"%$lating

gl$%ose #dminist"ation of ins$lin %o""e%ts this p"oblem

+5 D @eta=%a"otene and 7itamin , a"e antio-idants whi%h help to inhibit o-idation 7itamin , is fo$nd in

the following foods: wheat ge"m& %o"n& n$ts& seeds& oli/es& s*i$a"/& aspa"ag$s and othe" g"een leafy

/egetables Food so$"%es of beta=%a"otene in%l$de da" g"een /egetables& %a""ots& 6a$#!s and tomatoes

+8 A D"a/ity speeds $p digestion and p"e/ents "efl$- of stoma%h %ontents into the esophag$s

+ ) #bdominal distension may be asso%iated with pain& may indi%ate pe"fo"ation& a %ompli%ation that %o$ld

lead to pe"itonitis

+9 D It may tae . to 5 months to eat anything& b$t most people %an eat anything they want

.0 D Clay %olo"ed stools a"e indi%ati/e of hepati% obst"$%tion

.1 D St"eptomy%in is an aminogly%oside and damage on the th %"anial ne"/e ototo-i%ity is a %ommon side

effe%t of aminogly%osides

.2 D <ost pepti% $l%e" is %a$sed by ?eli%opte" pylo"i whi%h is a g"am negati/e ba%te"i$m

.+ D 12 to 2. ho$"s afte" s$btotal gast"e%tomy gast"i% d"ainage is no"mally b"own& whi%h indi%ates digested

food

.. C Hat%hing !7 is pe"missible be%a$se the eye does not need to mo/e "apidly with this a%ti/ity& and it

does not in%"ease int"ao%$la" p"ess$"e

. A Common signs and symptoms of f"a%t$"e in%l$de pain& defo"mity& sho"tening of the e-t"emity& %"epit$s

and swelling

.5 C !he d"oppe" sho$ld not to$%h any obEe%t o" any pa"t of the %lientKs ea"




.8 A S$dden de%"ease in d"ainage o" onset of se/e"e abdominal pain sho$ld be "epo"ted immediately to the

physi%ian be%a$se it %o$ld mean that obst"$%tion has been de/eloped

. ) Compli%ations of a%$te appendi%itis a"e pe"itonitis& pe"fo"ation and abs%ess de/elopment

.9 D # %lient with a%$te pan%"eatitis is p"one to %ompli%ations asso%iated with "espi"ato"y system

0 ) 'i/e" inflammation and obst"$%tion blo% the no"mal flow of bile ,-%ess bili"$bin t$"ns the sin and

s%le"a yellow and the $"ine da" and f"othy


1 # %lient is s%hed$led fo" inse"tion of an infe"io" /ena %a/a I7C filte" *$"se Pat"i%ia %ons$lts the physi%ian

abo$t withholding whi%h "eg$la"ly s%hed$led medi%ation on the day befo"e the s$"ge"yQ

a Potassi$m Chlo"ide

b Ha"fa"in Sodi$m% F$"osemide

d )o%$sate

2 # n$"se is planning to assess the %o"neal "efle- on $n%ons%io$s %lient Hhi%h of the following is the safest

stim$l$s to to$%h the %lientKs %o"neaQ

a Cotton b$ds

b Ste"ile glo/e

% Ste"ile tong$e dep"esso" d Hisp of %otton

+ # female %lient de/elops an infe%tion at the %athete" inse"tion site !he n$"se in %ha"ge $ses the te"m

iat"ogeni%T when des%"ibing the infe%tion be%a$se it "es$lted f"om:

a ClientKs de/elopmental le/el

b !he"ape$ti% p"o%ed$"e

% Poo" hygiene

d Inade6$ate dieta"y patte"ns. *$"se Ca"ol is assessing a %lient with Pa"insonKs disease !he n$"se "e%ogni(e b"adyinesia when the %lient

e-hibits:




a Intentional t"emo"

b Pa"alysis of limbs

% <$s%le spasm

d 'a% of spontaneo$s mo/ement

# %lient who s$ffe"ed f"om a$tomobile a%%ident %omplains of seeing f"e6$ent flashes of light !he n$"se sho$ld

e-pe%t:

a <yopia

b )eta%hed "etina% Dla$%oma

d S%le"ode"ma

5 ate with se/e"e head inE$"y is being monito"ed by the n$"se fo" in%"easing int"a%"anial p"ess$"e ICP Hhi%h

finding sho$ld be most indi%ati/e sign of in%"easing int"a%"anial p"ess$"eQ

a Inte"mittent ta%hy%a"dia

b Polydipsia

% !a%hypnea

d In%"eased "estlessness

8 # hospitali(ed %lient had a toni%=%loni% sei($"e while waling in the hall )$"ing the sei($"e the n$"se p"io"itysho$ld be:

a ?old the %lients a"ms and leg fi"mly

b Pla%e the %lient immediately to soft s$"fa%e% P"ote%ts the %lientKs head f"om inE$"y

d #ttempt to inse"t a tong$e dep"esso" between the %lientKs teeth

# %lient has $nde"gone "ight pne$mone%tomy Hhen t$"ning the %lient& the n$"se sho$ld plan to position the

%lient eithe":

a ight side=lying position o" s$pine

b ?igh fowle"s

% ight o" left side lying position

d 'ow fowle"Ks position

9 *$"se Benny sho$ld %a$tion a female %lient who is se-$ally a%ti/e in taing Isonia(id I*? be%a$se the d"$g

has whi%h of the following side effe%tsQ

a P"e/ents o/$lation

b ?as a m$tageni% effe%t on o/a% )e%"eases the effe%ti/eness of o"al %ont"a%epti/es

d In%"eases the "is of /aginal infe%tion

10 # %lient has $nde"gone gast"e%tomy *$"se Bo/y is awa"e that the best position fo" the %lient is:a 'eft side lying

b 'ow fowle"Ks

% P"one

d S$pine

11 )$"ing the initial postope"ati/e pe"iod of the %lientKs stoma !he n$"se e/al$ates whi%h of the following

obse"/ations sho$ld be "epo"ted immediately to the physi%ianQ

a Stoma is da" "ed to p$"ple

b Stoma is oo(es a small amo$nt of blood

% Stoma is lightly edemato$s

d Stoma does not e-pel stool

12 ate whi%h has diagnosed with $l%e"ati/e %olitis is following physi%ianKs o"de" fo" bed "est with bath"oom

p"i/ileges Hhat is the "ationale fo" this a%ti/ity "est"i%tionQ

a P"e/ent inE$"y

b P"omote "est and %omfo"t

% ed$%e intestinal pe"istalsis

d Conse"/e ene"gy

1+ *$"se C sho$ld "eg$la"ly assess the %lientKs ability to metaboli(e the total pa"ente"al n$t"ition !P*

sol$tion ade6$ately by monito"ing the %lient fo" whi%h of the following signs:a ?ype"gly%emia

b ?ypogly%emia

% ?ype"tension

d ,le/ate blood $"ea nit"ogen %on%ent"ation

1. # female %lient has an a%$te pan%"eatitis Hhi%h of the following signs and symptoms the n$"se wo$ld e-pe%t

to seeQ

a Constipation

b ?ype"tension

% #s%ites

d Ba$ndi%e

1 # %lient is s$spe%ted to de/elop tetany afte" a s$btotal thy"oide%tomy Hhi%h of the following symptoms

might indi%ate tetanyQ




a !ingling in the finge"s

b Pain in hands and feet

% !ension on the s$t$"e lines

d @leeding on the ba% of the d"essing

15 # yea" old woman has newly diagnosed with hypothy"oidism !he n$"se is awa"e that the signs and

symptoms of hypothy"oidism in%l$de:

a )ia""hea

b 7omiting% !a%hy%a"dia

d Height gain

18 # %lient has $nde"gone fo" an ileal %ond$it& the n$"se in %ha"ge sho$ld %losely monito" the %lient fo"

o%%$""en%e of whi%h of the following %ompli%ations "elated to pel/i% s$"ge"yQ

a #s%ites

b !h"ombophlebitis

% Ing$inal he"nia

d Pe"itonitis

1 )" <a"6$e( is abo$t to defib"illate a %lient in /ent"i%$la" fib"illation and says in a lo$d /oi%e %lea"T Hhatsho$ld be the a%tion of the n$"seQ

a Pla%es %ond$%ti/e gel pads fo" defib"illation on the %lientKs %hest

b !$"n off the me%hani%al /entilato" % Sh$ts off the %lientKs I7 inf$sion

d Steps away f"om the bed and mae s$"e all othe"s ha/e done the same

19 # %lient has been diagnosed with glome"$loneph"itis %omplains of thi"st !he n$"se sho$ld offe":

a B$i%e

b Dinge" ale

% <il shae

d ?a"d %andy

20 # %lient with a%$te "enal fail$"e is awa"e that the most se"io$s %ompli%ation of this %ondition is:

a Constipation

b #nemia

% Infe%tion

d Platelet dysf$n%tion21 *$"se a"en is %a"ing fo" %lients in the O !he n$"se is awa"e that the last physiologi% f$n%tion that the %lient

loss d$"ing the ind$%tion of anesthesia is:

a Cons%io$sness b Dag "efle-

% espi"ato"y mo/ement

d Co"neal "efle-

22 !he n$"se is assessing a %lient with ple$"al eff$sion !he n$"se e-pe%t to find:

a )e/iation of the t"a%hea towa"ds the in/ol/ed side

b ed$%ed o" absent of b"eath so$nds at the base of the l$ng

% <oist %"a%les at the poste"io" of the l$ngs

d In%"eased "esonan%e with pe"%$ssion of the in/ol/ed a"ea

2+ # %lient admitted with newly diagnosed with ?odginKs disease Hhi%h of the following wo$ld the n$"se

e-pe%t the %lient to "epo"tQ

a 'ymph node pain

b Height gain

% *ight sweats

d ?eada%he

2. # %lient has s$ffe"ed f"om fall and s$stained a leg inE$"y Hhi%h app"op"iate 6$estion wo$ld the n$"se as the

%lient to help dete"mine if the inE$"y %a$sed f"a%t$"eQ

a Is the pain sha"p and %ontin$o$sQT

b Is the pain d$ll a%heQT% )oes the dis%omfo"t feel lie a %"ampQT

d )oes the pain feel lie the m$s%le was st"et%hedQT

2 !he *$"se is assessing the %lientKs %asted e-t"emity fo" signs of infe%tion Hhi%h of the following findings is

indi%ati/e of infe%tionQ

a ,dema

b Hea distal p$lse

% Coolness of the sin

d P"esen%e of hot spotT on the %ast

25 *$"se hia is pe"fo"ming an otos%opi% e-amination on a female %lient with a s$spe%ted diagnosis of

mastoiditis *$"se hia wo$ld e-pe%t to note whi%h of the following if this diso"de" is p"esentQ

a !"anspa"ent tympani% memb"ane

b !hi% and immobile tympani% memb"ane

http://nursingcrib.com/types-of-anesthesia/

http://nursingcrib.com/types-of-anesthesia/




% Pea"ly %olo"ed tympani% memb"ane

d <obile tympani% memb"ane

28 *$"se Bo%elyn is %a"ing fo" a %lient with nasogast"i% t$be that is atta%hed to low s$%tion *$"se Bo%elyn

assesses the %lient fo" symptoms of whi%h a%id=base diso"de"Q

a espi"ato"y alalosis

b espi"ato"y a%idosis

% <etaboli% a%idosis

d <etaboli% alalosis2 # male ad$lt %lient has $nde"gone a l$mba" p$n%t$"e to obtain %e"eb"ospinal fl$id CSF fo" analysis Hhi%h

of the following /al$es sho$ld be negati/e if the CSF is no"malQ

a ed blood %ells

b Hhite blood %ells

% Ins$lin

d P"otein

29 # %lient is s$spe%ted of de/eloping diabetes insipid$s Hhi%h of the following is the most effe%ti/e

assessmentQ

a !aing /ital signs e/e"y . ho$"s b <onito"ing blood gl$%ose

% #ssessing #@D /al$es e/e"y othe" day

d <eas$"ing $"ine o$tp$t ho$"ly+0 # yea" old %lient is s$ffe"ing f"om a%$te phase of "he$matoid a"th"itis Hhi%h of the following wo$ld the

n$"se in %ha"ge identify as the lowest p"io"ity of the plan of %a"eQ

a P"e/ent Eoint defo"mity

b <aintaining $s$al ways of a%%omplishing tas

% elie/ing pain

d P"ese"/ing Eoint f$n%tion

+1 #mong the following& whi%h %lient is a$tot"ansf$sion possibleQ

a Client with #I)S

b Client with "$pt$"ed bowel

% Client who is in dange" of %a"dia% a""est

d Client with wo$nd infe%tion

+2 Hhi%h of the following is not a sign of th"omboembolismQa ,dema

b Swelling

% ednessd Coolness

++ *$"se @e%y is %a"ing fo" %lient who begins to e-pe"ien%e sei($"e while in bed Hhi%h a%tion sho$ld the n$"se

implement to p"e/ent aspi"ationQ

a Position the %lient on the side with head fle-ed fo"wa"d

b ,le/ate the head

% Use tong$e dep"esso" between teeth

d 'oosen "est"i%ti/e %lothing

+. # %lient has $nde"gone bone biopsy Hhi%h n$"sing a%tion sho$ld the n$"se p"o/ide afte" the p"o%ed$"eQ

a #dministe" analgesi%s /ia I<

b <onito" /ital signs

% <onito" the site fo" bleeding& swelling and hematoma fo"mation

d eep a"ea in ne$t"al position

+ # %lient is s$ffe"ing f"om low ba% pain Hhi%h of the following e-e"%ises will st"engthen the lowe" ba%

m$s%le of the %lientQ

a !ennis

b @asetball

% )i/ing

d Swimming+5 # %lient with pepti% $l%e" is being assessed by the n$"se fo" gast"ointestinal pe"fo"ation !he n$"se sho$ld

monito" fo":

a g$aia% stool test

b Slow& st"ong p$lse

% S$dden& se/e"e abdominal pain

d In%"eased bowel so$nds

+8 # %lient has $nde"gone s$"ge"y fo" "etinal deta%hment Hhi%h of the following goal sho$ld be p"io"iti(edQ

a P"e/ent an in%"ease int"ao%$la" p"ess$"e

b #lle/iate pain

% <aintain da"ened "oom

d P"omote low=sodi$m diet

+ # Client with gla$%oma has been p"es%"ibed with mioti%s !he n$"se is awa"e that mioti%s is fo":




a Const"i%ting p$pil

b ela-ing %ilia"y m$s%le

% Const"i%ting int"ao%$la" /essel

d Pa"aly(ing %ilia"y m$s%le

+9 Hhen s$%tioning an $n%ons%io$s %lient& whi%h n$"sing inte"/ention sho$ld the n$"se p"io"iti(e in maintaining

%e"eb"al pe"f$sionQ

a #dministe" di$"eti%s

b #dministe" analgesi%s% P"o/ide hygiene

d ?ype"o-ygenate befo"e and afte" s$%tioning

.0 Hhen dis%$ssing b"eathing e-e"%ises with a postope"ati/e %lient& *$"se ?a(el sho$ld in%l$de whi%h of the

following tea%hingQ

a Sho"t f"e6$ent b"eaths

b ,-hale with mo$th open

% ,-e"%ise twi%e a day

d Pla%e hand on the abdomen and feel it "ise

.1 'o$ie& with b$"ns o/e" +V of the body& %omplains of %hilling In p"omoting the %lientKs %omfo"t& the n$"sesho$ld:

a <aintain "oom h$midity below .0V

b Pla%e top sheet on the %lient% 'imit the o%%$""en%e of d"afts

d eep "oom tempe"at$"e at 0 deg"ees

.2 *$"se !"ish is awa"e that tempo"a"y hete"og"aft pig sin is $sed to t"eat b$"ns be%a$se this g"aft will:

a elie/e pain and p"omote "apid epitheliali(ation

b @e s$t$"ed in pla%e fo" bette" adhe"en%e

% )eb"ide ne%"oti% epitheli$m

d Con%$""ently $sed with topi%al antimi%"obials

.+ <a" has m$ltiple ab"asions and a la%e"ation to the t"$n and all fo$" e-t"emities says& I %anKt eat all this

foodT !he food that the n$"se sho$ld s$ggest to be eaten fi"st sho$ld be:

a <eat loaf and %offee

b <eat loaf and st"awbe""ies

% !omato so$p and apple pied !omato so$p and b$tte"ed b"ead

.. !ony "et$"ns fo"m s$"ge"y with pe"manent %olostomy )$"ing the fi"st 2. ho$"s the %olostomy does not d"ain

!he n$"se sho$ld be awa"e that:a P"ope" f$n%tioning of nasogast"i% s$%tion

b P"es$"gi%al de%"ease in fl$id intae

% #bsen%e of gast"ointestinal motility

d Intestinal edema following s$"ge"y

. Hhen tea%hing a %lient abo$t the signs of %olo"e%tal %an%e"& *$"se !"ish st"esses that the most %ommon

%omplaint of pe"sons with %olo"e%tal %an%e" is:

a #bdominal pain

b ?emo""hoids

% Change in %alibe" of stools

d Change in bowel habits

.5 'o$is de/elops pe"itonitis and sepsis afte" s$"gi%al "epai" of "$pt$"es di/e"ti%$l$m !he n$"se in %ha"ge sho$ld

e-pe%t an assessment of the %lient to "e/eal:

a !a%hy%a"dia

b #bdominal "igidity

% @"ady%a"dia

d In%"eased bowel so$nds

.8 Immediately afte" li/e" biopsy& the %lient is pla%ed on the "ight side& the n$"se is awa"e that that this position

sho$ld be maintained be%a$se it will:a ?elp stop bleeding if any o%%$"s

b ed$%e the fl$id t"apped in the bilia"y d$%ts

% Position with g"eatest %omfo"t

d P"omote %i"%$lating blood /ol$me

. !ony has diagnosed with hepatitis # !he info"mation f"om the health histo"y that is most liely lined to

hepatitis # is:

a ,-posed with a"seni% %ompo$nds at wo"

b Ho"ing as lo%al pl$mbe"

% Ho"ing at hemodialysis %lini%

d )ish washe" in "esta$"ants

.9 *$"se !"ish is awa"e that the labo"ato"y test "es$lt that most liely wo$ld indi%ate a%$te pan%"eatitis is an

ele/ated:






1+ A )$"ing !otal Pa"ente"al *$t"ition !P* administ"ation& the %lient sho$ld be monito"ed "eg$la"ly fo"

hype"gly%emia

1. D Ba$ndi%e may be p"esent in a%$te pan%"eatitis owing to obst"$%tion of the bilia"y d$%t

1 A !etany may o%%$" afte" thy"oide%tomy if the pa"athy"oid glands a"e a%%identally inE$"ed o" "emo/ed

15 D !ypi%al signs of hypothy"oidism in%l$des weight gain& fatig$e& de%"eased ene"gy& apathy& b"ittle nails& d"y

sin& %old intole"an%e& %onstipation and n$mbness

18 ) #fte" a pel/i% s$"ge"y& the"e is an in%"eased %han%e of th"ombophlebitits owing to the pel/i% manip$lation

that %an inte"fe"e with %i"%$lation and p"omote /eno$s stasis1 D Fo" the safety of all pe"sonnel& if the defib"illato" paddles a"e being dis%ha"ged& all pe"sonnel m$st stand

ba% and be %lea" of all the %onta%t with the %lient o" the %lientKs bed

19 D ?a"d %andy will "elie/e thi"st and in%"ease %a"bohyd"ates b$t does not s$pply e-t"a fl$id

20 C Infe%tion is "esponsible fo" one thi"d of the t"a$mati% o" s$"gi%ally ind$%ed death of %lients with "enal

fail$"e as well as medi%al ind$%ed a%$te "enal fail$"e #F

21 C !he"e is no "espi"ato"y mo/ement in stage . of anesthesia& p"io" to this stage& "espi"ation is dep"essed b$t

p"esent

22 ) Comp"ession of the l$ng by fl$id that a%%$m$lates at the base of the l$ngs "ed$%es e-pansion and ai"

e-%hange2+ C #ssessment of a %lient with ?odginKs disease most often "e/eals enla"ged& painless lymph node& fe/e"&

malaise and night sweats

2. A F"a%t$"ed pain is gene"ally des%"ibed as sha"p& %ontin$o$s& and in%"easing in f"e6$en%y2 D Signs and symptoms of infe%tion $nde" a %asted a"ea in%l$de odo" o" p$"$lent d"ainage and the p"esen%e of

hot spotT whi%h a"e a"eas on the %ast that a"e wa"me" than the othe"s

25 ) Otos%opi% e-amnation in a %lient with mastoiditis "e/eals a d$ll& "ed& thi% and immobile tymphani%

memb"ane with o" witho$t pe"fo"ation

28 D 'oss of gast"i% fl$id /ia nasogast"i% s$%tion o" /omiting %a$ses metaboli% alalosis be%a$se of the loss of

hyd"o%hlo"i% a%id whi%h is a potent a%id in the body

2 A !he ad$lt with no"mal %e"eb"ospinal fl$id has no "ed blood %ells

29 D <eas$"ing the $"ine o$tp$t to dete%t e-%ess amo$nt and %he%ing the spe%ifi% g"a/ity of $"ine samples to

dete"mine $"ine %on%ent"ation a"e app"op"iate meas$"es to dete"mine the onset of diabetes insipid$s

+0 ) !he n$"se sho$ld fo%$s mo"e on de/eloping less st"essf$l ways of a%%omplishing "o$tine tas

+1 C #$tot"ansf$sion is a%%eptable fo" the %lient who is in dange" of %a"dia% a""est

+2 D !he %lient with th"omboembolism does not ha/e %oolness++ A Positioning the %lient on one side with head fle-ed fo"wa"d allows the tong$e to fall fo"wa"d and fa%ilitates

d"ainage se%"etions the"efo"e p"e/ents aspi"ation

+. C *$"sing %a"e afte" bone biopsy in%l$des %lose monito"ing of the p$n%t$"ed site fo" bleeding& swelling andhematoma fo"mation

+ D Haling and swimming a"e /e"y helpf$l in st"engthening ba% m$s%les fo" the %lient s$ffe"ing f"om lowe"

ba% pain

+5 C S$dden& se/e"e abdominal pain is the most indi%ati/e sign of pe"fo"ation Hhen pe"fo"ation of an $l%e"

o%%$"s& the n$"se maybe $nable to hea" bowel so$nds at all

+8 A #fte" s$"ge"y to %o""e%t a deta%hed "etina& p"e/ention of in%"eased int"ao%$la" p"ess$"e is the p"io"ity goal

+ A <ioti% agent %onst"i%ts the p$pil and %ont"a%ts %ilia"y m$s%le !hese effe%ts widen the filt"ation angle and

pe"mit in%"eased o$t flow of a6$eo$s h$mo"

+9 D It is a p"io"ity to hype"o-ygenate the %lient befo"e and afte" s$%tioning to p"e/ent hypo-ia and to maintain

%e"eb"al pe"f$sion

.0 D #bdominal b"eathing imp"o/es l$ngs e-pansion

.1 C # Client with b$"ns is /e"y sensiti/e to tempe"at$"e %hanges be%a$se heat is loss in the b$"n a"eas

.2 A !he g"aft %o/e"s the ne"/e endings& whi%h "ed$%es pain and p"o/ides f"amewo" fo" g"an$lation

.+ ) <eat p"o/ides p"oteins and the f"$it p"oteins /itamin C that both p"omote wo$nd healing

.. C !his is p"ima"ily %a$sed by the t"a$ma of intestinal manip$lation and the dep"essi/e effe%ts anestheti%s and

analgesi%s

. D Constipation& dia""hea& andGo" %onstipation alte"nating with dia""hea a"e the most %ommon symptoms of

%olo"e%tal %an%e".5 ) Hith in%"eased int"aabdominal p"ess$"e& the abdominal wall will be%ome tende" and "igid

.8 A P"ess$"e applied in the p$n%t$"e site indi%ates that a bilia"y /essel was p$n%t$"e whi%h is a %ommon

%ompli%ation afte" li/e" biopsy

. ) ?epatitis # is p"ima"ily sp"ead /ia fe%al=o"al "o$te Sewage poll$ted wate" may ha"bo" the /i"$s

.9 ) #mylase %on%ent"ation is high in the pan%"eas and is ele/ated in the se"$m when the pan%"eas be%omes

a%$tely inflamed and also it disting$ishes pan%"eatitis f"om othe" a%$te abdominal p"oblems

0 A Sodi$m& whi%h is %on%e"ned with the "eg$lation of e-t"a%ell$la" fl$id /ol$me& it is lost with /omiting

Chlo"ide& whi%h balan%es %ations in the e-t"a%ell$la" %ompa"tments& is also lost with /omiting& be%a$se

sodi$m and %hlo"ide a"e pa"allel ele%t"olytes& hyponat"emia will a%%ompany





1 <a"%o who was diagnosed with b"ain t$mo" was s%hed$led fo" %"aniotomy In p"e/enting the de/elopment of

%e"eb"al edema afte" s$"ge"y& the n$"se sho$ld e-pe%t the $se of:

a )i$"eti%s

b #ntihype"tensi/e

% Ste"oids

d #nti%on/$lsants

2 ?alfway th"o$gh the administ"ation of blood& the female %lient %omplains of l$mba" pain #fte" stopping the

inf$sion *$"se ?a(el sho$ld:a In%"ease the flow of no"mal saline

b #ssess the pain f$"the"

% *otify the blood ban

d Obtain /ital signs

+ *$"se <a$"een nows that the positi/e diagnosis fo" ?I7 infe%tion is made based on whi%h of the following:

a # histo"y of high "is se-$al beha/io"s

b Positi/e ,'IS# and weste"n blot tests

% Identifi%ation of an asso%iated oppo"t$nisti% infe%tion

d ,/iden%e of e-t"eme weight loss and high fe/e"

. *$"se <a$"een is awa"e that a %lient who has been diagnosed with %h"oni% "enal fail$"e "e%ogni(es an ade6$ate

amo$nt of high=biologi%=/al$e p"otein when the food the %lient sele%ted f"om the men$ was:

a aw %a""ots




b #pple E$i%e

% Hhole wheat b"ead

d Cottage %heese

enneth who has diagnosed with $"emi% synd"ome has the potential to de/elop %ompli%ations Hhi%h among

the following %ompli%ations sho$ld the n$"se anti%ipates:

a Flapping hand t"emo"s

b #n ele/ated hemato%"it le/el

% ?ypotensiond ?ypoalemia

5 # %lient is admitted to the hospital with benign p"ostati% hype"plasia& the n$"se most "ele/ant assessment wo$ld

be:

a Flan pain "adiating in the g"oin

b )istention of the lowe" abdomen

% Pe"ineal edema

d U"eth"al dis%ha"ge

8 # %lient has $nde"gone with penile implant #fte" 2. h"s of s$"ge"y& the %lientKs s%"ot$m was edemato$s and

painf$l !he n$"se sho$ld:a #ssist the %lient with sit( bath

b #pply wa" soas in the s%"ot$m

% ,le/ate the s%"ot$m $sing a soft s$ppo"td P"epa"e fo" a possible in%ision and d"ainage

*$"se ha(el "e%ei/es eme"gen%y labo"ato"y "es$lts fo" a %lient with %hest pain and immediately info"ms the

physi%ian #n in%"eased myoglobin le/el s$ggests whi%h of the followingQ

a 'i/e" disease

b <yo%a"dial damage

% ?ype"tension

d Can%e"

9 *$"se <a$"een wo$ld e-pe%t the a %lient with mit"al stenosis wo$ld demonst"ate symptoms asso%iated with

%ongestion in the:

a ight at"i$m

b S$pe"io" /ena %a/a

% #o"tad P$lmona"y

10 # %lient has been diagnosed with hype"tension !he n$"se p"io"ity n$"sing diagnosis wo$ld be:

a Ineffe%ti/e health maintenan%e b Impai"ed sin integ"ity

% )efi%ient fl$id /ol$me

d Pain

11 *$"se ?a(el tea%hes the %lient with angina abo$t %ommon e-pe%ted side effe%ts of nit"ogly%e"in in%l$ding:

a high blood p"ess$"e

b stoma%h %"amps

% heada%he

d sho"tness of b"eath

12 !he following a"e lipid abno"malities Hhi%h of the following is a "is fa%to" fo" the de/elopment of

athe"os%le"osis and P7)Q

a ?igh le/els of low density lipid ')' %holeste"ol

b ?igh le/els of high density lipid ?)' %holeste"ol

% 'ow %on%ent"ation t"igly%e"ides

d 'ow le/els of ')' %holeste"ol

1+ Hhi%h of the following "ep"esents a signifi%ant "is immediately afte" s$"ge"y fo" "epai" of ao"ti% ane$"ysmQ

a Potential wo$nd infe%tion

b Potential ineffe%ti/e %oping

% Potential ele%t"olyte balan%ed Potential alte"ation in "enal pe"f$sion

1. *$"se Bosie sho$ld inst"$%t the %lient to eat whi%h of the following foods to obtain the best s$pply of 7itamin

@12Q

a dai"y p"od$%ts

b /egetables

% D"ains

d @"o%%oli

1 a"en has been diagnosed with aplasti% anemia !he n$"se monito"s fo" %hanges in whi%h of the following

physiologi% f$n%tionsQ

a @owel f$n%tion

b Pe"iphe"al sensation

% @leeding tenden%ies






28 Hhile pe"fo"ming a physi%al assessment of a male %lient with go$t of the g"eat toe& *$"se 7i/ian sho$ld

assess fo" additional tophi $"ate deposits on the:

a @$tto%s

b ,a"s

% Fa%e

d #bdomen

2 *$"se at"ina wo$ld "e%ogni(e that the demonst"ation of %"$t%h waling with t"ipod gait was $nde"stood

when the %lient pla%es weight on the:a Palms of the hands and a-illa"y "egions

b Palms of the hand

% #-illa"y "egions

d Feet& whi%h a"e set apa"t

29 <ang Bose with "he$matoid a"th"itis states& the only time I am witho$t pain is when I lie in bed pe"fe%tly

stillT )$"ing the %on/ales%ent stage& the n$"se in %ha"ge with <ang Bose sho$ld en%o$"age:

a #%ti/e Eoint fle-ion and e-tension

b Contin$ed immobility $ntil pain s$bsides

% ange of motion e-e"%ises twi%e dailyd Fle-ion e-e"%ises th"ee times daily

+0 # male %lient has $nde"gone spinal s$"ge"y& the n$"se sho$ld:

a Obse"/e the %lientKs bowel mo/ement and /oiding patte"ns b 'og="oll the %lient to p"one position

% #ssess the %lientKs feet fo" sensation and %i"%$lation

d ,n%o$"age %lient to d"in plenty of fl$ids

+1 <a"ina with a%$te "enal fail$"e mo/es into the di$"eti% phase afte" one wee of the"apy )$"ing this phase the

%lient m$st be assessed fo" signs of de/eloping:

a ?ypo/olemia

b "enal fail$"e

% metaboli% a%idosis

d hype"alemia

+2 *$"se B$dith obtains a spe%imen of %lea" nasal d"ainage f"om a %lient with a head inE$"y Hhi%h of the

following tests diffe"entiates m$%$s f"om %e"eb"ospinal fl$id CSFQ

a P"otein b Spe%ifi% g"a/ity

% Dl$%ose

d <i%"oo"ganism++ # 22 yea" old %lient s$ffe"ed f"om his fi"st toni%=%loni% sei($"e Upon awaening the %lient ass the n$"se&

Hhat %a$sed me to ha/e a sei($"eQ Hhi%h of the following wo$ld the n$"se in%l$de in the p"ima"y %a$se of

toni% %loni% sei($"es in ad$lts mo"e the 20 yea"sQ

a ,le%t"olyte imbalan%e

b ?ead t"a$ma

% ,pilepsy

d Congenital defe%t

+. Hhat is the p"io"ity n$"sing assessment in the fi"st 2. ho$"s afte" admission of the %lient with th"omboti%

C7#Q

a P$pil si(e and papilla"y "esponse

b %holeste"ol le/el

% ,%ho%a"diog"am

d @owel so$nds

+ *$"se 'inda is p"epa"ing a %lient with m$ltiple s%le"osis fo" dis%ha"ge f"om the hospital to home Hhi%h of the

following inst"$%tion is most app"op"iateQ

a P"a%ti%e $sing the me%hani%al aids that yo$ will need when f$t$"e disabilities a"iseT

b Follow good health habits to %hange the %o$"se of the diseaseT

% eep a%ti/e& $se st"ess "ed$%tion st"ategies& and a/oid fatig$ed Ao$ will need to a%%ept the ne%essity fo" a 6$iet and ina%ti/e lifestyleT

+5 !he n$"se is awa"e the ea"ly indi%ato" of hypo-ia in the $n%ons%io$s %lient is:

a Cyanosis

b In%"eased "espi"ations

% ?ype"tension

d estlessness

+8 # %lient is e-pe"ien%ing spinal sho% *$"se <y"na sho$ld e-pe%t the f$n%tion of the bladde" to be whi%h of

the followingQ

a *o"mal

b #toni%

% Spasti%

d Un%ont"olled




+ Hhi%h of the following stage the %a"%inogen is i""e/e"sibleQ

a P"og"ession stage

b Initiation stage

% eg"ession stage

d P"omotion stage

+9 #mong the following %omponents tho"o$gh pain assessment& whi%h is the most signifi%antQ

a ,ffe%t

b Ca$se% Ca$sing fa%to"s

d Intensity

.0 # 5 yea" old female is e-pe"ien%ing fla"e $p of p"$"it$s Hhi%h of the %lientKs a%tion %o$ld agg"a/ate the

%a$se of fla"e $psQ

a Sleeping in %ool and h$midified en/i"onment

b )aily baths with f"ag"ant soap

% Using %lothes made f"om 100V %otton

d In%"easing fl$id intae

.1 #t"opine s$lfate #t"opine is %ont"aindi%ated in all b$t one of the following %lientQa # %lient with high blood

b # %lient with bowel obst"$%tion

% # %lient with gla$%omad # %lient with U!I

.2 #mong the following %lients& whi%h among them is high "is fo" potential ha(a"ds f"om the s$"gi%al

e-pe"ien%eQ

a 58=yea"=old %lient

b .9=yea"=old %lient

% ++=yea"=old %lient

d 1=yea"=old %lient

.+ *$"se Bon assesses /ital signs on a %lient $nde"gone epid$"al anesthesia Hhi%h of the following wo$ld the

n$"se assess ne-tQ

a ?eada%he

b @ladde" distension

% )i((inessd #bility to mo/e legs

.. *$"se at"ina sho$ld anti%ipate that all of the following d"$gs may be $sed in the attempt to %ont"ol the

symptoms of <enie"eKs disease e-%ept:a #ntiemeti%s

b )i$"eti%s

% #ntihistamines

d Dl$%o%o"ti%oids

. Hhi%h of the following %ompli%ations asso%iated with t"a%heostomy t$beQ

a In%"eased %a"dia% o$tp$t

b #%$te "espi"ato"y dist"ess synd"ome #)S

% In%"eased blood p"ess$"e

d )amage to la"yngeal ne"/es

.5 *$"se Faith sho$ld "e%ogni(e that fl$id shift in an %lient with b$"n inE$"y "es$lts f"om in%"ease in the:

a !otal /ol$me of %i"%$lating whole blood

b !otal /ol$me of int"a/as%$la" plasma

% Pe"meability of %apilla"y walls

d Pe"meability of idney t$b$les

.8 #n +=yea"=old woman has se/e"al e%%hymoti% a"eas on he" "ight a"m !he b"$ises a"e p"obably %a$sed by:

a in%"eased %apilla"y f"agility and pe"meability

b in%"eased blood s$pply to the sin

% self infli%ted inE$"yd elde" ab$se

. *$"se #nna is awa"e that ea"ly adaptation of %lient with "enal %a"%inoma is:

a *a$sea and /omiting

b flan pain

% weight gain

d inte"mittent hemat$"ia

.9 # male %lient with t$be"%$losis ass *$"se @"ian how long the %hemothe"apy m$st be %ontin$ed *$"se

@"ianKs a%%$"ate "eply wo$ld be:

a 1 to + wees

b 5 to 12 months

% + to months

d + yea"s and mo"e






12 A #n in%"eased in ')' %holeste"ol %on%ent"ation has been do%$mented at "is fa%to" fo" the de/elopment of

athe"os%le"osis ')' %holeste"ol is not b"oen down into the li/e" b$t is deposited into the wall of the blood

/essels

1+ D !he"e is a potential alte"ation in "enal pe"f$sion manifested by de%"eased $"ine o$tp$t !he alte"ed "enal

pe"f$sion may be "elated to "enal a"te"y embolism& p"olonged hypotension& o" p"olonged ao"ti% %"oss=

%lamping d$"ing the s$"ge"y

1. A Dood so$"%e of /itamin @12 a"e dai"y p"od$%ts and meats

1 C #plasti% anemia de%"eases the bone ma""ow p"od$%tion of @CKs& white blood %ells& and platelets !he%lient is at "is fo" b"$ising and bleeding tenden%ies

15 )' #n ele%ti/e p"o%ed$"e is s%hed$led in ad/an%e so that all p"epa"ations %an be %ompleted ahead of time !he

/ital signs a"e the final %he% that m$st be %ompleted befo"e the %lient lea/es the "oom so that %ontin$ity of

%a"e and assessment is p"o/ided fo"

18 A !he pea in%iden%e of #%$te 'ympho%yti% 'e$emia #'' is . yea"s of age It is $n%ommon afte" 1

yea"s of age

1 D #%$te 'ympho%yti% 'e$emia #'' does not %a$se gast"i% distention It does in/ade the %ent"al ne"/o$s

system& and %lients e-pe"ien%e heada%hes and /omiting f"om meningeal i""itation

19 ) )isseminated Int"a/as%$la" Coag$lation )IC has not been fo$nd to "espond to o"al anti%oag$lants s$%h asCo$madin

20 A U"ine o$tp$t p"o/ides the most sensiti/e indi%ation of the %lientKs "esponse to the"apy fo" hypo/olemi%

sho% U"ine o$tp$t sho$ld be %onsistently g"eate" than +0 to + m'Gh"21 C ,a"ly wa"ning signs of la"yngeal %an%e" %an /a"y depending on t$mo" lo%ation ?oa"seness lasting 2 wees

sho$ld be e/al$ated be%a$se it is one of the most %ommon wa"ning signs

22 C Ste"oids de%"ease the bodyKs imm$ne "esponse th$s de%"easing the p"od$%tion of antibodies that atta% the

a%etyl%holine "e%epto"s at the ne$"om$s%$la" E$n%tion

2+ C !he osmoti% di$"eti% mannitol is %ont"aindi%ated in the p"esen%e of inade6$ate "enal f$n%tion o" hea"t

fail$"e be%a$se it in%"eases the int"a/as%$la" /ol$me that m$st be filte"ed and e-%"eted by the idney

2. A !hese de/i%es a"e mo"e a%%$"ate be%a$se they a"e easily to $sed and ha/e imp"o/ed adhe"en%e in ins$lin

"egimens by yo$ng people be%a$se the medi%ation %an be administe"ed dis%"eetly

2 C )amage to blood /essels may de%"ease the %i"%$lato"y pe"f$sion of the toes& this wo$ld indi%ate the la% of

blood s$pply to the e-t"emity

25 D' ,le/ation will help %ont"ol the edema that $s$ally o%%$"s

28 )' U"i% a%id has a low sol$bility& it tends to p"e%ipitate and fo"m deposits at /a"io$s sites whe"e blood flow isleast a%ti/e& in%l$ding %a"tilagino$s tiss$e s$%h as the ea"s

2 ) !he palms sho$ld bea" the %lientKs weight to a/oid damage to the ne"/es in the a-illa

29 A #%ti/e e-e"%ises& alte"nating e-tension& fle-ion& abd$%tion& and add$%tion& mobili(e e-$dates in the Eoints"elie/es stiffness and pain

+0 C' #lte"ation in sensation and %i"%$lation indi%ates damage to the spinal %o"d& if these o%%$"s notify physi%ian

immediately

+1 A In the di$"eti% phase fl$id "etained d$"ing the olig$"i% phase is e-%"eted and may "ea%h + to lite"s daily&

hypo/olemia may o%%$" and fl$ids sho$ld be "epla%ed

+2 C !he %onstit$ents of CSF a"e simila" to those of blood plasma #n e-amination fo" gl$%ose %ontent is done

to dete"mine whethe" a body fl$id is a m$%$s o" a CSF # CSF no"mally %ontains gl$%ose

++ ) !"a$ma is one of the p"ima"y %a$se of b"ain damage and sei($"e a%ti/ity in ad$lts Othe" %ommon %a$ses of

sei($"e a%ti/ity in ad$lts in%l$de neoplasms& withd"awal f"om d"$gs and al%ohol& and /as%$la" disease

+. A It is %"$%ial to monito" the p$pil si(e and papilla"y "esponse to indi%ate %hanges a"o$nd the %"anial ne"/es

+ C !he n$"se most positi/e app"oa%h is to en%o$"age the %lient with m$ltiple s%le"osis to stay a%ti/e& $se st"ess

"ed$%tion te%hni6$es and a/oid fatig$e be%a$se it is impo"tant to s$ppo"t the imm$ne system while "emaining

a%ti/e

+5 D estlessness is an ea"ly indi%ato" of hypo-ia !he n$"se sho$ld s$spe%t hypo-ia in $n%ons%io$s %lient who

s$ddenly be%omes "estless

+8 ) In spinal sho%& the bladde" be%omes %ompletely atoni% and will %ontin$e to fill $nless the %lient is

%athete"i(ed

+ A P"og"ession stage is the %hange of t$mo" f"om the p"eneoplasti% state o" low deg"ee of malignan%y to a fastg"owing t$mo" that %annot be "e/e"sed

+9 D Intensity is the maEo" indi%ati/e of se/e"ity of pain and it is impo"tant fo" the e/al$ation of the t"eatment

.0 )' !he $se of f"ag"ant soap is /e"y d"ying to sin hen%e %a$sing the p"$"it$s

.1 C' #t"opine s$lfate is %ont"aindi%ated with gla$%oma patients be%a$se it in%"eases int"ao%$la" p"ess$"e

.2 A # 58 yea" old %lient is g"eate" "is be%a$se the olde" ad$lt %lient is mo"e liely to ha/e a less=effe%ti/e

imm$ne system

.+ ) !he last a"ea to "et$"n sensation is in the pe"ineal a"ea& and the n$"se in %ha"ge sho$ld monito" the %lient fo"

distended bladde"

.. D Dl$%o%o"ti%oids play no signifi%ant "ole in disease t"eatment

. D !"a%heostomy t$be has se/e"al potential %ompli%ations in%l$ding bleeding& infe%tion and la"yngeal ne"/e

damage




.5 C In b$"n& the %apilla"ies and small /essels dilate& and %ell damage %a$se the "elease of a histamine=lie

s$bstan%e !he s$bstan%e %a$ses the %apilla"y walls to be%ome mo"e pe"meable and signifi%ant 6$antities of

fl$id a"e lost

.8 A #ging p"o%ess in/ol/es in%"eased %apilla"y f"agility and pe"meability Olde" ad$lts ha/e a de%"eased

amo$nt of s$b%$taneo$s fat and %a$se an in%"eased in%iden%e of b"$ise lie lesions %a$sed by %olle%tion of

e-t"a/as%$la" blood in loosely st"$%t$"ed de"mis

. D Inte"mittent pain is the %lassi% sign of "enal %a"%inoma It is p"ima"ily d$e to %apilla"y e"osion by the

%an%e"o$s g"owth.9 )' !$be"%le ba%ill$s is a d"$g "esistant o"ganism and taes a long time to be e"adi%ated Us$ally a %ombination

of th"ee d"$gs is $sed fo" minim$m of 5 months and at least si- months beyond %$lt$"e %on/e"sion

0 A' Patent ai"way is the most p"io"ityW the"efo"e "emo/al of se%"etions is ne%essa"y




PS(CHIATRIC NURSING Part 1

1 <a"%o app"oa%hed *$"se !"ish asing fo" ad/i%e on how to deal with his al%ohol addi%tion *$"se !"ish

sho$ld tell the %lient that the only effe%ti/e t"eatment fo" al%oholism is:

a Psy%hothe"apy

b #l%oholi%s anonymo$s ##

% !otal abstinen%e

d #/e"sion !he"apy

2 *$"se ?a(el is %a"ing fo" a male %lient who e-pe"ien%e false senso"y pe"%eptions with no basis in "eality

!his pe"%eption is nown as:a ?all$%inations

b )el$sions

% 'oose asso%iations

d *eologisms

+ *$"se <onet is %a"ing fo" a female %lient who has s$i%idal tenden%y Hhen a%%ompanying the %lient to

the "est"oom& *$"se <onet sho$ldM

a Di/e he" p"i/a%y

b #llow he" to $"inate

% Open the window and allow he" to get some f"esh ai"

d Obse"/e he"

. *$"se <a$"een is de/eloping a plan of %a"e fo" a female %lient with ano"e-ia ne"/osa Hhi%h a%tion

sho$ld the n$"se in%l$de in the planQ




a P"o/ide p"i/a%y d$"ing meals

b Set=$p a st"i%t eating plan fo" the %lient

% ,n%o$"age %lient to e-e"%ise to "ed$%e an-iety

d est"i%t /isits with the family

# %lient is e-pe"ien%ing an-iety atta% !he most app"op"iate n$"sing inte"/ention sho$ld in%l$deQ

a !$"ning on the tele/ision

b 'ea/ing the %lient alone

% Staying with the %lient and speaing in sho"t senten%esd #s the %lient to play with othe" %lients

5 # female %lient is admitted with a diagnosis of del$sions of D#*),U !his diagnosis "efle%ts a belief

that one is:

a @eing illed

b ?ighly famo$s and impo"tant

% esponsible fo" e/il wo"ld

d Conne%ted to %lient $n"elated to oneself

8 # 20 yea" old %lient was diagnosed with dependent pe"sonality diso"de" Hhi%h beha/io" is not most

liely to be e/iden%e of ineffe%ti/e indi/id$al %opingQ

a e%$""ent self=dest"$%ti/e beha/io"

b #/oiding "elationship

% Showing inte"est in solita"y a%ti/itiesd Inability to mae %hoi%es and de%ision witho$t ad/ise

# male %lient is diagnosed with s%hi(otypal pe"sonality diso"de" H

hi%h signs wo$ld this %lient e-hibit

d$"ing so%ial sit$ationQ

a Pa"anoid tho$ghts b ,motional affe%t

% Independen%e need

d #gg"essi/e beha/io"

9 *$"se Clai"e is %a"ing fo" a %lient diagnosed with b$limia !he most app"op"iate initial goal fo" a %lient

diagnosed with b$limia isQ

a ,n%o$"age to a/oid foods

b Identify an-iety %a$sing sit$ations

% ,at only th"ee meals a dayd #/oid shopping plenty of g"o%e"ies

10 *$"se !ony was %a"ing fo" a .1 yea" old female %lient Hhi%h beha/io" by the %lient indi%ates ad$lt

%ogniti/e de/elopmentQ

a Dene"ates new le/els of awa"eness

b #ss$mes "esponsibility fo" he" a%tions

% ?as ma-im$m ability to sol/e p"oblems and lea"n new sills

d ?e" pe"%eption a"e based on "eality

11 # ne$"om$s%$la" blo%ing agent is administe"ed to a %lient befo"e ,C! the"apy !he *$"se sho$ld

%a"ef$lly obse"/e the %lient fo"Q

a espi"ato"y diffi%$lties b *a$sea and /omiting

% )i((inessd Sei($"es

12 # 8 yea" old %lient is admitted to the hospital with the diagnosis of dementia of the #l(heime"Ks type and

dep"ession !he symptom that is $n"elated to dep"ession wo$ld beQ

a #patheti% "esponse to the en/i"onment

b I donKt nowT answe" to 6$estions

% Shallow of labile effe%t

d *egle%t of pe"sonal hygiene

1+ *$"se !"ish is wo"ing in a mental health fa%ilityW the n$"se p"io"ity n$"sing inte"/ention fo" a newly

admitted %lient with b$limia ne"/osa wo$ld be toQ

a !ea%h %lient to meas$"e I N O

b In/ol/e %lient in planning daily meal

% Obse"/e %lient d$"ing meals

d <onito" %lient %ontin$o$sly

1. *$"se Pat"i%ia is awa"e that the maEo" health %ompli%ation asso%iated with int"a%table ano"e-ia ne"/osa

wo$ld beQ

a Ca"dia% dys"hythmias "es$lting to %a"dia% a""est b Dl$%ose intole"an%e "es$lting in p"ot"a%ted hypogly%emia

% ,ndo%"ine imbalan%e %a$sing %old ameno""hea

d )e%"eased metabolism %a$sing %old intole"an%e

1 *$"se #nna %an minimi(e agitation in a dist$"bed %lient byQ

a In%"easing stim$lation




b limiting $nne%essa"y inte"a%tion

% in%"easing app"op"iate senso"y pe"%eption

d ens$"ing %onstant %lient and staff %onta%t

15 # +9 yea" old mothe" with obsessi/e=%omp$lsi/e diso"de" has be%ome immobili(ed by he" elabo"ate hand

washing and waling "it$als *$"se !"ish "e%ogni(es that the basis of OC diso"de" is often:

a P"oblems with being too %ons%ientio$s

b P"oblems with ange" and "emo"se

% Feelings of g$ilt and inade6$a%yd Feeling of $nwo"thiness and hopelessness

18 <a"io is %omplaining to othe" %lients abo$t not being allowed by staff to eep food in his "oom Hhi%h of

the following inte"/entions wo$ld be most app"op"iateQ

a #llowing a sna% to be ept in his "oom

b ep"imanding the %lient

% Igno"ing the %lients beha/io"

d Setting limits on the beha/io"

1 Conney with bo"de"line pe"sonality diso"de" who is to be dis%ha"ge soon th"eatens to do somethingT to

he"self if dis%ha"ged Hhi%h of the following a%tions by the n$"se wo$ld be most impo"tantQa #s a family membe" to stay with the %lient at home tempo"a"ily

b )is%$ss the meaning of the %lientKs statement with he"

% e6$est an immediate e-tension fo" the %lientd Igno"e the %lients statement be%a$se itKs a sign of manip$lation

19 Boey a %lient with antiso%ial pe"sonality diso"de" bel%hes lo$dly # staff membe" ass Boey& )o yo$

now why people find yo$ "ep$lsi/eQT this statement most liely wo$ld eli%it whi%h of the following %lient

"ea%tionQ

a )epensi/eness

b ,mba""assment

% Shame

d emo"sef$lness

20 Hhi%h of the following app"oa%hes wo$ld be most app"op"iate to $se with a %lient s$ffe"ing f"om

na"%issisti% pe"sonality diso"de" when dis%"epan%ies e-ist between what the %lient states and what a%t$ally

e-istQ

a ationali(ation b S$ppo"ti/e %onf"ontation

% 'imit setting

d Consisten%y21 Cely is e-pe"ien%ing al%ohol withd"awal e-hibits t"emo"s& diapho"esis and hype"a%ti/ity @lood p"ess$"e

is 190G8 mmhg and p$lse is 92 bpm Hhi%h of the medi%ations wo$ld the n$"se e-pe%t to administe"Q

a *alo-one *a"%an

b @en(l"opine Cogentin

% 'o"a(epam #ti/an

d ?alope"idol ?aldol

22 Hhi%h of the following foods wo$ld the n$"se !"ish eliminate f"om the diet of a %lient in al%ohol

withd"awalQ

a <il

b O"ange B$i%e

% Soda

d eg$la" Coffee

2+ Hhi%h of the following wo$ld *$"se ?a(el e-pe%t to assess fo" a %lient who is e-hibiting late signs of

he"oin withd"awalQ

a Aawning N diapho"esis

b estlessness N I""itability

% Constipation N steato""hea

d 7omiting and )ia""hea2. !o establish open and t"$sting "elationship with a female %lient who has been hospitali(ed with se/e"e

an-iety& the n$"se in %ha"ge sho$ldQ

a ,n%o$"age the staff to ha/e f"e6$ent inte"a%tion with the %lient

b Sha"e an a%ti/ity with the %lient

% Di/e %lient feedba% abo$t beha/io"

d espe%t %lientKs need fo" pe"sonal spa%e

2 *$"se <onette "e%ogni(es that the fo%$s of en/i"onmental <I'I,U the"apy is to:

a <anip$late the en/i"onment to b"ing abo$t positi/e %hanges in beha/io"

b #llow the %lientKs f"eedom to dete"mine whethe" o" not they will be in/ol/ed in a%ti/ities

% ole play life e/ents to meet indi/id$al needs

d Use nat$"al "emedies "athe" than d"$gs to %ont"ol beha/io"

25 *$"se !"ish wo$ld e-pe%t a %hild with a diagnosis of "ea%ti/e atta%hment diso"de" to:




a ?a/e mo"e positi/e "elation with the fathe" than the mothe"

b Cling to mothe" N %"y on sepa"ation

% @e able to de/elop only s$pe"fi%ial "elation with the othe"s

d ?a/e been physi%ally ab$se

28 Hhen tea%hing pa"ents abo$t %hildhood dep"ession *$"se !"ina sho$ld sayQ

a It may appea" a%ting o$t beha/io"

b )oes not "espond to %on/entional t"eatment

% Is sho"t in d$"ation N "esol/es easilyd 'oos almost identi%al to ad$lt dep"ession

2 *$"se Pe""y is awa"e that lang$age de/elopment in a$tisti% %hild "esembles:

a S%anning spee%h

b Spee%h lag

% Sh$tte"ing

d ,%holalia

29 # 50 yea" old female %lient who li/es alone tells the n$"se at the %omm$nity health %ente" I "eally donKt

need anyone to tal toT !he !7 is my best f"iend !he n$"se "e%ogni(es that the %lient is $sing the defense

me%hanism nown asQa )ispla%ement

b P"oEe%tion

% S$blimationd )enial

+0 Hhen wo"ing with a male %lient s$ffe"ing phobia abo$t bla% %ats& *$"se !"ish sho$ld anti%ipate that a

p"oblem fo" this %lient wo$ld beQ

a #n-iety when dis%$ssing phobia

b #nge" towa"d the fea"ed obEe%t

% )enying that the phobia e-ist

d )isto"tion of "eality when %ompleting daily "o$tines

+1 'inda is pa%ing the floo" and appea"s e-t"emely an-io$s !he d$ty n$"se app"oa%hes in an attempt to

alle/iate 'indaKs an-iety !he most the"ape$ti% 6$estion by the n$"se wo$ld beQ

a Ho$ld yo$ lie to wat%h !7Q

b Ho$ld yo$ lie me to tal with yo$Q

% #"e yo$ feeling $pset nowQd Igno"e the %lient

+2 *$"se Penny is awa"e that the symptoms that disting$ish post t"a$mati% st"ess diso"de" f"om othe" an-iety

diso"de" wo$ld be:a #/oidan%e of sit$ation N %e"tain a%ti/ities that "esemble the st"ess

b )ep"ession and a bl$nted affe%t when dis%$ssing the t"a$mati% sit$ation

% 'a% of inte"est in family N othe"s

d e=e-pe"ien%ing the t"a$ma in d"eams o" flashba%

++ *$"se @enEie is %omm$ni%ating with a male %lient with s$bstan%e=ind$%ed pe"sisting dementiaW the %lient

%annot "emembe" fa%ts and fills in the gaps with imagina"y info"mation *$"se @enEie is awa"e that this is

typi%al ofQ

a Flight of ideas

b #sso%iati/e looseness

% Confab$lation

d Con%"etism

+. *$"se Boey is awa"e that the signs N symptoms that wo$ld be most spe%ifi% fo" diagnosis ano"e-ia a"eQ

a ,-%essi/e weight loss& ameno""hea N abdominal distension

b Slow p$lse& 10V weight loss N alope%ia

% Comp$lsi/e beha/io"& e-%essi/e fea"s N na$sea

d ,-%essi/e a%ti/ity& memo"y lapses N an in%"eased p$lse

+ # %ha"a%te"isti% that wo$ld s$ggest to *$"se #nne that an adoles%ent may ha/e b$limia wo$ld be:

a F"e6$ent "eg$"gitation N "e=swallowing of food b P"e/io$s histo"y of gast"itis

% @adly stained teeth

d Positi/e body image

+5 *$"se <onette is awa"e that e-t"emely dep"essed %lients seem to do best in settings whe"e they ha/e:

a <$ltiple stim$li

b o$tine #%ti/ities

% <inimal de%ision maing

d 7a"ied #%ti/ities

+8 !o f$"the" assess a %lientKs s$i%idal potential *$"se at"ina sho$ld be espe%ially ale"t to the %lient

e-p"ession of:

a F"$st"ation N fea" of death

b #nge" N "esentment






. Hhen planning the dis%ha"ge of a %lient with %h"oni% an-iety& *$"se Ch"is e/al$ates a%hie/ement of the

dis%ha"ge maintenan%e goals Hhi%h goal wo$ld be most app"op"iately ha/ing been in%l$ded in the plan of

%a"e "e6$i"ing e/al$ationQ

a !he %lient eliminates all an-iety f"om daily sit$ations

b !he %lient igno"es feelings of an-iety

% !he %lient identifies an-iety p"od$%ing sit$ations

d !he %lient maintains %onta%t with a %"isis %o$nselo"

.9 *$"se !ina is %a"ing fo" a %lient with dep"ession who has not "esponded to antidep"essant medi%ation !hen$"se anti%ipates that what t"eatment p"o%ed$"e may be p"es%"ibedQ

a *e$"olepti% medi%ation

b Sho"t te"m se%l$sion

% Psy%hos$"ge"y

d ,le%t"o%on/$lsi/e the"apy

0 <a"io is admitted to the eme"gen%y "oom with d"$g=in%l$ded an-iety "elated to o/e" ingestion of

p"es%"ibed antipsy%hoti% medi%ation !he most impo"tant pie%e of info"mation the n$"se in %ha"ge sho$ld

obtain initially is the:

a 'ength of time on the med b *ame of the ingested medi%ation N the amo$nt ingested

% eason fo" the s$i%ide attempt

d *ame of the nea"est "elati/e N thei" phone n$mbe"

ANSERS a$% RATIONALES #r PS(CHIATRIC NURSING Part 1

1 C !otal abstinen%e is the only effe%ti/e t"eatment fo" al%oholism

2 A ?all$%inations a"e /is$al& a$dito"y& g$stato"y& ta%tile o" olfa%to"y pe"%eptions that ha/e no basis in "eality

+ D !he *$"se has a "esponsibility to obse"/e %ontin$o$sly the a%$tely s$i%idal %lient !he *$"se sho$ld wat%h

fo" %l$es& s$%h as %omm$ni%ating s$i%idal tho$ghts& and messagesW hoa"ding medi%ations and taling abo$t

death

. )' ,stablishing a %onsistent eating plan and monito"ing %lientKs weight a"e impo"tant to this diso"de"

C #pp"op"iate n$"sing inte"/entions fo" an an-iety atta% in%l$de $sing sho"t senten%es& staying with the %lient&

de%"easing stim$li& "emaining %alm and medi%ating as needed

5 ) )el$sion of g"ande$" is a false belief that one is highly famo$s and impo"tant

8 D Indi/id$al with dependent pe"sonality diso"de" typi%ally shows inde%isi/eness s$bmissi/eness and %linging

beha/io" so that othe"s will mae de%isions with them

A Clients with s%hi(otypal pe"sonality diso"de" e-pe"ien%e e-%essi/e so%ial an-iety that %an lead to pa"anoid

tho$ghts

9 ) @$limia diso"de" gene"ally is a maladapti/e %oping "esponse to st"ess and $nde"lying iss$es !he %lientsho$ld identify an-iety %a$sing sit$ation that stim$late the b$limi% beha/io" and then lea"n new ways of

%oping with the an-iety

10 A #n ad$lt age +1 to . gene"ates new le/el of awa"eness

11 A *e$"om$s%$la" @lo%e"& s$%h as SUCCI*A'C?O'I*, #ne%tine p"od$%es "espi"ato"y dep"ession

be%a$se it inhibits %ont"a%tions of "espi"ato"y m$s%les




12 C Hith dep"ession& the"e is little o" no emotional in/ol/ement the"efo"e little alte"ation in affe%t

1+ D !hese %lients often hide food o" fo"%e /omitingW the"efo"e they m$st be %a"ef$lly monito"ed

1. A !hese %lients ha/e se/e"ely depleted le/els of sodi$m and potassi$m be%a$se of thei" sta"/ation diet and

ene"gy e-pendit$"e& these ele%t"olytes a"e ne%essa"y fo" %a"dia% f$n%tioning

1 ) 'imiting $nne%essa"y inte"a%tion will de%"ease stim$lation and agitation

15 C it$alisti% beha/io" seen in this diso"de" is aimed at %ont"olling g$ilt and inade6$a%y by maintaining an

absol$te set patte"n of beha/io"

18 D !he n$"se needs to set limits in the %lientKs manip$lati/e beha/io" to help the %lient %ont"ol dysf$n%tional beha/io" # %onsistent app"oa%h by the staff is ne%essa"y to de%"ease manip$lation

1 ) #ny s$i%idal statement m$st be assessed by the n$"se !he n$"se sho$ld dis%$ss the %lientKs statement with

he" to dete"mine its meaning in te"ms of s$i%ide

19 A Hhen the staff membe" as the %lient if he wonde"s why othe"s find him "ep$lsi/e& the %lient is liely to

feel defensi/e be%a$se the 6$estion is belittling !he nat$"al tenden%y is to %o$nte"atta% the th"eat to self

image

20 ) !he n$"se wo$ld spe%ifi%ally $se s$ppo"ti/e %onf"ontation with the %lient to point o$t dis%"epan%ies

between what the %lient states and what a%t$ally e-ists to in%"ease "esponsibility fo" self

21 C !he n$"se wo$ld most liely administe" ben(odia(epine& s$%h as lo"a(epan ati/an to the %lient who ise-pe"ien%ing symptom: !he %lientKs e-pe"ien%es symptoms of withd"awal be%a$se of the "ebo$nd

phenomenon when the sedation of the C*S f"om al%ohol begins to de%"ease

22 D eg$la" %offee %ontains %affeine whi%h a%ts as psy%homoto" stim$lants and leads to feelings of an-iety andagitation Se"/ing %offee top the %lient may add to t"emo"s o" waef$lness

2+ D 7omiting and dia""hea a"e $s$ally the late signs of he"oin withd"awal& along with m$s%le spasm& fe/e"&

na$sea& "epetiti/e& abdominal %"amps and ba%a%he

2. D <o/ing to a %lientKs pe"sonal spa%e in%"eases the feeling of th"eat& whi%h in%"eases an-iety

2 A ,n/i"onmental <I'I,U the"apy aims at ha/ing e/e"ything in the %lientKs s$""o$nding a"ea towa"d

helping the %lient

25 C Child"en who ha/e e-pe"ien%ed atta%hment diffi%$lties with p"ima"y %a"egi/e" a"e not able to t"$st othe"s

and the"efo"e "elate s$pe"fi%ially

28 A Child"en ha/e diffi%$lty /e"bally e-p"essing thei" feelings& a%ting o$t beha/io"& s$%h as tempe" tant"$ms&

may indi%ate $nde"lying dep"ession

2 D !he a$tisti% %hild "epeat so$nds o" wo"ds spoen by othe"s

29 D !he %lient statement is an e-ample of the $se of denial& a defense that blo%s p"oblem by $n%ons%io$s"ef$sing to admit they e-ist

+0 A )is%$ssion of the fea"ed obEe%t t"igge"s an emotional "esponse to the obEe%t

+1 ) !he n$"se p"esen%e may p"o/ide the %lient with s$ppo"t N feeling of %ont"ol+2 D ,-pe"ien%ing the a%t$al t"a$ma in d"eams o" flashba% is the maEo" symptom that disting$ishes post

t"a$mati% st"ess diso"de" f"om othe" an-iety diso"de"

++ C Confab$lation o" the filling in of memo"y gaps with imagina"y fa%ts is a defense me%hanism $sed by

people e-pe"ien%ing memo"y defi%its

+. A !hese a"e the maEo" signs of ano"e-ia ne"/osa Height loss is e-%essi/e 1V of e-pe%ted weight

+ C )ental enamel e"osion o%%$"s f"om "epeated self=ind$%ed /omiting

+5 ) )ep"ession $s$ally is both emotional N physi%al # simple daily "o$tine is the best& least st"essf$l and least

an-iety p"od$%ing

+8 D !he e-p"ession of these feeling may indi%ate that this %lient is $nable to %ontin$e the st"$ggle of life

+ A St"$%t$"e tends to de%"ease agitation and an-iety and to in%"ease the %lientKs feeling of se%$"ity

+9 ) !he "it$als $sed by a %lient with obsessi/e %omp$lsi/e diso"de" help %ont"ol the an-iety le/el by

maintaining a set patte"n of a%tion

.0 C # pe"son with this diso"de" wo$ld not ha/e ade6$ate self=bo$nda"ies

.1 D 'oose asso%iations a"e tho$ghts that a"e p"esented witho$t the logi%al %onne%tions $s$ally ne%essa"y fo" the

listening to inte"p"et the message

.2 C ?elping the %lient to de/elop feeling of self wo"th wo$ld "ed$%e the %lientKs need to $se pathologi%

defenses

.+ ) Open ended 6$estions and silen%e a"e st"ategies $sed to en%o$"age %lients to dis%$ss thei" p"oblem indes%"ipti/e manne"

.. C Clients who a"e withd"awn may be immobile and m$te& and "e6$i"e %onsistent& "epeated inte"/entions

Comm$ni%ation with withd"awn %lients "e6$i"es m$%h patien%e f"om the n$"se !he n$"se fa%ilitates

%omm$ni%ation with the %lient by sitting in silen%e& asing open=ended 6$estion and pa$sing to p"o/ide

oppo"t$nities fo" the %lient to "espond

. D Hhen hall$%ination is p"esent& the n$"se sho$ld "einfo"%e "eality with the %lient

.5 A Pe"sonal %ha"a%te"isti%s of ab$se" in%l$de low self=esteem& immat$"ity& dependen%e& inse%$"ity and

Eealo$sy

.8 D # sho"t a%ting seletal m$s%le "ela-ant s$%h as s$%%inyl%holine #ne%tine is administe"ed d$"ing this

p"o%ed$"e to p"e/ent inE$"ies d$"ing sei($"e

. C e%ogni(ing sit$ations that p"od$%e an-iety allows the %lient to p"epa"e to %ope with an-iety o" a/oid

spe%ifi% stim$l$s




.9 D ,le%t"o%on/$lsi/e the"apy is an effe%ti/e t"eatment fo" dep"ession that has not "esponded to medi%ation

0 ) In an eme"gen%y& li/es sa/ing fa%ts a"e obtained fi"st !he name and the amo$nt of medi%ation ingested a"e

of o$tmost impo"tant in t"eating this potentially life th"eatening sit$ation


1 *$"se !ony sho$ld fi"st dis%$ss te"minating the n$"se=%lient "elationship with a %lient d$"ing the:

a !e"mination phase when dis%ha"ge plans a"e being made

b Ho"ing phase when the %lient shows some p"og"ess

% O"ientation phase when a %ont"a%t is established

d Ho"ing phase when the %lient b"ings it $p

2 <alo$ is diagnosed with maEo" dep"ession spends maEo"ity of the day lying in bed with the sheet p$lled o/e"

his head Hhi%h of the following app"oa%hes by the n$"se wo$ld be the most the"ape$ti%Qa >$estion the %lient $ntil he "esponds

b Initiate %onta%t with the %lient f"e6$ently

% Sit o$tside the %lients "oom

d Hait fo" the %lient to begin the %on/e"sation

+ Boe who is /e"y dep"essed e-hibits psy%homoto" "eta"dation& a flat affe%t and apathy !he n$"se in %ha"ge

obse"/es Boe to be in need of g"ooming and hygiene Hhi%h of the following n$"sing a%tions wo$ld be most

app"op"iateQ

a Haiting $ntil the %lientKs family %an pa"ti%ipate in the %lientKs %a"e

b #sing the %lient if he is "eady to tae showe"

% ,-plaining the impo"tan%e of hygiene to the %lient

d Stating to the %lient that itKs time fo" him to tae a showe"




. Hhen tea%hing <a"io with a typi%al dep"ession abo$t foods to a/oid while taing phenel(ine*a"dil& whi%h of

the following wo$ld the n$"se in %ha"ge in%l$deQ

a oasted %hi%en

b F"esh fish

% Salami

d ?amb$"ge"

Hhen assessing a female %lient who is "e%ei/ing t"i%y%li% antidep"essant the"apy& whi%h of the following

wo$ld ale"t the n$"se to the possibility that the %lient is e-pe"ien%ing anti%holine"gi% effe%tsQa U"ine "etention and bl$""ed /ision

b espi"ato"y dep"ession and %on/$lsion

% )eli"i$m and Sedation

d !"emo"s and %a"dia% a""hythmias

5 Fo" a male %lient with dysthymi% diso"de"& whi%h of the following app"oa%hes wo$ld the n$"se e-pe%t to

implementQ

a ,C!

b Psy%hothe"ape$ti% app"oa%h

% Psy%hoanalysisd #ntidep"essant the"apy

8 )anny who is diagnosed with bipola" diso"de" and a%$te mania& states the n$"se& Hhe"e is my da$ghte"Q I lo/e

'o$is ain& "ain go away )ogs eat di"tT !he n$"se inte"p"ets these statements as indi%ating whi%h of thefollowingQ

a ,%holalia

b *eologism

% Clang asso%iations

d Flight of ideas

!e""y with mania is sipping $p and down the hallway p"a%ti%ally "$nning into othe" %lients Hhi%h of the

following a%ti/ities wo$ld the n$"se in %ha"ge e-pe%t to in%l$de in !e""yKs plan of %a"eQ

a Hat%hing !7

b Cleaning day"oom tables

% 'eading g"o$p a%ti/ity

d eading a boo

9 Hhen assessing a male %lient fo" s$i%idal "is& whi%h of the following methods of s$i%ide wo$ld the n$"seidentify as most lethalQ

a H"ist %$tting

b ?ead banging% Use of g$n

d #spi"in o/e"dose

10 B$n has been hospitali(ed fo" maEo" dep"ession and s$i%idal ideation Hhi%h of the following statements

indi%ates to the n$"se that the %lient is imp"o/ingQ

a IKm of no $se to anyone anymo"eT

b I now my ids donKt need me anymo"e sin%e theyK"e g"ownT

% I %o$ldnKt ill myself be%a$se I donKt want to go to hellT

d I donKt thin abo$t illing myself as m$%h as I $sed toT

11 Hhi%h of the following a%ti/ities wo$ld *$"se !"ish "e%ommend to the %lient who be%omes /e"y an-io$s

when tho$ghts of s$i%ide o%%$"Q

a Using e-e"%ise bi%y%le

b <editating

% Hat%hing !7

d eading %omi%s

12 Hhen de/eloping the plan of %a"e fo" a %lient "e%ei/ing halope"idol& whi%h of the following medi%ations

wo$ld n$"se <onet anti%ipate administe"ing if the %lient de/eloped e-t"a py"amidal side effe%tsQ

a Olan(apine Jyp"e-a

b Pa"o-etine Pa-il% @en(t"opine mesylate Cogentin

d 'o"a(epam #ti/an

1+ Bon a s$spi%io$s %lient states that I now yo$ n$"ses a"e sp"aying my food with poison as yo$ tae it o$t of

the %a"tT Hhi%h of the following wo$ld be the best "esponse of the n$"seQ

a Di/ing the %lient %anned s$pplements $ntil the del$sion s$bsides

b #sing what ind of poison the %lient s$spe%ts is being $sed

% Se"/ing foods that %ome in sealed pa%ages

d #llowing the %lient to be the fi"st to open the %a"t and get a t"ay

1. # %lient is s$ffe"ing f"om %atatoni% beha/io"s Hhi%h of the following wo$ld the n$"se $se to dete"mine that

the medi%ation administe"ed P* ha/e been most effe%ti/eQ

a !he %lient "esponds to /e"bal di"e%tions to eat

b !he %lient initiates simple a%ti/ities witho$t di"e%tion




% !he %lient wals with the n$"se to he" "oom

d !he %lient is able to mo/e all e-t"emities o%%asionally

1 *$"se ?a(el in/ites new %lientKs pa"ents to attend the psy%ho ed$%ational p"og"am fo" families of the

%h"oni%ally mentally ill !he p"og"am wo$ld be most liely to help the family with whi%h of the following

iss$esQ

a )e/eloping a s$ppo"t netwo" with othe" families

b Feeling mo"e g$ilty abo$t the %lientKs illness

% e%ogni(ing the %lientKs weanessd <anaging thei" finan%ial %on%e"n and p"oblems

15 Hhen planning %a"e fo" )o"y with s%hi(otypal pe"sonality diso"de"& whi%h of the following wo$ld help the

%lient be%ome in/ol/ed with othe"sQ

a #ttending an a%ti/ity with the n$"se

b 'eading a sing a long in the afte"noon

% Pa"ti%ipating solely in g"o$p a%ti/ities

d @eing in/ol/ed with p"ima"ily one to one a%ti/ities

18 Hhi%h statement abo$t an indi/id$al with a pe"sonality diso"de" is t"$eQ

a Psy%hoti% beha/io" is %ommon d$"ing a%$te episodes b P"ognosis fo" "e%o/e"y is good with the"ape$ti% inte"/ention

% !he indi/id$al typi%ally "emains in the mainst"eam of so%iety& altho$gh he has p"oblems in so%ial and

o%%$pational "olesd !he indi/id$al $s$ally sees t"eatment willingly fo" symptoms that a"e pe"sonally dist"essf$l

1 *$"se Bohn is taling with a %lient who has been diagnosed with antiso%ial pe"sonality abo$t how to so%iali(e

d$"ing a%ti/ities witho$t being sed$%ti/e *$"se Bohn wo$ld fo%$s the dis%$ssion on whi%h of the following

a"easQ

a )is%$ssing his "elationship with his mothe"

b #sing him to e-plain "easons fo" his sed$%ti/e beha/io"

% S$ggesting to apologi(e to othe"s fo" his beha/io"

d ,-plaining the negati/e "ea%tions of othe"s towa"d his beha/io"

19 !ina with a hist"ioni% pe"sonality diso"de" is melod"amati% and "esponds to othe"s and sit$ations in an

e-agge"ated manne" *$"se !"ish wo$ld "e%ommend whi%h of the following a%ti/ities fo" !inaQ

a @aing %lass

b ole playing% S%"ap boo maing

d <$si% g"o$p

20 Boy has ente"ed the %hemi%al dependen%y $nit fo" t"eatment of al%ohol dependen%y Hhi%h of the following%lientKs possession will the n$"se most liely pla%e in a lo%ed a"eaQ

a !oothpaste

b Shampoo

% #ntisepti% wash

d <oist$"i(e"

21 Hhi%h of the following assessment wo$ld p"o/ide the best info"mation abo$t the %lientKs physiologi% "esponse

and the effe%ti/eness of the medi%ation p"es%"ibed spe%ifi%ally fo" al%ohol withd"awalQ

a Sleeping patte"n

b <ental ale"tness

% *$t"itional stat$s

d 7ital signs

22 #fte" administe"ing nalo-one *a"%an& an opioid antagonist& *$"se onald sho$ld monito" the female %lient

%a"ef$lly fo" whi%h of the followingQ

a espi"ato"y dep"ession

b ,pilepsy

% idney fail$"e

d Ce"eb"al edema

2+ Hhi%h of the following wo$ld n$"se onald $se as the best meas$"e to dete"mine a %lientKs p"og"ess in"ehabilitationQ

a !he way he gets along with his pa"ents

b !he n$mbe" of d"$g=f"ee days he has

% !he inds of f"iends he maes

d !he amo$nt of "esponsibility his Eob entails

2. # female %lient is b"o$ght by amb$lan%e to the hospital eme"gen%y "oom afte" taing an o/e"dose of

ba"bit$"ates is %omatose *$"se !"ish wo$ld be espe%ially ale"t fo" whi%h of the followingQ

a ,pilepsy

b <yo%a"dial Infa"%tion

% enal fail$"e

d espi"ato"y fail$"e






+5 Hhen de/eloping an initial n$"sing %a"e plan fo" a male %lient with a @ipola" I diso"de" mani% episode n$"se

on sho$ld plan toQ

a Isolate his gym time

b ,n%o$"age his a%ti/e pa"ti%ipation in $nit p"og"ams

% P"o/ide foods& fl$ids and "est

d ,n%o$"age his pa"ti%ipation in p"og"ams

+8 D"a%e is e-hibiting withd"awn patte"ns of beha/io" *$"se Bohnny is awa"e that this type of beha/io"

e/ent$ally p"od$%es feeling of:a ep"ession

b 'oneliness

% #nge"

d Pa"anoia

+ One mo"ning a female %lient on the inpatient psy%hiat"i% se"/i%e %omplains to n$"se ?a(el that she has been

waiting fo" o/e" an ho$" fo" someone to a%%ompany he" to a%ti/ities *$"se ?a(el "eplies to the %lient HeK"e

doing the best we %an !he"e a"e a lot of othe" people on the $nit who needs attention tooT !his statement

shows that the n$"seKs $se of:

a )efensi/e beha/io" b eality "einfo"%ement

% 'imit=setting beha/io"

d Imp$lse %ont"ol+9 # n$"sing diagnosis fo" a male %lient with a diagnosed m$ltiple pe"sonality diso"de" is %h"oni% low self=

esteem p"obably "elated to %hildhood ab$se !he most app"op"iate sho"t te"m %lient o$t%ome wo$ld be:

a 7e"bali(ing the need fo" an-iety medi%ations

b e%ogni(ing ea%h e-isting pe"sonality

% ,ngaging in obEe%t=o"iented a%ti/ities

d ,liminating defense me%hanisms and phobia

.0 # 2 yea" old male is admitted to a mental health fa%ility be%a$se of inapp"op"iate beha/io" !he %lient has

been hea"ing /oi%es& "esponding to imagina"y %ompanions and withd"awing to his "oom fo" se/e"al days at a

time *$"se <onette $nde"stands that the withd"awal is a defense against the %lientKs fea" of:

a Phobia

b Powe"lessness

% P$nishmentd eEe%tion

.1 Hhen asing the pa"ents abo$t the onset of p"oblems in yo$ng %lient with the diagnosis of s%hi(oph"enia&

*$"se 'inda wo$ld e-pe%t that they wo$ld "elate the %lientKs diffi%$lties began in:a ,a"ly %hildhood

b 'ate %hildhood

% #doles%en%e

d P$be"ty

.2 Bose who has been hospitali(ed with s%hi(oph"enia tells *$"se on& <y hea"t has stopped and my /eins ha/e

t$"ned to glass\T *$"se on is awa"e that this is an e-ample of:

a Somati% del$sions

b )epe"sonali(ation

% ?ypo%hond"iasis

d ,%holalia

.+ In "e%ogni(ing %ommon beha/io"s e-hibited by male %lient who has a diagnosis of s%hi(oph"enia& n$"se Bosie

%an anti%ipate:

a Sl$mped post$"e& pessimisti% o$t loo and flight of ideas

b D"andiosity& a""ogan%e and dist"a%tibility

% Hithd"awal& "eg"essed beha/io" and la% of so%ial sills

d )iso"ientation& fo"getf$lness and an-iety

.. One mo"ning& n$"se )iane finds a dist$"bed %lient %$"led $p in the fetal position in the %o"ne" of the day"oom

!he most a%%$"ate initial e/al$ation of the beha/io" wo$ld be that the %lient is:a Physi%ally ill and e-pe"ien%ing abdominal dis%omfo"t

b !i"ed and p"obably did not sleep well last night

% #ttempting to hide f"om the n$"se

d Feeling mo"e an-io$s today

. *$"se @ea noti%es a female %lient sitting alone in the %o"ne" smiling and taling to he"self eali(ing that the

%lient is hall$%inating *$"se @ea sho$ld:

a In/ite the %lient to help de%o"ate the day"oom

b 'ea/e the %lient alone $ntil he stops taling

% #s the %lient why he is smiling and taling

d !ell the %lient it is not good fo" him to tal to himself

.5 Hhen being admitted to a mental health fa%ility& a yo$ng female ad$lt tells *$"se <ylene that the /oi%es she

hea"s f"ighten he" *$"se <ylene $nde"stands that the %lient tends to hall$%inate mo"e /i/idly:



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1+0

a Hhile wat%hing !7

b )$"ing meal time

% )$"ing g"o$p a%ti/ities

d #fte" going to bed

.8 *$"se Bohn "e%ogni(es that pa"anoid del$sions $s$ally a"e "elated to the defense me%hanism of:

a P"oEe%tion

b Identifi%ation

% ep"essiond eg"ession

. Hhen planning %a"e fo" a male %lient $sing pa"anoid ideation& n$"se Basmin sho$ld "eali(e the impo"tan%e of:

a Di/ing the %lient diffi%$lt tass to p"o/ide stim$lation

b P"o/iding the %lient with a%ti/ities in whi%h s$%%ess %an be a%hie/ed

% emo/ing st"ess so that the %lient %an "ela-

d *ot pla%ing any demands on the %lient

.9 *$"se De""y is awa"e that the defense me%hanism %ommonly $sed by %lients who a"e al%oholi%s is:

a )ispla%ement

b )enial% P"oEe%tion

d Compensation

0 Hithin a few ho$"s of al%ohol withd"awal& n$"se Bohn sho$ld assess the male %lient fo" the p"esen%e of:a )iso"ientation& pa"anoia& ta%hy%a"dia

b !"emo"s& fe/e"& p"of$se diapho"esis

% I""itability& heightened ale"tness& Ee"y mo/ements

d Aawning& an-iety& %on/$lsions

ANSERS a$% RATIONALES #r PS(CHIATRIC NURSING Pa"t 2

1 C Hhen the n$"se and %lient ag"ee to wo" togethe"& a %ont"a%t sho$ld be established& the length of

the "elationship sho$ld be dis%$ssed in te"ms of its $ltimate te"mination

2 ) !he n$"se sho$ld initiate b"ief& f"e6$ent %onta%ts th"o$gho$t the day to let the %lient now that he

is impo"tant to the n$"se !his will positi/ely affe%t the %lientKs self=esteem

+ D !he %lient with dep"ession is p"eo%%$pied& has de%"eased ene"gy& and is $nable to mae

de%isions !he n$"se p"esents the sit$ation& ItKs time fo" a showe"T& and assists the %lient with pe"sonal

hygiene to p"ese"/e his dignity and self=esteem

. C Foods high in ty"amine& those that a"e fe"mented& pi%led& aged& o" smoed m$st be a/oided

be%a$se when they a"e ingested in %ombination with <#OIs a hype"tensi/e %"isis will o%%$" A #nti%holine"gi% effe%ts& whi%h "es$lt f"om blo%age of the pa"asympatheti% %"aniosa%"al

ne"/o$s system in%l$ding $"ine "etention& bl$""ed /ision& d"y mo$th N %onstipation

5 ) )ysthymia is a less se/e"e& %h"oni% dep"ession diagnosed when a %lient has had a dep"essed

mood fo" mo"e days than not o/e" a pe"iod of at least 2 yea"s Client with dysthymi% diso"de" benefit f"om

psy%hothe"ape$ti% app"oa%hes that assist the %lient in "e/e"sing the negati/e self image& negati/e feelings

abo$t the f$t$"e

8 D Flight of ideas is spee%h patte"n of "apid t"ansition f"om topi% to topi%& often witho$t finishing

one idea It is %ommon in mania




) !he %lient with mania is /e"y a%ti/e N needs to ha/e this ene"gy %hanneled in a %onst"$%ti/e tas

s$%h as %leaning o" tidying the "oom

9 C # %"$%ial fa%to" is dete"mining the lethality of a method is the amo$nt of time that o%%$"s

between initiating the method N the deli/e"y of the lethal impa%t of the method

10 D !he statement I donKt thin abo$t illing myself as m$%h as I $sed toT Indi%ates a lessening of

s$i%idal ideation and imp"o/ement in the %lientKs %ondition

11 A Using e-e"%ise bi%y%le is app"op"iate fo" the %lient who be%omes /e"y an-io$s when tho$ghts of

s$i%idal o%%$"12 C !he d"$g of %hoi%e fo" a %lient e-pe"ien%ing e-t"a py"amidal side effe%ts f"om halope"idol

?aldol is ben(t"opine mesylate %ogentin be%a$se of its anti %holine"gi% p"ope"ties

1+ D #llowing the %lient to be the fi"st to open the %a"t N tae a t"ay p"esents the %lient with the

"eality that the n$"ses a"e not to$%hing the food N t"ay& the"eby dispelling the del$sion

1. ) #ltho$gh all the a%tions indi%ate imp"o/ement& the ability to initiate simple a%ti/ities witho$t

di"e%tions indi%ates the most imp"o/ement in the %atatoni% beha/io"s

1 A Psy%hoed$%ational g"o$ps fo" families de/elop a s$ppo"t netwo" !hey p"o/ide ed$%ation abo$t

the bio%hemi%al etiology of psy%hiat"i% disease to "ed$%e& not in%"ease family g$ilt

15 C #ttending a%ti/ity with the n$"se assists the %lient to be%ome in/ol/ed with othe"s slowly !he

%lient with s%hi(otypal pe"sonality diso"de" needs s$ppo"t& indness N gentle s$ggestion to imp"o/e so%ial

sills N inte"pe"sonal "elationship

18 C #n indi/id$al with pe"sonality diso"de" $s$ally is not hospitali(ed $nless a %oe-isting #-is I

psy%hiat"i% diso"de" is p"esent Dene"ally& these indi/id$als mae ma"ginal adE$stments and "emain in so%iety&

altho$gh they typi%ally e-pe"ien%e "elationship and o%%$pational p"oblems "elated to thei" infle-ible

beha/io"s Pe"sonality diso"de"s a"e %h"oni% lifelong patte"ns of beha/io"W a%$te episodes do not o%%$"Psy%hoti% beha/io" is $s$ally not %ommon& altho$gh it %an o%%$" in eithe" s%hi(otypal pe"sonality diso"de" o"

bo"de"line pe"sonality diso"de" @e%a$se these diso"de"s a"e end$"ing and e/asi/e and the indi/id$al is

infle-ible& p"ognosis fo" "e%o/e"y is $nfa/o"able Dene"ally& the indi/id$al does not see t"eatment be%a$se he

does not pe"%ei/e p"oblems with his own beha/io" )ist"ess %an o%%$" based on othe" peopleKs "ea%tion to theindi/id$alKs beha/io"

1 D !he n$"se wo$ld e-plain the negati/e "ea%tions of othe"s towa"ds the %lientKs beha/io"s to mae

the %lients awa"e of the impa%t of his sed$%ti/e beha/io"s on othe"s

19 ) !he n$"se wo$ld $se "ole=playing to tea%h the %lient app"op"iate "esponses to othe"s and in/a"io$s sit$ations !his %lient d"amati(es e/ents& d"awn attention to self& and is $nawa"e of and does not deal

with feelings !he n$"se wo"s to help the %lient %la"ify t"$e feelings N lea"n to e-p"ess them app"op"iately

20 C #ntisepti% mo$thwash often %ontains al%ohol N sho$ld be ept in lo%ed a"ea& $nless labeling

%lea"ly indi%ates that the p"od$%t does not %ontain al%ohol

21 D <onito"ing of /ital signs p"o/ides the best info"mation abo$t the %lientKs o/e"all physiologi%

stat$s d$"ing al%ohol withd"awal N the physiologi% "esponse to the medi%ation $sed

22 A #fte" administe"ing nalo-one *a"%an the n$"se sho$ld monito" the %lientKs "espi"ato"y stat$s

%a"ef$lly& be%a$se the d"$g is sho"t a%ting N "espi"ato"y dep"ession may "e%$" afte" its effe%ts wea" off

2+ ) !he best meas$"e to dete"mine a %lientKs p"og"ess in "ehabilitation is the n$mbe" of d"$g= f"ee

days he has !he longe" the %lient is f"ee of d"$gs& the bette" the p"ognosis is

2. D @a"bit$"ates a"e C*S dep"essantsW the n$"se wo$ld be espe%ially ale"t fo" the possibility of

"espi"ato"y fail$"e espi"ato"y fail$"e is the most liely %a$se of death f"om ba"bit$"ate o/e" dose2 ) !he feeling of b$gs %"awling $nde" the sin is te"med as fo"mi%ation& and is asso%iated with

%o%aine $se

25 D !he n$"se wo$ld p"epa"e to administe" an antipsy%hoti% medi%ation s$%h as ?aldol to a %lient

e-pe"ien%ing amphetamine psy%hosis to de%"ease agitation N psy%hoti% symptoms& in%l$ding del$sions&

hall$%inations N %ogniti/e impai"ment

28 C #n a%id en/i"onment aids in the e-%"etion of PCP !he n$"se will definitely gi/e the %lient with

PCP into-i%ation %"anbe""y E$i%e to a%idify the $"ine to a ph of N a%%ele"ate e-%"etion

2 A !he n$"se wo$ld fa%ilitate p"og"essi/e "e/iew of the a%%ident and its %onse6$en%e to help the

%lient integ"ate feelings N memo"ies and to begin the g"ie/ing p"o%ess

29 ) !he n$"se inst"$%ts the n$"sing assistant to in/ite the %lient to l$n%h N a%%ompany him to the

dinning "oom to de%"ease manip$lation& se%onda"y gain& dependen%y and "einfo"%ement of negati/e beha/io"

while maintaining the %lientKs wo"th

+0 C !his p"o/ides s$ppo"t $ntil the indi/id$als %oping me%hanisms and pe"sonal s$ppo"t systems %an

be immobili(ed

+1 C esol/ing a loss is a slow& painf$l& %ontin$o$s p"o%ess $ntil a mental image of the dead pe"son&

almost de/oid of negati/e o" $ndesi"able feat$"es eme"ges

+2 A # mode"ate le/el of %ogniti/e impai"ment d$e to dementia is %ha"a%te"i(ed by in%"easing

dependen%e on en/i"onment N so%ial st"$%t$"e and by in%"easing psy%hologi% "igidity with a%%ent$ated

p"e/io$s t"aits N beha/io"s




++ C !his a%tion maintains fo" as long as possible& the %lients intelle%t$al f$n%tions by p"o/iding an

oppo"t$nity to $se them

+. A Indi/id$als with ano"e-ia often display i""itability& hospitality& and a dep"essed mood

+ D )ep"essed %lients demonst"ate de%"eased %omm$ni%ation be%a$se of la% of psy%hi% o" physi%al

ene"gy

+5 C !he %lient in a mani% episode of the illness often negle%ts basi% needs& these needs a"e a p"io"ity

to ens$"e ade6$ate n$t"ition& fl$id& and "est

+8 ) !he withd"awn patte"n of beha/io" p"esents the indi/id$al f"om "ea%hing o$t to othe"s fo"sha"ing the isolation p"od$%es feeling of loneliness

+ A !he n$"seKs "esponse is not the"ape$ti% be%a$se it does not "e%ogni(e the %lientKs needs b$t t"ies

to mae the %lient feel g$ilty fo" being demanding

+9 ) !he %lient m$st "e%ogni(e the e-isten%e of the s$b pe"sonalities so that inte"p"etation %an o%%$"

.0 D #n aloof& deta%hed& withd"awn post$"e is a means of p"ote%ting the self by withd"awing and

maintaining a safe& emotional distan%e

.1 C !he $s$al age of onset of s%hi(oph"enia is adoles%en%e o" ea"ly %hildhood

.2 A Somati% del$sion is a fi-ed false belief abo$t oneKs body

.+ C !hese a"e the %lassi% beha/io"s e-hibited by %lients with a diagnosis of s%hi(oph"enia

.. D !he fetal position "ep"esents "eg"essed beha/io" eg"ession is a way of "esponding to

o/e"whelming an-iety. ) !his p"o/ides a stim$l$s that %ompetes with and "ed$%es hall$%ination

.5 D #$dito"y hall$%inations a"e most t"o$blesome when en/i"onmental stim$li a"e diminished and

the"e a"e few %ompeting dist"a%tions

.8 A P"oEe%tion is a me%hanism in whi%h inne" tho$ghts and feelings a"e p"oEe%ted onto the

en/i"onment& seeming to %ome f"om o$tside the self "athe" than f"om within

. ) !his will help the %lient de/elop self=esteem and "ed$%e the $se of pa"anoid ideation

.9 ) )enial is a method of "esol/ing %onfli%t o" es%aping $npleasant "ealities by igno"ing thei"

e-isten%e

0 C #l%ohol is a %ent"al ne"/o$s system dep"essant !hese symptoms a"e the bodyKs ne$"ologi%

adaptation to the withd"awal of al%ohol


1 F"an%is who is addi%ted to %o%aine withd"aws f"om the d"$g *$"se on sho$ld e-pe%t to obse"/e:

a ?ype"a%ti/ity

b )ep"ession

% S$spi%iond )eli"i$m

2 *$"se Bohn is awa"e that a se"io$s effe%t of inhaling %o%aine isQ

a )ete"io"ation of nasal sept$m

b #%$te fl$id and ele%t"olyte imbalan%es

% ,-t"a py"amidal t"a%t symptoms

d ,sophageal /a"i%es

+ # tentati/e diagnosis of opiate addi%tion& *$"se Candy sho$ld assess a "e%ently hospitali(ed %lient fo" signs of

opiate withd"awal !hese signs wo$ld in%l$de:



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1++

a hino""hea& %on/$lsions& s$bno"mal tempe"at$"e

b *a$sea& dilated p$pils& %onstipation

% 'a%"imation& /omiting& d"owsiness

d <$s%le a%hes& papilla"y %onst"i%tion& yawning

. # . yea" old male %lient is b"o$ght to the psy%hiat"i% eme"gen%y "oom afte" attempting to E$mp off a b"idge

!he %lientKs wife states that he lost his Eob se/e"al months ago and has been $nable to find anothe" Eob !he

p"ima"y n$"sing inte"/ention at this time wo$ld be to assess fo":

a # past histo"y of dep"ession b C$""ent plans to %ommit s$i%ide

% !he p"esen%e of ma"ital diffi%$lties

d Feelings of e-%essi/e fail$"e

@efo"e helping a male %lient who has been se-$ally assa$lted& n$"se <a$"een sho$ld "e%ogni(e that the "apist is

moti/ated by feelings of:

a ?ostility

b Inade6$a%y

% In%ompeten%e

d Passion5 Hhen wo"ing with %hild"en who ha/e been se-$ally ab$sed by a family membe" it is impo"tant fo" the n$"se

to $nde"stand that these /i%tims $s$ally a"e o/e"whelmed with feelings of:

a ?$miliation b Conf$sion

% Self blame

d ?at"ed

8 Boy who has E$st e-pe"ien%ed he" se%ond spontaneo$s abo"tion e-p"esses ange" towa"ds he" physi%ian& the

hospital and the "otten n$"sing %a"eT Hhen assessing the sit$ation& the n$"se "e%ogni(es that the %lient may

be $sing the %oping me%hanism of:

a P"oEe%tion

b )ispla%ement

% )enial

d ea%tion fo"mation

!he most %"iti%al fa%to" fo" n$"se 'inda to dete"mine d$"ing %"isis inte"/ention wo$ld be the %lientKs:

a #/ailable sit$ational s$ppo"ts b Hillingness to "est"$%t$"e the pe"sonality

% )e/elopmental theo"y

d Unde"lying $n%ons%io$s %onfli%t9 *$"se !"ish s$ggests a %"isis inte"/ention g"o$p to a %lient e-pe"ien%ing a de/elopmental %"isis !hese g"o$ps

a"e s$%%essf$l be%a$se the:

a C"isis inte"/ention wo"e" is a psy%hologist and $nde"stands beha/io" patte"ns

b C"isis g"o$p s$pplies a wo"able sol$tion to the %lientKs p"oblem

% Client is en%o$"aged to tal abo$t pe"sonal p"oblems

d Client is assisted to in/estigate alte"nati/e app"oa%hes to sol/ing the identified p"oblem

10 *$"se onald %o$ld e/al$ate that the staffKs app"oa%h to setting limits fo" a demanding& ang"y %lient was

effe%ti/e if the %lient:

a #pologi(es fo" dis"$pting the $nitKs "o$tine when something is needed

b Unde"stands the "eason why f"e6$ent %alls to the staff we"e made

% )is%$ss %on%e"ns "ega"ding the emotional %ondition that "e6$i"ed hospitali(ations

d *o longe" %alls the n$"sing staff fo" assistan%e

11 *$"se Bohn is awa"e that the the"apy that has the highest s$%%ess "ate fo" people with phobias wo$ld be:

a Psy%hothe"apy aimed at "ea""anging maladapti/e tho$ght p"o%ess

b Psy%hoanalyti%al e-plo"ation of "ep"essed %onfli%ts of an ea"lie" de/elopment phase

% Systemati% desensiti(ation $sing "ela-ation te%hni6$e

d Insight the"apy to dete"mine the o"igin of the an-iety and fea"

12 Hhen n$"se ?a(el %onside"s a %lientKs pla%ement on the %ontin$$m of an-iety& a ey in dete"mining thedeg"ee of an-iety being e-pe"ien%ed is the %lientKs:

a Pe"%ept$al field

b )el$sional system

% <emo"y state

d C"eati/ity le/el

1+ In the diagnosis of a possible pe"/asi/e de/elopmental a$tisti% diso"de" !he n$"se wo$ld find it most $n$s$al

fo" a + yea" old %hild to demonst"ate:

a #n inte"est in m$si%

b #n atta%hment to odd obEe%ts

% it$alisti% beha/io"

d esponsi/eness to the pa"ents



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1+.

1. <alo$ with s%hi(oph"enia tells *$"se <elinda& <y intestines a"e "otted f"om wo"ms %hewing on themT !his

statement indi%ates a:

a Bealo$s del$sion

b Somati% del$sion

% )el$sion of g"ande$"

d )el$sion of pe"se%$tion

1 #ndy is admitted to the psy%hiat"i% $nit with a diagnosis of bo"de"line pe"sonality diso"de" *$"se ?ila"y

sho$ld e-pe%ts the assessment to "e/eal:a Coldness& deta%hment and la% of tende" feelings

b Somati% symptoms

% Inability to f$n%tion as "esponsible pa"ent

d Unp"edi%table beha/io" and intense inte"pe"sonal "elationships

15 POP#*O'O' Inde"al is $sed in the mental health setting to manage whi%h of the following %onditionsQ

a #ntipsy%hoti% X ind$%ed aathisia and an-iety

b Obsessi/e X %omp$lsi/e diso"de" OC) to "ed$%e "it$alisti% beha/io"

% )el$sions fo" %lients s$ffe"ing f"om s%hi(oph"enia

d !he mani% phase of bipola" illness as a mood stabili(e" 18 Hhi%h medi%ation %an %ont"ol the e-t"a py"amidal effe%ts asso%iated with antipsy%hoti% agentsQ

a Clo"a(epate !"an-ene

b #mantadine Symmet"el% )o-epin Sine6$an

d Pe"phena(ine !"ilafon

1 Hhi%h of the following statements sho$ld be in%l$ded when tea%hing %lients abo$t monoamine o-idase

inhibito" <#OI antidep"essantsQ

a )onKt tae aspi"in o" nonste"oidal anti=inflammato"y d"$gs *S#I)s

b ?a/e blood le/els s%"eened weely fo" le$%openia

% #/oid st"en$o$s a%ti/ity be%a$se of the %a"dia% effe%ts of the d"$g

d )onKt tae p"es%"ibed o" o/e" the %o$nte" medi%ations witho$t %ons$lting the physi%ian

19 "is pe"iodi%ally has a%$te pani% atta%s !hese atta%s a"e $np"edi%table and ha/e no appa"ent asso%iation

with a spe%ifi% obEe%t o" sit$ation )$"ing an a%$te pani% atta%& "is may e-pe"ien%e:

a ?eightened %on%ent"ation

b )e%"eased pe"%ept$al field% )e%"eased %a"dia% "ate

d )e%"eased "espi"ato"y "ate

20 Initial inte"/entions fo" <a"%o with a%$te an-iety in%l$de all e-%ept whi%h of the followingQa !o$%hing the %lient in an attempt to %omfo"t him

b #pp"oa%hing the %lient in %alm& %onfident manne"

% ,n%o$"aging the %lient to /e"bali(e feelings and %on%e"ns

d P"o/iding the %lient with a safe& 6$iet and p"i/ate pla%e

21 *$"se Bessie is assessing a %lient s$ffe"ing f"om st"ess and an-iety # %ommon physiologi%al "esponse to st"ess

and an-iety is:

a Uti%a"ia

b 7e"tigo

% Sedation

d )ia""hea

22 Hhen pe"fo"ming a physi%al e-amination on a female an-io$s %lient& n$"se *elli wo$ld e-pe%t to find whi%h

of the following effe%ts p"od$%ed by the pa"asympatheti% systemQ

a <$s%le tension

b ?ype"a%ti/e bowel so$nds

% )e%"eased $"ine o$tp$t

d Constipation

2+ Hhi%h of the following d"$gs ha/e been nown to be effe%ti/e in t"eating obsessi/e=%omp$lsi/e diso"de"

OC)Qa )i/alp"oe- depaote and 'ithi$m lithobid

b Chlo"dia(epo-ide 'ib"i$m and dia(epam /ali$m

% Fl$/o-amine '$/o- and %lomip"amine anaf"anil

d @en(t"opine Cogentin and diphenhyd"amine benad"yl

2. !ony with ago"aphobia has been symptom=f"ee fo" . months Classi% signs and symptoms of phobia in%l$de:

a Se/e"e an-iety and fea"

b Hithd"awal and fail$"e to disting$ish "eality f"om fantasy

% )ep"ession and weight loss

d Insomnia and inability to %on%ent"ate

2 Hhi%h n$"sing a%tion is most app"op"iate when t"ying to diff$se a %lientKs impending /iolent beha/io"Q

a Pla%e the %lient in se%l$sion

b 'ea/ing the %lient alone $ntil he %an tal abo$t his feelings




% In/ol/ing the %lient in a 6$iet a%ti/ity to di/e"t attention

d ?elping the %lient identify and e-p"ess feelings of an-iety and ange"

25 osana is in the se%ond stage of #l(heime"Ks disease who appea"s to be in pain Hhi%h 6$estion by *$"se

Benny wo$ld best eli%it info"mation abo$t the painQ

a Hhe"e is yo$" pain lo%atedQT

b )o yo$ h$"tQ pa$se )o yo$ h$"tQT

% Can yo$ des%"ibe yo$" painQT

d Hhe"e do yo$ h$"tQT28 *$"sing p"epa"ation fo" a %lient $nde"going ele%t"o%on/$lsi/e the"apy ,C! "esemble those $sed fo":

a Dene"al anesthesia

b Ca"dia% st"ess testing

% *e$"ologi% e-amination

d Physi%al the"apy

2 Bose who is "e%ei/ing monoamine o-idase inhibito" antidep"essant sho$ld a/oid ty"amine& a %ompo$nd fo$nd

in whi%h of the following foodsQ

a Figs and %"eam %heese

b F"$its and yellow /egetables% #ged %heese and Chianti wine

d D"een leafy /egetables

29 ,"linda& age & with maEo" dep"ession $nde"goes a si-th ele%t"o%on/$lsi/e the"apy ,C! t"eatmentHhen assessing the %lient immediately afte" ,C!& the n$"se e-pe%ts to find:

a Pe"manent sho"t=te"m memo"y loss and hype"tension

b Pe"manent long=te"m memo"y loss and hypomania

% !"ansito"y sho"t=te"m memo"y loss and pe"manent long=te"m memo"y loss

d !"ansito"y sho"t and long te"m memo"y loss and %onf$sion

+0 @a"ba"a with bipola" diso"de" is being t"eated with lithi$m fo" the fi"st time *$"se Clint sho$ld obse"/e the

%lient fo" whi%h %ommon ad/e"se effe%t of lithi$mQ

a Poly$"ia

b Sei($"es

% Constipation

d Se-$al dysf$n%tion

+1 *$"se F"ed is assessing a %lient who has E$st been admitted to the , depa"tment Hhi%h signs wo$ld s$ggestan o/e"dose of an antian-iety agentQ

a S$spi%io$sness& dilated p$pils and in%omplete @P

b #gitation& hype"a%ti/ity and g"andiose ideation% Combati/eness& sweating and %onf$sion

d ,motional lability& e$pho"ia and impai"ed memo"y

+2 )is%ha"ge inst"$%tions fo" a male %lient "e%ei/ing t"i%y%li% antidep"essants in%l$de whi%h of the following

info"mationQ

a est"i%t fl$ids and sodi$m intae

b )onKt %ons$me al%ohol

% )is%ontin$e if d"y mo$th and bl$""ed /ision o%%$"

d est"i%t fl$id and sodi$m intae

++ Impo"tant tea%hing fo" women in thei" %hildbea"ing yea"s who a"e "e%ei/ing antipsy%hoti% medi%ations

in%l$des whi%h of the followingQ

a In%"eased in%iden%e of dysmeno""hea while taing the d"$g

b O%%$""en%e of in%omplete libido d$e to medi%ation ad/e"se effe%ts

% Contin$ing p"e/io$s $se of %ont"a%eption d$"ing pe"iods of ameno""hea

d Inst"$%tion that ameno""hea is i""e/e"sible

+. # %lient "ef$ses to "emain on psy%hot"opi% medi%ations afte" dis%ha"ge f"om an inpatient psy%hiat"i% $nit

Hhi%h info"mation sho$ld the %omm$nity health n$"se assess fi"st d$"ing the initial follow=$p with this

%lientQ

a In%ome le/el and li/ing a""angements b In/ol/ement of family and s$ppo"t systems

% eason fo" inpatient admission

d eason fo" "ef$sal to tae medi%ations

+ !he n$"se $nde"stands that the the"ape$ti% effe%ts of typi%al antipsy%hoti% medi%ations a"e asso%iated with

whi%h ne$"ot"ansmitte" %hangeQ

a )e%"eased dopamine le/el

b In%"eased a%etyl%holine le/el

% Stabili(ation of se"otonin

d Stim$lation of D#@#

+5 Hhi%h of the following best e-plains why t"i%y%li% antidep"essants a"e $sed with %a$tion in elde"ly patientsQ

a Cent"al *e"/o$s System effe%ts

b Ca"dio/as%$la" system effe%ts




% Dast"ointestinal system effe%ts

d Se"otonin synd"ome effe%ts

+8 # %lient with dep"essi/e symptoms is gi/en p"es%"ibed medi%ations and tals with his the"apist abo$t his

belief that he is wo"thless and $nable to %ope with life Psy%hiat"i% %a"e in this t"eatment plan is based on

whi%h f"amewo"Q

a @eha/io"al f"amewo"

b Cogniti/e f"amewo"

% Inte"pe"sonal f"amewo" d Psy%hodynami% f"amewo"

+ # n$"se who e-plains that a %lientKs psy%hoti% beha/io" is $n%ons%io$sly moti/ated $nde"stands that the

%lientKs diso"de"ed beha/io" a"ises f"om whi%h of the followingQ

a #bno"mal thining

b #lte"ed ne$"ot"ansmitte"s

% Inte"nal needs

d esponse to stim$li

+9 # %lient with dep"ession has been hospitali(ed fo" t"eatment afte" taing a lea/e of absen%e f"om wo" !he

%lientKs employe" e-pe%ts the %lient to "et$"n to wo" following inpatient t"eatment !he %lient tells the n$"se&IKm no good IKm a fail$"eT #%%o"ding to %ogniti/e theo"y& these statements "efle%t:

a 'ea"ned beha/io"

b P$niti/e s$pe"ego and de%"eased self=esteem% Fa$lty tho$ght p"o%esses that go/e"n beha/io"

d ,/iden%e of diffi%$lt "elationships in the wo" en/i"onment

.0 !he n$"se des%"ibes a %lient as an-io$s Hhi%h of the following statement abo$t an-iety is t"$eQ

a #n-iety is $s$ally pathologi%al

b #n-iety is di"e%tly obse"/able

% #n-iety is $s$ally ha"mf$l

d #n-iety is a "esponse to a th"eat

.1 # %lient with a phobi% diso"de" is t"eated by systemati% desensiti(ation !he n$"se $nde"stands that this

app"oa%h will do whi%h of the followingQ

a ?elp the %lient e-e%$te a%tions that a"e fea"ed

b ?elp the %lient de/elop insight into i""ational fea"s

% ?elp the %lient s$bstit$tes one fea" fo" anothe" d ?elp the %lient de%"ease an-iety

.2 Hhi%h %lient o$t%ome wo$ld best indi%ate s$%%essf$l t"eatment fo" a %lient with an antiso%ial pe"sonality

diso"de"Qa !he %lient e-hibits %ha"ming beha/io" when a"o$nd a$tho"ity fig$"es

b !he %lient has de%"eased episodes of imp$lsi/e beha/io"s

% !he %lient maes statements of self=satisfa%tion

d !he %lientKs statements indi%ate no "emo"se fo" beha/io"s

.+ !he n$"se is %a"ing fo" a %lient with an a$toimm$ne diso"de" at a medi%al %lini%& whe"e alte"nati/e medi%ine is

$sed as an adE$n%t to t"aditional the"apies Hhi%h info"mation sho$ld the n$"se tea%h the %lient to help foste" a

sense of %ont"ol o/e" his symptomsQ

a Pathophysiology of disease p"o%ess

b P"in%iples of good n$t"ition

% Side effe%ts of medi%ations

d St"ess management te%hni6$es

.. Hhi%h of the following is the most disting$ishing feat$"e of a %lient with an antiso%ial pe"sonality diso"de"Q

a #ttention to detail and o"de"

b @i(a""e manne"isms and tho$ghts

% S$bmissi/e and dependent beha/io"

d )is"ega"d fo" so%ial and legal no"ms

. Hhi%h n$"sing diagnosis is most app"op"iate fo" a %lient with ano"e-ia ne"/osa who e-p"esses feelings of g$ilt

abo$t not meeting family e-pe%tationsQa #n-iety

b )ist$"bed body image

% )efensi/e %oping

d Powe"lessness

.5 # n$"se is e/al$ating the"apy with the family of a %lient with ano"e-ia ne"/osa Hhi%h of the following wo$ld

indi%ate that the the"apy was s$%%essf$lQ

a !he pa"ents "einfo"%ed in%"eased de%ision maing by the %lient

b !he pa"ents %lea"ly /e"bali(e thei" e-pe%tations fo" the %lient

% !he %lient /e"bali(es that family meals a"e now enEoyable

d !he %lient tells he" pa"ents abo$t feelings of low=self esteem

.8 # %lient with dysthymi% diso"de" "epo"ts to a n$"se that his life is hopeless and will ne/e" imp"o/e in the

f$t$"e ?ow %an the n$"se best "espond $sing a %ogniti/e app"oa%hQ




a #g"ee with the %lientKs painf$l feelings

b Challenge the a%%$"a%y of the %lientKs belief

% )eny that the sit$ation is hopeless

d P"esent a %hee"f$l attit$de

. # %lient with maEo" dep"ession has not /e"bali(ed p"oblem a"eas to staff o" pee"s sin%e admission to a

psy%hiat"i% $nit Hhi%h a%ti/ity sho$ld the n$"se "e%ommend to help this %lient e-p"ess himselfQ

a #"t the"apy in a small g"o$p

b @asetball game with pee"s on the $nit% eading a self=help boo on dep"ession

d Hat%hing mo/ie with the pee" g"o$p

.9 !he home health psy%hiat"i% n$"se /isits a %lient with %h"oni% s%hi(oph"enia who was "e%ently dis%ha"ged afte"

a p"olong stay in a state hospital !he %lient li/es in a boa"ding home& "epo"ts no family in/ol/ement& and has

little so%ial inte"a%tion !he n$"se plan to "efe" the %lient to a day t"eatment p"og"am in o"de" to help him with:

a <anaging his hall$%inations

b <edi%ation tea%hing

% So%ial sills t"aining

d 7o%ational t"aining0 Hhi%h a%ti/ity wo$ld be most app"op"iate fo" a se/e"ely withd"awn %lientQ

a #"t a%ti/ity with a staff membe"

b @oa"d game with a small g"o$p of %lients% !eam spo"t in the gym

d Hat%hing !7 in the day"oom

ANSERS a$% RATIONALES #r PS(CHIATRIC NURSING Pa"t +

1 ) !he"e is no set of symptoms asso%iated with %o%aine withd"awal& only the dep"ession that follows the

high %a$sed by the d"$g

2 A Co%aine is a %hemi%al that when inhaled& %a$ses dest"$%tion of the m$%o$s memb"anes of the nose

+ D !hese adaptations a"e asso%iated with opiate withd"awal whi%h o%%$"s afte" %essation o" "ed$%tion of

p"olonged mode"ate o" hea/y $se of opiates. ) Hhethe" the"e is a s$i%ide plan is a %"ite"ion when assessing the %lientKs dete"mination to mae anothe"

attempt

A apists a"e belie/ed to ha"bo" and a%t o$t hostile feelings towa"d all women th"o$gh the a%t of "ape

5 C !hese %hild"en often ha/e nonse-$al needs met by indi/id$al and a"e powe"less to "ef$se

#mbi/alen%e "es$lts in self=blame and also g$ilt

8 ) !he %lientKs ange" o/e" the abo"tion is shifted to the staff and the hospital be%a$se she is $nable to deal

with the abo"tion at this time




A Pe"sonal inte"nal st"ength and s$ppo"ti/e indi/id$als a"e %"iti%al fa%to"s that %an be employed to assist

the indi/id$al to %ope with a %"isis

9 D C"isis inte"/ention g"o$p helps %lient "eestablish psy%hologi% e6$ilib"i$m by assisting them to e-plo"e

new alte"nati/es fo" %oping It %onside"s "ealisti% sit$ations $sing "ational and fle-ible p"oblem sol/ing

methods

10 C !his wo$ld do%$ment that the %lient feels %omfo"table eno$gh to dis%$ss the p"oblems that ha/e

moti/ated the beha/io"

11 C !he most s$%%essf$l the"apy fo" people with phobias in/ol/es beha/io" modifi%ation te%hni6$es $singdesensiti(ation

12 A Pe"%ept$al field is a ey indi%ato" of an-iety le/el be%a$se the pe"%ept$al fields na""ow as an-iety

in%"eases

1+ D One of the symptoms of a$tisti% %hild displays a la% of "esponsi/eness to othe"s !he"e is little o" no

e-tension to the e-te"nal en/i"onment

1. ) Somati% del$sions fo%$s on bodily f$n%tions o" systems and %ommonly in%l$de del$sion abo$t fo$l

odo" emissions& inse%t manifestations& inte"nal pa"asites and misshapen pa"ts

1 D # %lient with bo"de"line pe"sonality displays a pe"/asi/e patte"n of $np"edi%table beha/io"& mood and

self image Inte"pe"sonal "elationships may be intense and $nstable and beha/io" may be inapp"op"iate and

imp$lsi/e

15 A P"op"anolol is a potent beta ad"ene"gi% blo%e" and p"od$%ing a sedating effe%t& the"efo"e it is $sed to

t"eat antipsy%hoti% ind$%ed aathisia and an-iety

18 ) #mantadine is an anti%holine"gi% d"$g $sed to "eli/e d"$g=ind$%ed e-t"a py"amidal ad/e"se effe%ts

s$%h as m$s%le weaness& in/ol$nta"y m$s%le mo/ements& pse$dopa"insonism and ta" di/e dysinesia

1 C <#OI antidep"essants when %ombined with a n$mbe" of d"$gs %an %a$se life=th"eatening hype"tensi/e

%"isis ItKs impe"ati/e that a %lient %he%s with his physi%ian and pha"ma%ist befo"e taing any othe"

medi%ations

19 ) Pani% is the most se/e"e le/el of an-iety )$"ing pani% atta%& the %lient e-pe"ien%es a de%"ease in the

pe"%ept$al field& be%oming mo"e fo%$sed on self& less awa"e of s$""o$ndings and $nable to p"o%ess

info"mation f"om the en/i"onment !he de%"eased pe"%ept$al field %ont"ib$tes to impai"ed attention and

inability to %on%ent"ate

20 A !he eme"gen%y n$"se m$st establish "appo"t and t"$st with the an-io$s %lient befo"e $sing the"ape$ti%

to$%h !o$%hing an an-io$s %lient may a%t$ally in%"ease an-iety21 D )ia""hea is a %ommon physiologi%al "esponse to st"ess and an-iety

22 ) !he pa"asympatheti% ne"/o$s system wo$ld p"od$%e in%omplete DI motility "es$lting in hype"a%ti/e

bowel so$nds& possibly leading to dia""hea

2+ C !he antidep"essants fl$/o-amine and %lomip"amine ha/e been effe%ti/e in the t"eatment of OC)

2. A Phobias %a$se se/e"e an-iety s$%h as pani% atta% that is o$t of p"opo"tion to the th"eat of the fea"ed

obEe%t o" sit$ation Physi%al signs and symptoms of phobias in%l$de p"of$se sweating& poo" moto" %ont"ol&

ta%hy%a"dia and ele/ated @P

2 D In many instan%es& the n$"se %an diff$se impending /iolen%e by helping the %lient identify and e-p"ess

feelings of ange" and an-iety S$%h statement as Hhat happened to get yo$ this ang"yQT may help the %lient

/e"bali(es feelings "athe" than a%t on them

25 ) Hhen speaing to a %lient with #l(heime"Ks disease& the n$"se sho$ld $se %lose=ended 6$estions

!hose that the %lient %an answe" with yesT o" noT whene/e" possible and a/oid 6$estions that "e6$i"e the%lient to mae %hoi%es epeating the 6$estion aids %omp"ehension

28 A !he n$"se sho$ld p"epa"e a %lient fo" ,C! in a manne" simila" to that fo" gene"al anesthesia

2 C #ged %heese and Chianti wine %ontain high %on%ent"ations of ty"amine

29 D ,C! %ommonly %a$ses t"ansito"y sho"t and long te"m memo"y loss and %onf$sion& espe%ially in

ge"iat"i% %lients It "a"ely "es$lts in pe"manent sho"t and long te"m memo"y loss

+0 A Poly$"ia %ommonly o%%$"s ea"ly in the t"eatment with lithi$m and %o$ld "es$lt in fl$id /ol$me defi%it

+1 D Signs of an-iety agent o/e"dose in%l$de emotional lability& e$pho"ia and impai"ed memo"y

+2 ) )"ining al%ohol %an potentiate the sedating a%tion of t"i%y%li% antidep"essants )"y mo$th and bl$""ed

/ision a"e no"mal ad/e"se effe%ts of t"i%y%li% antidep"essants

++ C Homen may e-pe"ien%e ameno""hea& whi%h is "e/e"sible& while taing antipsy%hoti%s #meno""hea

doesnKt indi%ate %essation of o/$lation th$s& the %lient %an still be p"egnant+. D !he fi"st a"e fo" assessment wo$ld be the %lientKs "eason fo" "ef$sing medi%ation !he %lient may not

$nde"stand the p$"pose fo" the medi%ation& may be e-pe"ien%ing dist"essing side effe%ts& o" may be %on%e"ned

abo$t the %ost of medi%ine In any %ase& the n$"se %annot p"o/ide app"op"iate inte"/ention befo"e assessing the

%lientKs p"oblem with the medi%ation !he patientKs in%ome le/el& li/ing a""angements& and in/ol/ement of

family and s$ppo"t systems a"e "ele/ant iss$es following dete"mination of the %lientKs "eason fo" "ef$sing

medi%ation !he n$"se p"o/iding follow=$p %a"e wo$ld ha/e a%%ess to the %lientKs medi%al "e%o"d and sho$ld

al"eady now the "eason fo" inpatient admission




+ A ,-%ess dopamine is tho$ght to be the %hemi%al %a$se fo" psy%hoti% thining !he typi%al antipsy%hoti%s

a%t to blo% dopamine "e%epto"s and the"efo"e de%"ease the amo$nt of ne$"ot"ansmitte" at the synapses !he

typi%al antipsy%hoti%s do not in%"ease a%etyl%holine& stabili(e se"otonin& stim$late D#@#

+5 ) !he !C#s affe%t no"epineph"ine as well as othe" ne$"ot"ansmitte"s& and th$s ha/e signifi%ant

%a"dio/as%$la" side effe%ts !he"efo"e& they a"e $sed with %a$tion in elde"ly %lients who may ha/e in%"eased

"is fa%to"s fo" %a"dia% p"oblems be%a$se of thei" age and othe" medi%al %onditions !he "emaining side

effe%ts wo$ld apply to any %lient taing a !C# and a"e not pa"ti%$la" to an elde"ly pe"son

+8 ) Cogniti/e thining the"apy fo%$ses on the %lientKs mispe"%eptions abo$t self& othe"s and the wo"ld thatimpa%t f$n%tioning and %ont"ib$te to symptoms Using medi%ations to alte" ne$"ot"ansmitte" a%ti/ity is a

psy%hobiologi% app"oa%h to t"eatment !he othe" answe" %hoi%es a"e f"amewo"s fo" %a"e& b$t hey a"e not

appli%able to this sit$ation

+ C !he %on%ept that beha/io" is moti/ated and has meaning %omes f"om the psy%hodynami% f"amewo"

#%%o"ding to this pe"spe%ti/e& beha/io" a"ises f"om inte"nal wishes o" needs <$%h of what moti/ates beha/io" %omes f"om the $n%ons%io$s !he "emaining "esponses do not add"ess the inte"nal fo"%es tho$ght to

moti/ate beha/io"

+9 C !he %lient is demonst"ating fa$lty tho$ght p"o%esses that a"e negati/e and that go/e"n his beha/io" in

his wo" sit$ation X iss$es that a"e typi%ally e-amined $sing a %ogniti/e theo"y app"oa%h Iss$es in/ol/ing

lea"ned beha/io" a"e best e-plo"ed th"o$gh beha/io" theo"y& not %ogniti/e theo"y Iss$es in/ol/ing ego

de/elopment a"e the fo%$s of psy%hoanalyti% theo"y Option . is in%o""e%t be%a$se the"e is no e/iden%e in this

sit$ation that the %lient has %onfli%t$al "elationships in the wo" en/i"onment.0 D #n-iety is a "esponse to a th"eat a"ising f"om inte"nal o" e-te"nal stim$li

.1 A Systemati% desensiti(ation is a beha/io"al the"apy te%hni6$e that helps %lients with i""ational fea"s and

a/oidan%e beha/io" to fa%e the thing they fea"& witho$t e-pe"ien%ing an-iety !he"e is no attempt to p"omote

insight with this p"o%ed$"e& and the %lient will not be ta$ght to s$bstit$te one fea" fo" anothe" #ltho$gh the

%lientKs an-iety may de%"ease with s$%%essf$l %onf"ontation of i""ational fea"s& the p$"pose of the p"o%ed$"e is

spe%ifi%ally "elated to pe"fo"ming a%ti/ities that typi%ally a"e a/oided as pa"t of the phobi% "esponse

.2 ) # %lient with antiso%ial pe"sonality diso"de" typi%ally has f"e6$ent episodes of a%ting imp$lsi/ely with

poo" ability to delay self=g"atifi%ation !he"efo"e& de%"eased f"e6$en%y of imp$lsi/e beha/io"s wo$ld be

e/iden%e of imp"o/ement Cha"ming beha/io" when a"o$nd a$tho"ity fig$"es and statements indi%ating no

"emo"se a"e e-amples of symptoms typi%al of someone with this diso"de" and wo$ld not indi%ate s$%%essf$l

t"eatment Self=satisfa%tion wo$ld be /iewed as a positi/e %hange if the %lient e-p"esses low self=esteemW

howe/e" this is not a %ha"a%te"isti% of a %lient with antiso%ial pe"sonality diso"de"

.+ D In a$toimm$ne diso"de"s& st"ess and the "esponse to st"ess %an e-a%e"bate symptoms St"ess

management te%hni6$es %an help the %lient "ed$%e the psy%hologi%al "esponse to st"ess& whi%h in t$"n willhelp "ed$%e the physiologi% st"ess "esponse !his will affo"d the %lient an in%"eased sense of %ont"ol o/e" his

symptoms !he n$"se %an add"ess the "emaining answe" %hoi%es in he" tea%hing abo$t the %lientKs disease and

t"eatmentW howe/e"& nowledge alone will not help the %lient to manage his st"ess effe%ti/ely eno$gh to

%ont"ol symptoms

.. D )is"ega"d fo" established "$les of so%iety is the most %ommon %ha"a%te"isti% of a %lient with antiso%ial

pe"sonality diso"de" #ttention to detail and o"de" is %ha"a%te"isti% of someone with obsessi/e %omp$lsi/e

diso"de" @i(a""e manne"isms and tho$ghts a"e %ha"a%te"isti%s of a %lient with s%hi(oid o" s%hi(otypal diso"de"S$bmissi/e and dependent beha/io"s a"e %ha"a%te"isti% of someone with a dependent pe"sonality

. D !he %lient with ano"e-ia typi%ally feels powe"less& with a sense of ha/ing little %ont"ol o/e" any aspe%t

of life besides eating beha/io" Often& pa"ental e-pe%tations and standa"ds a"e 6$ite high and lead to the

%lientsK sense of g$ilt o/e" not meas$"ing $p

.5 A One of the %o"e iss$es %on%e"ning the family of a %lient with ano"e-ia is %ont"ol !he familyKs

a%%eptan%e of the %lientKs ability to mae independent de%isions is ey to s$%%essf$l family inte"/ention

#ltho$gh the "emaining options may o%%$" d$"ing the p"o%ess of the"apy& they wo$ld not ne%essa"ily indi%ate

a s$%%essf$l o$t%omeW the %ent"al family iss$es of dependen%e and independen%e a"e not add"esses on these

"esponses

.8 ) Use of %ogniti/e te%hni6$es allows the n$"se to help the %lient "e%ogni(e that this negati/e beliefs may

be disto"tions and that& by %hanging his thining& he %an adopt mo"e positi/e beliefs that a"e "ealisti% and

hopef$l #g"eeing with the %lientKs feelings and p"esenting a %hee"f$l attit$de a"e not %onsistent with a

%ogniti/e app"oa%h and wo$ld not be helpf$l in this sit$ation )enying the %lientKs feelings is belittling and

may %on/ey that the n$"se does not $nde"stand the depth of the %lientKs dist"ess. A' #"t the"apy p"o/ides a nonth"eatening /ehi%le fo" the e-p"ession of feelings& and $se of a small g"o$p

will help the %lient be%ome %omfo"table with pee"s in a g"o$p setting @asetball is a %ompetiti/e game that

"e6$i"es ene"gyW the %lient with maEo" dep"ession is not liely to pa"ti%ipate in this a%ti/ity e%ommending

that the %lient "ead a self=help boo may in%"ease& not de%"ease his isolation Hat%hing mo/ie with a pee"g"o$p does not g$a"antee that inte"a%tion will o%%$"W the"efo"e& the %lient may "emain isolated

.9 C' )ay t"eatment p"og"ams p"o/ide %lients with %h"oni%& pe"sistent mental illness t"aining in so%ial sills&

s$%h as meeting and g"eeting people& asing 6$estions o" di"e%tions& pla%ing an o"de" in a "esta$"ant& taingt$"ns in a g"o$p setting a%ti/ity #ltho$gh management of hall$%inations and medi%ation tea%hing may also be

pa"t of the p"og"am offe"ed in a day t"eatment& the n$"se is "efe""ing the %lient in this sit$ation be%a$se of his



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1.0

need fo" so%iali(ation sills 7o%ational t"aining gene"ally taes pla%e in a "ehabilitation fa%ilityW the %lient

des%"ibed in this sit$ation wo$ld not be a %andidate fo" this se"/i%e

0 A' !he best app"oa%h with a withd"awn %lient is to initiate b"ief& nondemanding a%ti/ities on a one=to=one

basis !his app"oa%h gi/es the n$"se an oppo"t$nity to establish a t"$sting "elationship with the %lient # boa"d

game with a g"o$p %lients o" playing a team spo"t in the gym may o/e"whelm a se/e"ely withd"awn %lient

Hat%hing !7 is a solita"y a%ti/ity that will "einfo"%e the %lientKs withd"awal f"om othe"s




PROFESSIONAL ADUSTMENT

1 # n$"se who wo$ld lie to p"a%ti%e n$"sing in the Philippines %an obtain a li%ense to p"a%ti%e by:

# Paying the p"ofessional ta- afte" taing the boa"d e-ams

@ Passing the boa"d e-ams and taing the oath of p"ofessionalsC Paying the e-amination fee befo"e taing the boa"d e-ams




) Unde"going the inte"/iew %ond$%ted by the @oa"d of *$"sing and taing the boa"d e-ams

#nswe": @ Passing the boa"d e-ams and taing the oath of p"ofessionals

Fo" a n$"se to obtain a li%ense to p"a%ti%e n$"sing in the Philippines& sGhe m$st pass the boa"d e-aminations and

then tae the oath of p"ofessionals befo"e the @oa"d of *$"sing

2 e%ip"o%ity of li%ense to p"a%ti%e "e6$i"es that the %o$nt"y of o"igin of the inte"ested fo"eign n$"se %omplies

with the following %onditions:# !he %o$nt"y of o"igin has simila" p"epa"ation fo" a n$"se and has laws allowing Filipino n$"ses to p"a%ti%e in

thei" %o$nt"y

@ !he Philippines is "e%ogni(ed by the %o$nt"y of o"igin as one that has high 6$ality of n$"sing ed$%ation

C !he %o$nt"y of o"igin "e6$i"es Filipinos to tae thei" own boa"d e-amination

) !he %o$nt"y of o"igin e-empts Filipinos f"om passing thei" li%ens$"e e-amination

#nswe": # !he %o$nt"y of o"igin has simila" p"epa"ation fo" a n$"se and has laws allowing Filipino n$"ses to

p"a%ti%e in thei" %o$nt"y

#%%o"ding to the Philippine *$"ses #%t of 2002& fo"eign n$"ses wanting to p"a%ti%e in the Philippines m$st show

p"oof that hisGhe" %o$nt"y of o"igin meets the two essential %onditions: a the "e6$i"ements fo" "egist"ation

between the two %o$nt"ies a"e s$bstantially the sameW and b the %o$nt"y of o"igin of the fo"eign n$"se has laws

allowing the Filipino n$"se to p"a%ti%e in hisGhe" %o$nt"y E$st lie its own %iti(ens

+ *$"ses p"a%ti%ing the p"ofession in the Philippines and a"e employed in go/e"nment hospitals a"e "e6$i"ed to

pay ta-es s$%h as:

# @oth in%ome ta- and p"ofessional ta-

@ In%ome ta- only sin%e they a"e e-empt f"om paying p"ofessional ta-

C P"ofessional ta- whi%h is paid by all n$"ses employed in both go/e"nment and p"i/ate hospitals

) In%ome ta- whi%h paid e/e"y <a"%h 1 and p"ofessional ta- whi%h is paid e/e"y Ban$a"y +1

#nswe": @ In%ome ta- only sin%e they a"e e-empt f"om paying p"ofessional ta-

#%%o"ding to the <agna Ca"ta fo" P$bli% ?ealth Ho"e"s& go/e"nment n$"ses a"e e-empted f"om paying

p"ofessional ta- ?en%e& as an employee in the go/e"nment& sGhe will pay only the in%ome ta-

. #%%o"ding to # 918+ Philippine *$"sing #%t of 2002& a g"ad$ate n$"se who wants to tae m$st li%ens$"e

e-amination m$st %omply with the following 6$alifi%ations:# #t least 21 yea"s old& g"ad$ate of @S* f"om a "e%ogni(ed s%hool& and of good mo"al %ha"a%te"

@ #t least 1 yea"s old& g"ad$ate of @S* f"om a "e%ogni(ed s%hool and of good mo"al %ha"a%te"

C #t least 1 yea"s old& p"o/ided that when sGhe passes the boa"d e-ams& sGhe m$st be at least 21 yea"s oldW @S*

g"ad$ate of a "e%ogni(ed s%hool& and of good mo"al %ha"a%te"

) Filipino %iti(en o" a %iti(en of a %o$nt"y whe"e we ha/e "e%ip"o%ityW g"ad$ate of @S* f"om a "e%ogni(ed s%hool

and of good mo"al %ha"a%te"

#nswe": ) Filipino %iti(en o" a %iti(en of a %o$nt"y whe"e we ha/e "e%ip"o%ityW g"ad$ate of @S* f"om a

"e%ogni(ed s%hool and of good mo"al %ha"a%te"

# 918+ se%tion 1+ states that the 6$alifi%ations to tae the boa"d e-ams a"e: Filipino %iti(en o" %iti(en of a%o$nt"y whe"e the Philippines has "e%ip"o%ityW of good mo"al %ha"a%te" and g"ad$ate of @S* f"om a "e%ogni(ed

s%hool of n$"sing !he"e is no e-pli%it p"o/ision abo$t the age "e6$i"ement in # 918+ $nlie in #815. oldlaw

Hhi%h of the following is !U, abo$t membe"ship to the Philippine *$"ses #sso%iation P*#Q

# <embe"ship to P*# is mandato"y and is stip$lated in the Philippine *$"sing #%t of 2002

@ <embe"ship to P*# is %omp$lso"y fo" newly "egiste"ed n$"ses wanting to ente" the p"a%ti%e of n$"sing in the

%o$nt"y

C <embe"ship to P*# is /ol$nta"y and is en%o$"aged by the PC Code of ,thi%s fo" *$"ses

) <embe"ship to P*# is "e6$i"ed by go/e"nment hospitals p"io" to employment

#nswe": C <embe"ship to P*# is /ol$nta"y and is en%o$"aged by the PC Code of ,thi%s fo" *$"ses

<embe"ship to any o"gani(ation& in%l$ding the P*#& is only /ol$nta"y and this "ight to Eoin any o"gani(ation is

g$a"anteed in the 198 %onstit$tion of the Philippines ?owe/e"& the PC Code of ,thi%s states that one of the

ethi%al obligations of the p"ofessional n$"se towa"ds the p"ofession is to be an a%ti/e membe" of the a%%"edited

p"ofessional o"gani(ation

5 Hhen the li%ense of the n$"se is "e/oed& it means that the n$"se:

# Is no longe" allowed to p"a%ti%e the p"ofession fo" the "est of he" life

@ Hill ne/e" ha/e he"Ghis li%ense "e=iss$ed sin%e it has been "e/oed



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1.+

C <ay apply fo" "e=iss$an%e of hisGhe" li%ense based on %e"tain %onditions stip$lated in # 918+

) Hill "emain $nable to p"a%ti%e p"ofessional n$"sing

#nswe": C <ay apply fo" "e=iss$an%e of hisGhe" li%ense based on %e"tain %onditions stip$lated in # 918+

# 918+ se% 2. states that fo" e6$ity and E$sti%e& a "e/oed li%ense maybe "e=iss$ed p"o/ided that the following

%onditions a"e met: a the %a$se fo" "e/o%ation of li%ense has al"eady been %o""e%ted o" "emo/edW and& b at least

fo$" yea"s has elapsed sin%e the li%ense has been "e/oed

8 #%%o"ding to the %$""ent n$"sing law& the minim$m ed$%ational 6$alifi%ation fo" a fa%$lty membe" of a %ollege

of n$"sing is:

# Only a <aste" of #"ts in *$"sing is a%%eptable

@ <aste"s deg"ee in *$"sing o" in the "elated fields

C #t least a do%to"ate in n$"sing

) #t least 1 $nits in the <aste" of #"ts in *$"sing P"og"am

#nswe": @ <aste"s deg"ee in *$"sing o" in the "elated fields

#%%o"ding to # 918+ se% 28& the ed$%ational 6$alifi%ation of a fa%$lty membe" tea%hing in a %ollege of n$"sing

m$st be maste"s deg"ee whi%h maybe in n$"sing o" "elated fields lie ed$%ation& allied health p"ofessions&

psy%hology

!he ed$%ational 6$alifi%ation of a n$"se to be%ome a s$pe"/iso" in a hospital is:

# @S* with at least 9 $nits of post g"ad$ate st$dies in n$"sing administ"ation

@ <aste" of #"ts in *$"sing maEo" in administ"ation

C #t least 2 yea"s e-pe"ien%e as a headn$"se

) #t least 1 $nits of post g"ad$ate st$dies in n$"sing administ"ation

#nswe": # @S* with at least 9 $nits of post g"ad$ate st$dies in n$"sing administ"ation

#%%o"ding to # 918+ se% 29& the ed$%ational 6$alifi%ation to be a s$pe"/iso" in a hospital is at least 9 $nits of

postg"ad$ate st$dies in n$"sing administ"ation # maste"s deg"ee in n$"sing is "e6$i"ed fo" the %hief n$"se of a

se%onda"y o" te"tia"y hospital

9 !he @oa"d of *$"sing has 6$asi=E$di%ial powe" #n e-ample of this powe" is:# !he @oa"d %an iss$e "$les and "eg$lations that will go/e"n the p"a%ti%e of n$"sing

@ !he @oa"d %an in/estigate /iolations of the n$"sing law and %ode of ethi%s

C !he @oa"d %an /isit a s%hool applying fo" a pe"mit in %ollabo"ation with C?,)

) !he @oa"d p"epa"es the boa"d e-aminations

#nswe": @ !he @oa"d %an in/estigate /iolations of the n$"sing law and %ode of ethi%s>$asi=E$di%ial powe" means that the @oa"d of *$"sing has the a$tho"ity to in/estigate /iolations of the n$"sing

law and %an iss$e s$mmons& s$bpoena o" s$bpoena d$%es te%$m as needed

10 Hhen a n$"se %a$ses an inE$"y to the patient and the inE$"y %a$sed be%omes the p"oof of the negligent a%t& the

p"esen%e of the inE$"y is said to e-emplify the p"in%iple of:

# Fo"%e maEe$"e

@ espondeat s$pe"io" C es ipsa lo6$it$"

) ?oldo/e" do%t"ine

#nswe": C es ipsa lo6$it$"

es ipsa lo6$it$" lite"ally means the thing speas fo" itself !his means in ope"ational te"ms that the inE$"y %a$sed

is the p"oof that the"e was a negligent a%t

11 ,ns$"ing that the"e is an info"med %onsent on the pa"t of the patient befo"e a s$"ge"y is done& ill$st"ates the

bioethi%al p"in%iple of:

# @enefi%en%e@ #$tonomy

C !"$th tellingG/e"a%ity

) *on=malefi%en%e

#nswe": @ #$tonomy

Info"med %onsent means that the patient f$lly $nde"stands what will be the s$"ge"y to be done& the "iss in/ol/ed

and the alte"nati/e sol$tions so that when sGhe gi/e %onsent it is done with f$ll nowledge and is gi/en f"eely !he

a%tion of allowing the patient to de%ide whethe" a s$"ge"y is to be done o" not e-emplifies the bioethi%al p"in%iple



COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1..

of a$tonomy

12 Hhen a n$"se is p"o/iding %a"e to he"Ghis patient& sGhe m$st "emembe" that she is d$ty bo$nd not to do doing

any a%tion that will %a$se the patient ha"m !his is the meaning of the bioethi%al p"in%iple:

# *on=malefi%en%e

@ @enefi%en%e

C B$sti%e

) Solida"ity

#nswe": # *on=malefi%en%e

*on=malefi%en%e means do not %a$se ha"m o" do any a%tion that will %a$se any ha"m to the patientG%lient !o do

good is "efe""ed as benefi%en%e

1+ Hhen the patient is ased to testify in %o$"t& sGhe m$st abide by the ethi%al p"in%iple of:

# P"i/ileged %omm$ni%ation

@ Info"med %onsent

C Solida"ity

) #$tonomy

#nswe": # P"i/ileged %omm$ni%ation#ll %onfidential info"mation that %omes to the nowledge of the n$"se in the %a"e of he"Ghis patients is %onside"ed

p"i/ileged %omm$ni%ations ?en%e& sGhe is not allowed to E$st "e/eal the %onfidential info"mation a"bit"a"ily SGhe

may only be allowed to b"ea the seal of se%"e%y in %e"tain %onditions One s$%h %ondition is when the %o$"t

o"de"s the n$"se to testify in a %" iminal o" medi%o=legal %ase

1. Hhen the do%to" o"de"s do not "es$s%itateT& this means that

# !he n$"se need not gi/e d$e %a"e to the patient sin%e sGhe is te"minally ill

@ !he patient need not be gi/en food and wate" afte" all sGhe is dying

C !he n$"ses and the attending physi%ian sho$ld not do any he"oi% o" e-t"ao"dina"y meas$"es fo" the patient

) !he patient need not be gi/en o"dina"y %a"e so that he"Ghis dying p"o%ess is hastened

#nswe": C !he n$"ses and the attending physi%ian sho$ld not do any he"oi% o" e-t"ao"dina"y meas$"es fo" the patient

)o not "es$s%itateT is a medi%al o"de" whi%h is w"itten on the %ha"t afte" the do%to" has %ons$lted the family and

this means that the membe"s of the health team a"e not "e6$i"ed to gi/e e-t"ao"dina"y meas$"es b$t %annot

withhold the basi% needs lie food& wate"& and ai" It also means that the n$"se is still d$ty bo$nd to gi/e the basi%

n$"sing %a"e to the te"minally ill patient and ens$"e that the spi"it$al needs of the patient is taen %a"ed of

1 Hhi%h of the following statements is !U, of abo"tion in the PhilippinesQ

# Ind$%ed abo"tion is allowed in %ases of "ape and in%est

@ Ind$%ed abo"tion is both a %"iminal a%t and an $nethi%al a%t fo" the n$"se

C #bo"tion maybe %onside"ed a%%eptable if the mothe" is $np"epa"ed fo" the p"egnan%y

) # n$"se who pe"fo"ms ind$%ed abo"tion will ha/e no legal a%%o$ntability if the mothe" "e6$ested that the

abo"tion done on he"

#nswe": @ Ind$%ed abo"tion is both a %"iminal a%t and an $nethi%al a%t fo" the n$"se

Ind$%ed abo"tion is %onside"ed a %"iminal a%t whi%h is p$nishable by imp"isonment whi%h maybe $p to a

ma-im$m of 12 yea"s if the n$"se gets paid fo" it #lso& the PC Code of ,thi%s states that the n$"se m$st "espe%t

life and m$st not do any a%tion that will dest"oy life #bo"tion is an a%t that dest"oys life albeit at the beginningof life

LEADERSHIP a$% MANAGEMENT

1 <s Cast"o is newly=p"omoted to a patient %a"e manage" position She $pdates he" nowledge on the theo"ies in

management and leade"ship in o"de" to be%ome effe%ti/e in he" new "ole She lea"ns that some manage"s ha/e low

%on%e"n fo" se"/i%es and high %on%e"n fo" staff Hhi%h style of management "efe"s to thisQ




# O"gani(ation <an

@ Impo/e"ished <anagement

C Co$nt"y Cl$b <anagement

) !eam <anagement

#nswe": C Co$nt"y Cl$b <anagement

Co$nt"y %l$b management style p$ts %on%e"n fo" the staff as n$mbe" one p"io"ity at the e-pense of the deli/e"y of

se"/i%es ?eGshe "$ns the depa"tment E$st lie a %o$nt"y %l$b whe"e e/e"y one is happy in%l$ding the manage"

2 ?e" fo"me" manage" demonst"ated passion fo" se"/ing he" staff "athe" than being se"/ed She taes time to

listen& p"efe"s to be a tea%he" fi"st befo"e being a leade"& whi%h is %ha"a%te"isti% of

# !"ansfo"mational leade"

@ !"ansa%tional leade"

C Se"/ant leade"

) Cha"ismati% leade"

#nswe": C Se"/ant leade" Se"/ant leade"s a"e open=minded& listen deeply& t"y to f$lly $nde"stand othe"s and not being E$dgmental

+ On the othe" hand& <s Cast"o noti%es that the Chief *$"se ,-e%$ti/e has %ha"ismati% leade"ship style Hhi%hof the following beha/io"s best des%"ibes this styleQ

# Possesses inspi"ational 6$ality that maes followe"s gets att"a%ted of him and "ega"ds him with "e/e"en%e

@ #%ts as he does be%a$se he e-pe%ts that his beha/io" will yield positi/e "es$lts

C Uses /isioning as the %o"e of his leade"ship

) <at%hes his leade"ship style to the sit$ation at hand

#nswe": # Possesses inspi"ational 6$ality that maes followe"s gets att"a%ted of him and "ega"ds him with

"e/e"en%e

Cha"ismati% leade"s mae the followe"s feel at ease in thei" p"esen%e !hey feel that they a"e in good hands

whene/e" the leade" is a"o$nd

. Hhi%h of the following %on%l$sions of <s Cast"o abo$t leade"ship %ha"a%te"isti%s is !U,Q# !he"e is a high %o""elation between the %omm$ni%ation sills of a leade" and the ability to get the Eob done

@ # manage" is effe%ti/e when he has the ability to plan well

C #ssessment of pe"sonal t"aits is a "eliable tool fo" p"edi%ting a manage"Ks potential) !he"e is good e/iden%e that %e"tain pe"sonal 6$alities fa/o" s$%%ess in manage"ial "ole

#nswe": C #ssessment of pe"sonal t"aits is a "eliable tool fo" p"edi%ting a manage"Ks potential

It is not %on%l$si/e that %e"tain 6$alities of a pe"son wo$ld mae him be%ome a good manage" It %an only p"edi%t

a manage"Ks potential of be%oming a good one

She "eads abo$t Path Doal theo"y Hhi%h of the following beha/io"s is manifested by the leade" who $ses this

theo"yQ

# e%ogni(es staff fo" going beyond e-pe%tations by gi/ing them %itations

@ Challenges the staff to tae indi/id$al a%%o$ntability fo" thei" own p"a%ti%e

C #dmonishes staff fo" being lagga"ds

) eminds staff abo$t the san%tions fo" non pe"fo"man%e

#nswe": # e%ogni(es staff fo" going beyond e-pe%tations by gi/ing them %itations

Path Doal theo"y a%%o"ding to ?o$se and asso%iates "ewa"ds good pe"fo"man%e so that othe"s wo$ld do the same

5 One leade"ship theo"y states that leade"s a"e bo"n and not made&T whi%h "efe"s to whi%h of the following

theo"iesQ# !"ait

@ Cha"ismati%

C D"eat <an

) Sit$ational

#nswe": C D"eat <an

'eade"s be%ome leade"s be%a$se of thei" bi"th "ight !his is also %alled Deneti% theo"y o" the #"istotelian theo"y

8 She %ame a%"oss a theo"y whi%h states that the leade"ship style is effe%ti/e dependent on the sit$ation Hhi%h of

the following styles best fits a sit$ation when the followe"s a"e self=di"e%ted& e-pe"ts and a"emat$"ed indi/id$alsQ

# )emo%"ati%

@ #$tho"ita"ian




C 'aisse( fai"e

) @$"ea$%"ati%

#nswe": C 'aisse( fai"e

'aisse( fai"e leade"ship is p"efe""ed when the followe"s now what to do and a"e e-pe"ts in the field !his

leade"ship style is "elationship=o"iented "athe" than tas=%ente"ed

She s$"fs the inte"net fo" mo"e info"mation abo$t leade"ship styles She "eads abo$t sha"ed leade"ship as a p"a%ti%e in some magnet hospitals Hhi%h of the following des%"ibes this style of leade"shipQ

# 'eade"ship beha/io" is gene"ally dete"mined by the "elationship between the leade"Ks pe"sonality and the

spe%ifi% sit$ation

@ 'eade"s belie/e that people a"e basi%ally good and need not be %losely %ont"olled

C 'eade"s "ely hea/ily on /isioning and inspi"e membe"s to a%hie/e "es$lts

) 'eade"ship is sha"ed at the point of %a"e

#nswe": ) 'eade"ship is sha"ed at the point of %a"e

Sha"ed go/e"nan%e allows the staff n$"ses to ha/e the a$tho"ity& "esponsibility and a%%o$ntability fo" thei" own p"a%ti%e

9 <s Cast"o lea"ns that some leade"s a"e t"ansa%tional leade"s Hhi%h of the following does *O! %ha"a%te"i(e at"ansa%tional leade"Q

# Fo%$ses on management tass

@ Is a %a"etae"

C Uses t"ade=offs to meet goals

) Inspi"es othe"s with /ision

#nswe": ) Inspi"es othe"s with /ision

Inspi"es othe"s with a /ision is %ha"a%te"isti% of a t"ansfo"mational leade" ?e is fo%$sed mo"e on the day=to=day

ope"ations of the depa"tmentG$nit

10 She finds o$t that some manage"s ha/e bene/olent=a$tho"itati/e style of management Hhi%h of the following

beha/io"s will she e-hibit most lielyQ# ?a/e %ondes%ending t"$st and %onfiden%e in thei" s$bo"dinates

@ Di/es e%onomi% o" ego awa"ds

C Comm$ni%ates downwa"d to the staff ) #llows de%ision maing among s$bo"dinates

#nswe": # ?a/e %ondes%ending t"$st and %onfiden%e in thei" s$bo"dinates

@ene/olent=a$tho"itati/e manage"s p"etentio$sly show thei" t"$st and %onfiden%e to thei" followe"s

11 ?a""y is a Unit <anage" I the <edi%al Unit ?e is not satisfied with the way things a"e going in his $nit

Patient satisfa%tion "ate is 50V fo" two %onse%$ti/e months and staff mo"ale is at its lowest ?e de%ides to plan

and initiate %hanges that will p$sh fo" a t$"na"o$nd in the %ondition of the $nit Hhi%h of the following a%tions is

a p"io"ity fo" ?a""yQ

# Call fo" a staff meeting and tae this $p in the agenda

@ See help f"om he" manage"

C )e/elop a st"ategi% a%tion on how to deal with these %on%e"ns

) Igno"e the iss$es sin%e these will be "esol/ed nat$"ally

#nswe": # Call fo" a staff meeting and tae this $p in the agenda

!his will allow fo" the pa"ti%ipation of e/e"y staff in the $nit If they %ont"ib$te to the sol$tions of the p"oblem&

they will own the sol$tionsW hen%e the %han%e fo" %omplian%e wo$ld be g"eate"

12 She nows that the"e a"e e-te"nal fo"%es that infl$en%e %hanges in his $nit Hhi%h of the following is *O! an

e-te"nal fo"%eQ

# <emo f"om the C,O to %$t down on ele%t"i%al %ons$mption

@ )emands of the labo" se%to" to in%"ease wages

C 'ow mo"ale of staff in he" $nit

) ,-a%ting "eg$lato"y and a%%"editation standa"ds

#nswe": C 'ow mo"ale of staff in he" $nit

'ow mo"ale of staff is an inte"nal fa%to" that affe%ts only the $nit #ll the "est of the options emanate f"om the top

e-e%$ti/e o" f"om o$tside the instit$tion






C <edi%ations and t"eatments "e6$i"ed fo" all patients

) Patients who need the most %a"e

#nswe": ) Patients who need the most %a"e

In setting p"io"ities fo" a g"o$p of patients& those who need the most %a"e sho$ld be n$mbe"=one p"io"ity to ens$"e

that thei" %"iti%al needs a"e met ade6$ately !he needs of othe" patients who need less %a"e %a be attended to late"

o" e/en delegated to assisti/e pe"sonnel a%%o"ding to "$les on delegation

20 She is hopef$l that he" $nit will mae a big t$"na"o$nd in the s$%%eeding months Hhi%h of the following

a%tions of ?a""y demonst"ates that he has "ea%hed the thi"d stage of %hangeQ

# Honde"s why things a"e not what it $sed to be

@ Finds sol$tions to the p"oblems

C Integ"ate the sol$tions to his day=to=day a%ti/ities

) Sele%ts the best %hange st"ategy

#nswe": C Integ"ate the sol$tions to his day=to=day a%ti/ities

Integ"ate the sol$tions to his day=to=day a%ti/ities is a e-pe%ted to happen d$"ing the thi"d stage of %hange whenthe %hange agent in%o"po"ate the sele%ted sol$tions to his system and begins to %"eate a %hange

21 B$li$s is a newly=appointed n$"se manage" of !he Dood Shephe"d <edi%al Cente"& a te"tia"y hospital lo%atedwithin the hea"t of the met"opolis ?e thins of s%hed$ling planning wo"shop with his staff in o"de" to ens$"e an

effe%ti/e and effi%ient management of the depa"tment Sho$ld he de%ide to %ond$%t a st"ategi% planning wo"shop&

whi%h of the following is *O! a %ha"a%te"isti% of this a%ti/ityQ

# 'ong=te"m goal=setting

@ ,-tends to += yea"s in the f$t$"e

C Fo%$ses on "o$tine tass

) )ete"mines di"e%tions of the o"gani(ation

#nswe": C Fo%$ses on "o$tine tass

St"ategi% planning in/ol/es options #& @ and ) e-%ept C whi%h is att"ib$ted to ope"ational planning

22 Hhi%h of the following statements "efe" to the /ision of the hospitalQ

# !he Dood Shephe"d <edi%al Cente" is a t"endsette" in te"tia"y health %a"e in the Philippines in the ne-t fi/eyea"s

@ !he offi%e"s and staff of !he Dood Shephe"d <edi%al Cente" belie/e in the $ni6$e nat$"e of the h$man pe"son

C #ll the n$"ses shall $nde"go %ontin$ing %ompeten%y t"aining p"og"am) !he Dood Shephe"d <edi%al Cente" aims to p"o/ide a patient=%ente"ed %a"e in a total healing en/i"onment

#nswe": # !he Dood Shephe"d <edi%al Cente" is a t"endsette" in te"tia"y health %a"e in the Philippines in the

ne-t fi/e yea"s

# /ision "efe"s to what the instit$tion wants to be%ome within a pa"ti%$la" pe"iod of time

2+ !he statement& !he Dood Shephe"d <edi%al Cente" aims to p"o/ide patient=%ente"ed %a"e in a total healing

en/i"onmentT "efe"s to whi%h of the followingQ

# 7ision

@ Doal

C Philosophy

) <ission

#nswe": @ Doal

2. B$li$s plans to "e/isit the o"gani(ational %ha"t of the depa"tment ?e plans to %"eate a new position of a Patient

,d$%ato" who has a %oo"dinating "elationship with the head n$"se in the $nit Hhi%h of the following will liely

depi%t this o"gani(ational "elationshipQ

# @o-

@ Solid line

C @"oen line) )otted line

#nswe": C @"oen line

!his is a staff "elationship hen%e it is depi%ted by a b"oen line in the o"gani(ational st"$%t$"e

2 ?e liewise st"esses the need fo" all the employees to follow o"de"s and inst"$%tions f"om him and not f"om

anyone else Hhi%h of the following p"in%iples does he "efe" toQ

# S%ala" %hain

@ )is%ipline




C Unity of %ommand

) O"de"

#nswe": C Unity of %ommand

!he p"in%iple of $nity of %ommand means that employees sho$ld "e%ei/e o"de"s %oming f"om only one manage"

and not f"om two manage"s !his a/e"ts the possibility of sowing %onf$sion among the membe"s of the

o"gani(ation

25 B$li$s o"ients his staff on the patte"ns of "epo"ting "elationship th"o$gho$t the o"gani(ation Hhi%h of the

following p"in%iples "efe" to thisQ

# Span of %ont"ol

@ ?ie"a"%hy

C ,sp"it dK %o"ps

) Unity of di"e%tion

#nswe": @ ?ie"a"%hy

?ie"a"%hy "efe"s to the patte"n of "epo"ting o" the fo"mal line of a$tho"ity in an o"gani(ational st"$%t$"e

28 ?e emphasi(es to the team that they need to p$t thei" effo"ts togethe" towa"ds the attainment of the goals of

the p"og"am Hhi%h of the following p"in%iples "efe"s to thisQ# Span of %ont"ol

@ Unity of di"e%tion

C Unity of %ommand

) Command "esponsibility

#nswe": @ Unity of di"e%tion

Unity of di"e%tion means ha/ing one goal o" one obEe%ti/e fo" the team to p$"s$eW hen%e all membe"s of the

o"gani(ation sho$ld p$t thei" effo"ts togethe" towa"ds the attainment of thei" %ommon goal o" obEe%ti/e

2 B$li$s st"esses the impo"tan%e of p"omoting êsp"it d %o"psK among the membe"s of the $nit Hhi%h of the

following "ema"s of the staff indi%ates that they $nde"stand what he pointed o$tQ

# 'etKs wo" togethe" in ha"monyW we need to be s$ppo"ti/e of one anothe"T@ In o"de" that we a%hie/e the same "es$ltsW we m$st all follow the di"e%ti/es of B$li$s and not f"om othe"

manage"sT

C He will ens$"e that all the "eso$"%es we need a"e a/ailable when neededT) He need to p$t o$" effo"ts togethe" in o"de" to "aise the ba" of e-%ellen%e in the %a"e we p"o/ide to all o$"

patientsT

#nswe": # 'etKs wo" togethe" in ha"monyW we need to be s$ppo"ti/e of one anothe"T

!he p"in%iple of êsp"it dK %o"psK "efe"s to p"omoting ha"mony in the wo"pla%e& whi%h is essential in maintaining

a %limate %ond$%i/e to wo"

29 ?e dis%$sses the goal of the depa"tment Hhi%h of the following statements is a goalQ

# In%"ease the patient satisfa%tion "ate

@ ,liminate the in%iden%e of delayed administ"ation of medi%ations

C ,stablish "appo"t with patients

) ed$%e "esponse time to two min$tes

#nswe": # In%"ease the patient satisfa%tion "ate

Doal is a desi"ed "es$lt towa"ds whi%h effo"ts a"e di"e%ted Options #@& C and ) a"e all obEe%ti/es whi%h a"e

aimed at spe%ifi% end

+0 ?e wants to infl$en%e the %$stoma"y way of thining and beha/ing that is sha"ed by the membe"s of thedepa"tment Hhi%h of the following te"ms "efe" to thisQ

# O"gani(ational %ha"t

@ C$lt$"al netwo"

C O"gani(ational st"$%t$"e

) O"gani(ational %$lt$"e

#nswe": ) O"gani(ational %$lt$"e

#n o"gani(ational %$lt$"e "efe"s to the way the membe"s of the o"gani(ation thin togethe" and do things a"o$nd

them togethe" ItKs thei" way of life in that o"gani(ation

+1 ?e asse"ts the impo"tan%e of p"omoting a positi/e o"gani(ational %$lt$"e in thei" $nit Hhi%h of the following

beha/io"s indi%ate that this is attained by the g"o$pQ




# P"oa%ti/e and %a"ing with one anothe"

@ Competiti/e and pe"fe%tionist

C Powe"f$l and oppositional

) Obedient and $n%omplaining

#nswe": # P"oa%ti/e and %a"ing with one anothe"

Positi/e %$lt$"e is based on h$manism and affiliati/e no"ms

+2 Stephanie is a new Staff ,d$%ato" of a p"i/ate te"tia"y hospital She %ond$%ts o"ientation among new staff

n$"ses in he" depa"tment Boseph& one of the new staff n$"ses& wants to $nde"stand the %hannel of %omm$ni%ation&

span of %ont"ol and lines of %omm$ni%ation Hhi%h of the following will p"o/ide this info"mationQ

# O"gani(ational st"$%t$"e

@ Poli%y

C Bob des%"iption

) <an$al of p"o%ed$"es

#nswe": # O"gani(ational st"$%t$"eO"gani(ational st"$%t$"e p"o/ides info"mation on the %hannel of a$tho"ity& ie& who "epo"ts to whom and with

what a$tho"ityW the n$mbe" of people who di"e%tly "epo"ts to the /a"io$s le/els of hie"a"%hy and the lines of

%omm$ni%ation whethe" line o" staff

++ Stephanie is often seen inte"a%ting with the medi%al inte"n d$"ing %offee b"eas and afte" d$ty ho$"s Hhat

type of o"gani(ational st"$%t$"e is thisQ

# Fo"mal

@ Info"mal

C Staff

) 'ine

#nswe": @ Info"mal

!his is $s$ally not p$blished and oftentimes %on%ealed

+. She taes p"ide in saying that the hospital has a de%ent"ali(ed st"$%t$"e Hhi%h of the following is *O!%ompatible with this type of modelQ

# Flat o"gani(ation

@ Pa"ti%ipato"y app"oa%hC Sha"ed go/e"nan%e

) !all o"gani(ation

#nswe": ) !all o"gani(ation

!all o"gani(ations a"e highly %ent"ali(ed o"gani(ations whe"e de%ision maing is %ente"ed on one a$tho"ity le/el

+ Cent"ali(ed o"gani(ations ha/e some ad/antages Hhi%h of the following statements a"e !U,Q

1 ?ighly %ost=effe%ti/e

2 <aes management easie"

+ efle%ts the inte"est of the wo"e"

. #llows 6$i% de%isions o" a%tions

# 1 N 2

@ 2 N .

C 2& +N .

) 1& 2& N .

#nswe": # 1 N 2Cent"ali(ed o"gani(ations a"e needs only a few manage"s hen%e they a"e less e-pensi/e and easie" to manage

+5 Stephanie delegates effe%ti/ely if she has a$tho"ity to a%t& whi%h is @,S! defined as:

# ha/ing "esponsibility to di"e%t othe"s

@ being a%%o$ntable to the o"gani(ation

C ha/ing legitimate "ight to a%t

) telling othe"s what to do

#nswe": C ha/ing legitimate "ight to a%t

#$tho"ity is a legitimate o" offi%ial "ight to gi/e %ommand !his is an offi%ially san%tioned "esponsibility

+8 ega"dless of the si(e of a wo" g"o$p& eno$gh staff m$st be a/ailable at all times to a%%omplish %e"tain




p$"poses Hhi%h of these p$"poses in *O! in%l$dedQ

# <eet the needs of patients

@ P"o/ide a pai" of hands to othe" $nits as needed

C Co/e" all time pe"iods ade6$ately

) #llow fo" g"owth and de/elopment of n$"sing staff

#nswe": @ P"o/ide a pai" of hands to othe" $nits as needed

P"o/iding a pai" of hands fo" othe" $nits is not a p$"pose in doing an effe%ti/e staffing p"o%ess !his is a f$n%tionof a staffing %oo"dinato" at a %ent"ali(ed model

+ Hhi%h of the following g$idelines sho$ld be least %onside"ed in fo"m$lating obEe%ti/es fo" n$"sing %a"eQ

# H"itten n$"sing %a"e plan

@ ?olisti% app"oa%h

C P"es%"ibed standa"ds

) Staff p"efe"en%es

#nswe": ) Staff p"efe"en%esStaff p"efe"en%es sho$ld be the least p"io"ity in fo"m$lating obEe%ti/es of n$"sing %a"e Indi/id$al p"efe"en%es

sho$ld be s$bo"dinate to the inte"est of the patients

+9 Stephanie %onside"s shifting to t"ansfo"mational leade"ship Hhi%h of the following statements best des%"ibes

this type of leade"shipQ

# Uses /isioning as the essen%e of leade"ship

@ Se"/es the followe"s "athe" than being se"/edC <aintains f$ll t"$st and %onfiden%e in the s$bo"dinates

) Possesses innate %ha"isma that maes othe"s feel good in his p"esen%e

#nswe": # Uses /isioning as the essen%e of leade"ship

!"ansfo"mational leade"ship "elies hea/ily on /isioning as the %o"e of leade"ship

.0 #s a manage"& she fo%$ses he" ene"gy on both the 6$ality of se"/i%es "ende"ed to the patients as well as the

welfa"e of the staff of he" $nit Hhi%h of the following management styles does she adoptQ# Co$nt"y %l$b management

@ O"gani(ation man management

C !eam management

) #$tho"ity=obedien%e management

#nswe": C !eam management

!eam management has a high %on%e"n fo" se"/i%es and high %on%e"n fo" staff

.1 athe"ine is a yo$ng Unit <anage" of the Pediat"i% Ha"d <ost of he" staff n$"ses a"e senio" to he"& /e"y

a"ti%$late& %onfident and sometimes agg"essi/e athe"ine feels $n%omfo"table belie/ing that she is the s%apegoat

of e/e"ything that goes w"ong in he" depa"tment Hhi%h of the following is the best a%tion that she m$st taeQ

# Identify the so$"%e of the %onfli%t and $nde"stand the points of f"i%tion@ )is"ega"d what she feels and %ontin$e to wo" independently

C See help f"om the )i"e%to" of *$"sing

) >$it he" Eob and loo fo" anothe" employment

#nswe": # Identify the so$"%e of the %onfli%t and $nde"stand the points of f"i%tion

!his in/ol/es a p"oblem sol/ing app"oa%h& whi%h add"esses the "oot %a$se of the p"oblem

.2 #s a yo$ng manage"& she nows that %onfli%t o%%$"s in any o"gani(ation Hhi%h of the following statements

"ega"ding %onfli%t is *O! t"$eQ

# Can be dest"$%ti/e if the le/el is too high

@ Is not benefi%ialW hen%e it sho$ld be p"e/ented at all times

C <ay "es$lt in poo" pe"fo"man%e) <ay %"eate leade"s

#nswe": @ Is not benefi%ialW hen%e it sho$ld be p"e/ented at all times

Confli%ts a"e benefi%ial be%a$se it s$"fa%es o$t iss$es in the open and %an be sol/ed "ight away 'iewise&

membe"s of the team be%ome mo"e %ons%ientio$s with thei" wo" when they a"e awa"e that othe" membe"s of the

team a"e wat%hing them




.+ athe"ine tells one of the staff& I donKt ha/e time to dis%$ss the matte" with yo$ now See me in my offi%e

late"T when the latte" ass if they %an tal abo$t an iss$e Hhi%h of the following %onfli%t "esol$tion st"ategies did

she $seQ

# Smoothing

@ Comp"omise

C #/oidan%e) est"i%tion

#nswe": C #/oidan%e

!his st"ategy sh$ns dis%$ssing the iss$e head=on and p"efe"s to postpone it to a late" time In effe%t the p"oblem

"emains $nsol/ed and both pa"ties a"e in a lose=lose sit$ation

.. athleen nows that one of he" staff is e-pe"ien%ing b$"no$t Hhi%h of the following is the best thing fo" he"

to doQ

# #d/ise he" staff to go on /a%ation

@ Igno"e he" obse"/ationsW it will be "esol/ed e/en witho$t inte"/ention

C emind he" to show loyalty to the instit$tion

) 'et the staff /entilate he" feelings and as how she %an be of help

#nswe": ) 'et the staff /entilate he" feelings and as how she %an be of helpea%hing o$t and helping the staff is the most effe%ti/e st"ategy in dealing with b$"n o$t nowing that someone

is "eady to help maes the staff feel impo"tantW hen%e he" self=wo"th is enhan%ed

. She nows that pe"fo"man%e app"aisal %onsists of all the following a%ti/ities ,;C,P!:

# Setting spe%ifi% standa"ds and a%ti/ities fo" indi/id$al pe"fo"man%e

@ Using agen%y standa"ds as a g$ide

C )ete"mine a"eas of st"ength and weanesses) Fo%$sing a%ti/ity on the %o""e%tion of identified beha/io"

#nswe": ) Fo%$sing a%ti/ity on the %o""e%tion of identified beha/io"

Pe"fo"man%e app"aisal deal with both positi/e and negati/e pe"fo"man%eW is not meant to be a fa$lt=finding

a%ti/ity

.5 Hhi%h of the following statements is *O! t"$e abo$t pe"fo"man%e app"aisalQ

# Info"ming the staff abo$t the spe%ifi% imp"essions of thei" wo" help imp"o/e thei" pe"fo"man%e

@ # /e"bal app"aisal is an a%%eptable s$bstit$te fo" a w"itten "epo"t

C Patients a"e the best so$"%e of info"mation "ega"ding pe"sonnel app"aisal

) !he o$t%ome of pe"fo"man%e app"aisal "ests p"ima"ily with the staff

#nswe": C Patients a"e the best so$"%e of info"mation "ega"ding pe"sonnel app"aisal

!he patient %an be a so$"%e of info"mation abo$t the pe"fo"man%e of the staff b$t it is ne/e" the best so$"%e

)i"e%tly obse"/ing the staff is the best so$"%e of info"mation fo" pe"sonnel app"aisal

.8 !he"e a"e times when athe"ine e/al$ates he" staff as she maes he" daily "o$nds Hhi%h of the following is

*O! a benefit of %ond$%ting an info"mal app"aisalQ

# !he staff membe" is obse"/ed in nat$"al setting

@ In%idental %onf"ontation and %ollabo"ation is allowed

C !he e/al$ation is fo%$sed on obEe%ti/e data systemati%ally

) !he e/al$ation may p"o/ide /alid info"mation fo" %ompilation of a fo"mal "epo"t

#nswe": C !he e/al$ation is fo%$sed on obEe%ti/e data systemati%ally

Colle%ting obEe%ti/e data systemati%ally %an not be a%hie/ed in an info"mal app"aisal It is fo%$sed on what

a%t$ally happens in the nat$"al wo" setting

. She %ond$%ts a 5=month pe"fo"man%e "e/iew session with a staff membe" Hhi%h of the following a%tions isapp"op"iateQ

# She ass anothe" n$"se to attest the session as a witness

@ She info"ms the staff that she may as anothe" n$"se to "ead the app"aisal befo"e the session is o/e"

C She tells the staff that the session is manage"=%ente"ed) !he session is p"i/ate between the two membe"s

#nswe": ) !he session is p"i/ate between the two membe"s

!he session is p"i/ate between the manage" and the staff and "emains to be so when the two pa"ties do not di/$lge

the info"mation to othe"s




.9 #le-and"a is tased to o"gani(e the new wing of the hospital She was gi/en the a$tho"ity to do as she

deems fit She is awa"e that the di"e%to" of n$"sing has s$bstantial t"$st and %onfiden%e in he" %apabilities&

%omm$ni%ates th"o$gh downwa"d and $pwa"d %hannels and $s$ally $ses the ideas and opinions of he" staff

Hhi%h of the following is he" style of managementQ

# @ene/olent Xa$tho"itati/e@ Cons$ltati/e

C ,-ploiti/e=a$tho"itati/e) Pa"ti%ipati/e

#nswe": @ Cons$ltati/e

# %ons$ltati/e manage" is almost lie a pa"ti%ipati/e manage" !he pa"ti%ipati/e manage" has %omplete t"$st and

%onfiden%e in the s$bo"dinate& always $ses the opinions and ideas of s$bo"dinates and %omm$ni%ates in all

di"e%tions

2 She de%ides to ill$st"ate the o"gani(ational st"$%t$"e Hhi%h of the following elements is *O! in%l$dedQ

# 'e/el of a$tho"ity

@ 'ines of %omm$ni%ation

C Span of %ont"ol

) Unity of di"e%tion

#nswe": ) Unity of di"e%tion

Unity of di"e%tion is a management p"in%iple& not an element of an o"gani(ational st"$%t$"e

1 She plans of assigning %ompetent people to fill the "oles designed in the hie"a"%hy Hhi%h p"o%ess "efe"s to

thisQ

# Staffing

@ S%hed$ling

C e%"$itment

) Ind$%tion

#nswe": # StaffingStaffing is a management f$n%tion in/ol/ing p$tting the best people to a%%omplish tass and a%ti/ities to attain the

goals of the o"gani(ation

2 She %he%s the do%$menta"y "e6$i"ements fo" the appli%ants fo" staff n$"se position Hhi%h one is *O!

ne%essa"yQ# Ce"tifi%ate of p"e/io$s employment

@ e%o"d of "elated lea"ning e-pe"ien%e ',

C <embe"ship to a%%"edited p"ofessional o"gani(ation

) P"ofessional identifi%ation %a"d

#nswe": @ e%o"d of "elated lea"ning e-pe"ien%e ',e%o"d of ', is not "e6$i"ed fo" employment p$"poses b$t it is "e6$i"ed fo" the n$"seKs li%ens$"e e-amination

+ Hhi%h phase of the employment p"o%ess in%l$des getting on the pay"oll and %ompleting do%$menta"y

"e6$i"ementsQ

# O"ientation

@ Ind$%tion

C Sele%tion

) e%"$itment

#nswe": @ Ind$%tion

!his step in the "e%"$itment p"o%ess gi/es time fo" the staff to s$bmit all the do%$menta"y "e6$i"ements fo"

employment

. She t"ies to design an o"gani(ational st"$%t$"e that allows %omm$ni%ation to flow in all di"e%tions and in/ol/e

wo"e"s in de%ision maing Hhi%h fo"m of o"gani(ational st"$%t$"e is thisQ

# Cent"ali(ed

@ )e%ent"ali(ed

C <at"i-

) Info"mal




#nswe": @ )e%ent"ali(ed

)e%ent"ali(ed st"$%t$"es allow the staff to mae de%isions on matte"s pe"taining to thei" p"a%ti%e and %omm$ni%ate

in downwa"d& $pwa" d& late"al and diagonal flow

In a ho"i(ontal %ha"t& the lowest le/el wo"e" is lo%ated at the

# 'eftmost bo-@ <iddle

C ightmost bo-) @ottom

#nswe": C ightmost bo-

!he leftmost bo- is o%%$pied by the highest a$tho"ity while the lowest le/el wo"e" o%%$pies the "ightmost bo-

5 She de%ides to ha/e a de%ent"ali(ed staffing system Hhi%h of the following is an ad/antage of this system of

staffingQ

# g"eate" %ont"ol of a%ti/ities

@ Conse"/es time

C Compatible with %omp$te"i(ation

) P"omotes bette" inte"pe"sonal "elationship

#nswe": ) P"omotes bette" inte"pe"sonal "elationship

)e%ent"ali(ed st"$%t$"es allow the staff to sol/e de%isions by themsel/es& in/ol/e them in de%ision maingW hen%e

they a"e always gi/en oppo"t$nities to inte"a%t with one anothe"

8 #$b"ey thins abo$t p"ima"y n$"sing as a system to deli/e" %a"e Hhi%h of the following a%ti/ities is *O!

done by a p"ima"y n$"seQ

# Collabo"ates with the physi%ian@ P"o/ides %a"e to a g"o$p of patients togethe" with a g"o$p of n$"ses

C P"o/ides %a"e fo" =5 patients d$"ing thei" hospital stay

) Pe"fo"ms %omp"ehensi/e initial assessment

#nswe": @ P"o/ides %a"e to a g"o$p of patients togethe" with a g"o$p of n$"ses!his f$n%tion is done in team n$"sing whe"e the n$"se is a membe" of a team that p"o/ides %a"e fo" a g"o$p of

patients

Hhi%h patte"n of n$"sing %a"e in/ol/es the %a"e gi/en by a g"o$p of pa"ap"ofessional wo"e"s led by a

p"ofessional n$"se who tae %a"e of patients with the same disease %onditions and a"e lo%ated geog"aphi%ally nea"

ea%h othe"Q

# Case method

@ <od$la" n$"sing

C *$"sing %ase management) !eam n$"sing

#nswe": @ <od$la" n$"sing

<od$la" n$"sing is a /a"iant of team n$"sing !he diffe"en%e lies in the fa%t that the membe"s in mod$la" n$"singa"e pa"ap"ofessional wo"e"s

9 St aphael <edi%al Cente" E$st opened its new Pe"fo"man%e Imp"o/ement )epa"tment <s 7alen%ia is

appointed as the >$ality Cont"ol Offi%e" She %ommits he"self to he" new "ole and plans he" st"ategies to "eali(e

the goals and obEe%ti/es of the depa"tment Hhi%h of the following is a p"ima"y tas that they sho$ld pe"fo"m to

ha/e an effe%ti/e %ont"ol systemQ

# <ae an inte"p"etation abo$t st"engths and weanesses

@ Identify the /al$es of the depa"tment

C Identify st"$%t$"e& p"o%ess& o$t%ome standa"ds N %"ite"ia

) <eas$"e a%t$al pe"fo"man%es

#nswe": @ Identify the /al$es of the depa"tment

Identify the /al$es of the depa"tment will set the g$iding p"in%iples within whi%h the depa"tment will ope"ate its

a%ti/ities

50 <s 7alen%ia de/elops the standa"ds to be followed #mong the following standa"ds& whi%h is %onside"ed as a

st"$%t$"e standa"dQ

# !he patients /e"bali(ed satisfa%tion of the n$"sing %a"e "e%ei/ed

@ otation of d$ty will be done e/e"y fo$" wees fo" all patient %a"e pe"sonnel




C #ll patients shall ha/e thei" weights taen "e%o"ded

) Patients shall answe" the e/al$ation fo"m befo"e dis%ha"ge

#nswe": @ otation of d$ty will be done e/e"y fo$" wees fo" all patient %a"e pe"sonnel

St"$%t$"e standa"ds in%l$de management system& fa%ilities& e6$ipment& mate"ials needed to deli/e" %a"e to patients

otation of d$ty is a management system

51 Hhen she p"esents the n$"sing p"o%ed$"es to be followed& she "efe"s to what type of standa"dsQ# P"o%ess

@ O$t%ome

C St"$%t$"e

) C"ite"ia

#nswe": # P"o%ess

P"o%ess standa"ds in%l$de %a"e plans& n$"sing p"o%ed$"e to be done to add"ess the needs of the patients

52 !he following a"e basi% steps in the %ont"olling p"o%ess of the depa"tment Hhi%h of the following is *O!

in%l$dedQ

# <eas$"e a%t$al pe"fo"man%e

@ Set n$"sing standa"ds and %"ite"iaC Compa"e "es$lts of pe"fo"man%e to standa"ds and obEe%ti/es

) Identify possible %o$"ses of a%tion

#nswe": ) Identify possible %o$"ses of a%tion

!his is a step in a 6$ality %ont"ol p"o%ess and not a basi% step in the %ont"ol p"o%ess

5+ Hhi%h of the following statements "efe"s to %"ite"iaQ

# #g"eed on le/el of n$"sing %a"e

@ Cha"a%te"isti%s $sed to meas$"e the le/el of n$"sing %a"e

C Step=by=step g$idelines

) Statement whi%h g$ide the g"o$p in de%ision maing and p"oblem sol/ing

#nswe": @ Cha"a%te"isti%s $sed to meas$"e the le/el of n$"sing %a"e

C"ite"ia a"e spe%ifi% %ha"a%te"isti%s $sed to meas$"e the standa"d of %a"e

5. She wants to ens$"e that e/e"y tas is %a""ied o$t as planned Hhi%h of the following tass is *O! in%l$ded in

the %ont"olling p"o%essQ

# Inst"$%ting the membe"s of the standa"ds %ommittee to p"epa"e poli%ies

@ e/iewing the e-isting poli%ies of the hospital

C ,/al$ating the %"edentials of all n$"sing staff

) Che%ing if a%ti/ities %onfo"m to s%hed$le

#nswe": # Inst"$%ting the membe"s of the standa"ds %ommittee to p"epa"e poli%ies

Inst"$%ting the membe"s in/ol/es a di"e%ting f$n%tion

5 <s 7alen%ia p"epa"es the p"o%ess standa"ds Hhi%h of the following is *O! a p"o%ess standa"dQ

# Initial assessment shall be done to all patients within twenty fo$" ho$"s $pon admission

@ Info"med %onsent shall be se%$"ed p"io" to any in/asi/e p"o%ed$"eC PatientsK "epo"ts 9V satisfa%tion "ate p"io" to dis%ha"ge f"om the hospital

) Patient ed$%ation abo$t thei" illness and t"eatment shall be p"o/ided fo" all patients and thei" families

#nswe": C PatientsK "epo"ts 9V satisfa%tion "ate p"io" to dis%ha"ge f"om the hospital

!his "efe"s to an o$t%ome standa"d& whi%h is a "es$lt of the %a"e that is "ende"ed to the patient

55 Hhi%h of the following is e/iden%e that the %ont"olling p"o%ess is effe%ti/eQ# !he things that we"e planned a"e done

@ Physi%ians do not %omplain

C ,mployees a"e %ontended

) !he"e is an in%"ease in %$stome" satisfa%tion "ate

#nswe": # !he things that we"e planned a"e done

Cont"olling is defined as seeing to it that what is planned is done




58 <s 7alen%ia is "esponsible to the n$mbe" of pe"sonnel "epo"ting to he" !his p"in%iple "efe"s to:

# Span of %ont"ol

@ Unity of %ommand

C Ca""ot and sti% p"in%iple

) ,sp"it dK %o"ps

#nswe": # Span of %ont"ol

Span of %ont"ol "efe"s to the n$mbe" of wo"e"s who "epo"t di"e%tly to a manage"

5 She notes that the"e is an in%"easing $n"est of the staff d$e to fatig$e b"o$ght abo$t by sho"tage of staff

Hhi%h a%tion is a p"io"ityQ

# ,/al$ate the o/e"all "es$lt of the $n"est

@ Initiate a g"o$p inte"a%tionC )e/elop a plan and implement it

) Identify e-te"nal and inte"nal fo"%es

#nswe": @ Initiate a g"o$p inte"a%tion

Initiate a g"o$p inte"a%tion will be an oppo"t$nity to dis%$ss the p"oblem in the open

NURSING RESEARCH Part 1

1 e/in is a membe" of the *$"sing esea"%h Co$n%il of the hospital ?is fi"st assignment is to dete"mine the

le/el of patient satisfa%tion on the %a"e they "e%ei/ed f"om the hospital ?e plans to in%l$de all ad$lt patients

admitted f"om #p"il to <ay& with a/e"age length of stay of +=. days& fi"st admission& and with no %ompli%ations

Hhi%h of the following is an e-t"aneo$s /a"iable of the st$dyQ

# )ate of admission






eliability is "epeatability of the inst"$mentW it %an eli%it the same "esponses e/en with /a"ied administ"ation ofthe inst"$ment

Hhi%h %"ite"ia "efe" to the ability of the inst"$ment to dete%t fine diffe"en%es among the s$bEe%ts being st$diedQ

# Sensiti/ity

@ eliabilityC 7alidity

) ObEe%ti/ity

#nswe": # Sensiti/ity

Sensiti/ity is an att"ib$te of the inst"$ment that allow the "espondents to disting$ish diffe"en%es of the optionswhe"e to %hoose f"om

9 Hhi%h of the following te"ms "efe" to the deg"ee to whi%h an inst"$ment meas$"es what it is s$pposed to be

meas$"eQ

# 7alidity

@ eliability

C <eaningf$lness

) Sensiti/ity

#nswe": # 7alidity

7alidity is ens$"ing that the inst"$ment %ontains app"op"iate 6$estions abo$t the "esea"%h topi%

10 ?e plans fo" his sampling method Hhi%h sampling method gi/es e6$al %han%e to all $nits in the pop$lation to

get pi%edQ

# andom

@ #%%idental

C >$ota

) B$dgment

#nswe": # andom

andom sampling gi/es e6$al %han%e fo" all the elements in the pop$lation to be pi%ed as pa"t of the sample

11 aphael is inte"ested to lea"n mo"e abo$t t"ans%$lt$"al n$"sing be%a$se he is assigned at the family s$ites

whe"e most patients %ome f"om diffe"ent %$lt$"es and %o$nt"ies Hhi%h of the following designs is app"op"iate fo"

this st$dyQ

# D"o$nded theo"y

@ ,thnog"aphy

C Case st$dy

) Phenomenology

#nswe": @ ,thnog"aphy

,thnog"aphy is fo%$sed on patte"ns of beha/io" of sele%ted people within a %$lt$"e

12 !he n$"sing theo"ist who de/eloped t"ans%$lt$"al n$"sing theo"y is

# )o"othea O"em

@ <adeleine 'eininge"

C @etty *ewman

) S" Callista oy

#nswe": @ <adeleine 'eininge"

<adeleine 'eininge" de/eloped the theo"y on t"ans%$lt$"al theo"y based on he" obse"/ations on the beha/io" of

sele%ted people within a %$lt$"e

1+ Hhi%h of the following statements best des%"ibes a phenomenologi%al st$dyQ# In/ol/es the des%"iption and inte"p"etation of %$lt$"al beha/io"

@ Fo%$ses on the meaning of e-pe"ien%es as those who e-pe"ien%e it

C In/ol/es an in=depth st$dy of an indi/id$al o" g"o$p

) In/ol/es %olle%ting and analy(ing data that aims to de/elop theo"ies g"o$nded in "eal=wo"ld obse"/ations

#nswe": @ Fo%$ses on the meaning of e-pe"ien%es as those who e-pe"ien%e it

Phenomenologi%al st$dy in/ol/es $nde"standing the meaning of e-pe"ien%es as those who e-pe"ien%ed the




phenomenon

1. ?e systemati%ally plans his sampling plan Sho$ld he de%ides to in%l$de whoe/e" patients a"e admitted d$"ing

the st$dy he $ses what sampling methodQ

# B$dgment

@ #%%identalC andom

) >$ota

#nswe": @ #%%idental

#%%idental sampling is a non=p"obability sampling method whi%h in%l$des those who a"e at the site d$"ing data%olle%tion

1 ?e finally de%ides to $se E$dgment sampling Hhi%h of the following a%tions of aphael is %o""e%tQ

# Plans to in%l$de whoe/e" is the"e d$"ing his st$dy

@ )ete"mines the diffe"ent nationality of patients f"e6$ently admitted and de%ides to get "ep"esentations samples

f"om ea%h

C #ssigns n$mbe"s fo" ea%h of the patients& pla%e these in a fishbowl and d"aw 10 f"om it

) )e%ides to get 20 samples f"om the admitted patients

#nswe": @ )ete"mines the diffe"ent nationality of patients f"e6$ently admitted and de%ides to get

"ep"esentations samples f"om ea%h

B$dgment sampling in/ol/es in%l$ding samples a%%o"ding to the nowledge of the in/estigato" abo$t the

pa"ti%ipants in the st$dy

15 ?e nows that %e"tain patients who a"e in a spe%iali(ed "esea"%h setting tend to "espond psy%hologi%ally to the

%onditions of the st$dy !his is "efe""ed to as

# @ias

@ ?awtho"ne effe%t

C ?alo effe%t

) ?o"ns effe%t

#nswe": @ ?awtho"ne effe%t

?awtho"ne effe%t is based on the st$dy of ,lton <ayo and %ompany abo$t the effe%t of an inte"/ention done toimp"o/e the wo"ing %onditions of the wo"e"s on thei" p"od$%ti/ity It "es$lted to an in%"eased p"od$%ti/ity b$t

not d$e to the inte"/ention b$t d$e to the psy%hologi%al effe%ts of being obse"/ed !hey pe"fo"med diffe"ently

be%a$se they we"e $nde" obse"/ation

18 Hhi%h of the following items "efe" to the sense of %los$"e that aphael e-pe"ien%es when data %olle%tion

%eases to yield any new info"mationQ

# Sat$"ation

@ P"e%ision

C 'imitation

) ele/an%e

#nswe": # Sat$"ation

Sat$"ation is a%hie/ed when the in/estigato" %an not e-t"a%t new "esponses f"om the info"mants& b$t instead& gets

the same "esponses "epeatedly

1 In 6$alitati/e "esea"%h the a%t$al analysis of data begins with:

# sea"%h fo" themes

@ /alidation of themati% analysis

C wea/e the themati% st"ands togethe"

) 6$asi statisti%s

#nswe": # sea"%h fo" themes

!he in/estigato" sta"ts data analysis by looing fo" themes f"om the /e"batim "esponses of the info"mants

19 aphael is also inte"ested to now the %oping abilities of patients who a"e newly diagnosed to ha/e te"minal

%an%e" Hhi%h of the following types of "esea"%h is app"op"iateQ

# Phenomenologi%al

@ ,thnog"aphi%C D"o$nded !heo"y




) Case St$dy

#nswe": C D"o$nded !heo"y

D"o$nded theo"y ind$%ti/ely de/elops a theo"y based on the obse"/ed p"o%esses in/ol/ing sele%ted people

20 Hhi%h of the following titles of the st$dy is app"op"iate fo" this st$dyQ

# 'i/ed ,-pe"ien%es of !e"minally=Ill Can%e" Patients

@ Coping Sills of !e"minally=Ill Can%e" Patients in a Sele%ted ?ospitalC !wo Case St$dies of !e"minally=Ill Patients in <anila

) @eliefs N P"a%ti%es of Patients with !e"minal Can%e"

#nswe": @ Coping Sills of !e"minally=Ill Can%e" Patients in a Sele%ted ?ospital

!he title has a spe%ifi% phenomenon& sample and "esea"%h lo%ale

21 <s <ontana plans to %ond$%t a "esea"%h on the $se of a new method of pain assessment s%ale Hhi%h of the

following is the se%ond step in the %on%ept$ali(ing phase of the "esea"%h p"o%essQ

# Fo"m$lating the "esea"%h hypothesis

@ e/iew "elated lite"at$"e

C Fo"m$lating and delimiting the "esea"%h p"oblem

) )esign the theo"eti%al and %on%ept$al f"amewo"

#nswe": @ e/iew "elated lite"at$"e

#fte" fo"m$lating and delimiting the "esea"%h p"oblem& the "esea"%he" %ond$%ts a "e/iew of "elated lite"at$"e to

dete"mine the e-tent of what has been done on the st$dy by p"e/io$s "esea"%he"s

22 Hhi%h of the following %odes of "esea"%h ethi%s "e6$i"es info"med %onsent in all %ases go/e"ning h$man

s$bEe%tsQ

# ?elsini )e%la"ation

@ *$"embe"g Code

C @elmont epo"t

) IC* Code of ,thi%s

#nswe": # ?elsini )e%la"ation

?elsini )e%la"ation is the fi"st inte"national attempt to set $p ethi%al standa"ds in "esea"%h in/ol/ing h$man

"esea"%h s$bEe%ts

2+ Hhi%h of the following ethi%al p"in%iples was *O! a"ti%$lated in the @elmont epo"tQ

# @enefi%en%e

@ espe%t fo" h$man dignity

C B$sti%e

) *on=malefi%en%e

#nswe": ) *on=malefi%en%e *on=malefi%en%e is not a"ti%$lated in the @elmont epo"t It only in%l$des benefi%en%e& "espe%t fo" h$man dignity

and E$sti%e

2. Hhi%h one of the following %"ite"ia sho$ld be %onside"ed as a top p"io"ity in n$"sing %a"eQ

# #/oidan%e of dest"$%ti/e %hanges@ P"ese"/ation of life

C #ss$"an%e of safety

) P"ese"/ation of integ"ity

#nswe": @ P"ese"/ation of life

!he p"ese"/ation of life at all %ost is a p"ima"y "esponsibility of the n$"se !his is embodied in the Code of ,thi%s

fo" "egiste"ed n$"ses @O* esol$tion 220 s 200.

2 Hhi%h of the following p"o%ed$"es ens$"es that the in/estigato" has f$lly des%"ibed to p"ospe%ti/e s$bEe%ts the

nat$"e of the st$dy and the s$bEe%ts "ightsQ

# )eb"iefing

@ F$ll dis%los$"e

C Info"med %onsent

) Co/e" data %olle%tion






C analysis

) %on%l$sion

#nswe": @ inte"p"etation

Inte"p"etation in%l$des the infe"en%es of the "esea"%he" abo$t the findings of the st$dy

+2 !he st$dy is said to be %ompleted when <s <ontana a%hie/ed whi%h of the following a%ti/itiesQ

# P$blished the "es$lts in a n$"sing Eo$"nal@ P"esented the st$dy in a "esea"%h fo"$m

C !he "es$lts of the st$dy is $sed by the n$"ses in the hospital

) S$bmitted the "esea"%h "epo"t to the C,O

#nswe": C !he "es$lts of the st$dy is $sed by the n$"ses in the hospital

!he last step in the "esea"%h p"o%ess is the $tili(ation of the "esea"%h findings

++ Sit$ation: Stephanie is a n$"se "esea"%he" of the Patient Ca"e Se"/i%es )i/ision She plans to %ond$%t a

lite"at$"e sea"%h fo" he" st$dy

Hhi%h of the following is the fi"st step in sele%ting app"op"iate mate"ials fo" he" "e/iewQ

# !"a% down most of the "ele/ant "eso$"%es@ Copy "ele/ant mate"ials

C O"gani(e mate"ials a%%o"ding to f$n%tion

) Synthesi(e lite"at$"e gathe"ed

#nswe": # !"a% down most of the "ele/ant "eso$"%es

!he fi"st step in the "e/iew of "elated lite"at$"e is to t"a% down "ele/ant so$"%es befo"e %opying these !he last

step is to synthesi(e the lite"at$"e gathe"ed

+. She nows that the most impo"tant %atego"ies of info"mation in lite"at$"e "e/iew is the:

# "esea"%h findings

@ theo"eti%al f"amewo"

C methodology) opinions

#nswe": # "esea"%h findings

!he "esea"%h findings is the most impo"tant %atego"y of info"mation that the "esea"%he" sho$ld %opy be%a$se this

will gi/e he" /al$able info"mation as to what has been dis%o/e"ed in past st$dies abo$t the same topi%

+ She also %onside"s a%%essing ele%t"oni% data bases fo" he" lite"at$"e "e/iew Hhi%h of the following is the most

$sef$l ele%t"oni% database fo" n$"sesQ

# CI*#?'

@ <,)'I*,

C ?ealthS!#

) ,<@#S,

#nswe": # CI*#?'

!his "efe"s to C$m$lati/e Inde- to *$"sing and #llied ?ealth 'ite"at$"e whi%h is a "i%h so$"%e fo" lite"at$"e

"e/iew fo" n$"ses !he "est of the sites a"e fo" medi%ine& pha"ma%y and othe" health="elated sites

+5 Hhile "e/iewing Eo$"nal a"ti%les& Stephanie got inte"ested in "eading the b"ief s$mma"y of the a"ti%le pla%ed at

the beginning of the Eo$"nal "epo"t Hhi%h of the following "efe"s to thisQ

# Int"od$%tion@ P"efa%e

C #bst"a%t

) @a%g"o$nd

#nswe": C #bst"a%t

#bst"a%t %ontains %on%ise des%"iption of the ba%g"o$nd of the st$dy& "esea"%h 6$estions& "esea"%h obEe%ti/es&

methods& findings& impli%ations to n$"sing p"a%ti%e as well as eywo"ds $sed in the st$dy

+8 She notes down ideas that we"e de"i/ed f"om the des%"iption of an in/estigation w"itten by the pe"son who

%ond$%ted it Hhi%h type of "efe"en%e so$"%e "efe"s to thisQ

# Footnote

@ @ibliog"aphy




C P"ima"y so$"%e

) ,ndnotes

#nswe": C P"ima"y so$"%e!his "efe"s to a p"ima"y so$"%e whi%h is a di"e%t a%%o$nt of the in/estigation done by the in/estigato" In %ont"ast

to this is a se%onda"y so$"%e& whi%h is w"itten by someone othe" than the o"iginal "esea"%he"

+ She %ame a%"oss a st$dy whi%h is "efe""ed to as meta=analysis Hhi%h of the following statements best definesthis type of st$dyQ

# !"eats the findings f"om one st$dy as a single pie%e of data

@ Findings f"om m$ltiple st$dies a"e %ombined to yield a data set whi%h is analy(ed as indi/id$al data

C ep"esents an appli%ation of statisti%al p"o%ed$"es to findings f"om ea%h "epo"t

) !e%hni6$e fo" 6$antitati/ely %ombining and th$s integ"ating the "es$lts of m$ltiple st$dies on a gi/en topi%

#nswe": ) !e%hni6$e fo" 6$antitati/ely %ombining and th$s integ"ating the "es$lts of m$ltiple st$dies on a

gi/en topi%

!ho$gh all the options a"e %o""e%t& the best definition is option ) be%a$se it %ombines 6$antitati/ely the "es$lts

and at the same time it integ"ates the "es$lts of the diffe"ent st$dies as one finding

+9 !his ind of "esea"%h gathe"s data in detail abo$t a indi/id$al o" g"o$ps and p"esented in na""ati/e fo"m&whi%h is

# Case st$dy

@ ?isto"i%al

C #nalyti%al

) ,-pe"imental

#nswe": # Case st$dy

Case st$dy fo%$ses on in=depth in/estigations of single entity o" small n$mbe" of entities It attempts to analy(e

and $nde"stand iss$es of impo"tan%e to histo"y& de/elopment o" %i"%$mstan%es of the pe"son o" entity $nde" st$dy

.0 Stephanie is finished with the steps in the %on%ept$al phase when she has %ond$%ted the '#S! step& whi%h is

# fo"m$lating and delimiting the p"oblem

@ "e/iew of "elated lite"at$"e

C de/elop a theo"eti%al f"amewo" ) fo"m$late a hypothesis

#nswe": ) fo"m$late a hypothesis

!he last step in the %on%ept$ali(ing phase of the "esea"%h p"o%ess is fo"m$lating a hypothesis !he "est a"e the fi"st

th"ee steps in this phase

.1 She states the hypothesis of the st$dy Hhi%h of the following is a n$ll hypothesisQ

# Infants who a"e b"eastfed ha/e the same weight as those who a"e bottle fed

@ @ottle=fed infants ha/e lowe" weight than b"east=fed infants

C C$ddled infants sleep longe" than those who a"e left by themsel/es to sleep

) Child"en of absentee pa"ents a"e mo"e p"one to e-pe"ien%e dep"ession than those who li/e with both pa"ents

#nswe": # Infants who a"e b"eastfed ha/e the same weight as those who a"e bottle fed

*$ll hypothesis p"edi%ts that the"e is no %hange& no diffe"en%e o" no "elationship between the /a"iables in the

st$dy

.2 She notes that the dependent /a"iable in the hypothesis )$"ation of sleep of %$ddled infants is longe" than

those infants who a"e not %$ddled by mothe"sT is

# C$ddled infants

@ )$"ation of sleep

C Infants) #bsen%e of %$ddling

#nswe": @ )$"ation of sleep

)$"ation of sleep is the êffe%tK dependent /a"iable of %$ddling ^%a$seK independent /a"iable

.+ Sit$ation: #"etha is a n$"se "esea"%he" in a te"tia"y hospital She is tased to %ond$%t a "esea"%h on the effe%ts

of st"$%t$"ed dis%ha"ge plan fo" post=open hea"t s$"ge"y patients

She states the signifi%an%e of the "esea"%h p"oblem Hhi%h of the following statements is the <OS! signifi%ant




fo" this st$dyQ

# Imp"o/ement in patient %a"e

@ )e/elopment of a theo"eti%al basis fo" n$"sing

C In%"ease the a%%o$ntability of n$"ses

) Imp"o/es the image of n$"sing

#nswe": # Imp"o/ement in patient %a"e

!he $ltimate goal of %ond$%ting "esea"%h is to imp"o/e patient %a"e whi%h is a%hie/ed by enhan%ing the p"a%ti%eof n$"ses when they $tili(e "esea"%h "es$lts in thei" p"a%ti%e

.. ega"dless of the signifi%an%e of the st$dy& the feasibility of the st$dy needs to be %onside"ed Hhi%h of the

following is %onside"ed a p"io"ityQ

# #/ailability of "esea"%h s$bEe%ts

@ @$dgeta"y allo%ation

C !ime f"ame

) ,-pe"ien%e of the "esea"%he"

#nswe": # #/ailability of "esea"%h s$bEe%ts

#/ailability is the most impo"tant %"ite"ia to be %onside"ed by the "esea"%he" in dete"mining whethe" the st$dy is

feasible o" not *o matte" how signifi%ant the st$dy may be if the"e a"e no a/ailable s$bEe%tsG"espondents& thest$dy %an not p$sh th"o$gh

.5 #"etha nows that a good "esea"%h p"oblem e-hibits the following %ha"a%te"isti%sW whi%h one is *O!

in%l$dedQ

# Clea"ly identified the /a"iablesGphenomenon $nde" %onside"ation

@ Spe%ifies the pop$lation being st$died

C Implies the feasibility of empi"i%al testing

) Indi%ates the hypothesis to be tested

#nswe": ) Indi%ates the hypothesis to be tested

*ot all st$dies "e6$i"e a hypothesis s$%h as 6$alitati/e st$dies& whi%h does not deal with /a"iables b$t with

phenomenon o" %on%epts

.8 She states the p$"poses of the st$dy Hhi%h of the following des%"ibe the p$"pose of a st$dyQ

1 ,stablishes the gene"al di"e%tion of a st$dy

2 Capt$"es the essen%e of the st$dy

+ Fo"mally a"ti%$lates the goals of the st$dy. Sometimes wo"ded as an intent

# 1& 2& +

@ 2& +& .

C 1& +& .

) 1& 2& +& .

#nswe": ) 1& 2& +& .

!he p$"poses of a "esea"%h st$dy %o/e"s all the options indi%ated

. She opts to $se inte"/iews in data %olle%tion In addition to /alidity& what is the othe" <OS! se"io$s weaness

of this methodQ

# #%%$"a%y

@ Sensiti/ity

C ObEe%ti/ity) eliability

#nswe": # #%%$"a%y

#%%$"a%y and /alidity a"e the most se"io$s weanesses of the self="epo"t data !his is d$e to the fa%t that the"espondents sometimes do not want to tell the t"$th fo" fea" of being "eEe%ted o" in o"de" to please theinte"/iewe"

.9 She plans to s$bEe%t he" inst"$ment to p"etesting Hhi%h of the following is *O! a%hie/ed in doing

p"etestingQ

# )ete"mines how m$%h time it taes to administe" the inst"$ment pa%age

@ Identify pa"ts that a"e diffi%$lt to "ead o" $nde"stand

C )ete"mine the b$dgeta"y allo%ation fo" the st$dy




) )ete"mine if the meas$"es yield data with s$ffi%ient /a"iability

#nswe": C )ete"mine the b$dgeta"y allo%ation fo" the st$dy

)ete"mining b$dgeta"y allo%ation fo" the st$dy is not a p$"pose of doing a p"etesting of the inst"$ments !his is

done at an ea"lie" stage of the design and planning phase

0 She tests the inst"$ment whethe" it loos as tho$gh it is meas$"ing app"op"iate %onst"$%ts Hhi%h of the

following "efe"s to thisQ# Fa%e /alidity

@ Content /alidity

C Const"$%t 7alidity

) C"ite"ion="elated /alidity

#nswe": # Fa%e /alidity

Fa%e /alidity meas$"es whethe" the inst"$ment appea"s to be meas$"ing the app"op"iate %onst"$%t It is the easiest

type of /alidity testing

1 Hhi%h of the following 6$estions wo$ld dete"mine the %onst"$%t /alidity of the inst"$mentQ

# Hhat is this inst"$ment "eally meas$"ingQT

@ ?ow "ep"esentati/e a"e the 6$estions on this test of the $ni/e"se of 6$estions on this topi%QTC )oes the 6$estion ased loos as tho$gh it is meas$"ing the app"op"iate %onst"$%tQT

) )oes the inst"$ment %o""elate highly with an e-te"nal %"ite"ionQ

#nswe": # Hhat is this inst"$ment "eally meas$"ingQT

Const"$%t /alidity aims to /alidate what the inst"$ment is "eally meas$"ing !he mo"e abst"a%t the %on%ept& the

mo"e diffi%$lt to meas$"e the %onst"$%t

2 Hhi%h of the following e-pe"imental "esea"%h designs wo$ld be app"op"iate fo" this st$dy if she wants to find

o$t a %a$se and effe%t "elationship between the st"$%t$"ed dis%ha"ge plan and %omplian%e to home %a"e "egimen

among the s$bEe%tsQ

# !"$e e-pe"iment

@ >$asi e-pe"imentC Post=test only design

) Solomon fo$"=g"o$p

#nswe": C Post=test only design

Post= !est only design is app"op"iate be%a$se it is impossible to meas$"e the %omplian%e to home %a"e "egimen

/a"iable p"io" to the dis%ha"ge of the patient f"om the hospital

+ One hypothesis that she fo"m$lated is Complian%e to home %a"e "egimen is g"eate" among patients who

"e%ei/ed the st"$%t$"ed dis%ha"ge plan than those who "e%ei/ed /e"bal dis%ha"ge inst"$%tionsK Hhi%h is the

independent /a"iable in this st$dyQ

# St"$%t$"ed dis%ha"ge plan

@ Complian%e to home %a"e "egimenC Post=open hea"t s$"ge"y patients) D"eate" %omplian%e

#nswe": # St"$%t$"ed dis%ha"ge plan

St"$%t$"ed dis%ha"ge plan is the inte"/ention o" the ^%a$seK in the st$dy that "es$lts to an êffe%tK& whi%h is

%omplian%e to home %a"e "egimen o" the dependent /a"iable

. Sit$ation : #lyssa plans to %ond$%t a st$dy abo$t n$"sing p"a%ti%e in the %o$nt"y She de%ides to "ef"esh he"

nowledge abo$t the diffe"ent types of "esea"%h in o"de" to %hoose the most app"op"iate design fo" he" st$dy

She %ame a%"oss s$"/eys& lie the So%ial Heathe" Station and P$lse #sia S$"/ey Hhi%h of the following is

the p$"pose of this ind of "esea"%hQ

# Obtains info"mation "ega"ding the p"e/alen%e& dist"ib$tion and inte""elationships of /a"iables within a

pop$lation at a pa"ti%$la" time

@ Det an a%%$"ate and %omplete data abo$t a phenomenon

C )e/elop a tool fo" data gathe"ing

) Fo"m$late a f"amewo" fo" the st$dy

#nswe": # Obtains info"mation "ega"ding the p"e/alen%e& dist"ib$tion and inte""elationships of /a"iables within

a pop$lation at a pa"ti%$la" time




S$"/eys a"e done to gathe" info"mation on peopleKs a%tions& nowledge& intentions& opinions and attit$des

5 She will liely $se self="epo"t method Hhi%h of the following self="epo"t methods is the most "espe%ted

method $sed in s$"/eysQ

# Pe"sonal inte"/iews

@ >$estionnai"es

C !elephone inte"/iews

) ating S%ale

#nswe": # Pe"sonal inte"/iews

Pe"sonal inte"/iews is the best method of %olle%ting s$"/ey data be%a$se the 6$ality of info"mation they yield is

highe" than othe" methods and be%a$se "elati/ely few people "ef$se to be inte"/iewed in pe"son

8 #lyssa "eads abo$t e-plo"ato"y "esea"%h Hhi%h of the following is the p$"pose of doing this type of "esea"%hQ

# Ind$%ti/ely de/elops a theo"y based on obse"/ations abo$t p"o%esses in/ol/ing sele%ted people

@ <aes new nowledge $sef$l and p"a%ti%al

C Identifies the /a"iables in the st$dy

) Finds o$t the %a$se and effe%t "elationship between /a"iables

#nswe": C Identifies the /a"iables in the st$dy,-plo"ato"y "esea"%h is the fi"st le/el of in/estigation and it deals with identifying the /a"iables in the st$dy

She "e/iews 6$alitati/e design of "esea"%h Hhi%h of the following is t"$e abo$t ethnog"aphi% st$dyQ

# )e/elops theo"ies that in%"ease the nowledge abo$t a %e"tain phenomenon

@ Fo%$ses on the meanings of life e-pe"ien%es of people

C )eals with patte"ns and e-pe"ien%es of a defined %$lt$"al g"o$p in a holisti% fashion

) In=depth in/estigation of a single entity

#nswe": C )eals with patte"ns and e-pe"ien%es of a defined %$lt$"al g"o$p in a holisti% fashion

,thnog"aphi% "esea"%h deals with the %$lt$"al patte"ns and beliefs of %e"tain %$lt$"e g"o$ps

9 She nows that the p$"pose of doing ethnog"aphi% st$dy is to:

# Unde"stand the wo"ld/iew of a %$lt$"al g"o$p

@ St$dy the life e-pe"ien%es of peopleC )ete"mine the "elationship between /a"iables

) In/estigate intensi/ely a single entity

#nswe": # Unde"stand the wo"ld/iew of a %$lt$"al g"o$p

!he aim of ethnog"aphe"s is to lea"n f"om the membe"s of a %$lt$"al g"o$p by $nde"standing thei" way of life as

they pe"%ei/e and li/e it

50 #lyssa wants to lea"n mo"e abo$t e-pe"imental design Hhi%h is the p$"pose of this "esea"%hQ

# !est the %a$se and effe%t "elationship among the /a"iable $nde" a %ont"olled sit$ation

@ Identify the /a"iables in the st$dy

C P"edi%ts the f$t$"e based on %$""ent inte"/ention

) )es%"ibe the %ha"a%te"isti%s& opinions& attit$des o" beha/io"s of %e"tain pop$lation abo$t a %$""ent iss$e o"

e/ent

#nswe": # !est the %a$se and effe%t "elationship among the /a"iable $nde" a %ont"olled sit$ation

,-pe"imental "esea"%h is a 'e/el III in/estigation whi%h dete"mines the %a$se and effe%t "elationshi p between/a"iables

51 She nows that the"e a"e th"ee elements of e-pe"imental "esea"%h Hhi%h is *O! in%l$dedQ

# <anip$lation

@ andomi(ationC Cont"ol

) !"ial

#nswe": ) !"ial

!"ial is not an element of e-pe"imental "esea"%h <anip$lation of /a"iables& "andomi(ation and %ont"ol a"e the

th"ee elements of this type of "esea"%h




52 #lyssa nows that the"e a"e times when only manip$lation of st$dy /a"iables is possible and the elements of

%ont"ol o" "andomi(ation a"e not attendant Hhi%h type of "esea"%h is "efe""ed to thisQ

# Field st$dy

@ >$asi=e-pe"iment

C Solomon=Fo$" g"o$p design

) Post=test only design

#nswe": @ >$asi=e-pe"iment>$asi=e-pe"iment is done when "andomi(ation and %ont"ol of the /a"iables a"e not possible

5+ One of the "elated st$dies that she "eads is a phenomenologi%al "esea"%h Hhi%h of the following 6$estions is

answe"ed by this type of 6$alitati/e "esea"%hQ

# T Hhat is the way of life of this %$lt$"al g"o$pQT

@ Hhat is the effe%t of the inte"/ention to the dependent /a"iableQT

C Hhat the essen%e of the phenomenon is as e-pe"ien%ed by these peopleQT

) Hhat is the %o"e %atego"y that is %ent"al in e-plaining what is going on in that so%ial s%eneQT

#nswe": C Hhat the essen%e of the phenomenon is as e-pe"ien%ed by these peopleQT

Phenomenologi%al "esea"%h deals with the meaning of e-pe"ien%es as those who e-pe"ien%ed the phenomenon

$nde"stand it

5. Othe" st$dies a"e %atego"i(ed a%%o"ding to the time f"ame Hhi%h of the following "efe"s to a st$dy of

/a"iables in the p"esent whi%h is lined to a /a"iable that o%%$""ed in the pastQ

# P"ospe%ti/e design

@ et"ospe%ti/e design

C C"oss se%tional st$dy

) 'ongit$dinal st$dy

#nswe": @ et"ospe%ti/e design

et"ospe%ti/e st$dies a"e done in o"de" to establish a %o""elation between p"esent /a"iables and the ante%edent

fa%to"s that ha/e %a$sed it

5 Sit$ation : ?a""y a new "esea"%h staff of the esea"%h and )e/elopment )epa"tment of a te"tia"y hospital is

tased to %ond$%t a "esea"%h st$dy abo$t the in%"eased in%iden%e of noso%omial infe%tion in the hospital

Hhi%h of the following ethi%al iss$es sho$ld he %onside" in the %ond$%t of his st$dyQ

1 Confidentiality of info"mation gi/en to him by the s$bEe%ts2 Self=dete"mination whi%h in%l$des the "ight to withd"aw f"om the st$dy g"o$p

+ P"i/a%y o" the "ight not to be e-posed p$bli%ly

. F$ll dis%los$"e abo$t the st$dy to be %ond$%ted

# 1& 2& +

@ 1& +& .

C 2& +& .) 1& 2& +& .

#nswe": ) 1& 2& +& .

!his in%l$des all the options as these a"e the fo$" basi% "ights of s$bEe%ts fo" "esea"%h

55 Hhi%h of the following is the best tool fo" data gathe"ingQ

# Inte"/iew s%hed$le

@ >$estionnai"eC Use of labo"ato"y data

) Obse"/ation

#nswe": C Use of labo"ato"y dataIn%iden%e of noso%omial infe%tion is best %olle%ted th"o$gh the $se of biophysiologi% meas$"es& pa"ti%$la"ly in

/it"o meas$"ements& hen%e labo"ato"y data is essential

58 )$"ing data %olle%tion& ?a""y en%o$nte"s a patient who "ef$ses to tal to him Hhi%h of the following is a

limitation of the st$dyQ

# PatientKs "ef$sal to f$lly di/$lge info"mation

@ Patients with histo"y of fe/e" and %o$gh

C Patients admitted o" who sees %ons$ltation at the , and do%to"s offi%es




) Conta%ts of patients with histo"y of fe/e" and %o$gh

#nswe": # PatientKs "ef$sal to f$lly di/$lge info"mation

PatientKs "ef$sal to di/$lge info"mation is a limitation be%a$se it is beyond the %ont"ol of ?a""y

5 Hhat type of "esea"%h is app"op"iate fo" this st$dyQ

# )es%"ipti/e= %o""elational

@ ,-pe"imentC >$asi=e-pe"iment

) ?isto"i%al

#nswe": # )es%"ipti/e= %o""elational

)es%"ipti/e= %o""elational st$dy is the most app"op"iate fo" this st$dy be%a$se it st$dies the /a"iables that %o$ld bethe ante%edents of the in%"eased in%iden%e of noso%omial infe%tion

59 In the statement& F"e6$ent hand washing of health wo"e"s de%"eases the in%iden%e of noso%omial infe%tions

among post=s$"ge"y patientsT& the dependent /a"iable is

# in%iden%e of noso%omial infe%tions

@ de%"eases

C f"e6$ent hand washing) post=s$"ge"y patients

#nswe": # in%iden%e of noso%omial infe%tions

!he dependent /a"iable is the in%iden%e of noso%omial infe%tion& whi%h is the o$t%ome o" effe%t of the

independent /a"ia ble& f"e6$ent hand washing

80 ?a""y nows that he has to p"ote%t the "ights of h$man "esea"%h s$bEe%ts Hhi%h of the following a%tions of

?a""y ens$"es anonymityQ

# eep the identities of the s$bEe%t se%"et

@ Obtain info"med %onsent

C P"o/ide e6$al t"eatment to all the s$bEe%ts of the st$dy

) elease findings only to the pa"ti%ipants of the st$dy

#nswe": # eep the identities of the s$bEe%t se%"et

eeping the identities of the "esea"%h s$bEe%t se%"et will ens$"e anonymity be%a$se this will hinde" p"o/iding lin

between the info"mation gi/en to whoe/e" is its so$"%e

81 ?e is o"iented to the $se of ele%t"oni% databases fo" n$"sing "esea"%h Hhi%h of the following will she liely

a%%essQ

# <,)'I*,

@ *ational Instit$te of *$"sing esea"%hC #me"i%an Bo$"nal of *$"sing

) Inte"national Co$n%il of *$"ses

#nswe": @ *ational Instit$te of *$"sing esea"%h *ational Instit$te fo" *$"sing esea"%h is a $sef$l so$"%e of info"mation fo" n$"sing "esea"%h !he "est of the

options may be helpf$l b$t *I* is the most $sef$l site fo" n$"ses

82 ?e de/elops methods fo" data gathe"ing Hhi%h of the following %"ite"ia of a good inst"$ment "efe"s to the

ability of the inst"$ment to yield the same "es$lts $pon its "epeated administ"ationQ

# 7alidity

@ Spe%ifi%ity

C Sensiti/ity

) eliability

#nswe": ) eliability

eliability is %onsisten%y of the "esea"%h inst"$ment It "efe"s to the "epeatability of the inst"$ment in e-t"a%ting

the same "esponses $pon its "epeated administ"ation

8+ ?a""y is awa"e of the impo"tan%e of %ont"olling th"eats to inte"nal /alidity fo" e-pe"imental "esea"%h& whi%h

in%l$de the following e-amples ,;C,P!:

# ?isto"y

@ <at$"ation

C #tt"ition




) )esign

#nswe": ) )esign

)esign is not a th"eat to inte"nal /alidity of the inst"$ment E$st lie the othe" options

8. ?is %olleag$e ass abo$t the e-te"nal /alidity of the "esea"%h findings Hhi%h of the "esponses of ?a""y is

app"op"iateQ !he "esea"%h findings %an be

# gene"ali(ed to othe" settings o" samples@ shown to "es$lt only f"om the effe%t of the independent /a"iable

C "efle%ted as "es$lts of e-t"aneo$s /a"iables

) f"ee of sele%tion biases

#nswe": # gene"ali(ed to othe" settings o" samples,-te"nal /alidity "efe"s to the gene"ali(ability of "esea"%h findings to othe" settings o" samples !his is an iss$e of

impo"tan%e to e/iden%e=based n$"sing p"a%ti%e

NURSING RESEARCH Part 2

Sit0ati#$ 1 Ao$ a"e fo"t$nate to be %hosen as pa"t

of the "esea"%h team in the hospital # "e/iew of the

following I<PO!#*! n$"sing %on%epts was

made:




1 # p"ofessional n$"se %an do "esea"%h fo"

/a"ied "easons e-%ept:

a P"ofessional ad/an%ement th"o$gh

"esea"%h pa"ti%ipation

b !o /alidate "es$lts of new n$"sing

modalities

% Fo" finan%ial gainsd !o imp"o/e n$"sing %a"e

2 ,a%h n$"se pa"ti%ipant was ased to identify

a p"oblem #fte" the identifi%ation of the

"esea"%h p"oblem& whi%h of the following sho$ld

be doneQ

a <ethodology

b e/iew of "elated lite"at$"e% #%nowledgement

d Fo"m$late hypothesis

+ Hhi%h of the following %omm$ni%ate the

"es$lts of the "esea"%h to the "eade"s !hey

fa%ilitate the des%"iption of the data

a ?ypothesis

b Statisti%s

% esea"%h p"oblem

d !ables and g"aphs

. In 6$antitati/e data& whi%h of the following

is des%"ibed as the distan%e in the s%o"ing $nits

of the /a"iable f"om the highest to the lowe"Q

a F"e6$en%y

b <ean% <edian

d ange

!his e-p"esses the /a"iability of the data in

"efe"en%e to the mean It p"o/ides as with a

n$me"i%al estimate of how fa"& on the a/e"age

the sepa"ate obse"/ation a"e f"om the mean:

a <ode

b Standa"d de/iation

% <edian

d F"e6$en%y

Sit0ati#$ 2 S$"/ey and statisti%s a"e impo"tant pa"t

if "esea"%h that is ne%essa"y to e-plain the

%ha"a%te"isti%s of the pop$lation

5 #%%o"ding to H?O statisti%s on thehomeless pop$lation a"o$nd the wo"ld& whi%h of

the following g"o$ps of people in the wo"ld

disp"opo"tionately "ep"esents the homeless

pop$lationQ

a ?ispani%s

b #sians

% #f"i%an #me"i%ans

d Ca$%asians

8 #ll b$t one of the following in not a

meas$"e of %ent"al tenden%y:

a <ode

b 7a"ian%e

% Standa"d de/iation

d ange

In the /al$es: 8& & & 92& 90& what is the

meanQ

a 2

b .

% 8

d 90

9 In the /al$es: 0& 0& 0& 2& 2& 90& 90& 100&

what is the modeQ

a 0

b 2

% 90d

10 In the /al$es: 0& 0& 10& 10& 2& 5& 100&

200& what is the medianQ

a 812

b 22

% 10 and 2

d 82

11 )"aw lots& lotte"y& table of "andom n$mbe"s

o" a sampling that ens$"es that ea%h element ofthe pop$lation has an e6$al and independent

%han%e of being %hosen is %alled:

a Cl$ste"

b Simple

% St"atified

d Systemati%

12 #n in/estigato" wants to dete"mine some of

the p"oblems e-pe"ien%ed by diabeti% %lients

when $sing ins$lin p$mp !he in/estigato" went

to a %lini% whe"e he pe"sonally nows se/e"al

diabeti% %lients ha/ing p"oblem with ins$lin

p$mp !he type of sampling done by the

in/estigato" is %alled:

a P"obability

b P$"posi/e

% Snowball

d In%idental

1+ If the "esea"%he" implemented a new

st"$%t$"ed %o$nseling p"og"am with a

"andomi(ed g"o$p of s$bEe%t and a "o$tine

%o$nseling p"og"am with anothe" "andomi(ed

g"o$p of s$bEe%t& the "esea"%h is $tili(ing whi%h

designQ

a >$asi e-pe"imental

b ,-pe"imental

% Compa"ati/e

d <ethodologi%al




1. Hhi%h of the following is not t"$e abo$t a

p$"e e-pe"imental "esea"%hQ

a !he"e is a %ont"ol g"o$p

b !he"e is an e-pe"imental g"o$p

% Sele%tion of s$bEe%ts in the %ont"ol g"o$p is

"andomi(ed

d !he"e is a %a"ef$l sele%tion of s$bEe%ts in thee-pe"imental g"o$p

1 !he "esea"%he" implemented a medi%ation

"egimen $sing a new type of %ombination d"$gs

to mani% patients while anothe" g"o$p of mani%

patients "e%ei/es the "o$tine d"$gs !he

"esea"%he" howe/e" handpi%ed the e-pe"imental

g"o$p fo" they a"e the %lients with m$ltiple

episodes if bipola" diso"de" !he "esea"%he"$tili(ed whi%h "esea"%h designQ

a >$asi e-pe"imental b P$"e e-pe"imental

% Phenomenologi%al

d 'ongit$dinal

Sit0ati#$ 3 #s a n$"se& yo$ a"e e-pe%ted to

pa"ti%ipate in initiating o" pa"ti%ipating in the

%ond$%t of "esea"%h st$dies to imp"o/e n$"sing

p"a%ti%e Ao$ ha/e to be $pdated on the latest t"ends

and iss$es affe%ting the p"ofession and the best

p"a%ti%es a""i/ed at by the p"ofession

15 Ao$ a"e inte"ested to st$dy the effe%ts ofmediation and "ela-ation on the pain

e-pe"ien%ed by %an%e" patients Hhat type of

/a"iable is painQ

a )ependent

b Co""elational

% Independent

d )emog"aphi%

18 Ao$ wo$ld lie to %ompa"e the s$ppo"t

system of patient with %h"oni% illness and those

with a%$te illness ?ow will yo$ best state yo$"

p"oblemQ

a # des%"ipti/e st$dy to %ompa"e the s$ppo"t

systems of patients with %h"oni% illness and

those with a%$te illness in te"ms of

demog"aphi% data and nowledge abo$t

inte"/ention

b !he effe%ts of the types of s$ppo"t system of

patients with %h"oni% illness and those witha%$te illness

% # %ompa"ati/e analysis of the s$ppo"t

system of patients with %h"oni% illness and

those with a%$te illness

d # st$dy to %ompa"e the s$ppo"t system of

patients with %h"oni% illness and those with

a%$te illness

e Hhat a"e the diffe"en%es of the s$ppo"t

system being "e%ei/ed by patient with

%h"oni% illness and patients with a%$te

illnessQ

1 Ao$ wo$ld lie to %ompa"e the s$ppo"t

system of patients with %h"oni% illness to those

with a%$te illness Conside"ing that the

hypothesis was: Clients with %h"oni% illness

ha/e lesse" s$ppo"t system than %lients with

a%$te illnessT Hhat type of "esea"%h is thisQ

a )es%"ipti/e b Co""elational& non e-pe"imental

% ,-pe"imental

d >$asi e-pe"imental

19 In any "esea"%h st$dy whe"e indi/id$al

pe"sons a"e in/ol/ed& it is impo"tant that an

info"med %onsent of the st$dy is obtained !he

following a"e essential info"mation abo$t the

%onsent that yo$ sho$ld dis%lose to the p"ospe%ti/e s$bEe%ts e-%ept:

a Consent to in%omplete dis%los$"e b )es%"iption of benefits& "iss& and

dis%omfo"ts

% ,-planation of p"o%ed$"e

d #ss$"an%e of anonymity and %onfidentiality

20 In the hypothesis: !he $tili(ation of

te%hnology in tea%hing imp"o/es the "etention

and attention of the n$"sing st$dents&T whi%h is

the dependent /a"iableQ

a Utili(ation of te%hnology

b Imp"o/ement in the "etention and attention% *$"sing st$dents

d !ea%hing

Sit0ati#$ 4 Ao$ a"e an a%ti/ely p"a%ti%ing n$"se

who has E$st finished yo$" g"ad$ate st$dies Ao$

lea"ned the /al$e of "esea"%h and wo$ld lie to

$tili(e the nowledge and sills gained in the

appli%ation of "esea"%h to the n$"sing se"/i%e !he

following 6$estions apply to "esea"%h

21 Hhi%h type of "esea"%h in6$i"y in/estigates

the iss$es of h$man %omple-ity eg

$nde"standing the h$man e-pe"tiseQ

a 'ogi%al position

b *at$"alisti% in6$i"y

% Positi/ism

d >$antitati/e esea"%h

22 Hhi%h of the following st$dies is based on

6$antitati/e "esea"%hQ

a # st$dy e-amining the be"ea/ement p"o%ess

in spo$ses of %lients with te"minal %an%e"

b # st$dy e-plo"ing fa%to"s infl$en%ing weight

%ont"ol beha/io"

% # st$dy meas$"ing the effe%ts of sleep

dep"i/ation on wo$nd healing

d # st$dy e-amining %lientKs feeling befo"e&

d$"ing and afte" a bone ma""ow aspi"ation

2+ Hhi%h of the following st$dies is based on

6$alitati/e "esea"%hQ




a # st$dy e-amining %lients "ea%tions to st"ess

afte" open hea"t s$"ge"y

b # st$dy meas$"ing n$t"ition and weight

lossGgain in %lients with %an%e"

% # st$dy e-amining o-ygen le/els afte"

endot"a%heal s$%tioning

d # st$dy meas$"ing diffe"en%es in blood p"ess$"e befo"e& d$"ing and afte" a p"o%ed$"e

2. #n yea" old %lient in a n$"sing home tells

a n$"se& I signed the pape"s fo" that "esea"%h

st$dy be%a$se the do%to" was so insistent and I

want him to %ontin$e taing %a"e of meT Hhi%h

%lient "ight is being /iolatedQ

a ight of self dete"mination b ight to p"i/a%y and %onfidentiality

% ight to f$ll dis%los$"e

d ight not to be ha"med

2 # s$pposition o" system of ideas that is

p"oposed to e-plain a gi/en phenomenonT& best

defines:

a # pa"adigm

b # %on%ept

% # theo"y

d # %on%ept$al f"amewo"

Sit0ati#$ 5 <aste"y of "esea"%h design

dete"mination is essential in passing the *',

25 <onette wants to now if the length of time

she will st$dy fo" the boa"d e-amination is p"opo"tional to he" boa"d "ating )$"ing the

)e%embe" 2008 boa"d e-amination& she st$died

fo" si- months and gained 5V On B$ne 200

boa"d e-am& she st$died fo" 5 months again fo" a

total of one yea" and gained 8.V On *o/embe"

200& she st$died fo" 5 months fo" a total of one

and a half yea" and gained 2V !he "esea"%h

design she $sed is:

a Compa"ati/e

b Co""elational

% ,-pe"imental

d >$alitati/e

28 od"igo was always eating high fat diet

Ao$ want to dete"mine if what will be the effe%t

of high %holeste"ol food to od"igo in the ne-t

10 yea"s Ao$ will $se:

a Compa"ati/e

b Co""elational

% ?isto"i%al

d 'ongit$dinal

2 Comm$nity # was sele%ted "andomly as

well as Comm$nity @& n$"se C"ystal %ond$%ted

tea%hing to Comm$nity # and assessed if

Comm$nity # will ha/e a bette" stat$s than

Comm$nity @ !his is an e-ample of:

a Compa"ati/e

b Co""elational

% ,-pe"imental

d >$alitati/e

29 Faye "esea"%hed in the de/elopment of a

new way to meas$"e intelligen%e by %"eating a

100=item 6$estionnai"e that will assess the%ogniti/e sills of an indi/id$al !he design best

s$ited fo" this st$dy is:

a ?isto"i%al

b <ethodologi%al

% S$"/ey

d Case st$dy

+0 Bay ,mman$elle is %ond$%ting a "esea"%hst$dy on how alph& an #I)S %lient li/es his

life # design s$ited fo" this is:

a ?isto"i%al

b Case st$dy

% Phenomenologi%al

d ,thnog"aphi%

+1 <ae%ee is to pe"fo"m a st$dy abo$t how

n$"ses pe"fo"m s$"gi%al asepsis d$"ing Ho"ld

Ha" II # design best fo" this st$dy is:

a ?isto"i%al

b Case st$dy

% Phenomenologi%ald ,thnog"aphi%

+2 <edel %ond$%ts sampling at @a"angay<aligaya ?e %olle%ted 100 "andom indi/id$als

and dete"mine who is thei" fa/o"ite a%to" 0V

said Piolo& 20V said Bohn 'loyd& while some

answe"ed Sam& )ingdong& i%ha"d& and )e"e

<edel %ond$%ted what type of "esea"%h st$dyQ

a Phenomenologi%al

b Case st$dy

% *on e-pe"imental

d S$"/ey

++ <a" and !obe"ts /isited a t"ibe lo%ated

somewhe"e in China& it is %alled Shin Bea t"ibe

!hey st$died the way of life& t"adition& and the

so%ietal st"$%t$"e of these people !hey will best

$se whi%h "esea"%h designQ

a ?isto"i%al b Case st$dy

% Phenomenologi%al

d ,thnog"aphi%

+. Be((a and Benny "esea"%hed abo$t !@ X its

t"ansmission& %a$sati/e agent and fa%to"s&

t"eatment& signs and symptoms& as well as

medi%ation and all othe" in=depth info"mation

abo$t t$be"%$losis !his st$dy is best s$ited fo"

whi%h "esea"%h designQ

a ?isto"i%al




b Case st$dy

% Phenomenologi%al

d ,thnog"aphi%

&'#)iana& #"lene& and Sally a"e to %ond$%t a

st$dy abo$t "elationship of the n$mbe" of family

membe"s in the ho$sehold and the ele%t"i%ity

bill& whi%h of the following is the best "esea"%hdesign s$ited fo" this st$dyQ

1 )es%"ipti/e

2 ,-plo"ato"y

+ ,-planato"y

. Co""elational

Compa"ati/e5 ,-pe"imental

a 1 and .

b 2 and

% + and 5d 1 and

e 2 and .

Sit0ati#$ ; #s a n$"se "esea"%he"& 7in( m$st ha/e

a /e"y good $nde"standing of the %ommon te"ms of

%on%ept $sed in "esea"%h

+5 !he info"mation that an in/estigato" lie

7in( %olle%ts f"om the s$bEe%ts o" pa"ti%ipants in

a "esea"%h st$dy is $s$ally %alled:

a ?ypothesis b )ata% 7a"iable

d Con%ept

+8 Hhi%h of the following $s$ally "efe"s to the

independent /a"iables in doing "esea"%hQ

a es$lt

b Ca$se

% O$tp$t

d ,ffe%t

+ !he "e%ipients of e-pe"imental t"eatment in

an e-pe"imental design o" the indi/id$als to be

obse"/ed in a non=e-pe"imental design a"e

%alled:

a Setting

b S$bEe%ts

% !"eatment

d Sample

+9 !he de/i%e o" te%hni6$es that 7in( employs

to %olle%t data is %alled:

a Sample

b Inst"$ment

% ?ypothesis

d Con%ept

.0 !he $se of anothe" pe"sonKs ideas o"

wo"dings witho$t gi/ing app"op"iate %"edit

"es$lts f"om ina%%$"ate o" in%omplete att"ib$tion

of mate"ials to its "eso$"%es Hhi%h of the

following is "efe""ed to when anothe" pe"sonKs

idea is inapp"op"iately %"edited as oneKs ownQ

a Plagia"ism

b >$otation% #ss$mption

d Pa"aph"ase

COMPREHENSIVE EXAMINATION Part 1

1 # woman in a %hild bea"ing age "e%ei/es a "$bella /a%%ination *$"se Boy wo$ld gi/e he" whi%h of the

following inst"$%tionsQ

Suggested Answer ey

C @ ) ) @

@ # @ # )@ @ @ ) #

# , # # @

@ C # # C@ ) C @ C

# ) ) @ )

@ @ @ @ #




a ef"ain f"om eating eggs o" egg p"od$%ts fo" 2. ho$"s

b #/oid ha/ing se-$al inte"%o$"se

% )onKt get p"egnant at least + months

d #/oid e-pos$"e to s$n

2 Bonas who is diagnosed with en%ephalitis is $nde" the t"eatment of <annitol Hhi%h of the following

patient o$t%omes indi%ate to *$"se onald that the t"eatment of <annitol has been effe%ti/e fo" a patient

that has in%"eased int"a%"anial p"ess$"eQ

a In%"eased $"ina"y o$tp$t b )e%"eased

% Slowed papilla"y "esponse

d )e%"eased le/el of %ons%io$sness

+ <a"y ased *$"se <a$"een abo$t the in%$bation pe"iod of "abies Hhi%h statement by the *$"se

<a$"een is app"op"iateQ

a In%$bation pe"iod is 5 months

b In%$bation pe"iod is 1 wee

% In%$bation pe"iod is 1 month

d In%$bation pe"iod /a"ies depending on the site of the bite. Hhi%h of the following sho$ld *$"se Che""y do fi"st in taing %a"e of a male %lient with "abiesQ

a ,n%o$"age the patient to tae a bath

b Co/e" I7 bottle with b"own pape" bag% Pla%e the patient nea" the %omfo"t "oom

d Pla%e the patient nea" the doo"

Hhi%h of the following is the s%"eening test fo" deng$e hemo""hagi% fe/e"Q

a Complete blood %o$nt

b ,'IS#

% $mpel=leeds test

d Sedimentation "ate

5 <" )ela osa is s$spe%ted to ha/e mala"ia afte" a b$siness t"ip in Palawan !he most impo"tant

diagnosti% test in mala"ia is:

a H@C %o$nt

b U"inalysis

% ,'IS#d Pe"iphe"al blood smea"

8 !he *$"se s$pe"/iso" is planning fo" patientKs assignment fo" the #< shift !he n$"se s$pe"/iso"

a/oids assigning whi%h of the following staff membe"s to a %lient with he"pes (oste"Qa *$"se who ne/e" had %hi%en po-

b *$"se who ne/e" had "oseola

% *$"se who ne/e" had ge"man measles

d *$"se who ne/e" had m$mps

Cla"issa is 8 wees p"egnant F$"the" e-amination "e/ealed that she is s$s%eptible to "$bella Hhen

wo$ld be the most app"op"iate fo" he" to "e%ei/e "$bella imm$ni(ationQ

a #t on%e

b )$"ing 2nd t"imeste"

% )$"ing +"d t"imeste"

d #fte" the deli/e"y of the baby

9 # female %hild with "$bella sho$ld be isolated f"om a:

a 21 yea" old male %o$sin li/ing in the same ho$se

b 1 yea" old siste" who "e%ently got ma""ied

% 11 yea" old siste" who had "$beola d$"ing %hildhood

d . yea" old gi"l who li/es ne-t doo"

10 Hhat is the p"ima"y p"e/ention of lep"osyQ

a *$t"ition

b 7itamins% @CD /a%%ination

d )P! /a%%ination

11 # ba%te"ia whi%h %a$ses diphthe"ia is also nown asQ

a #moeba

b Chole"a

% lebs=loeffle" ba%ill$s

d Spi"o%hete

12 *$"se on pe"fo"med manto$- sin test today <onday to a male ad$lt %lient Hhi%h statement by

the %lient indi%ates that he $nde"stood the inst"$%tion wellQ

a I will %ome ba% late"

b I will %ome ba% ne-t month

% I will %ome ba% on F"iday




d I will %ome ba% on Hednesday& same time& to "ead the "es$lt

1+ # male %lient had $nde"gone <anto$- sin test *$"se onald notes an mm a"ea of ind$"ations at

the site of the sin test !he n$"se inte"p"ets the "es$lt as:

a *egati/e

b Un%e"tain and needs to be "epeated

% Positi/e

d In%on%l$si/e

1. !ony will sta"t a 5 month the"apy with Isonia(id I*? *$"se !"ish plans to tea%h the %lient to:a Use al%ohol mode"ately

b #/oid /itamin s$pplements while o the"apy

% In%omplete intae of dai"y p"od$%ts

d <ay be dis%ontin$ed if symptoms s$bsides

1 Hhi%h is the p"ima"y %ha"a%te"isti% lesion of syphilisQ

a So"e eyes

b So"e th"oat

% Chan%"oid

d Chan%"e15 Hhat is the fast b"eathing of Bana who is + wees oldQ

a 50 b"eaths pe" min$te

b .0 b"eaths pe" min$te% 10 b"eaths pe" min$te

d 20 b"eaths pe" min$te

18 Hhi%h of the following signs and symptoms indi%ate some dehyd"ationQ

a )"ins eage"ly

b estless and i""itable

% Un%ons%io$s

d # and @

1 Hhat is the fi"st line fo" dysente"yQ

a #mo-i%illin

b !et"a%y%line

% Cefale-in

d Co=t"imo-a(ole19 In home made o"esol& what is the "atio of salt and s$ga" if yo$ want to p"epa"e with 1 lite" of wate"Q

a 1 tbsp salt and tbsp s$ga"

b 1 tbsp salt and tsp s$ga" % 1 tsp salt and tsp s$ga"

d tsp salt and tsp s$ga"

20 Dentian 7iolet is $sed fo":

a Ho$nd

b Umbili%al infe%tions

% ,a" infe%tions

d @$"n

21 Hhi%h of the following is a li/e atten$ated ba%te"ial /a%%ineQ

a @CD

b OP7

% <easles

d *one of the abo/e

22 ,PI is based onQ

a @asi% health se"/i%es

b S%ope of %omm$nity affe%ted

% ,pidemiologi%al sit$ation

d esea"%h st$dies

2+ !!+ p"o/ides how many pe"%entage of p"ote%tion against tetan$sQa 100

b 99

% 0

d 90

2. !empe"at$"e of "ef"ige"ato" to maintain poten%y of measles and OP7 /a%%ine is:

a =2 0C to = 0C

b =1 0C to =2 0C

% 1 0C to 2 0C

d 2 0C to 0C

2 )ipthe"ia /a%%ine is a:

a @a%te"ial to-in

b illed ba%te"ia




% 'i/e atten$ated

d Plasma de"i/ati/es

25 @$dgeting is $nde" in whi%h pa"t of management p"o%essQ

a )i"e%ting

b Cont"olling

% O"gani(ing

d Planning

28 !ime table showing planned wo" days and shifts of n$"sing pe"sonnel is:a Staffing

b S%hed$le

% S%hed$ling

d Planning

2 # fo"%e within an indi/id$al that infl$en%es the st"ength of beha/io"Q

a <oti/ation

b ,n/y

% ewa"d

d Self=esteem29 !o be the leading hospital in the PhilippinesT is best ill$st"ate in:

a <ission

b Philosophy% 7ision

d ObEe%ti/e

+0 It is the p"ofessionally desi"ed no"ms against whi%h a staff pe"fo"man%e will be %ompa"edQ

a Bob des%"iptions

b S$"/ey

% Flow %ha"t

d Standa"ds

+1 ep"imanding a staff n$"se fo" wo" that is done in%o""e%tly is an e-ample of what type of

"einfo"%ementQ

a Feedba%

b Positi/e "einfo"%ement

% Pe"fo"man%e app"aisald *egati/e "einfo"%ement

+2 >$estions that a"e answe"able only by %hoosing an option f"om a set of gi/en alte"nati/es a"e nown

asQa S$"/ey

b Close ended

% >$estionnai"e

d )emog"aphi%

++ # "esea"%he" that maes a gene"ali(ation based on obse"/ations of an indi/id$alKs beha/io" is said to

be whi%h type of "easoning:

a Ind$%ti/e

b 'ogi%al

% Illogi%al

d )ed$%ti/e

+. !he balan%e of a "esea"%hKs benefit /s its "iss to the s$bEe%t is:

a #nalysis

b is=benefit "atio

% Pe"%entile

d <a-im$m "is

+ #n indi/id$alGobEe%t that belongs to a gene"al pop$lation is aGan:

a ,lement

b S$bEe%t% espondent

d #$tho"

+5 #n ill$st"ation that shows how the membe"s of an o"gani(ation a"e %onne%ted:

a Flow%ha"t

b @a" g"aph

% O"gani(ational %ha"t

d 'ine g"aph

+8 !he fi"st %ollege of n$"sing that was established in the Philippines is:

a Fatima Uni/e"sity

b Fa" ,aste"n Uni/e"sity

% Uni/e"sity of the ,ast

d Uni/e"sity of Sto !omas




+ Flo"en%e nightingale is bo"n on:

a F"an%e

b @"itain

% US

d Italy

+9 ObEe%ti/e data is also %alled:

a Co/e"t

b O/e"t% Infe"en%e

d ,/al$ation

.0 #n e-ample of s$bEe%ti/e data is:

a Si(e of wo$nds

b 7S

% 'etha"gy

d !he statement of patient <y hand is painf$lT

.1 Hhat is the best position in palpating the b"eastQ

a !"endelenb$"g b Side lying

% S$pine

d 'ithotomy.2 Hhen is the best time in pe"fo"ming b"east self e-aminationQ

a 8 days afte" menst"$al pe"iod

b 8 days befo"e menst"$al pe"iod

% days afte" menst"$al pe"iod

d days befo"e menst"$al pe"iod

.+ Hhi%h of the following sho$ld be gi/en the highest p"io"ity befo"e pe"fo"ming physi%al e-amination

to a patientQ

a P"epa"ation of the "oom

b P"epa"ation of the patient

% P"epa"ation of the n$"se

d P"epa"ation of en/i"onment

.. It is a flip o/e" %a"d $s$ally ept in po"table file at n$"sing stationa *$"sing %a"e plan

b <edi%ine and t"eatment "e%o"d

% a"de-d !P sheet

. Bose has $nde"gone tho"a%entesis !he n$"se in %ha"ge is awa"e that the best position fo" Bose is:

a Semi fowle"s

b 'ow fowle"s

% Side lying& $naffe%ted side

d Side lying& affe%ted side

.5 !he deg"ee of patients abdominal distension may be dete"mined by:

a #$s%$ltation

b Palpation

% Inspe%tion

d Pe"%$ssion

.8 # male %lient is addi%ted with hall$%inogen Hhi%h physiologi% effe%t sho$ld the n$"se e-pe%tQ

a @"adyp"ea

b @"ady%a"dia

% Const"i%ted p$pils

d )ilated p$pils

. !"istan a . yea" old boy has s$ffe"ed f"om f$ll thi%ness b$"ns of the fa%e& %hest and ne% Hhat will

be the p"io"ity n$"sing diagnosisQa Ineffe%ti/e ai"way %lea"an%e "elated to edema

b Impai"ed mobility "elated to pain

% Impai"ed $"ina"y elimination "elated to fl$id loss

d is fo" infe%tion "elated to epide"mal dis"$ption

.9 In assessing a %lientKs in%ision 1 day afte" the s$"ge"y& *$"se @etty e-pe%t to see whi%h of the

following as signs of a lo%al inflammato"y "esponseQ

a D"eenish dis%ha"ge

b @"own e-$dates at in%ision edges

% Pallo" a"o$nd s$t$"es

d edness and wa"mth

0 *$"se onald is awa"e that the amioti% fl$id in the thi"d t"imeste" weighs app"o-imately:

a 2 ilog"ams






b F"e6$ent inte"nal e-amination I,

% CS

d Ute"ine atomy

5+ On 2nd postpa"t$m day& whi%h height wo$ld yo$ e-pe%t to find the f$nd$s in a woman who has had a

%aesa"ian bi"thQ

a 1 finge" abo/e $mbili%$s

b 2 finge"s abo/e $mbili%$s

% 2 finge"s below $mbili%$sd 1 finge" below $mbili%$s

5. Hhi%h of the following %"ite"ia allows *$"se "is to pe"fo"m home deli/e"iesQ

a *o"mal findings d$"ing assessment

b P"e/io$s CS

% )iabetes histo"y

d ?ype"tensi/e histo"y

5 *$"se Ca"la is awa"e that one of the following /a%%ines is done by int"am$s%$la" I< inEe%tionQ

a <easles

b OP7% @CD

d !etan$s to-oid

55 #sin law is on whi%h legal basis:a # 50

b # 2888

% I 182

d 5510

58 *$"se Bohn is awa"e that the he"bal medi%ine app"op"iate fo" $"olithiasis is:

a #ap$l%o

b Sambong

% !saang g$bat

d @ayabas

5 Comm$nityGP$bli% health bag is defined as:

a #n essential and indispensable e6$ipment of the %omm$nity health n$"se d$"ing home /isit

b It %ontains d"$gs and e6$ipment $sed by the %omm$nity health n$"se% Is a "e6$i"ement in the health %ente" and fo" home /isit

d It is a tool $sed by the %omm$nity health n$"se in "ende"ing effe%ti/e p"o%ed$"es d$"ing home

/isit59 !!. p"o/ides how many pe"%entage of p"ote%tion against tetan$sQ

a 80

b 0

% 90

d 99

80 !hi"d postpa"t$m /isit m$st be done by p$bli% health n$"se:

a Hithin 2. ho$"s afte" deli/e"y

b #fte" 2=. wees

% Hithin 1 wee

d #fte" 2 months

81 *$"se Candy is awa"e that the family planning method that may gi/e 9V p"ote%tion to anothe"

p"egnan%y to women

a Pills

b !$bal ligation

% 'a%tational #meno""hea method '#<

d IU)

82 Hhi%h of the following is not a pa"t of I<CI %ase management p"o%ess

a Co$nsel the mothe" b Identify the illness

% #ssess the %hild

d !"eat the %hild

8+ If a yo$ng %hild has pne$monia when sho$ld the mothe" b"ing him ba% fo" follow $pQ

a #fte" 2 days

b In the afte"noon

% #fte" . days

d #fte" days

8. It is the %e"tifi%ation "e%ognition p"og"am that de/elop and p"omotes standa"d fo" health fa%ilities:

a Fo"m$la

b !$to gam$tan

% Sent"ong p"og"am mo/ement




d Sent"ong sigla mo/ement

8 @aby <a"ie was bo"n <ay 2+& 19. *$"se Bohn will e-pe%t finge" th$mb opposition on:

a #p"il 19

b Feb"$a"y 19

% <a"%h 19

d B$ne 19

85 @aby eese is a 12 month old %hild *$"se Oli/e" wo$ld anti%ipate how many teethQ

a 9 b 8

%

d 5

88 Hhi%h of the following is the p"ima"y antidote fo" !ylenol poisoningQ

a *a"%an

b )igo-in

% #%etyl%ysteine

d Fl$ma(enil

8 # male %hild has an intelligen%e 6$otient of app"o-imately .0 Hhi%h ind of en/i"onment andinte"dis%iplina"y p"og"am most liely to benefit this %hild wo$ld be best des%"ibed as:

a ?abit t"aining

b Shelte"ed wo"shop% C$stodial

d ,d$%ational

89 *$"se B$dy is awa"e that following %ondition wo$ld "efle%t p"esen%e of %ongenital DI anomalyQ

a Co"d p"olapse

b Polyhyd"amios

% Pla%enta p"e/ia

d Oligohyd"amios

0 *$"se Ch"istine p"o/ides health tea%hing fo" the pa"ents of a %hild diagnosed with %elia% disease

*$"se Ch"istine tea%hes the pa"ents to in%l$de whi%h of the following food items in the %hildKs diet:

a ye toast

b Oatmeal

% Hhite b"eadd i%e

1 *$"se andy is planning to administe" o"al medi%ation to a + yea" old %hild *$"se andy is awa"e

that the best way to p"o%eed is by:a Ho$ld yo$ lie to d"in yo$" medi%ineQT

b If yo$ tae yo$" medi%ine now& IKll gi/e yo$ lollipopT

% See the othe" boy too his medi%ineQ *ow itKs yo$" t$"nT

d ?e"eKs yo$" medi%ine Ho$ld yo$ lie a mango o" o"ange E$i%eQT

2 #t what age a %hild %an b"$sh he" teeth witho$t helpQ

a 5 yea"s

b 8 yea"s

% yea"s

d yea"s

+ ibi/a"in 7i"a(ole is p"es%"ibed fo" a female hospitali(ed %hild with S7 *$"se B$dy p"epa"e this

medi%ation /ia whi%h "o$teQ

a Int"a /eno$s

b O"al

% O-ygen tent

d S$b%$taneo$s

. !he p"esent %hai"man of the @oa"d of *$"sing in the Philippines is:

a <a"ia Boanna Ce"/antes

b Ca"men%ita #ba6$in% 'eono" ose"o

d P"imiti/a Pa6$i%

!he obligation to maintain effi%ient ethi%al standa"ds in the p"a%ti%e of n$"sing belong to this body:

a @O*

b #*S#P

% P*#

d *

5 # male n$"se was fo$nd g$ilty of negligen%e ?is li%ense was "e/oed e=iss$an%e of "e/oed

%e"tifi%ates is afte" how many yea"sQ

a 1 yea"

b 2 yea"s

% + yea"s




d . yea"s

8 Hhi%h of the following info"mation %annot be seen in the PC identifi%ation %a"dQ

a egist"ation )ate

b 'i%ense *$mbe"

% )ate of #ppli%ation

d Signat$"e of PC %hai"pe"son

@"eastfeeding is being enfo"%ed by mil %ode o":

a ,O 1 b # 8500

% # 5800

d P) 995

9 Self go/e"nan%e& ability to %hoose o" %a""y o$t de%ision witho$t $nd$e p"ess$"e o" %oe"%ion f"om

anyone:

a 7e"a%ity

b #$tonomy

% Fidelity

d @enefi%en%e90 # male patient %omplained be%a$se his s%hed$led s$"ge"y was %an%elled be%a$se of ea"th6$ae !he

hospital pe"sonnel may be e-%$sed be%a$se of:

a Do/e"nan%e b espondent s$pe"io"

% Fo"%e maEe$"e

d es ipsa lo6$ito"

91 @eing on time& meeting deadlines and %ompleting all s%hed$led d$ties is what /i"t$eQ

a Fidelity

b #$tonomy

% 7e"a%ity

d Confidentiality

92 !his 6$ality is being demonst"ated by *$"se on who "aises the side "ails of a %onf$sed and

diso"iented patientQ

a esponsibility

b eso$"%ef$lness% #$tonomy

d P"$den%e

9+ Hhi%h of the following is fo"mal %ontin$ing ed$%ationQa Confe"en%e

b ,n"ollment in g"ad$ate s%hool

% ef"eshe" %o$"se

d Semina"

9. !he @S* %$""i%$l$m p"epa"es the g"ad$ates to be%omeQ

a *$"se gene"alist

b *$"se spe%ialist

% P"ima"y health n$"se

d Clini%al inst"$%to"

9 )isposal of medi%al "e%o"ds in go/e"nment hospitalGinstit$tions m$st be done in %lose %oo"dination

with what agen%yQ

a )epa"tment of ?ealth

b e%o"ds <anagement #"%hi/es Offi%e

% <et"o <anila )e/elopment #$tho"ity

d @$"ea$ of Inte"nal e/en$e

95 *$"se Bolina m$st see to it that the w"itten %onsent of mentally ill patients m$st be taen f"om:

a *$"se

b P"iest% Family lawye"

d Pa"entsGlegal g$a"dians

98 Hhen *$"se Cla"en%e "espe%ts the %lientKs self=dis%los$"e& this is a ga$ge fo" the n$"sesK

a espe%tf$lness

b 'oyalty

% !"$stwo"thiness

d P"ofessionalism

9 !he *$"se is awa"e that the following tass %an be safely delegated by the n$"se to a non=n$"se health

wo"e" e-%ept:

a !aing /ital signs

b Change I7 inf$sions

% !"ansfe""ing the %lient f"om bed to %hai"




d I""igation of *D!

99 )$"ing the e/ening "o$nd *$"se !ina saw <" !o"alba meditating and afte"wa"ds sta"ted singing

p"aye"f$l hymns Hhat wo$ld be the best "esponse of *$"se !inaQ

a Call the attention of the %lient and en%o$"age to sleep

b epo"t the in%iden%e to head n$"se

% espe%t the %lientKs a%tion

d )o%$ment the sit$ation

100 In %a"ing fo" a dying %lient& yo$ sho$ld pe"fo"m whi%h of the following a%ti/itiesa )o not "es$s%itate

b #ssist %lient to pe"fo"m #)'

% ,n%o$"age to e-e"%ise

d #ssist %lient towa"ds a pea%ef$l death

101 !he *$"se is awa"e that the ability to ente" into the life of anothe" pe"son and pe"%ei/e his %$""ent

feelings and thei" meaning is nown:

a @elongingness

b Den$ineness

% ,mpathyd espe%t

102 !he te"mination phase of the *P is best des%"ibed one of the following:

a e/iew p"og"ess of the"apy and attainment of goals b ,-plo"ing the %lientKs tho$ghts& feelings and %on%e"ns

% Identifying and sol/ing patients p"oblem

d ,stablishing "appo"t

10+ )$"ing the p"o%ess of %o%aine withd"awal& the physi%ian o"de"s whi%h of the following:

a ?alope"idol ?aldol

b Imip"amine !of"anil

% @en(t"opine Cogentin

d )ia(epam 7ali$m

10. !he n$"se is awa"e that %o%aine is %lassified as:

a ?all$%inogen

b Psy%ho stim$lant

% #n-iolyti%d *a"%oti%

10 In %omm$nity health n$"sing& it is the most impo"tant "is fa%to" in the de/elopment of mental

illnessQa Sepa"ation of pa"ents

b Politi%al p"oblems

% Po/e"ty

d Se-$al ab$se

105 #ll of the following a"e %ha"a%te"isti%s of %"isis e-%ept

a !he %lient may be%ome "esisti/e and a%ti/e in stopping the %"isis

b It is self=limiting fo" .=5 wees

% It is $ni6$e in e/e"y indi/id$al

d It may also affe%t the family of the %lient

108 F"e$d states that tempe" tant"$ms is obse"/ed in whi%h of the following:

a O"al

b #nal

% Phalli%

d 'aten%y

10 !he n$"se is awa"e that ego de/elopment begins d$"ing:

a !oddle" pe"iod

b P"es%hool age

% S%hool aged Infan%y

109 Sit$ation: # 19 yea" old n$"sing st$dent has lost +5 lbs fo" . wees ?e" pa"ents b"o$ght he" to the

hospital fo" medi%al e/al$ation !he diagnosis was #*O,;I# *,7OS# !he P"ima"y gain of a %lient

with ano"e-ia ne"/osa is:

a Height loss

b Height gain

% ed$%e an-iety

d #tt"a%ti/e appea"an%e

110 !he n$"se is awa"e that the p"ima"y n$"sing diagnosis fo" the %lient is:

a #lte"ed n$t"ition : less than body "e6$i"ement

b #lte"ed n$t"ition : mo"e than body "e6$i"ement

% Impai"ed tiss$e integ"ity




d is fo" maln$t"ition

111 #fte" 1. days in the hospital& whi%h finding indi%ates that he" %ondition in imp"o/ingQ

a She tells the n$"se that she had no idea that she is thin

b She a""i/es ea"lie" than s%hed$led time of g"o$p the"apy

% She tells the n$"se that she eat + times o" mo"e in a day

d She gained . lbs in two wees

112 !he n$"se is awa"e that ata"a%ti%s o" psy%hi% ene"gi(e"s a"e also nown as:

a #nti mani% b #nti dep"essants

% #ntipsy%hoti%s

d #nti an-iety

11+ nown as mood ele/ato"s:

a #nti dep"essants

b #ntipsy%hoti%s

% #nti mani%

d #nti an-iety

11. !he p"io"ity of %a"e fo" a %lient with #l(heime"Ks disease isa ?elp %lient de/elop %oping me%hanism

b ,n%o$"age to lea"n new hobbies and inte"est

% P"o/ide him stim$lating en/i"onmentd Simplify the en/i"onment to eliminate the need to mae %ho"es

11 #$tism is diagnosed at:

a Infan%y

b + yea"s old

% yea"s old

d S%hool age

115 !he %ommon %ha"a%te"isti% of a$tism %hild is:

a Imp$lsiti/ity

b Self dest"$%ti/eness

% ?ostility

d Hithd"awal

118 !he n$"se is awa"e that the most %ommon indi%ation in $sing ,C! is:a S%hi(oph"enia

b @ipola"

% #no"e-ia *e"/osad )ep"ession

11 # the"apy that fo%$ses on he"e and now p"in%iple to p"omote self=a%%eptan%eQ

a Destalt the"apy

b Cogniti/e the"apy

% @eha/io" the"apy

d Pe"sonality the"apy

119 # %lient has many i""ational tho$ghts !he goal of the"apy is to %hange he":

a Pe"sonality

b Comm$ni%ation

% @eha/io"

d Cognition

120 !he app"op"iate n$t"ition fo" @ipola" I diso"de"& in mani% phase is:

a 'ow fat& low sodi$m

b 'ow %alo"ie& high fat

% Finge" foods& high in %alo"ie

d Small f"e6$ent feedings

121 Hhi%h of the following a%ti/ity wo$ld be best fo" a dep"essed %lientQ

a Chess b @asetball

% Swimming

d Finge" painting

122 !he n$"se is awa"e that %lients with se/e"e dep"ession& possess whi%h defense me%hanism:

a Int"oEe%tion

b S$pp"ession

% ep"ession

d P"oEe%tion

12+ *$"se Bohn is awa"e that self m$tilation among @ipola" diso"de" patients is a means of:

a O/e"%oming fea" of fail$"e

b O/e"%oming feeling of inse%$"ity

% elie/ing dep"ession




d elie/ing an-iety

12. Hhi%h of the following may %a$se an in%"ease in the %ystitis symptomsQ

a Hate"

b O"ange E$i%e

% Coffee

d <ango E$i%e

12 In %a"ing fo" %lients with "enal %al%$li& whi%h is the p"io"ity n$"sing inte"/entionQ

a e%o"d /ital signs b St"ain $"ine

% 'imit fl$ids

d #dministe" analgesi%s as p"es%"ibed

125 In patient with "enal fail$"e& the diet sho$ld be:

a 'ow p"otein& low sodi$m& low potassi$m

b 'ow p"otein& high potassi$m

% ?igh %a"bohyd"ate& low p"otein

d ?igh %al%i$m& high p"otein

128 Hhi%h of the following %annot be %o""e%ted by dialysisQa ?ype"nat"emia

b ?ype"alemia

% ,le/ated %"eatinined )e%"eased hemoglobin

12 !ony with infe%tion is "e%ei/ing antibioti% the"apy 'ate" the %lient %omplaints of "inging in the ea"s

!his ototo-i%ity is damage to:

a .th C*

b th C*

% 8th C*

d 9th C*

129 *$"se ,mma p"o/ides tea%hing to a patient with "e%$""ent $"ina"y t"a%t infe%tion in%l$des the

following:

a In%"ease intae of tea& %offee and %olas

b 7oid e/e"y 5 ho$"s pe" day

% 7oid immediately afte" inte"%o$"sed !ae t$b bath e/e"yday

1+0 Hhi%h assessment finding indi%ates %i"%$lato"y %onst"i%tion in a male %lient with a newly applied

long leg %astQa @lan%hing o" %yanosis of legs

b Complaints of p"ess$"e o" tightness

% Inability to mo/e toes

d *$mbness of toes

1+1 )$"ing a%$te go$t atta%& the n$"se administe" whi%h of the following d"$g:

a P"ednisone )eltasone

b Col%hi%ines

% #spi"in

d #llop$"inol Jylop"im

1+2 Info"mation in the patients %ha"t is inadmissible in %o$"t as e/iden%e when:

a !he %lient obEe%ts to its $se

b ?andw"iting is not legible

% It has too many $noffi%ial abb"e/iations

d !he %lients pa"ents "ef$ses to $se it

1++ *$"se a"en is "e/ising a %lient plan of %a"e )$"ing whi%h step of the n$"sing p"o%ess does s$%h

"e/ision tae pla%eQ

a Planning

b Implementation% )iagnosing

d ,/al$ation

1+. Hhen e-amining a %lient with abdominal pain& *$"se ?a(el sho$ld assess:

a Symptomati% 6$ad"ant eithe" se%ond o" fi"st

b !he symptomati% 6$ad"ant last

% !he symptomati% 6$ad"ant fi"st

d #ny 6$ad"ant

1+ ?ow long will n$"se Bohn obtain an a%%$"ate "eading of tempe"at$"e /ia o"al "o$teQ

a + min$tes

b 1 min$te

% min$tes

d 1 min$tes




1+5 !he one filing the %"iminal %a"e against an a%%$sed pa"ty is said to be theQ

a D$ilty

b #%%$sed

% Plaintiff

d Hitness

1+8 # male %lient has a standing )* o"de" ?e then s$ddenly stopped b"eathing and yo$ a"e at his

bedside Ao$ wo$ld:

a Call the physi%ian b Stay with the %lient and do nothing

% Call anothe" n$"se

d Call the family

1+ !he #*# "e%ogni(ed n$"sing info"mati%s he"alding its establishment as a new field in n$"sing

d$"ing what yea"Q

a 199.

b 1992

% 2000

d 20011+9 Hhen is the fi"st %e"tifi%ation of n$"sing info"mati%s gi/enQ

a 1990=199+

b 2001=2002% 199.=1995

d 200=200

1.0 !he n$"se is assessing a female %lient with possible diagnosis of osteoa"th"itis !he most signifi%ant

"is fa%to" fo" osteoa"th"itis is:

a Obesity

b a%e

% Bob

d #ge

1.1 # male %lient %omplains of /e"tigo *$"se @ea anti%ipates that the %lient may ha/e a p"oblem with

whi%h po"tion of the ea"Q

a !ympani% memb"anes

b Inne" ea" % #$"i%le

d ,-te"nal ea"

1.2 Hhen pe"fo"ming Hebe"Ks test& *$"se osean e-pe%ts that this %lient will hea" a On $naffe%ted side

b 'onge" th"o$gh bone than ai" %ond$%tion

% On affe%ted side by bone %ond$%tion

d @y neithe" bone o" ai" %ond$%tion

1.+ !oy with a tentati/e diagnosis of myasthenia g"a/is is admitted fo" diagnosti% mae $p <yasthenia

g"a/is %an %onfi"med by:

a e"nigKs sign

b @"$d(insiKs sign

% # positi/e sweat %hlo"ide test

d # positi/e ed"ophoni$m !ensilon test

1.. # male %lient is hospitali(ed with D$illain=@a""e Synd"ome Hhi%h assessment finding is the most

signifi%antQ

a ,/en& $nlabo"ed "espi"ations

b Soft& non distended abdomen

% U"ine o$tp$t of 0 mlGh"

d Ha"m sin

1. Fo" a female %lient with s$spe%ted int"a%"anial p"ess$"e ICP& a most app"op"iate "espi"ato"y goal is:

a <aintain pa"tial p"ess$"e of a"te"ial o-ygen Pa O2 abo/e 0mm?g b P"omote elimination of %a"bon dio-ide

% 'owe" the P?

d P"e/ent "espi"ato"y alalosis

1.5 Hhi%h n$"sing assessment wo$ld identify the ea"liest sign of ICPQ

a Change in le/el of %ons%io$sness

b !empe"at$"e of o/e" 10+RF

% Hidening p$lse p"ess$"e

d Une6$al p$pils

1.8 !he g"eatest dange" of an $n%o""e%ted at"ial fib"illation fo" a male patient will be whi%h of the

following:

a P$lmona"y embolism

b Ca"dia% a""est




% !h"omb$s fo"mation

d <yo%a"dial infa"%tion

1. 'inda& # +0 yea" old post hyste"e%tomy %lient has /isited the health %ente" She in6$i"ed abo$t @S,

and ased the n$"se when @S, sho$ld be pe"fo"med Ao$ answe"ed that the @S, is best pe"fo"med:

a 8 days afte" menst"$ation

b #t the same day ea%h month

% )$"ing menst"$ation

d @efo"e menst"$ation1.9 #n infant is o"de"ed to "e%i/e 00 ml of )*SS fo" 2. ho$"s !he Int"a/eno$s d"ip is "$nning at 50

gttsGmin ?ow many d"ops pe" min$te sho$ld the flow "ate beQ

a 50 gttsGmin

b 21 gttsGmin

% +0 gttsGmin

d 1 gttsGmin

10 <" D$tie""e( is to "e%ei/e 1 lite" of )' to "$n fo" 12 ho$"s !he d"op fa%to" of the I7 inf$sion set

is 10 d"ops pe" min$te #pp"o-imately how many d"ops pe" min$tes sho$ld the I7 be "eg$latedQ

a 1+=1. d"ops b 18=1 d"ops

% 10=12 d"ops

d 1=15 d"ops

A$s-!r &!

COMPRENSIVE EXAMINATION Part 2




1 # .+=yea"=old #f"i%an #me"i%an male is admitted with si%le %ell anemia !he n$"se plans to assess

%i"%$lation in the lowe" e-t"emities e/e"y 2 ho$"s Hhi%h of the following o$t%ome %"ite"ia wo$ld the n$"se

$seQ

#@ody tempe"at$"e of 99RF o" less

@!oes mo/ed in a%ti/e "ange of motion

CSensation "epo"ted when soles of feet a"e to$%hed

)Capilla"y "efill of + se%onds

2 # +0=yea"=old male f"om ?aiti is b"o$ght to the eme"gen%y depa"tment in si%le %ell %"isis Hhat is the best position fo" this %lientQ

#Side=lying with nees fle-ed

@nee=%hest

C?igh Fowle"s with nees fle-ed

)Semi=Fowle"s with legs e-tended on the bed

+ # 2=yea"=old male is admitted in si%le %ell %"isis Hhi%h of the following inte"/entions wo$ld be of

highest p"io"ity fo" this %lientQ

#!aing ho$"ly blood p"ess$"es with me%hani%al %$ff

@,n%o$"aging fl$id intae of at least 200m' pe" ho$" CPosition in high Fowle"s with nee gat%h "aised

)#dministe"ing !ylenol as o"de"ed

. Hhi%h of the following foods wo$ld the n$"se en%o$"age the %lient in si%le %ell %"isis to eatQ#Pea%hes

@Cottage %heese

CPopsi%le

)'ima beans

# newly admitted %lient has si%le %ell %"isis !he n$"se is planning %a"e based on assessment of the

%lient !he %lient is %omplaining of se/e"e pain in his feet and hands !he p$lse o-imet"y is 92 Hhi%h of the

following inte"/entions wo$ld be implemented fi"stQ #ss$me that the"e a"e o"de"s fo" ea%h inte"/ention

##dE$st the "oom tempe"at$"e

@Di/e a bol$s of I7 fl$ids

CSta"t O2

)#dministe" mepe"idine )eme"ol 8mg I7 p$sh

5 !he n$"se is inst"$%ting a %lient with i"on=defi%ien%y anemia Hhi%h of the following meal plans wo$ldthe n$"se e-pe%t the %lient to sele%tQ

#oast beef& gelatin salad& g"een beans& and pea%h pie

@Chi%en salad sandwi%h& %oleslaw& F"en%h f"ies& i%e %"eam

C,gg salad on wheat b"ead& %a""ot sti%s& lett$%e salad& "aisin pie

)Po" %hop& %"eamed potatoes& %o"n& and %o%on$t %ae

8 Clients with si%le %ell anemia a"e ta$ght to a/oid a%ti/ities that %a$se hypo-ia and hypo-emia Hhi%h of

the following a%ti/ities wo$ld the n$"se "e%ommendQ

## family /a%ation in the o%y <o$ntains

@Chape"oning the lo%al boys %l$b on a snow=siing t"ip

C!"a/eling by ai"plane fo" b$siness t"ips)# b$s t"ip to the <$se$m of *at$"al ?isto"y

!he n$"se is %ond$%ting an admission assessment of a %lient with /itamin @12 defi%ien%y Hhi%h of thefollowing wo$ld the n$"se in%l$de in the physi%al assessmentQ

#Palpate the spleen

@!ae the blood p"ess$"e

C,-amine the feet fo" pete%hiae

),-amine the tong$e

9 #n #f"i%an #me"i%an female %omes to the o$tpatient %lini% !he physi%ian s$spe%ts /itamin @12

defi%ien%y anemia @e%a$se Ea$ndi%e is often a %lini%al manifestation of this type of anemia& what body pa"t

wo$ld be the best indi%ato"Q

#ConE$n%ti/a of the eye

@Soles of the feet

Coof of the mo$th

)Shins

10 !he n$"se is %ond$%ting a physi%al assessment on a %lient with anemia Hhi%h of the following %lini%al

manifestations wo$ld be most indi%ati/e of the anemiaQ

#@P 1.5G

@espi"ations 2 shallowCHeight gain of 10 po$nds in 5 months

)Pin %omple-ion

11 !he n$"se is tea%hing the %lient with poly%ythemia /e"a abo$t p"e/ention of %ompli%ations of the disease

Hhi%h of the following statements by the %lient indi%ates a need fo" f$"the" tea%hingQ

#LI will d"in 00m' of fl$id o" less ea%h dayL




@LI will wea" s$ppo"t hose when I am $pL

CLI will $se an ele%t"i% "a(o" fo" sha/ingL

)LI will eat foods low in i"onL

12 # ++=yea"=old male is being e/al$ated fo" possible a%$te le$emia Hhi%h of the following wo$ld the

n$"se in6$i"e abo$t as a pa"t of the assessmentQ

#!he %lient %olle%ts stamps as a hobby

@!he %lient "e%ently lost his Eob as a postal wo"e"

C!he %lient had "adiation fo" t"eatment of ?odgins disease as a teenage")!he %lients b"othe" had le$emia as a %hild

1+ #n #f"i%an #me"i%an %lient is admitted with a%$te le$emia !he n$"se is assessing fo" signs and

symptoms of bleeding Hhe"e is the best site fo" e-amining fo" the p"esen%e of pete%hiaeQ

#!he abdomen

@!he tho"a-

C!he ea"lobes

)!he soles of the feet

1. # %lient with a%$te le$emia is admitted to the on%ology $nit Hhi%h of the following wo$ld be most

impo"tant fo" the n$"se to in6$i"eQ#L?a/e yo$ noti%ed a %hange in sleeping habits "e%entlyQL

@L?a/e yo$ had a "espi"ato"y infe%tion in the last 5 monthsQL

CL?a/e yo$ lost weight "e%entlyQL)L?a/e yo$ noti%ed %hanges in yo$" ale"tnessQL

1 Hhi%h of the following wo$ld be the p"io"ity n$"sing diagnosis fo" the ad$lt %lient with a%$te le$emiaQ

#O"al m$%o$s memb"ane& alte"ed "elated to %hemothe"apy

@is fo" inE$"y "elated to th"ombo%ytopenia

CFatig$e "elated to the disease p"o%ess

)Inte""$pted family p"o%esses "elated to life=th"eatening illness of a family membe"

15 # 21=yea"=old male with ?odgins lymphoma is a senio" at the lo%al $ni/e"sity ?e is engaged to be

ma""ied and is to begin a new Eob $pon g"ad$ation Hhi%h of the following diagnoses wo$ld be a p"io"ity fo"

this %lientQ

#Se-$al dysf$n%tion "elated to "adiation the"apy

@#nti%ipato"y g"ie/ing "elated to te"minal illness

C!iss$e integ"ity "elated to p"olonged bed "est)Fatig$e "elated to %hemothe"apy

18 # %lient has a$toimm$ne th"ombo%ytopeni% p$"p$"a !o dete"mine the %lients "esponse to t"eatment& the

n$"se wo$ld monito":#Platelet %o$nt

@Hhite blood %ell %o$nt

CPotassi$m le/els

)Pa"tial p"oth"ombin time P!!

1 !he home health n$"se is /isiting a %lient with a$toimm$ne th"ombo%ytopeni% p$"p$"a #!P !he %lients

platelet %o$nt %$""ently is 0& It will be most impo"tant to tea%h the %lient and family abo$t:

#@leeding p"e%a$tions

@P"e/ention of falls

CO-ygen the"apy

)Conse"/ation of ene"gy

19 # %lient with a pit$ita"y t$mo" has had a t"ansphenoidal hyposphe%tomy Hhi%h of the following

inte"/entions wo$ld be app"op"iate fo" this %lientQ

#Pla%e the %lient in !"endelenb$"g position fo" post$"al d"ainage

@,n%o$"age %o$ghing and deep b"eathing e/e"y 2 ho$"s

C,le/ate the head of the bed +0R

),n%o$"age the 7alsal/a mane$/e" fo" bowel mo/ements

20 !he %lient with a histo"y of diabetes insipid$s is admitted with poly$"ia& polydipsia& and mental

%onf$sion !he p"io"ity inte"/ention fo" this %lient is:#<eas$"e the $"ina"y o$tp$t

@Che% the /ital signs

C,n%o$"age in%"eased fl$id intae

)Heigh the %lient

21 # %lient with hemophilia has a nosebleed Hhi%h n$"sing a%tion is most app"op"iate to %ont"ol the

bleedingQ

#Pla%e the %lient in a sitting position with the head hype"e-tended

@Pa% the na"es tightly with ga$(e to apply p"ess$"e to the so$"%e of bleeding

CPin%h the soft lowe" pa"t of the nose fo" a minim$m of min$tes

)#pply i%e pa%s to the fo"ehead and ba% of the ne%

22 # %lient has had a $nilate"al ad"enale%tomy to "emo/e a t$mo" !o p"e/ent %ompli%ations& the most

impo"tant meas$"ement in the immediate post=ope"ati/e pe"iod fo" the n$"se to tae is:




#@lood p"ess$"e

@!empe"at$"e

CO$tp$t

)Spe%ifi% g"a/ity

2+ # %lient with #ddisons disease has been admitted with a histo"y of na$sea and /omiting fo" the past +

days !he %lient is "e%ei/ing I7 gl$%o%o"ti%oids Sol$=<ed"ol Hhi%h of the following inte"/entions wo$ld

the n$"se implementQ

#Dl$%omete" "eadings as o"de"ed@IntaeGo$tp$t meas$"ements

CSodi$m and potassi$m le/els monito"ed

))aily weights

2. # %lient had a total thy"oide%tomy yeste"day !he %lient is %omplaining of tingling a"o$nd the mo$th and

in the finge"s and toes Hhat wo$ld the n$"ses ne-t a%tion beQ

#Obtain a %"ash %a"t

@Che% the %al%i$m le/el

C#ssess the d"essing fo" d"ainage

)#ssess the blood p"ess$"e fo" hype"tension2 # +2=yea"=old mothe" of th"ee is b"o$ght to the %lini% ?e" p$lse is 2& the"e is a weight gain of +0 po$nds

in . months& and the %lient is wea"ing two sweate"s !he %lient is diagnosed with hypothy"oidism Hhi%h of

the following n$"sing diagnoses is of highest p"io"ityQ#Impai"ed physi%al mobility "elated to de%"eased end$"an%e

@?ypothe"mia "Gt de%"eased metaboli% "ate

C)ist$"bed tho$ght p"o%esses "Gt inte"stitial edema

))e%"eased %a"dia% o$tp$t "Gt b"ady%a"dia

25 !he %lient p"esents to the %lini% with a se"$m %holeste"ol of 28mgGd' and is pla%ed on "os$/astatin

C"esto" Hhi%h inst"$%tion sho$ld be gi/en to the %lientQ

#epo"t m$s%le weaness to the physi%ian

@#llow si- months fo" the d"$g to tae effe%t

C!ae the medi%ation with f"$it E$i%e

)#s the do%to" to pe"fo"m a %omplete blood %o$nt befo"e sta"ting the medi%ation

28 !he %lient is admitted to the hospital with hype"tensi/e %"ises )ia(o-ide ?ype"stat is o"de"ed )$"ing

administ"ation& the n$"se sho$ld:#Utili(e an inf$sion p$mp

@Che% the blood gl$%ose le/el

CPla%e the %lient in !"endelenb$"g position)Co/e" the sol$tion with foil

2 !he 5=month=old %lient with a /ent"al septal defe%t is "e%ei/ing )igitalis fo" "eg$lation of his hea"t "ate

Hhi%h finding sho$ld be "epo"ted to the do%to"Q

#@lood p"ess$"e of 125G0

@@lood gl$%ose of 110mgGd'

C?ea"t "ate of 50bpm

)espi"ato"y "ate of +0 pe" min$te

29 !he %lient admitted with angina is gi/en a p"es%"iption fo" nit"ogly%e"ine !he %lient sho$ld be inst"$%ted

to:

#eplenish his s$pply e/e"y + months

@!ae one e/e"y 1 min$tes if pain o%%$"s

C'ea/e the medi%ation in the b"own bottle

)C"$sh the medi%ation and tae with wate"

+0 !he %lient is inst"$%ted "ega"ding foods that a"e low in fat and %holeste"ol Hhi%h diet sele%tion is lowest

in sat$"ated fatsQ

#<a%a"oni and %heese

@Sh"imp with "i%e

C!$"ey b"east)Spaghetti

+1 !he %lient is admitted with left=sided %ongesti/e hea"t fail$"e In assessing the %lient fo" edema& the n$"se

sho$ld %he% the:

#Feet

@*e%

C?ands

)Sa%"$m

+2 !he n$"se is %he%ing the %lients %ent"al /eno$s p"ess$"e !he n$"se sho$ld pla%e the (e"o of the

manomete" at the:

#Phlebostati% a-is

@P<I

C,"bs point




)!ail of Spen%e

++ !he physi%ian o"de"s lisinop"il Jest"il and f$"osemide 'asi- to be administe"ed %on%omitantly to the

%lient with hype"tension !he n$"se sho$ld:

#>$estion the o"de"

@#dministe" the medi%ations

C#dministe" sepa"ately

)Conta%t the pha"ma%y

+. !he best method of e/al$ating the amo$nt of pe"iphe"al edema is:#Heighing the %lient daily

@<eas$"ing the e-t"emity

C<eas$"ing the intae and o$tp$t

)Che%ing fo" pitting

+ # %lient with /aginal %an%e" is being t"eated with a "adioa%ti/e /aginal implant !he %lients h$sband ass

the n$"se if he %an spend the night with his wife !he n$"se sho$ld e-plain that:

#O/e"night stays by family membe"s is against hospital poli%y

@!he"e is no need fo" him to stay be%a$se staffing is ade6$ate

C?is wife will "est m$%h bette" nowing that he is at home)7isitation is limited to +0 min$tes when the implant is in pla%e

+5 !he n$"se is %a"ing fo" a %lient hospitali(ed with a fa%ial st"oe Hhi%h diet sele%tion wo$ld be s$ited to

the %lientQ#oast beef sandwi%h& potato %hips& pi%le spea"& i%ed tea

@Split pea so$p& mashed potatoes& p$dding& mil

C!omato so$p& %heese toast& Bello& %offee

)?amb$"ge"& baed beans& f"$it %$p& i%ed tea

+8 !he physi%ian has p"es%"ibed *o/alog ins$lin fo" a %lient with diabetes mellit$s Hhi%h statement

indi%ates that the %lient nows when the pea a%tion of the ins$lin o%%$"sQ

#LI will mae s$"e I eat b"eafast within 10 min$tes of taing my ins$linL

@LI will need to %a""y %andy o" some fo"m of s$ga" with me all the timeL

CLI will eat a sna% a"o$nd th"ee o%lo% ea%h afte"noonL

)LI %an sa/e my desse"t f"om s$ppe" fo" a bedtime sna%L

+ !he n$"se is tea%hing basi% infant %a"e to a g"o$p of fi"st=time pa"ents !he n$"se sho$ld e-plain that a

sponge bath is "e%ommended fo" the fi"st 2 wees of life be%a$se:#*ew pa"ents need time to lea"n how to hold the baby

@!he $mbili%al %o"d needs time to sepa"ate

C*ewbo"n sin is easily t"a$mati(ed by washing)!he %han%e of %hilling the baby o$tweighs the benefits of bathing

+9 # %lient with le$emia is "e%ei/ing !"imet"e-ate #fte" "e/iewing the %lients %ha"t& the physi%ian o"de"s

Hell%o/o"in le$%o/o"in %al%i$m !he "ationale fo" administe"ing le$%o/o"in %al%i$m to a %lient "e%ei/ing

!"imet"e-ate is to:

#!"eat i"on=defi%ien%y anemia %a$sed by %hemothe"ape$ti% agents

@C"eate a syne"gisti% effe%t that sho"tens t"eatment time

CIn%"ease the n$mbe" of %i"%$lating ne$t"ophils

)e/e"se d"$g to-i%ity and p"e/ent tiss$e damage

.0 # .=month=old is b"o$ght to the well=baby %lini% fo" imm$ni(ation In addition to the )P! and polio

/a%%ines& the baby sho$ld "e%ei/e:

#?ib tite"

@<$mps /a%%ine

C?epatitis @ /a%%ine

)<<

.1 !he physi%ian has p"es%"ibed *e-i$m esomep"a(ole fo" a %lient with e"osi/e gast"itis !he n$"se sho$ld

administe" the medi%ation:

#+0 min$tes befo"e meals

@Hith ea%h mealCIn a single dose at bedtime

)+0 min$tes afte" meals

.2 # %lient on the psy%hiat"i% $nit is in an $n%ont"olled "age and is th"eatening othe" %lients and staff Hhat

is the most app"op"iate a%tion fo" the n$"se to taeQ

#Call se%$"ity fo" assistan%e and p"epa"e to sedate the %lient

@!ell the %lient to %alm down and as him if he wo$ld lie to play %a"ds

C!ell the %lient that if he %ontin$es his beha/io" he will be p$nished

)'ea/e the %lient alone $ntil he %alms down

.+ Hhen the n$"se %he%s the f$nd$s of a %lient on the fi"st postpa"t$m day& she notes that the f$nd$s is fi"m&

is at the le/el of the $mbili%$s& and is displa%ed to the "ight !he ne-t a%tion the n$"se sho$ld tae is to:

#Che% the %lient fo" bladde" distention

@#ssess the blood p"ess$"e fo" hypotension




C)ete"mine whethe" an o-yto%i% d"$g was gi/en

)Che% fo" the e-p$lsion of small %lots

.. # %lient is admitted to the hospital with a tempe"at$"e of 99RF& %omplaints of blood=tinged hemoptysis&

fatig$e& and night sweats !he %lients symptoms a"e %onsistent with a diagnosis of:

#Pne$monia

@ea%tion to anti/i"al medi%ation

C!$be"%$losis

)S$pe"infe%tion d$e to low C). %o$nt. !he %lient is seen in the %lini% fo" t"eatment of mig"aine heada%hes !he d"$g Imit"e- s$mat"iptan

s$%%inate is p"es%"ibed fo" the %lient Hhi%h of the following in the %lients histo"y sho$ld be "epo"ted to the

do%to"Q

#)iabetes

@P"in(metals angina

CCan%e"

)Cl$ste" heada%hes

.5 !he %lient with s$spe%ted meningitis is admitted to the $nit !he do%to" is pe"fo"ming an assessment to

dete"mine meningeal i""itation and spinal ne"/e "oot inflammation # positi/e e"nigs sign is %ha"ted if then$"se notes:

#Pain on fle-ion of the hip and nee

@*$%hal "igidity on fle-ion of the ne% CPain when the head is t$"ned to the left side

))i((iness when %hanging positions

.8 !he %lient with #l(heime"s disease is being assisted with a%ti/ities of daily li/ing when the n$"se notes

that the %lient $ses he" toothb"$sh to b"$sh he" hai" !he n$"se is awa"e that the %lient is e-hibiting:

##gnosia

@#p"a-ia

C#nomia

)#phasia

. !he %lient with dementia is e-pe"ien%ing %onf$sion late in the afte"noon and befo"e bedtime !he n$"se is

awa"e that the %lient is e-pe"ien%ing what is nown as:

#Ch"oni% fatig$e synd"ome

@*o"mal agingCS$ndowning

))el$sions

.9 !he %lient with %onf$sion says to the n$"se& LI ha/ent had anything to eat all day long Hhen a"e theygoing to b"ing b"eafastQL !he n$"se saw the %lient in the day "oom eating b"eafast with othe" %lients +0

min$tes befo"e this %on/e"sation Hhi%h "esponse wo$ld be best fo" the n$"se to maeQ

#LAo$ now yo$ had b"eafast +0 min$tes agoL

@LI am so so""y that they didnt get yo$ b"eafast Ill "epo"t it to the %ha"ge n$"seL

CLIll get yo$ some E$i%e and toast Ho$ld yo$ lie something elseQL

)LAo$ will ha/e to wait a whileW l$n%h will be he"e in a little whileL

0 !he do%to" has p"es%"ibed ,-elon "i/astigmine fo" the %lient with #l(heime"s disease Hhi%h side effe%t

is most often asso%iated with this d"$gQ

#U"ina"y in%ontinen%e

@?eada%hes

CConf$sion

)*a$sea

1 # %lient is admitted to the labo" and deli/e"y $nit in a%ti/e labo" )$"ing e-amination& the n$"se notes a

pap$la" lesion on the pe"ine$m Hhi%h initial a%tion is most app"op"iateQ

#)o%$ment the finding

@epo"t the finding to the do%to"

CP"epa"e the %lient fo" a C=se%tion

)Contin$e p"ima"y %a"e as p"es%"ibed2 # %lient with a diagnosis of ?P7 is at "is fo" whi%h of the followingQ

#?odgins lymphoma

@Ce"/i%al %an%e"

C<$ltiple myeloma

)O/a"ian %an%e"

+ )$"ing the initial inte"/iew& the %lient "epo"ts that she has a lesion on the pe"ine$m F$"the" in/estigation

"e/eals a small bliste" on the /$l/a that is painf$l to to$%h !he n$"se is awa"e that the most liely so$"%e of

the lesion is:

#Syphilis

@?e"pes

CDono""hea

)Condylomata




. # %lient /isiting a family planning %lini% is s$spe%ted of ha/ing an S!I !he best diagnosti% test fo"

t"eponema pallid$m is:

#7ene"eal )isease esea"%h 'ab 7)'

@apid plasma "eagin P

CFlo"es%ent t"eponemal antibody F!#

)!haye"=<a"tin %$lt$"e !<C

# 1=yea"=old p"imig"a/ida is admitted with a tentati/e diagnosis of ?,''P synd"ome Hhi%h labo"ato"y

finding is asso%iated with ?,''P synd"omeQ#,le/ated blood gl$%ose

@,le/ated platelet %o$nt

C,le/ated %"eatinine %lea"an%e

),le/ated hepati% en(ymes

5 !he n$"se is assessing the deep tendon "efle-es of a %lient with p"ee%lampsia Hhi%h method is $sed to

eli%it the bi%eps "efle-Q

#!he n$"se pla%es he" th$mb on the m$s%le inset in the ante%$bital spa%e and taps the th$mb b"isly with

the "efle- hamme"

@!he n$"se loosely s$spends the %lients a"m in an open hand while tapping the ba% of the %lients elbowC!he n$"se inst"$%ts the %lient to dangle he" legs as the n$"se st"ies the a"ea below the patella with the

bl$nt side of the "efle- hamme"

)!he n$"se inst"$%ts the %lient to pla%e he" a"ms loosely at he" side as the n$"se st"ies the m$s%le inse"t E$st abo/e the w"ist

8 # p"imig"a/ida with diabetes is admitted to the labo" and deli/e"y $nit at +. wees gestation Hhi%h

do%to"s o"de" sho$ld the n$"se 6$estionQ

#<agnesi$m s$lfate .gm 2V I7

@@"ethine 10m%g I7

CStadol 1mg I7 p$sh e/e"y . ho$"s as needed p"n fo" pain

)#n%ef 2gm I7P@ e/e"y 5 ho$"s

# diabeti% m$ltig"a/ida is s%hed$led fo" an amnio%entesis at +2 wees gestation to dete"mine the 'GS

"atio and phosphatidyl gly%e"ol le/el !he 'GS "atio is 1:1 and the p"esen%e of phosphatidylgly%e"ol is noted

!he n$"ses assessment of this data is:

#!he infant is at low "is fo" %ongenital anomalies

@!he infant is at high "is fo" int"a$te"ine g"owth "eta"dationC!he infant is at high "is fo" "espi"ato"y dist"ess synd"ome

)!he infant is at high "is fo" bi"th t"a$ma

9 Hhi%h obse"/ation in the newbo"n of a diabeti% mothe" wo$ld "e6$i"e immediate n$"sing inte"/entionQ#C"ying

@Haef$lness

CBitte"iness

)Aawning

50 !he n$"se %a"ing fo" a %lient "e%ei/ing int"a/eno$s magnesi$m s$lfate m$st %losely obse"/e fo" side

effe%ts asso%iated with d"$g the"apy #n e-pe%ted side effe%t of magnesi$m s$lfate is:

#)e%"eased $"ina"y o$tp$t

@?ype"somnolen%e

C#bsen%e of nee Ee" "efle-

))e%"eased "espi"ato"y "ate

51 !he %lient has ele%ted to ha/e epid$"al anesthesia to "elie/e labo" pain If the %lient e-pe"ien%es

hypotension& the n$"se wo$ld:

#Pla%e he" in !"endelenb$"g position

@)e%"ease the "ate of I7 inf$sion

C#dministe" o-ygen pe" nasal %ann$la

)In%"ease the "ate of the I7 inf$sion

52 # %lient has %an%e" of the pan%"eas !he n$"se sho$ld be most %on%e"ned abo$t whi%h n$"sing diagnosisQ

##lte"ation in n$t"ition@#lte"ation in bowel elimination

C#lte"ation in sin integ"ity

)Ineffe%ti/e indi/id$al %oping

5+ !he n$"se is %a"ing fo" a %lient with as%ites Hhi%h is the best method to $se fo" dete"mining ea"ly

as%itesQ

#Inspe%tion of the abdomen fo" enla"gement

@@iman$al palpation fo" hepatomegaly

C)aily meas$"ement of abdominal gi"th

)#ssessment fo" a fl$id wa/e

5. !he %lient a""i/es in the eme"gen%y depa"tment afte" a moto" /ehi%le a%%ident *$"sing assessment

findings in%l$de @P 0G+.& p$lse "ate 120& and "espi"ations 20 Hhi%h is the %lients most app"op"iate p"io"ity

n$"sing diagnosisQ




##lte"ation in %e"eb"al tiss$e pe"f$sion

@Fl$id /ol$me defi%it

CIneffe%ti/e ai"way %lea"an%e

)#lte"ation in senso"y pe"%eption

5 !he home health n$"se is /isiting an 1=yea"=old with osteogenesis impe"fe%ta Hhi%h info"mation

obtained on the /isit wo$ld %a$se the most %on%e"nQ !he %lient:

#'ies to play football

@)"ins se/e"al %a"bonated d"ins pe" dayC?as two siste"s with si%le %ell t"a%t

)Is taing a%etaminophen to %ont"ol pain

55 !he n$"se wo"ing the o"gan t"ansplant $nit is %a"ing fo" a %lient with a white blood %ell %o$nt of )$"ing

e/ening /isitation& a /isito" b"ings a baset of f"$it Hhat a%tion sho$ld the n$"se taeQ

##llow the %lient to eep the f"$it

@Pla%e the f"$it ne-t to the bed fo" easy a%%ess by the %lient

COffe" to wash the f"$it fo" the %lient

)!ell the family membe"s to tae the f"$it home

58 !he n$"se is %a"ing fo" the %lient following a la"ynge%tomy when s$ddenly the %lient be%omesnon"esponsi/e and pale& with a @P of 90G.0 systoli% !he initial n$"ses a%tion sho$ld be to:

#Pla%e the %lient in !"endelenb$"g position

@In%"ease the inf$sion of )e-t"ose in no"mal salineC#dministe" at"opine int"a/eno$sly

)<o/e the eme"gen%y %a"t to the bedside

5 !he %lient admitted 2 days ea"lie" with a l$ng "ese%tion a%%identally p$lls o$t the %hest t$be Hhi%h a%tion

by the n$"se indi%ates $nde"standing of the management of %hest t$besQ

#O"de" a %hest -="ay

@einse"t the t$be

CCo/e" the inse"tion site with a 7aseline ga$(e

)Call the do%to"

59 # %lient being t"eated with sodi$m wa"fa"in has a P"otime of 120 se%onds Hhi%h inte"/ention wo$ld be

most impo"tant to in%l$de in the n$"sing %a"e planQ

##ssess fo" signs of abno"mal bleeding

@#nti%ipate an in%"ease in the Co$madin dosageCInst"$%t the %lient "ega"ding the d"$g the"apy

)In%"ease the f"e6$en%y of ne$"ologi%al assessments

80 Hhi%h sele%tion wo$ld p"o/ide the most %al%i$m fo" the %lient who is . months p"egnantQ## g"anola ba"

@# b"an m$ffin

C# %$p of yog$"t

)# glass of f"$it E$i%e

81 !he %lient with p"ee%lampsia is admitted to the $nit with an o"de" fo" magnesi$m s$lfate Hhi%h a%tion by

the n$"se indi%ates $nde"standing of the possible side effe%ts of magnesi$m s$lfateQ

#!he n$"se pla%es a sign o/e" the bed not to %he% blood p"ess$"e in the "ight a"m

@!he n$"se pla%es a padded tong$e blade at the bedside

C!he n$"se inse"ts a Foley %athete"

)!he n$"se da"ens the "oom

82 # 5=yea"=old %lient is admitted to the $nit with a hemoglobin of 5gGd' !he physi%ian has w"itten an o"de"

to t"ansf$se 2 $nits of whole blood Hhen dis%$ssing the t"eatment& the %hilds mothe" tells the n$"se that she

does not belie/e in ha/ing blood t"ansf$sions and that she will not allow he" %hild to ha/e the t"eatment

Hhat n$"sing a%tion is most app"op"iateQ

##s the mothe" to lea/e while the blood t"ansf$sion is in p"og"ess

@,n%o$"age the mothe" to "e%onside"

C,-plain the %onse6$en%es witho$t t"eatment

)*otify the physi%ian of the mothe"s "ef$sal8+ # %lient is admitted to the $nit 2 ho$"s afte" an e-plosion %a$ses b$"ns to the fa%e !he n$"se wo$ld be

most %on%e"ned with the %lient de/eloping whi%h of the followingQ

#?ypo/olemia

@'a"yngeal edema

C?ype"nat"emia

)?ype"alemia

8. !he n$"se is e/al$ating n$t"itional o$t%omes fo" an elde"ly %lient with b$limia Hhi%h data best indi%ates

that the plan of %a"e is effe%ti/eQ

#!he %lient sele%ts a balan%ed diet f"om the men$

@!he %lients hemoglobin and hemato%"it imp"o/e

C!he %lients tiss$e t$"go" imp"o/es

)!he %lient gains weight




8 !he %lient is admitted following "epai" of a f"a%t$"ed tibia and %ast appli%ation Hhi%h n$"sing assessment

sho$ld be "epo"ted to the do%to"Q

#Pain beneath the %ast

@Ha"m toes

CPedal p$lses wea and "apid

)Pa"esthesia of the toes

85 !he %lient is ha/ing an a"te"iog"am )$"ing the p"o%ed$"e& the %lient tells the n$"se& LIm feeing "eally

hotL Hhi%h "esponse wo$ld be bestQ#LAo$ a"e ha/ing an alle"gi% "ea%tion I will get an o"de" fo" @enad"ylL

@L!hat feeling of wa"mth is no"mal when the dye is inEe%tedL

CL!hat feeling of wa"mth indi%ates that the %lots in the %o"ona"y /essels a"e dissol/ingL

)LI will tell yo$" do%to" and let him e-plain to yo$ the "eason fo" the hot feeling that yo$ a"e e-pe"ien%ingL

88 !he n$"se is obse"/ing se/e"al health%a"e wo"e"s p"o/iding %a"e Hhi%h a%tion by the health%a"e wo"e"

indi%ates a need fo" f$"the" tea%hingQ

#!he n$"sing assistant wea"s glo/es while gi/ing the %lient a bath

@!he n$"se wea"s goggles while d"awing blood f"om the %lient

C!he do%to" washes his hands befo"e e-amining the %lient)!he n$"se wea"s glo/es to tae the %lients /ital signs

8 !he %lient is ha/ing ele%t"o%on/$lsi/e the"apy fo" t"eatment of se/e"e dep"ession Hhi%h of the following

indi%ates that the %lients ,C! has been effe%ti/eQ#!he %lient loses %ons%io$sness

@!he %lient /omits

C!he %lients ,CD indi%ates ta%hy%a"dia

)!he %lient has a g"and mal sei($"e

89 !he =yea"=old is being tested fo" ente"obiasis pinwo"ms !o %olle%t a spe%imen fo" assessment of

pinwo"ms& the n$"se sho$ld tea%h the mothe" to:

#,-amine the pe"ianal a"ea with a flashlight 2 o" + ho$"s afte" the %hild is asleep

@S%"ape the sin with a pie%e of %a"dboa"d and b"ing it to the %lini%

CObtain a stool spe%imen in the afte"noon

)@"ing a hai" sample to the %lini% fo" e/al$ation

0 !he n$"se is tea%hing the mothe" "ega"ding t"eatment fo" ente"obiasis Hhi%h inst"$%tion sho$ld be gi/en

"ega"ding the medi%ationQ#!"eatment is not "e%ommended fo" %hild"en less than 10 yea"s of age

@!he enti"e family sho$ld be t"eated

C<edi%ation the"apy will %ontin$e fo" 1 yea")Int"a/eno$s antibioti% the"apy will be o"de"ed

1 !he "egiste"ed n$"se is maing assignments fo" the day Hhi%h %lient sho$ld be assigned to the p"egnant

n$"seQ

#!he %lient "e%ei/ing linea" a%%ele"ato" "adiation the"apy fo" l$ng %an%e"

@!he %lient with a "adi$m implant fo" %e"/i%al %an%e"

C!he %lient who has E$st been administe"ed sol$ble b"a%hythe"apy fo" thy"oid %an%e"

)!he %lient who "et$"ned f"om pla%ement of i"idi$m seeds fo" p"ostate %an%e"

2 !he n$"se is planning "oom assignments fo" the day Hhi%h %lient sho$ld be assigned to a p"i/ate "oom if

only one is a/ailableQ

#!he %lient with C$shings disease

@!he %lient with diabetes

C!he %lient with a%"omegaly

)!he %lient with my-edema

+ !he n$"se %a"ing fo" a %lient in the neonatal intensi/e %a"e $nit administe"s ad$lt=st"ength )igitalis to the

+=po$nd infant #s a "es$lt of he" a%tions& the baby s$ffe"s pe"manent hea"t and b"ain damage !he n$"se %an

be %ha"ged with:

#*egligen%e

@!o"tC#ssa$lt

)<alp"a%ti%e

. Hhi%h assignment sho$ld not be pe"fo"med by the li%ensed p"a%ti%al n$"seQ

#Inse"ting a Foley %athete"

@)is%ontin$ing a nasogast"i% t$be

CObtaining a sp$t$m spe%imen

)Sta"ting a blood t"ansf$sion

!he %lient "et$"ns to the $nit f"om s$"ge"y with a blood p"ess$"e of 90G0& p$lse 1+2& and "espi"ations +0

Hhi%h a%tion by the n$"se sho$ld "e%ei/e p"io"ityQ

#Contin$ing to monito" the /ital signs

@Conta%ting the physi%ian

C#sing the %lient how he feels






)7omiting and dia""hea

98 !he n$"se is %a"ing fo" a %lient admitted with epiglottis @e%a$se of the possibility of %omplete obst"$%tion

of the ai"way& whi%h of the following sho$ld the n$"se ha/e a/ailableQ

#Int"a/eno$s a%%ess s$pplies

@# t"a%heostomy set

CInt"a/eno$s fl$id administ"ation p$mp

)S$pplemental o-ygen

9 # 2=yea"=old %lient with D"a/es disease is admitted to the $nit Hhat wo$ld the n$"se e-pe%t theadmitting assessment to "e/ealQ

#@"ady%a"dia

@)e%"eased appetite

C,-ophthalmos

)Height gain

99 !he n$"se is p"o/iding dieta"y inst"$%tions to the mothe" of an =yea"=old %hild diagnosed with %elia%

disease Hhi%h of the following foods& if sele%ted by the mothe"& wo$ld indi%ate he" $nde"standing of the

dieta"y inst"$%tionsQ

#?am sandwi%h on whole=wheat toast@Spaghetti and meatballs

C?amb$"ge" with et%h$p

)Cheese omelet100 !he n$"se is %a"ing fo" an 0=yea"=old with %h"oni% b"on%hitis Upon the mo"ning "o$nds& the n$"se finds

an O2 sat of 85V Hhi%h of the following a%tions sho$ld the n$"se tae fi"stQ

#*otify the physi%ian

@e%he% the O2 sat$"ation le/el in 1 min$tes

C#pply o-ygen by mas

)#ssess the %hilds p$lse

101 # g"a/ida III pa"a 0 is admitted to the labo" and deli/e"y $nit !he do%to" pe"fo"ms an amniotomy Hhi%h

obse"/ation wo$ld the n$"se be e-pe%ted to mae afte" the amniotomyQ

#Fetal hea"t tones 150bpm

@# mode"ate amo$nt of st"aw=%olo"ed fl$id

C# small amo$nt of g"eenish fl$id

)# small segment of the $mbili%al %o"d102 !he %lient is admitted to the $nit # /aginal e-am "e/eals that she is 2%m dilated Hhi%h of the following

statements wo$ld the n$"se e-pe%t he" to maeQ

#LHe ha/e a name pi%ed o$t fo" the babyL

@LI need to p$sh when I ha/e a %ont"a%tionL

CLI %ant %on%ent"ate if anyone is to$%hing meL

)LHhen %an I get my epid$"alQL

10+ !he %lient is ha/ing fetal hea"t "ates of 90X110bpm d$"ing the %ont"a%tions !he fi"st a%tion the n$"se

sho$ld tae is:

#eposition the monito"

@!$"n the %lient to he" left side

C#s the %lient to amb$late

)P"epa"e the %lient fo" deli/e"y10. In e/al$ating the effe%ti/eness of I7 Pito%in fo" a %lient with se%onda"y dysto%ia& the n$"se sho$ld e-pe%t:

## painless deli/e"y

@Ce"/i%al effa%ement

CInf"e6$ent %ont"a%tions

)P"og"essi/e %e"/i%al dilation10 # /aginal e-am "e/eals a footling b"ee%h p"esentation !he n$"se sho$ld tae whi%h of the following

a%tions at this timeQ

##nti%ipate the need fo" a Caesa"ean se%tion

@#pply the fetal hea"t monito"

CPla%e the %lient in Den$ Pe%to"al position

)Pe"fo"m an $lt"aso$nd e-am

105 # /aginal e-am "e/eals that the %e"/i- is .%m dilated& with inta%t memb"anes and a fetal hea"t tone "ate of150X180bpm !he n$"se de%ides to apply an e-te"nal fetal monito" !he "ationale fo" this implementation is:

#!he %e"/i- is %losed

@!he memb"anes a"e still inta%t

C!he fetal hea"t tones a"e within no"mal limits

)!he %ont"a%tions a"e intense eno$gh fo" inse"tion of an inte"nal monito"

108 !he following a"e all n$"sing diagnoses app"op"iate fo" a g"a/ida 1 pa"a 0 in labo" Hhi%h one wo$ld be

most app"op"iate fo" the p"imag"a/ida as she %ompletes the ea"ly phase of labo"Q

#Impai"ed gas e-%hange "elated to hype"/entilation

@#lte"ation in pla%ental pe"f$sion "elated to mate"nal position




CImpai"ed physi%al mobility "elated to fetal=monito"ing e6$ipment

)Potential fl$id /ol$me defi%it "elated to de%"eased fl$id intae

10 #s the %lient "ea%hes %m dilation& the n$"se notes late de%ele"ations on the fetal monito" !he F?

baseline is 15X18bpm with /a"iability of 0X2bpm Hhat is the most liely e-planation of this patte"nQ

#!he baby is asleep

@!he $mbili%al %o"d is %omp"essed

C!he"e is a /agal "esponse

)!he"e is $te"opla%ental ins$ffi%ien%y109 !he n$"se notes /a"iable de%ele"ations on the fetal monito" st"ip !he most app"op"iate initial a%tion

wo$ld be to:

#*otify he" do%to"

@Sta"t an I7

Ceposition the %lient

)eadE$st the monito"

110 Hhi%h of the following is a %ha"a%te"isti% of a "eass$"ing fetal hea"t "ate patte"nQ

## fetal hea"t "ate of 180X10bpm

@# baseline /a"iability of 2X+bpmCOmino$s pe"iodi% %hanges

)#%%ele"ation of F? with fetal mo/ements

111 !he "ationale fo" inse"ting a F"en%h %athete" e/e"y ho$" fo" the %lient with epid$"al anesthesia is:#!he bladde" fills mo"e "apidly be%a$se of the medi%ation $sed fo" the epid$"al

@?e" le/el of %ons%io$sness is s$%h that she is in a t"an%elie state

C!he sensation of the bladde" filling is diminished o" lost

)She is emba""assed to as fo" the bedpan that f"e6$ently

112 # %lient in the family planning %lini% ass the n$"se abo$t the most liely time fo" he" to %on%ei/e !he

n$"se e-plains that %on%eption is most liely to o%%$" when:

#,st"ogen le/els a"e low

@'$teni(ing ho"mone is high

C!he endomet"ial lining is thin

)!he p"ogeste"one le/el is low

11+ # %lient tells the n$"se that she plans to $se the "hythm method of bi"th %ont"ol !he n$"se is awa"e that

the s$%%ess of the "hythm method depends on the:##ge of the %lient

@F"e6$en%y of inte"%o$"se

Ceg$la"ity of the menses)ange of the %lients tempe"at$"e

11. # %lient with diabetes ass the n$"se fo" ad/i%e "ega"ding methods of bi"th %ont"ol Hhi%h method of

bi"th %ont"ol is most s$itable fo" the %lient with diabetesQ

#Int"a$te"ine de/i%e

@O"al %ont"a%epti/es

C)iaph"agm

)Cont"a%epti/e sponge

11 !he do%to" s$spe%ts that the %lient has an e%topi% p"egnan%y Hhi%h symptom is %onsistent with a

diagnosis of e%topi% p"egnan%yQ

#Painless /aginal bleeding

@#bdominal %"amping

C!h"obbing pain in the $ppe" 6$ad"ant

)S$dden& stabbing pain in the lowe" 6$ad"ant

115 !he n$"se is tea%hing a p"egnant %lient abo$t n$t"itional needs d$"ing p"egnan%y Hhi%h men$ sele%tion

will best meet the n$t"itional needs of the p"egnant %lientQ

#?amb$"ge" pattie& g"een beans& F"en%h f"ies& and i%ed tea

@oast beef sandwi%h& potato %hips& baed beans& and %ola

C@aed %hi%en& f"$it %$p& potato salad& %oleslaw& yog$"t& and i%ed tea)Fish sandwi%h& gelatin with f"$it& and %offee

118 !he %lient with hype"emesis g"a/ida"$m is at "is fo" de/eloping:

#espi"ato"y alalosis witho$t dehyd"ation

@<etaboli% a%idosis with dehyd"ation

Cespi"ato"y a%idosis witho$t dehyd"ation

)<etaboli% alalosis with dehyd"ation

11 # %lient tells the do%to" that she is abo$t 20 wees p"egnant !he most definiti/e sign of p"egnan%y is:

#,le/ated h$man %ho"ioni% gonadat"opin

@!he p"esen%e of fetal hea"t tones

CUte"ine enla"gement

)@"east enla"gement and tende"ness

119 !he n$"se is %a"ing fo" a neonate whose mothe" is diabeti% !he n$"se will e-pe%t the neonate to be:




#?ypogly%emi%& small fo" gestational age

@?ype"gly%emi%& la"ge fo" gestational age

C?ypogly%emi%& la"ge fo" gestational age

)?ype"gly%emi%& small fo" gestational age

120 Hhi%h of the following inst"$%tions sho$ld be in%l$ded in the n$"ses tea%hing "ega"ding o"al

%ont"a%epti/esQ

#Height gain sho$ld be "epo"ted to the physi%ian

@#n alte"nate method of bi"th %ont"ol is needed when taing antibioti%sCIf the %lient misses one o" mo"e pills& two pills sho$ld be taen pe" day fo" 1 wee

)Changes in the menst"$al flow sho$ld be "epo"ted to the physi%ian

121 !he n$"se is dis%$ssing b"eastfeeding with a postpa"t$m %lient @"eastfeeding is %ont"aindi%ated in the

postpa"t$m %lient with:

#)iabetes

@Positi/e ?I7

C?ype"tension

)!hy"oid disease

122 # %lient is admitted to the labo" and deli/e"y $nit %omplaining of /aginal bleeding with /e"y littledis%omfo"t !he n$"ses fi"st a%tion sho$ld be to:

##ssess the fetal hea"t tones

@Che% fo" %e"/i%al dilationCChe% fo" fi"mness of the $te"$s

)Obtain a detailed histo"y

12+ # %lient telephones the eme"gen%y "oom stating that she thins that she is in labo" !he n$"se sho$ld tell

the %lient that labo" has p"obably beg$n when:

#?e" %ont"a%tions a"e 2 min$tes apa"t

@She has ba% pain and a bloody dis%ha"ge

CShe e-pe"ien%es abdominal pain and f"e6$ent $"ination

)?e" %ont"a%tions a"e min$tes apa"t

12. !he n$"se is tea%hing a g"o$p of p"enatal %lients abo$t the effe%ts of %iga"ette smoe on fetal

de/elopment Hhi%h %ha"a%te"isti% is asso%iated with babies bo"n to mothe"s who smoed d$"ing p"egnan%yQ

#'ow bi"th weight

@'a"ge fo" gestational ageCP"ete"m bi"th& b$t app"op"iate si(e fo" gestation

)D"owth "eta"dation in weight and length

12 !he physi%ian has o"de"ed an inEe%tion of hoDam fo" the postpa"t$m %lient whose blood type is #negati/e b$t whose baby is O positi/e !o p"o/ide postpa"t$m p"ophyla-is& hoDam sho$ld be administe"ed:

#Hithin 82 ho$"s of deli/e"y

@Hithin 1 wee of deli/e"y

CHithin 2 wees of deli/e"y

)Hithin 1 month of deli/e"y

125 #fte" the physi%ian pe"fo"ms an amniotomy& the n$"ses fi"st a%tion sho$ld be to assess the:

#)eg"ee of %e"/i%al dilation

@Fetal hea"t tones

CClients /ital signs

)Clients le/el of dis%omfo"t

128 # %lient is admitted to the labo" and deli/e"y $nit !he n$"se pe"fo"ms a /aginal e-am and dete"mines that

the %lients %e"/i- is %m dilated with 8V effa%ement @ased on the n$"ses assessment the %lient is in whi%h

phase of labo"Q

##%ti/e

@'atent

C!"ansition

),a"ly

12 # newbo"n with na"%oti% abstinen%e synd"ome is admitted to the n$"se"y *$"sing %a"e of the newbo"nsho$ld in%l$de:

#!ea%hing the mothe" to p"o/ide ta%tile stim$lation

@H"apping the newbo"n sn$gly in a blanet

CPla%ing the newbo"n in the infant seat

)Initiating an ea"ly infant=stim$lation p"og"am

129 # %lient ele%ts to ha/e epid$"al anesthesia to "elie/e the dis%omfo"t of labo" Following the initiation of

epid$"al anesthesia& the n$"se sho$ld gi/e p"io"ity to:

#Che%ing fo" %e"/i%al dilation

@Pla%ing the %lient in a s$pine position

CChe%ing the %lients blood p"ess$"e

)Obtaining a fetal hea"t "ate

1+0 !he n$"se is awa"e that the best way to p"e/ent post= ope"ati/e wo$nd infe%tion in the s$"gi%al %lient is to:




##dministe" a p"es%"ibed antibioti%

@Hash he" hands fo" 2 min$tes befo"e %a"e

CHea" a mas when p"o/iding %a"e

)#s the %lient to %o/e" he" mo$th when she %o$ghs

1+1 !he elde"ly %lient is admitted to the eme"gen%y "oom Hhi%h symptom is the %lient with a f"a%t$"ed hip

most liely to e-hibitQ

#Pain

@)isalignmentCCool e-t"emity

)#bsen%e of pedal p$lses

1+2 !he n$"se nows that a 50=yea"=old female %lients s$s%eptibility to osteopo"osis is most liely "elated to:

#'a% of e-e"%ise

@?o"monal dist$"ban%es

C'a% of %al%i$m

)Deneti% p"edisposition

1++ # 2=yea"=old is admitted fo" "epai" of a f"a%t$"ed fem$" and is pla%ed in @"yants t"a%tion Hhi%h finding

by the n$"se indi%ates that the t"a%tion is wo"ing p"ope"lyQ#!he infant no longe" %omplains of pain

@!he b$tto%s a"e 1R off the bed

C!he legs a"e s$spended in the t"a%tion)!he pins a"e se%$"ed within the p$lley

1+. # %lient with a f"a%t$"ed hip has been pla%ed in @$%s t"a%tion Hhi%h statement is t"$e "ega"ding

balan%ed seletal t"a%tionQ @alan%ed seletal t"a%tion:

#Utili(es a Steinman pin

@e6$i"es that both legs be se%$"ed

CUtili(es i"s%hne" wi"es

)Is $sed p"ima"ily to heal the f"a%t$"ed hips

1+ !he %lient is admitted fo" an open "ed$%tion inte"nal fi-ation of a f"a%t$"ed hip Immediately following

s$"ge"y& the n$"se sho$ld gi/e p"io"ity to assessing the:

#Se"$m %olle%tion )a/ol d"ain

@Clients pain

C*$t"itional stat$s)Immobili(e"

1+5 Hhi%h statement made by the family membe" %a"ing fo" the %lient with a pe"%$taneo$s gast"ostomy t$be

indi%ates $nde"standing of the n$"ses tea%hingQ#LI m$st fl$sh the t$be with wate" afte" feedings and %lamp the t$beL

@LI m$st %he% pla%ement fo$" times pe" dayL

CLI will "epo"t to the do%to" any signs of indigestionL

)LIf my fathe" is $nable to swallow& I will dis%ontin$e the feeding and %all the %lini%L

1+8 !he n$"se is assessing the %lient with a total nee "epla%ement 2 ho$"s post=ope"ati/e Hhi%h info"mation

"e6$i"es notifi%ation of the do%to"Q

#@leeding on the d"essing is +%m in diamete"

@!he %lient has a tempe"at$"e of 5RF

C!he %lients hemato%"it is 25V

)!he $"ina"y o$tp$t has been 50 d$"ing the last 2 ho$"s

1+ !he n$"se is %a"ing fo" the %lient with a =yea"=old diagnosis of pl$mbism Hhi%h info"mation in the

health histo"y is most liely "elated to the de/elopment of pl$mbismQ

#!he %lient has t"a/eled o$t of the %o$nt"y in the last 5 months

@!he %lients pa"ents a"e silled stained=glass a"tists

C!he %lient li/es in a ho$se b$ilt in 1

)!he %lient has se/e"al b"othe"s and siste"s

1+9 # %lient with a total hip "epla%ement "e6$i"es spe%ial e6$ipment Hhi%h e6$ipment wo$ld assist the %lient

with a total hip "epla%ement with a%ti/ities of daily li/ingQ#?igh=seat %ommode

@e%line"

C!,*S $nit

)#bd$%tion pillow

1.0 #n elde"ly %lient with an abdominal s$"ge"y is admitted to the $nit following s$"ge"y In anti%ipation of

%ompli%ations of anesthesia and na"%oti% administ"ation& the n$"se sho$ld:

##dministe" o-ygen /ia nasal %ann$la

@?a/e na"%an nalo-ane a/ailable

CP"epa"e to administe" blood p"od$%ts

)P"epa"e to do %a"dio"es$s%itation

1.1 Hhi%h "oommate wo$ld be most s$itable fo" the 5=yea"=old male with a f"a%t$"ed fem$" in $ssells

t"a%tionQ




#15=yea"=old female with s%oliosis

@12=yea"=old male with a f"a%t$"ed fem$"

C10=yea"=old male with sa"%oma

)5=yea"=old male with osteomylitis

1.2 # %lient with osteoa"th"itis has a p"es%"iption fo" Celeb"e- %ele%o-ib Hhi%h inst"$%tion sho$ld be

in%l$ded in the dis%ha"ge tea%hingQ

#!ae the medi%ation with mil

@epo"t %hest painCemain $p"ight afte" taing fo" +0 min$tes

)#llow 5 wees fo" optimal effe%ts

1.+ # %lient with a f"a%t$"ed tibia has a plaste"=of=Pa"is %ast applied to immobili(e the f"a%t$"e Hhi%h a%tion

by the n$"se indi%ates $nde"standing of a plaste"=of=Pa"is %astQ !he n$"se:

#?andles the %ast with the finge"tips

@Petals the %ast

C)"ies the %ast with a hai" d"ye"

)#llows 2. ho$"s befo"e bea"ing weight

1.. !he teenage" with a fibe"glass %ast ass the n$"se if it will be oay to allow his f"iends to a$tog"aph his%ast Hhi%h "esponse wo$ld be bestQ

#LIt will be al"ight fo" yo$" f"iends to a$tog"aph the %astL

@L@e%a$se the %ast is made of plaste"& a$tog"aphing %an weaen the %astLCLIf they dont $se %hal to a$tog"aph& it is oayL

)L#$tog"aphing o" w"iting on the %ast in any fo"m will ha"m the %astL

1. !he n$"se is assigned to %a"e fo" the %lient with a Steinmen pin )$"ing pin %a"e& she notes that the 'P*

$ses ste"ile glo/es and >=tips to %lean the pin Hhi%h a%tion sho$ld the n$"se tae at this timeQ

##ssisting the 'P* with opening ste"ile pa%ages and pe"o-ide

@!elling the 'P* that %lean glo/es a"e allowed

C!elling the 'P* that the "egiste"ed n$"se sho$ld pe"fo"m pin %a"e

)#sing the 'P* to %lean the weights and p$lleys with pe"o-ide

1.5 # %hild with s%oliosis has a spi%a %ast applied Hhi%h a%tion spe%ifi% to the spi%a %ast sho$ld be taenQ

#Che% the bowel so$nds

@#ssess the blood p"ess$"e

COffe" pain medi%ation)Che% fo" swelling

1.8 !he %lient with a %e"/i%al f"a%t$"e is pla%ed in t"a%tion Hhi%h type of t"a%tion will be $tili(ed at the time

of dis%ha"geQ#$ssells t"a%tion

@@$%s t"a%tion

C?alo t"a%tion

)C"$t%hfield tong t"a%tion

1. # %lient with a total nee "epla%ement has a CP< %ontin$o$s passi/e motion de/i%e applied d$"ing the

post=ope"ati/e pe"iod Hhi%h statement made by the n$"se indi%ates $nde"standing of the CP< ma%hineQ

#LUse of the CP< will pe"mit the %lient to amb$late d$"ing the the"apyL

@L!he CP< ma%hine %ont"ols sho$ld be positioned distal to the siteL

CLIf the %lient %omplains of pain d$"ing the the"apy& I will t$"n off the ma%hine and %all the do%to"L

)LUse of the CP< ma%hine will alle/iate the need fo" physi%al the"apy afte" the %lient is dis%ha"gedL

1.9 # %lient with a f"a%t$"ed hip is being ta$ght %o""e%t $se of the wale" !he n$"se is awa"e that the %o""e%t

$se of the wale" is a%hie/ed if the:

#Palms "est lightly on the handles

@,lbows a"e fle-ed 0R

CClient wals to the f"ont of the wale"

)Client %a""ies the wale"

10 Hhen assessing a labo"ing %lient& the n$"se finds a p"olapsed %o"d !he n$"se sho$ld:

##ttempt to "epla%e the %o"d@Pla%e the %lient on he" left side

C,le/ate the %lients hips

)Co/e" the %o"d with a d"y& ste"ile ga$(e

11 !he n$"se is %a"ing fo" a +0=yea"=old male admitted with a stab wo$nd Hhile in the eme"gen%y "oom& a

%hest t$be is inse"ted Hhi%h of the following e-plains the p"ima"y "ationale fo" inse"tion of %hest t$besQ

#!he t$be will allow fo" e6$ali(ation of the l$ng e-pansion

@Chest t$bes se"/e as a method of d"aining blood and se"o$s fl$id and assist in "einflating the l$ngs

CChest t$bes "elie/e pain asso%iated with a %ollapsed l$ng

)Chest t$bes assist with %a"dia% f$n%tion by stabili(ing l$ng e-pansion

12 # %lient who deli/e"ed this mo"ning tells the n$"se that she plans to b"eastfeed he" baby !he n$"se is

awa"e that s$%%essf$l b"eastfeeding is most dependent on the:

#<othe"s ed$%ational le/el




@Infants bi"th weight

CSi(e of the mothe"s b"east

)<othe"s desi"e to b"eastfeed

1+ !he n$"se is monito"ing the p"og"ess of a %lient in labo" Hhi%h finding sho$ld be "epo"ted to the

physi%ian immediatelyQ

#!he p"esen%e of s%ant bloody dis%ha"ge

@F"e6$ent $"ination

C!he p"esen%e of g"een=tinged amnioti% fl$id)<ode"ate $te"ine %ont"a%tions

1. !he n$"se is meas$"ing the d$"ation of the %lients %ont"a%tions Hhi%h statement is t"$e "ega"ding the

meas$"ement of the d$"ation of %ont"a%tionsQ

#)$"ation is meas$"ed by timing f"om the beginning of one %ont"a%tion to the beginning of the ne-t

%ont"a%tion

@)$"ation is meas$"ed by timing f"om the end of one %ont"a%tion to the beginning of the ne-t %ont"a%tion

C)$"ation is meas$"ed by timing f"om the beginning of one %ont"a%tion to the end of the same %ont"a%tion

))$"ation is meas$"ed by timing f"om the pea of one %ont"a%tion to the end of the same %ont"a%tion

1 !he physi%ian has o"de"ed an int"a/eno$s inf$sion of Pito%in fo" the ind$%tion of labo" Hhen %a"ing fo"the obstet"i% %lient "e%ei/ing int"a/eno$s Pito%in& the n$"se sho$ld monito" fo":

#<ate"nal hypogly%emia

@Fetal b"ady%a"diaC<ate"nal hype""efle-ia

)Fetal mo/ement

15 # %lient with diabetes /isits the p"enatal %lini% at 2 wees gestation Hhi%h statement is t"$e "ega"ding

ins$lin needs d$"ing p"egnan%yQ

#Ins$lin "e6$i"ements mode"ate as the p"egnan%y p"og"esses

@# de%"eased need fo" ins$lin o%%$"s d$"ing the se%ond t"imeste"

C,le/ations in h$man %ho"ioni% gonadot"ophin de%"ease the need fo" ins$lin

)Fetal de/elopment depends on ade6$ate ins$lin "eg$lation

18 # %lient in the p"enatal %lini% is assessed to ha/e a blood p"ess$"e of 10G95 !he n$"se sho$ld gi/e

p"io"ity to:

#P"o/iding a %alm en/i"onment

@Obtaining a diet histo"yC#dministe"ing an analgesi%

)#ssessing fetal hea"t tones

1 # p"imig"a/ida& age .2& is 5 wees p"egnant @ased on the %lients age& he" infant is at "is fo":#)own synd"ome

@espi"ato"y dist"ess synd"ome

C!$"ne"s synd"ome

)Pathologi%al Ea$ndi%e

19 # %lient with a missed abo"tion at 29 wees gestation is admitted to the hospital !he %lient will most

liely be t"eated with:

#<agnesi$m s$lfate

@Cal%i$m gl$%onate

C)inop"ostone P"ostin ,

)@"omo%"ystine Pa"del

150 # %lient with p"ee%lampsia has been "e%ei/ing an inf$sion %ontaining magnesi$m s$lfate fo" a blood

p"ess$"e that is 150G0W deep tendon "efle-es a"e 1 pl$s& and the $"ina"y o$tp$t fo" the past ho$" is 100m'

!he n$"se sho$ld:

#Contin$e the inf$sion of magnesi$m s$lfate while monito"ing the %lients blood p"ess$"e

@Stop the inf$sion of magnesi$m s$lfate and %onta%t the physi%ian

CSlow the inf$sion "ate and t$"n the %lient on he" left side

)#dministe" %al%i$m gl$%onate I7 p$sh and %ontin$e to monito" the blood p"ess$"e

151 Hhi%h statement made by the n$"se des%"ibes the inhe"itan%e patte"n of a$tosomal "e%essi/e diso"de"sQ##n affe%ted newbo"n has $naffe%ted pa"ents

@#n affe%ted newbo"n has one affe%ted pa"ent

C#ffe%ted pa"ents ha/e a one in fo$" %han%e of passing on the defe%ti/e gene

)#ffe%ted pa"ents ha/e $naffe%ted %hild"en who a"e %a""ie"s

152 # p"egnant %lient& age +2& ass the n$"se why he" do%to" has "e%ommended a se"$m alpha fetop"otein !he

n$"se sho$ld e-plain that the do%to" has "e%ommended the test:

#@e%a$se it is a state law

@!o dete%t %a"dio/as%$la" defe%ts

C@e%a$se of he" age

)!o dete%t ne$"ologi%al defe%ts

15+ # %lient with hypothy"oidism ass the n$"se if she will still need to tae thy"oid medi%ation d$"ing the

p"egnan%y !he n$"ses "esponse is based on the nowledge that:




#!he"e is no need to tae thy"oid medi%ation be%a$se the fet$ss thy"oid p"od$%es a thy"oid=stim$lating

ho"mone

@eg$lation of thy"oid medi%ation is mo"e diffi%$lt be%a$se the thy"oid gland in%"eases in si(e d$"ing

p"egnan%y

CIt is mo"e diffi%$lt to maintain thy"oid "eg$lation d$"ing p"egnan%y d$e to a slowing of metabolism

)Fetal g"owth is a""ested if thy"oid medi%ation is %ontin$ed d$"ing p"egnan%y

15. !he n$"se is "esponsible fo" pe"fo"ming a neonatal assessment on a f$ll=te"m infant #t 1 min$te& the

n$"se %o$ld e-pe%t to find:##n api%al p$lse of 100

@#n absen%e of ton$s

CCyanosis of the feet and hands

)Ba$ndi%e of the sin and s%le"a

15 # %lient with si%le %ell anemia is admitted to the labo" and deli/e"y $nit d$"ing the fi"st phase of labo"

!he n$"se sho$ld anti%ipate the %lients need fo":

#S$pplemental o-ygen

@Fl$id "est"i%tion

C@lood t"ansf$sion))eli/e"y by Caesa"ean se%tion

155 # %lient with diabetes has an o"de" fo" $lt"asonog"aphy P"epa"ation fo" an $lt"aso$nd in%l$des:

#In%"easing fl$id intae@'imiting amb$lation

C#dministe"ing an enema

)Hithholding food fo" ho$"s

158 #n infant who weighs po$nds at bi"th wo$ld be e-pe%ted to weigh how many po$nds at 1 yea"Q

#1. po$nds

@15 po$nds

C1 po$nds

)2. po$nds

15 # p"egnant %lient with a histo"y of al%ohol addi%tion is s%hed$led fo" a nonst"ess test !he nonst"ess test:

#)ete"mines the l$ng mat$"ity of the fet$s

@<eas$"es the a%ti/ity of the fet$s

CShows the effe%t of %ont"a%tions on the fetal hea"t "ate)<eas$"es the ne$"ologi%al well=being of the fet$s

159 # f$ll=te"m male has hypospadias Hhi%h statement des%"ibes hypospadiasQ

#!he $"eth"al opening is absent@!he $"eth"a opens on the do"sal side of the penis

C!he penis is sho"te" than $s$al

)!he $"eth"a opens on the /ent"al side of the penis

180 # g"a/ida III pa"a II is admitted to the labo" $nit 7aginal e-am "e/eals that the %lients %e"/i- is %m

dilated& with %omplete effa%ement !he p"io"ity n$"sing diagnosis at this time is:

##lte"ation in %oping "elated to pain

@Potential fo" inE$"y "elated to p"e%ipitate deli/e"y

C#lte"ation in elimination "elated to anesthesia

)Potential fo" fl$id /ol$me defi%it "elated to *PO stat$s

181 !he %lient with /a"i%ella will most liely ha/e an o"de" fo" whi%h %atego"y of medi%ationQ

##ntibioti%s

@#ntipy"eti%s

C#nti/i"als

)#nti%oag$lants

182 # %lient is admitted %omplaining of %hest pain Hhi%h of the following d"$g o"de"s sho$ld the n$"se

6$estionQ

#*it"ogly%e"in

@#mpi%illinCP"op"anolol

)7e"apamil

18+ Hhi%h of the following inst"$%tions sho$ld be in%l$ded in the tea%hing fo" the %lient with "he$matoid

a"th"itisQ

##/oid e-e"%ise be%a$se it fatig$es the Eoints

@!ae p"es%"ibed anti=inflammato"y medi%ations with meals

C#lte"nate hot and %old pa%s to affe%ted Eoints

)#/oid weight=bea"ing a%ti/ity

18. # %lient with a%$te pan%"eatitis is e-pe"ien%ing se/e"e abdominal pain Hhi%h of the following o"de"s

sho$ld be 6$estioned by the n$"seQ

#<epe"idine 100mg I< 6 . ho$"s P* pain

@<ylanta +0 %%s 6 . ho$"s /ia *D




CCimetadine +00mg PO 6id

)<o"phine mg I< 6 . ho$"s P* pain

18 !he %lient is admitted to the %hemi%al dependen%e $nit with an o"de" fo" %ontin$o$s obse"/ation !he

n$"se is awa"e that the do%to" has o"de"ed %ontin$o$s obse"/ation be%a$se:

#?all$%inogeni% d"$gs %"eate both stim$lant and dep"essant effe%ts

@?all$%inogeni% d"$gs ind$%e a state of alte"ed pe"%eption

C?all$%inogeni% d"$gs p"od$%e se/e"e "espi"ato"y dep"ession

)?all$%inogeni% d"$gs ind$%e "apid physi%al dependen%e185 # %lient with a histo"y of ab$sing ba"bit$"ates ab"$ptly stops taing the medi%ation !he n$"se sho$ld gi/e

p"io"ity to assessing the %lient fo":

#)ep"ession and s$i%idal ideation

@!a%hy%a"dia and dia""hea

C<$s%le %"amping and abdominal pain

)!a%hy%a"dia and e$pho"i% mood

188 )$"ing the assessment of a labo"ing %lient& the n$"se notes that the F?! a"e lo$dest in the $ppe"="ight

6$ad"ant !he infant is most liely in whi%h positionQ

#ight b"ee%h p"esentation@ight o%%ipital ante"io" p"esentation

C'eft sa%"al ante"io" p"esentation

)'eft o%%ipital t"ans/e"se p"esentation18 !he p"ima"y physiologi%al alte"ation in the de/elopment of asthma is:

#@"on%hiola" inflammation and dyspnea

@?ype"se%"etion of abno"mally /is%o$s m$%$s

CInfe%tio$s p"o%esses %a$sing m$%osal edema

)Spasm of b"on%hiola" smooth m$s%le

189 # %lient with mania is $nable to finish he" dinne" !o help he" maintain s$ffi%ient no$"ishment& the n$"se

sho$ld:

#Se"/e high=%alo"ie foods she %an %a""y with he"

@,n%o$"age he" appetite by sending o$t fo" he" fa/o"ite foods

CSe"/e he" small& att"a%ti/ely a""anged po"tions

)#llow he" in the $nit it%hen fo" e-t"a food whene/e" she pleases

10 !o maintain @"yants t"a%tion& the n$"se m$st mae %e"tain that the %hilds:#?ips a"e "esting on the bed& with the legs s$spended at a "ight angle to the bed

@?ips a"e slightly ele/ated abo/e the bed and the legs a"e s$spended at a "ight angle to the bed

C?ips a"e ele/ated abo/e the le/el of the body on a pillow and the legs a"e s$spended pa"allel to the bed)?ips and legs a"e flat on the bed& with the t"a%tion positioned at the foot of the bed

11 Hhi%h a%tion by the n$"se indi%ates $nde"standing of he"pes (oste"Q

#!he n$"se %o/e"s the lesions with a ste"ile d"essing

@!he n$"se wea"s glo/es when p"o/iding %a"e

C!he n$"se administe"s a p"es%"ibed antibioti%

)!he n$"se administe"s o-ygen

12 !he %lient has an o"de" fo" a t"o$gh to be d"awn on the %lient "e%ei/ing 7an%omy%in !he n$"se is awa"e

that the n$"se sho$ld %onta%t the lab fo" them to %olle%t the blood:

#1 min$tes afte" the inf$sion

@+0 min$tes befo"e the inf$sion

C1 ho$" afte" the inf$sion

)2 ho$"s afte" the inf$sion

1+ !he %lient $sing a diaph"agm sho$ld be inst"$%ted to:

#ef"ain f"om eeping the diaph"agm in longe" than . ho$"s

@eep the diaph"agm in a %ool lo%ation

C?a/e the diaph"agm "esi(ed if she gains po$nds

)?a/e the diaph"agm "esi(ed if she has any s$"ge"y

1. !he n$"se is p"o/iding postpa"t$m tea%hing fo" a mothe" planning to b"eastfeed he" infant Hhi%h of the%lients statements indi%ates the need fo" additional tea%hingQ

#LIm wea"ing a s$ppo"t b"aL

@LIm e-p"essing mil f"om my b"eastL

CLIm d"ining fo$" glasses of fl$id d$"ing a 2.=ho$" pe"iodL

)LHhile Im in the showe"& Ill allow the wate" to "$n o/e" my b"eastsL

1 )amage to the 7II %"anial ne"/e "es$lts in:

#Fa%ial pain

@#bsen%e of ability to smell

C#bsen%e of eye mo/ement

)!innit$s

15 # %lient is "e%ei/ing Py"idi$m phena(opy"idine hyd"o%hlo"ide fo" a $"ina"y t"a%t infe%tion !he %lient

sho$ld be ta$ght that the medi%ation may:




#Ca$se dia""hea

@Change the %olo" of he" $"ine

CCa$se mental %onf$sion

)Ca$se %hanges in taste

18 Hhi%h of the following tests sho$ld be pe"fo"med befo"e beginning a p"es%"iption of #%%$taneQ

#Che% the %al%i$m le/el

@Pe"fo"m a p"egnan%y test

C<onito" api%al p$lse)Obtain a %"eatinine le/el

1 # %lient with #I)S is taing Jo/i"a- a%y%lo/i" Hhi%h n$"sing inte"/ention is most %"iti%al d$"ing the

administ"ation of a%y%lo/i"Q

#'imit the %lients a%ti/ity

@,n%o$"age a high=%a"bohyd"ate diet

CUtili(e an in%enti/e spi"omete" to imp"o/e "espi"ato"y f$n%tion

),n%o$"age fl$ids

19 # %lient is admitted fo" an <I !he n$"se sho$ld 6$estion the %lient "ega"ding:

#P"egnan%y@# titani$m hip "epla%ement

C#lle"gies to antibioti%s

)Inability to mo/e his feet190 !he n$"se is %a"ing fo" the %lient "e%ei/ing #mphote"i%in @ Hhi%h of the following indi%ates that the

%lient has e-pe"ien%ed to-i%ity to this d"$gQ

#Changes in /ision

@*a$sea

CU"ina"y f"e6$en%y

)Changes in sin %olo"

191 !he n$"se sho$ld /isit whi%h of the following %lients fi"stQ

#!he %lient with diabetes with a blood gl$%ose of 9mgGd'

@!he %lient with hype"tension being maintained on 'isinop"il

C!he %lient with %hest pain and a histo"y of angina

)!he %lient with ayna$ds disease

192 # %lient with %ysti% fib"osis is taing pan%"eati% en(ymes !he n$"se sho$ld administe" this medi%ation:#On%e pe" day in the mo"ning

@!h"ee times pe" day with meals

COn%e pe" day at bedtime)Fo$" times pe" day

19+ Cata"a%ts "es$lt in opa%ity of the %"ystalline lens Hhi%h of the following best e-plains the f$n%tions of

the lensQ

#!he lens %ont"ols stim$lation of the "etina

@!he lens o"%hest"ates eye mo/ement

C!he lens fo%$ses light "ays on the "etina

)!he lens magnifies small obEe%ts

19. # %lient who has gla$%oma is to ha/e mioti% eyed"ops instilled in both eyes !he n$"se nows that the

p$"pose of the medi%ation is to:

##nestheti(e the %o"nea

@)ilate the p$pils

CConst"i%t the p$pils

)Pa"aly(e the m$s%les of a%%ommodation

19 # %lient with a se/e"e %o"neal $l%e" has an o"de" fo" Dentamy%in gtt 6 . ho$"s and *eomy%in 1 gtt 6 .

ho$"s Hhi%h of the following s%hed$les sho$ld be $sed when administe"ing the d"opsQ

##llow min$tes between the two medi%ations

@!he medi%ations may be $sed togethe"

C!he medi%ations sho$ld be sepa"ated by a %y%loplegi% d"$g)!he medi%ations sho$ld not be $sed in the same %lient

195 !he %lient with %olo" blindness will most liely ha/e p"oblems disting$ishing whi%h of the following

%olo"sQ

#O"ange

@7iolet

Ced

)Hhite

198 !he %lient with a pa%emae" sho$ld be ta$ght to:

#epo"t anle edema

@Che% his blood p"ess$"e daily

Cef"ain f"om $sing a mi%"owa/e o/en

)<onito" his p$lse "ate




19 !he %lient with en$"esis is being ta$ght "ega"ding bladde" "et"aining !he n$"se sho$ld ad/ise the %lient to

"ef"ain f"om d"ining afte":

#1900

@1200

C1000

)0800

199 Hhi%h of the following diet inst"$%tions sho$ld be gi/en to the %lient with "e%$""ing $"ina"y t"a%t

infe%tionsQ#In%"ease intae of meats

@#/oid %it"$s f"$its

CPe"fo"m pe"i%a"e with hyd"ogen pe"o-ide

))"in a glass of %"anbe""y E$i%e e/e"y day

200 !he physi%ian has p"es%"ibed *P? ins$lin fo" a %lient with diabetes mellit$s Hhi%h statement indi%ates

that the %lient nows when the pea a%tion of the ins$lin o%%$"sQ

#LI will mae s$"e I eat b"eafast within 2 ho$"s of taing my ins$linL

@LI will need to %a""y %andy o" some fo"m of s$ga" with me all the timeL

CLI will eat a sna% a"o$nd th"ee o%lo% ea%h afte"noonL)LI %an sa/e my desse"t f"om s$ppe" fo" a bedtime sna%L

201 # %lient with pne$ma%ystis %a"ini pne$monia is "e%ei/ing t"imet"e-ate !he "ationale fo" administe"ing

le$%o/o"in %al%i$m to a %lient "e%ei/ing <ethot"e-ate is to:#!"eat anemia

@C"eate a syne"gisti% effe%t

CIn%"ease the n$mbe" of white blood %ells

)e/e"se d"$g to-i%ity

202 # %lient tells the n$"se that she is alle"gi% to eggs& dogs& "abbits& and %hi%en feathe"s Hhi%h o"de" sho$ld

the n$"se 6$estionQ

#!@ sin test

@$bella /a%%ine

C,'IS# test

)Chest -="ay

20+ !he physi%ian has p"es%"ibed "antidine Janta% fo" a %lient with e"osi/e gast"itis !he n$"se sho$ld

administe" the medi%ation:#+0 min$tes befo"e meals

@Hith ea%h meal

CIn a single dose at bedtime)50 min$tes afte" meals

20. # tempo"a"y %olostomy is pe"fo"med on the %lient with %olon %an%e" !he n$"se is awa"e that the p"o-imal

end of a do$ble ba""el %olostomy:

#Is the opening on the %lients left side

@Is the opening on the distal end on the %lients left side

CIs the opening on the %lients "ight side

)Is the opening on the distal "ight side

20 Hhile assessing the postpa"tal %lient& the n$"se notes that the f$nd$s is displa%ed to the "ight @ased on

this finding& the n$"se sho$ld:

##s the %lient to /oid

@#ssess the blood p"ess$"e fo" hypotension

C#dministe" o-yto%in

)Che% fo" /aginal bleeding

205 !he physi%ian has o"de"ed an <I fo" a %lient with an o"thopedi% ailment #n <I sho$ld not be done if

the %lient has:

#!he need fo" o-ygen the"apy

@# histo"y of %la$st"ophobia

C# pe"manent pa%emae" )Senso"y deafness

208 # 5=month=old %lient is pla%ed on st"i%t bed "est following a he"nia "epai" Hhi%h toy is best s$ited to the

%lientQ

#Colo"f$l %"ib mobile

@?and=held ele%t"oni% games

CCa"s in a plasti% %ontaine"

)+0=pie%e Eigsaw p$((le

20 !he n$"se is p"epa"ing to dis%ha"ge a %lient with a long histo"y of polio !he n$"se sho$ld tell the %lient

that:

#!aing a hot bath will de%"ease stiffness and spasti%ity

@# s%hed$le of st"en$o$s e-e"%ise will imp"o/e m$s%le st"ength

Cest pe"iods sho$ld be s%hed$led th"o$gho$t the day




)7is$al dist$"ban%es %an be %o""e%ted with p"es%"iption glasses

209 # %lient on the postpa"t$m $nit has a p"o%toepisiotomy !he n$"se sho$ld anti%ipate administe"ing whi%h

medi%ationQ

#)$l%ola- s$pposito"y

@)o%$sate sodi$m Cola%e

C<ethye"gono/ine maleate <ethe"gine

)@"omo%"iptine s$lfate Pa"lodel

210 # %lient with pan%"eati% %an%e" has an inf$sion of !P* !otal Pa"ente"al *$t"ition !he do%to" haso"de"ed fo" sliding=s%ale ins$lin !he most liely e-planation fo" this o"de" is:

#!otal Pa"ente"al *$t"ition leads to negati/e nit"ogen balan%e and ele/ated gl$%ose le/els

@!otal Pa"ente"al *$t"ition %annot be managed with o"al hypogly%emi%s

C!otal Pa"ente"al *$t"ition is a high=gl$%ose sol$tion that often ele/ates the blood gl$%ose le/els

)!otal Pa"ente"al *$t"ition leads to f$"the" pan%"eati% disease

211 #n adoles%ent p"imig"a/ida who is 10 wees p"egnant attends the antepa"tal %lini% fo" a fi"st %he%=$p !o

de/elop a tea%hing plan& the n$"se sho$ld initially assess:

#!he %lients nowledge of the signs of p"ete"m labo"

@!he %lients feelings abo$t the p"egnan%yCHhethe" the %lient was $sing a method of bi"th %ont"ol

)!he %lients tho$ght abo$t f$t$"e %hild"en

212 #n obstet"i% %lient is admitted with dehyd"ation Hhi%h I7 fl$id wo$ld be most app"op"iate fo" the %lientQ#. no"mal saline

@)e-t"ose 1V in wate"

C'a%tated inge"s

))e-t"ose V in . no"mal saline

21+ !he physi%ian has o"de"ed a thy"oid s%an to %onfi"m the diagnosis @efo"e the p"o%ed$"e& the n$"se

sho$ld:

##ssess the %lient fo" alle"gies

@@ol$s the %lient with I7 fl$id

C!ell the %lient he will be asleep

)Inse"t a $"ina"y %athete"

21. !he physi%ian has o"de"ed an inEe%tion of hoDam fo" a %lient with blood type # negati/e !he n$"se

$nde"stands that hoDam is gi/en to:#P"o/ide imm$nity against h isoen(ymes

@P"e/ent the fo"mation of h antibodies

C,liminate %i"%$lating h antibodies)Con/e"t the h fa%to" f"om negati/e to positi/e

21 !he n$"se is %a"ing fo" a %lient admitted to the eme"gen%y "oom afte" a fall ;="ays "e/eal that the %lient

has se/e"al f"a%t$"ed bones in the foot Hhi%h t"eatment sho$ld the n$"se anti%ipate fo" the f"a%t$"ed footQ

##ppli%ation of a sho"t in%l$si/e spi%a %ast

@Stabili(ation with a plaste"=of=Pa"is %ast

CS$"ge"y with i"s%hne" wi"e implantation

)# ga$(e d"essing only

215 # %lient with bladde" %an%e" is being t"eated with i"idi$m seed implants !he n$"ses dis%ha"ge tea%hing

sho$ld in%l$de telling the %lient to:

#St"ain his $"ine

@In%"ease his fl$id intae

Cepo"t $"ina"y f"e6$en%y

)#/oid p"olonged sitting

218 Following a hea"t t"ansplant& a %lient is sta"ted on medi%ation to p"e/ent o"gan "eEe%tion Hhi%h %atego"y

of medi%ation p"e/ents the fo"mation of antibodies against the new o"ganQ

##nti/i"als

@#ntibioti%s

CImm$nos$pp"essants)#nalgesi%s

21 !he n$"se is p"epa"ing a %lient fo" %ata"a%t s$"ge"y !he n$"se is awa"e that the p"o%ed$"e will $se:

#<yd"iati%s to fa%ilitate "emo/al

@<ioti% medi%ations s$%h as !imopti%

C# lase" to smooth and "eshape the lens

)Sili%one oil inEe%tions into the eyeball

219 # %lient with #l(heime"s disease is awaiting pla%ement in a silled n$"sing fa%ility Hhi%h long=te"m

plans wo$ld be most the"ape$ti% fo" the %lientQ

#Pla%ing mi""o"s in se/e"al lo%ations in the home

@Pla%ing a pi%t$"e of he"self in he" bed"oom

CPla%ing simple signs to indi%ate the lo%ation of the bed"oom& bath"oom& and so on

)#lte"nating health%a"e wo"e"s to p"e/ent bo"edom




220 # %lient with an abdominal %hole%yste%tomy "et$"ns f"om s$"ge"y with a Ba%son=P"att d"ain !he %hief

p$"pose of the Ba%son=P"att d"ain is to:

#P"e/ent the need fo" d"essing %hanges

@ed$%e edema at the in%ision

CP"o/ide fo" wo$nd d"ainage

)eep the %ommon bile d$%t open

221 !he n$"se is pe"fo"ming an initial assessment of a newbo"n Ca$%asian male deli/e"ed at +2 wees

gestation !he n$"se %an e-pe%t to find the p"esen%e of:#<ongolian spots

@S%"otal "$gae

C?ead lag

)7e"ni- %aseosa

222 !he n$"se is %a"ing fo" a %lient admitted with m$ltiple t"a$ma F"a%t$"es in%l$de the pel/is& fem$"& and

$lna Hhi%h finding sho$ld be "epo"ted to the physi%ian immediatelyQ

#?emat$"ia

@<$s%le spasms

C)i((iness)*a$sea

22+ # %lient is b"o$ght to the eme"gen%y "oom by the poli%e ?e is %ombati/e and yells& LI ha/e to get o$t of

he"e !hey a"e t"ying to ill meL Hhi%h assessment is most liely %o""e%t in "elation to this statementQ#!he %lient is e-pe"ien%ing an a$dito"y hall$%ination

@!he %lient is ha/ing a del$sion of g"ande$"

C!he %lient is e-pe"ien%ing pa"anoid del$sions

)!he %lient is into-i%ated

22. !he n$"se is p"epa"ing to s$%tion the %lient with a t"a%heotomy !he n$"se notes a p"e/io$sly $sed bottle

of no"mal saline on the %lients bedside table !he"e is no label to indi%ate the date o" time of initial $se !he

n$"se sho$ld:

#'ip the bottle and $se a pa% of ste"ile .-. fo" the d"essing

@Obtain a new bottle and label it with the date and time of fi"st $se

C#s the wa"d se%"eta"y when the sol$tion was "e6$ested

)'abel the e-isting bottle with the %$""ent date and time

22 #n infants #pga" s%o"e is 9 at min$tes !he n$"se is awa"e that the most liely %a$se fo" the ded$%tionof one point is:

#!he baby is %old

@!he baby is e-pe"ien%ing b"ady%a"diaC!he babys hands and feet a"e bl$e

)!he baby is letha"gi%

225 !he p"ima"y "eason fo" "apid %ontin$o$s "ewa"ming of the a"ea affe%ted by f"ostbite is to:

#'essen the amo$nt of %ell$la" damage

@P"e/ent the fo"mation of bliste"s

CP"omote mo/ement

)P"e/ent pain and dis%omfo"t

228 # %lient "e%ently sta"ted on hemodialysis wants to now how the dialysis will tae the pla%e of his

idneys !he n$"ses "esponse is based on the nowledge that hemodialysis wo"s by:

#Passing wate" th"o$gh a dialy(ing memb"ane

@,liminating plasma p"oteins f"om the blood

C'owe"ing the p? by "emo/ing non/olatile a%ids

)Filte"ing waste th"o$gh a dialy(ing memb"ane

22 )$"ing a home /isit& a %lient with #I)S tells the n$"se that he has been e-posed to measles Hhi%h a%tion

by the n$"se is most app"op"iateQ

##dministe" an antibioti%

@Conta%t the physi%ian fo" an o"de" fo" imm$ne glob$lin

C#dministe" an anti/i"al)!ell the %lient that he sho$ld "emain in isolation fo" 2 wees

229 # %lient hospitali(ed with <S# methi%illin="esistant staph a$"e$s is pla%ed on %onta%t p"e%a$tions

Hhi%h statement is t"$e "ega"ding p"e%a$tions fo" infe%tions sp"ead by %onta%tQ

#!he %lient sho$ld be pla%ed in a "oom with negati/e p"ess$"e

@Infe%tion "e6$i"es %lose %onta%tW the"efo"e& the doo" may "emain open

C!"ansmission is highly liely& so the %lient sho$ld wea" a mas at all times

)Infe%tion "e6$i"es sin=to=sin %onta%t and is p"e/ented by hand washing& glo/es& and a gown

2+0 # %lient who is admitted with an abo/e=the=nee amp$tation tells the n$"se that his foot h$"ts and it%hes

Hhi%h "esponse by the n$"se indi%ates $nde"standing of phantom limb painQ

#L!he pain will go away in a few daysL

@L!he pain is d$e to pe"iphe"al ne"/o$s system inte""$ptions I will get yo$ some pain medi%ationL

CL!he pain is psy%hologi%al be%a$se yo$" foot is no longe" the"eL




)L!he pain and it%hing a"e d$e to the infe%tion yo$ had befo"e the s$"ge"yL

2+1 # %lient with %an%e" of the pan%"eas has $nde"gone a Hhipple p"o%ed$"e !he n$"se is awa"e that d$"ing

the Hhipple p"o%ed$"e& the do%to" will "emo/e the:

#?ead of the pan%"eas

@P"o-imal thi"d se%tion of the small intestines

CStoma%h and d$oden$m

),sophag$s and EeE$n$m

2+2 !he physi%ian has o"de"ed a minimal=ba%te"ia diet fo" a %lient with ne$t"openia !he %lient sho$ld beta$ght to a/oid eating:

#F"$its

@Salt

CPeppe"

)et%h$p

2++ # %lient is dis%ha"ged home with a p"es%"iption fo" Co$madin sodi$m wa"fa"in !he %lient sho$ld be

inst"$%ted to:

#?a/e a P"otime done monthly

@,at mo"e f"$its and /egetablesC)"in mo"e li6$ids

)#/oid %"owds

2+. !he n$"se is assisting the physi%ian with "emo/al of a %ent"al /eno$s %athete" !o fa%ilitate "emo/al& then$"se sho$ld inst"$%t the %lient to:

#Pe"fo"m the 7alsal/a mane$/e" as the %athete" is ad/an%ed

@!$"n his head to the left side and hype"e-tend the ne%

C!ae slow& deep b"eaths as the %athete" is "emo/ed

)!$"n his head to the "ight while maintaining a sniffing position

2+ # %lient has an o"de" fo" st"eptoinase @efo"e administe"ing the medi%ation& the n$"se sho$ld assess the

%lient fo":

##lle"gies to pineapples and bananas

@# histo"y of st"epto%o%%al infe%tions

CP"io" the"apy with phenytoin

)# histo"y of al%ohol ab$se

2+5 !he n$"se is p"o/iding dis%ha"ge tea%hing fo" the %lient with le$emia !he %lient sho$ld be told to a/oid:#Using oil= o" %"eam=based soaps

@Flossing between the teeth

C!he intae of salt)Using an ele%t"i% "a(o"

2+8 !he n$"se is %hanging the ties of the %lient with a t"a%heotomy !he safest method of %hanging the

t"a%heotomy ties is to:

##pply the new tie befo"e "emo/ing the old one

@?a/e a helpe" p"esent

C?old the t"a%heotomy with the nondominant hand while "emo/ing the old tie

)#s the do%to" to s$t$"e the t"a%heostomy in pla%e

2+ !he n$"se is monito"ing a %lient following a l$ng "ese%tion !he ho$"ly o$tp$t f"om the %hest t$be was

+00m' !he n$"se sho$ld gi/e p"io"ity to:

#!$"ning the %lient to the left side

@<iling the t$be to ens$"e paten%y

CSlowing the int"a/eno$s inf$sion

)*otifying the physi%ian

2+9 !he infant is admitted to the $nit with tet"ology of falot !he n$"se wo$ld anti%ipate an o"de" fo" whi%h

medi%ationQ

#)igo-in

@,pineph"ine

C#minophyline)#t"opine

2.0 !he n$"se is ed$%ating the ladys %l$b in self=b"east e-am !he n$"se is awa"e that most malignant b"east

masses o%%$" in the !ail of Spen%e On the diag"am& pla%e an ; on the !ail of Spen%e




2.1 !he toddle" is admitted with a %a"dia% anomaly !he n$"se is awa"e that the infant with a /ent"i%$la"

septal defe%t will:

#!i"e easily

@D"ow no"mally

C*eed mo"e %alo"ies)@e mo"e s$s%eptible to /i"al infe%tions

2.2 !he n$"se is monito"ing a %lient with a histo"y of stillbo"n infants !he n$"se is awa"e that a nonst"ess test

%an be o"de"ed fo" this %lient to:

#)ete"mine l$ng mat$"ity@<eas$"e the fetal a%ti/ity

CShow the effe%t of %ont"a%tions on fetal hea"t "ate

)<eas$"e the well=being of the fet$s

2.+ !he n$"se is e/al$ating the %lient who was admitted ho$"s ago fo" ind$%tion of labo" !he following

g"aph is noted on the monito" Hhi%h a%tion sho$ld be taen fi"st by the n$"seQ

#Inst"$%t the %lient to p$sh

@Pe"fo"m a /aginal e-am

C!$"n off the Pito%in inf$sion

)Pla%e the %lient in a semi=Fowle"s position

2.. !he n$"se notes the following on the ,CD monito" !he n$"se wo$ld e/al$ate the %a"dia% a""hythmia as:

##t"ial fl$tte"

@# sin$s "hythm

C7ent"i%$la" ta%hy%a"dia

)#t"ial fib"illation

2. # %lient with %lotting diso"de" has an o"de" to %ontin$e 'o/eno- eno-apa"in inEe%tions afte" dis%ha"ge

!he n$"se sho$ld tea%h the %lient that 'o/eno- inEe%tions sho$ld:




#@e inEe%ted into the deltoid m$s%le

@@e inEe%ted into the abdomen

C#spi"ate afte" the inEe%tion

)Clea" the ai" f"om the sy"inge befo"e inEe%tions

2.5 !he n$"se has a p"eop o"de" to administe" 7ali$m dia(epam 10mg and Phene"gan p"ometha(ine 2mg

!he %o""e%t method of administe"ing these medi%ations is to:

##dministe" the medi%ations togethe" in one sy"inge

@#dministe" the medi%ation sepa"atelyC#dministe" the 7ali$m& wait min$tes& and then inEe%t the Phene"gan

)>$estion the o"de" be%a$se they %annot be gi/en at the same time

2.8 # %lient with f"e6$ent $"ina"y t"a%t infe%tions ass the n$"se how she %an p"e/ent the "eo%%$""en%e !he

n$"se sho$ld tea%h the %lient to:

#)o$%he afte" inte"%o$"se

@7oid e/e"y + ho$"s

CObtain a $"inalysis monthly

)Hipe f"om ba% to f"ont afte" /oiding

2. Hhi%h tas sho$ld be assigned to the n$"sing assistantQ#Pla%ing the %lient in se%l$sion

@,mptying the Foley %athete" of the p"ee%lampti% %lient

CFeeding the %lient with dementia)#mb$lating the %lient with a f"a%t$"ed hip

2.9 !he %lient has "e%ently "et$"ned f"om ha/ing a thy"oide%tomy !he n$"se sho$ld eep whi%h of the

following at the bedsideQ

## t"a%heotomy set

@# padded tong$e blade

C#n endot"a%heal t$be

)#n ai"way

20 !he physi%ian has o"de"ed a histoplasmosis test fo" the elde"ly %lient !he n$"se is awa"e that

histoplasmosis is t"ansmitted to h$mans by:

#Cats

@)ogs

C!$"tles)@i"ds




A$s-!rs a$% Rati#$a+!s #r C#6*r!/!$si8! E<a6i$ati#$ Part 2

1 #nswe" ) is %o""e%t It is impo"tant to assess the e-t"emities fo" blood /essel o%%l$sion in the %lient with si%le

%ell anemia be%a$se a %hange in %apilla"y "efill wo$ld indi%ate a %hange in %i"%$lation @ody tempe"at$"e&motion& and sensation wo$ld not gi/e info"mation "ega"ding pe"iphe"al %i"%$lationW the"efo"e& answe"s #& @&

and C a"e in%o""e%t

2 #nswe" ) is %o""e%t Pla%ing the %lient in semi=Fowle"Ks position p"o/ides the best o-ygenation fo" this %lient

Fle-ion of the hips and nees& whi%h in%l$des the nee=%hest position& impedes %i"%$lation and is not %o""e%t positioning fo" this %lient !he"efo"e& answe"s #& @& and C a"e in%o""e%t

+ #nswe" @ is %o""e%t It is impo"tant to eep the %lient in si%le %ell %"isis hyd"ated to p"e/ent f$"the" si%ling of

the blood #nswe" # is in%o""e%t be%a$se a me%hani%al %$ff pla%es too m$%h p"ess$"e on the a"m #nswe" C is

in%o""e%t be%a$se "aising the nee gat%h impedes %i"%$lation #nswe" ) is in%o""e%t be%a$se !ylenol is too

mild an analgesi% fo" the %lient in %"isis

. #nswe" C is %o""e%t ?yd"ation is impo"tant in the %lient with si%le %ell disease to p"e/ent th"omb$s

fo"mation Popsi%les& gelatin& E$i%e& and p$dding ha/e high fl$id %ontent !he foods in answe"s #& @& and ) do

not aid in hyd"ation and a"e& the"efo"e& in%o""e%t

#nswe" C is %o""e%t !he most p"ominent %lini%al manifestation of si%le %ell %"isis is pain ?owe/e"& the p$lse

o-imet"y indi%ates that o-ygen le/els a"e lowW th$s& o-ygenation taes p"e%eden%e o/e" pain "elief #nswe" #

is in%o""e%t be%a$se altho$gh a wa"m en/i"onment "ed$%es pain and minimi(es si%ling& it wo$ld not be a

p"io"ity #nswe" @ is in%o""e%t be%a$se altho$gh hyd"ation is impo"tant& it wo$ld not "e6$i"e a bol$s #nswe") is in%o""e%t be%a$se )eme"ol is a%idifying to the blood and in%"eases si%ling

5 #nswe" C is %o""e%t ,gg yols& wheat b"ead& %a""ots& "aisins& and g"een& leafy /egetables a"e all high in i"on&whi%h is an impo"tant mine"al fo" this %lient oast beef& %abbage& and po" %hops a"e also high in i"on& b$t the

side dishes a%%ompanying these %hoi%es a"e notW the"efo"e& answe"s #& @& and ) a"e in%o""e%t

8 #nswe" ) is %o""e%t !aing a t"ip to the m$se$m is the only answe" that does not pose a th"eat # family

/a%ation in the o%y <o$ntains at high altit$des& %old tempe"at$"es& and ai"plane t"a/el %an %a$se si%lingepisodes and sho$ld be a/oidedW the"efo"e& answe"s #& @& and C a"e in%o""e%t

#nswe" ) is %o""e%t !he tong$e is smooth and beefy "ed in the %lient with /itamin @12 defi%ien%y& so

e-amining the tong$e sho$ld be in%l$ded in the physi%al assessment @leeding& splenomegaly& and blood

p"ess$"e %hanges do not o%%$"& maing answe"s #& @& and C in%o""e%t

9 #nswe" C is %o""e%t !he o"al m$%osa and ha"d palate "oof of the mo$th a"e the best indi%ato"s of Ea$ndi%e in

da"=sinned pe"sons !he %onE$n%ti/a %an ha/e no"mal deposits of fat& whi%h gi/e a yellowish h$eW th$s&answe" # is in%o""e%t !he soles of the feet %an be yellow if they a"e %allo$sed& maing answe" @ in%o""e%tW the

shins wo$ld be an a"ea of da"e" pigment& so answe" ) is in%o""e%t

10 #nswe" @ is %o""e%t Hhen the"e a"e fewe" "ed blood %ells& the"e is less hemoglobin and less o-ygen

!he"efo"e& the %lient is often sho"t of b"eath& as indi%ated in answe" @ !he %lient with anemia is often pale in

%olo"& has weight loss& and may be hypotensi/e #nswe"s #& C& and ) a"e within no"mal and& the"efo"e& a"e

in%o""e%t

11 #nswe" # is %o""e%t !he %lient with poly%ythemia /e"a is at "is fo" th"omb$s fo"mation ?yd"ating the

%lient with at least +' of fl$id pe" day is impo"tant in p"e/enting %lot fo"mation& so the statement to d"in lessthan 00m' is in%o""e%t #nswe"s @& C& and ) a"e in%o""e%t be%a$se they all %ont"ib$te to the p"e/ention of

%ompli%ations S$ppo"t hose p"omotes /eno$s "et$"n& the ele%t"i% "a(o" p"e/ents bleeding d$e to inE$"y& and a

diet low in i"on is essential to p"e/enting f$"the" "ed %ell fo"mation

12 #nswe" C is %o""e%t adiation t"eatment fo" othe" types of %an%e" %an "es$lt in le$emia Some hobbies ando%%$pations in/ol/ing %hemi%als a"e lined to le$emia& b$t not the ones in these answe"sW the"efo"e& answe"s

# and @ a"e in%o""e%t #nswe" ) is in%o""e%t be%a$se the in%iden%e of le$emia is highe" in twins than in

siblings

1+ #nswe" ) is %o""e%t Pete%hiae a"e not $s$ally /is$ali(ed on da" sin !he soles of the feet and palms of the

hand p"o/ide a lighte" s$"fa%e fo" assessing the %lient fo" peti%hiae #nswe"s #& @& and C a"e in%o""e%t be%a$se

the sin might be too da" to mae an assessment

1. #nswe" @ is %o""e%t !he %lient with le$emia is at "is fo" infe%tion and has often had "e%$""ent "espi"ato"y

infe%tions d$"ing the p"e/io$s 5 months Insomnolen%e& weight loss& and a de%"ease in ale"tness also o%%$" in

le$emia& b$t bleeding tenden%ies and infe%tions a"e the p"ima"y %lini%al manifestationsW the"efo"e& answe"s #&

C& and ) a"e in%o""e%t

1 #nswe" @ is %o""e%t !he %lient with a%$te le$emia has bleeding tenden%ies d$e to de%"eased platelet %o$nts&

and any inE$"y wo$ld e-a%e"bate the p"oblem !he %lient wo$ld "e6$i"e %lose monito"ing fo" hemo""hage&

whi%h is of highe" p"io"ity than the diagnoses in answe"s #& C& and )& whi%h a"e in%o""e%t

15 #nswe" # is %o""e%t adiation the"apy often %a$ses ste"ility in male %lients and wo$ld be of p"ima"yimpo"tan%e to this %lient !he psy%hoso%ial needs of the %lient a"e impo"tant to add"ess in light of the age and

life %hoi%es ?odginKs disease& howe/e"& has a good p"ognosis when diagnosed ea"ly #nswe"s @& C& and )

a"e in%o""e%t be%a$se they a"e of lesse" p"io"ity

18 #nswe" # is %o""e%t Clients with a$toimm$ne th"ombo%ytopeni% p$"p$"a #!P ha/e low platelet %o$nts&

maing answe" # the %o""e%t answe" Hhite %ell %o$nts& potassi$m le/els& and P!! a"e not affe%ted in #!PW

th$s& answe"s @& C& and ) a"e in%o""e%t




1 #nswe" # is %o""e%t !he no"mal platelet %o$nt is 120&000X.00&000 @leeding o%%$"s in %lients with low

platelets !he p"io"ity is to p"e/ent and minimi(e bleeding O-ygenation in answe" C is impo"tant& b$t platelets

do not %a""y o-ygen #nswe"s @ and ) a"e of lesse" p"io"ity and a"e in%o""e%t in this instan%e

19 #nswe" C is %o""e%t ,le/ating the head of the bed +0R a/oids p"ess$"e on the sella t$"%i%a and alle/iates

heada%hes #nswe"s #& @& and ) a"e in%o""e%t be%a$se !"endelenb$"g& 7alsal/a mane$/e"& and %o$ghing all

in%"ease the int"a%"anial p"ess$"e20 #nswe" @ is %o""e%t !he la"ge amo$nt of fl$id loss %an %a$se fl$id and ele%t"olyte imbalan%e that sho$ld be

%o""e%ted !he loss of ele%t"olytes wo$ld be "efle%ted in the /ital signs <eas$"ing the $"ina"y o$tp$t isimpo"tant& b$t the stem al"eady says that the %lient has poly$"ia& so answe" # is in%o""e%t ,n%o$"aging fl$id

intae will not %o""e%t the p"oblem& maing answe" C in%o""e%t #nswe" ) is in%o""e%t be%a$se weighing the

%lient is not ne%essa"y at this time

21 #nswe" C is %o""e%t !he %lient sho$ld be positioned $p"ight and leaning fo"wa"d& to p"e/ent aspi"ation of

blood #nswe"s #& @& and ) a"e in%o""e%t be%a$se di"e%t p"ess$"e to the nose stops the bleeding& and i%e pa%s

sho$ld be applied di"e%tly to the nose as well If a pa% is ne%essa"y& the na"es a"e loosely pa%ed

22 #nswe" # is %o""e%t @lood p"ess$"e is the best indi%ato" of %a"dio/as%$la" %ollapse in the %lient who has had

an ad"enal gland "emo/ed !he "emaining gland might ha/e been s$pp"essed d$e to the t$mo" a%ti/ity

!empe"at$"e wo$ld be an indi%ato" of infe%tion& de%"eased o$tp$t wo$ld be a %lini%al manifestation b$t wo$ld

tae longe" to o%%$" than blood p"ess$"e %hanges& and spe%ifi% g"a/ity %hanges o%%$" with othe" diso"de"sW

the"efo"e& answe"s @& C& and ) a"e in%o""e%t

2+ #nswe" # is %o""e%t I7 gl$%o%o"ti%oids "aise the gl$%ose le/els and often "e6$i"e %o/e"age with ins$lin#nswe" @ is not ne%essa"y at this time& sodi$m and potassi$m le/els wo$ld be monito"ed when the %lient is

"e%ei/ing mine"al %o"ti%oids& and daily weights is $nne%essa"yW the"efo"e& answe"s @& C& and ) a"e in%o""e%t

2. #nswe" @ is %o""e%t !he pa"athy"oid glands a"e "esponsible fo" %al%i$m p"od$%tion and %an be damaged

d$"ing a thy"oide%tomy !he tingling is d$e to low %al%i$m le/els !he %"ash %a"t wo$ld be needed in"espi"ato"y dist"ess b$t wo$ld not be the ne-t a%tion to taeW th$s& answe" # is in%o""e%t ?ype"tension o%%$"s

in thy"oid sto"m and the d"ainage wo$ld o%%$" in hemo""hage& so answe"s C and ) a"e in%o""e%t

2 #nswe" ) is %o""e%t !he de%"ease in p$lse %an affe%t the %a"dia% o$tp$t and lead to sho%& whi%h wo$ld tae

p"e%eden%e o/e" the othe" %hoi%esW the"efo"e& answe"s #& @& and C a"e in%o""e%t

25 #nswe" # is %o""e%t !he %lient taing antilipidemi%s sho$ld be en%o$"aged to "epo"t m$s%le weaness

be%a$se this is a sign of "habdomyositis !he medi%ation taes effe%t within 1 month of beginning the"apy& so

answe" @ is in%o""e%t !he medi%ation sho$ld be taen with wate" be%a$se f"$it E$i%e& pa"ti%$la"ly g"apef"$it&

%an de%"ease the effe%ti/eness& maing answe" C in%o""e%t 'i/e" f$n%tion st$dies sho$ld be %he%ed befo"e beginning the medi%ation& not afte" the fa%t& maing answe" ) in%o""e%t

28 #nswe" @ is %o""e%t ?ype"stat is gi/en I7 p$sh fo" hype"tensi/e %"ises& b$t it often %a$ses hype"gly%emia

!he gl$%ose le/el will d"op "apidly when stopped #nswe" # is in%o""e%t be%a$se the hype"stat is gi/en by I7

p$sh !he %lient sho$ld be pla%ed in do"sal "e%$mbent position& not a !"endelenb$"g position& as stated in

answe" C #nswe" ) is in%o""e%t be%a$se the medi%ation does not ha/e to be %o/e"ed with foil

2 #nswe" C is %o""e%t # hea"t "ate of 50 in the baby sho$ld be "epo"ted immediately !he dose sho$ld be held

if the hea"t "ate is below 100bpm !he blood gl$%ose& blood p"ess$"e& and "espi"ations a"e within no"mal limitsW

th$s answe"s #& @& and ) a"e in%o""e%t

29 #nswe" C is %o""e%t *it"ogly%e"ine sho$ld be ept in a b"own bottle o" e/en a spe%ial ai"= and wate"=tight&

solid o" plated sil/e" o" gold %ontaine" be%a$se of its instability and tenden%y to be%ome less potent whene-posed to ai"& light& o" wate" !he s$pply sho$ld be "eplenished e/e"y 5 months& not + months& and one tablet

sho$ld be taen e/e"y min$tes $ntil pain s$bsides& so answe"s # and @ a"e in%o""e%t If the pain does nots$bside& the %lient sho$ld "epo"t to the eme"gen%y "oom !he medi%ation sho$ld be taen s$bling$ally and

sho$ld not be %"$shed& as stated in answe" )

+0 #nswe" C is %o""e%t !$"ey %ontains the least amo$nt of fats and %holeste"ol 'i/e"& eggs& beef& %"eam

sa$%es& sh"imp& %heese& and %ho%olate sho$ld be a/oided by the %lientW th$s& answe"s #& @& and ) a"e in%o""e%t

!he %lient sho$ld bae meat "athe" than f"ying to a/oid adding fat to the meat d$"ing %ooing

+1 #nswe" @ is %o""e%t !he E$g$la" /eins in the ne% sho$ld be assessed fo" distension !he othe" pa"ts of the

body will be edemato$s in "ight=sided %ongesti/e hea"t fail$"e& not left=sidedW th$s& answe"s #& C& and ) a"e

in%o""e%t

+2 #nswe" # is %o""e%t !he phlebostati% a-is is lo%ated at the fifth inte"%ostals spa%e mida-illa"y line and is the

%o""e%t pla%ement of the manomete" !he P<I o" point of ma-imal imp$lse is lo%ated at the fifth inte"%ostals

spa%e mid%la/i%$la" line& so answe" @ is in%o""e%t ,"bKs point is the point at whi%h yo$ %an hea" the /al/es

%lose sim$ltaneo$sly& maing answe" C in%o""e%t !he !ail of Spen%e the $ppe" o$te" 6$ad"ant is the a"ea

whe"e most b"east %an%e"s a"e lo%ated and has nothing to do with pla%ement of a manomete"W th$s& answe" ) is

in%o""e%t

++ #nswe" @ is %o""e%t Jest"il is an #C, inhibito" and is f"e6$ently gi/en with a di$"eti% s$%h as 'asi- fo"

hype"tension #nswe"s #& C& and ) a"e in%o""e%t be%a$se the o"de" is a%%$"ate !he"e is no need to 6$estion theo"de"& administe" the medi%ation sepa"ately& o" %onta%t the pha"ma%y

+. #nswe" @ is %o""e%t !he best indi%ato" of pe"iphe"al edema is meas$"ing the e-t"emity # pape" tape

meas$"e sho$ld be $sed "athe" than one of plasti% o" %loth& and the a"ea sho$ld be ma"ed with a pen& p"o/iding

the most obEe%ti/e assessment #nswe" # is in%o""e%t be%a$se weighing the %lient will not indi%ate pe"iphe"al

edema #nswe" C is in%o""e%t be%a$se %he%ing the intae and o$tp$t will not indi%ate pe"iphe"al edema




#nswe" ) is in%o""e%t be%a$se %he%ing fo" pitting edema is less "eliable than meas$"ing with a pape" tape

meas$"e

+ #nswe" ) is %o""e%t Clients with "adi$m implants sho$ld ha/e %lose %onta%t limited to +0 min$tes pe" /isit

!he gene"al "$le is limiting time spent e-posed to "adi$m& p$tting distan%e between people and the "adi$m

so$"%e& and $sing lead to shield against the "adi$m !ea%hing the family membe" these p"in%iples is e-t"emely

impo"tant #nswe"s #& @& and C a"e not empatheti% and do not add"ess the 6$estionW the"efo"e& they a"e

in%o""e%t

+5 #nswe" @ is %o""e%t !he %lient with a fa%ial st"oe will ha/e diffi%$lty swallowing and %hewing& and thefoods in answe" @ p"o/ide the least amo$nt of %hewing !he foods in answe"s #& C& and ) wo$ld "e6$i"e mo"e

%hewing and& th$s& a"e in%o""e%t

+8 #nswe" # is %o""e%t *o/alog ins$lin onsets /e"y 6$i%ly& so food sho$ld be a/ailable within 10X1 min$tes

of taing the ins$lin #nswe" @ does not add"ess a pa"ti%$la" type of ins$lin& so it is in%o""e%t *P? ins$lin

peas in X12 ho$"s& so a sna% sho$ld be eaten at the e-pe%ted pea time It may not be + pm as stated in

answe" C #nswe" ) is in%o""e%t be%a$se the"e is no need to sa/e the desse"t $ntil bedtime

+ #nswe" @ is %o""e%t !he $mbili%al %o"d needs time to d"y and fall off befo"e p$tting the infant in the t$b

#ltho$gh answe"s #& C& and ) might be impo"tant& they a"e not the p"ima"y answe" to the 6$estion

+9 #nswe" ) is %o""e%t 'e$%o/o"in is the antidote fo" <ethot"e-ate and !"imet"e-ate whi%h a"e foli% a%idantagonists 'e$%o/o"in is a foli% a%id de"i/ati/e #nswe"s #& @& and C a"e in%o""e%t be%a$se 'e$%o/o"in does

not t"eat i"on defi%ien%y& in%"ease ne$t"ophils& o" ha/e a syne"gisti% effe%t

.0 #nswe" # is %o""e%t !he ?emophil$s infl$en(a /a%%ine is gi/en at . months with the polio /a%%ine#nswe"s @& C& and ) a"e in%o""e%t be%a$se these /a%%ines a"e gi/en late" in life

.1 #nswe" @ is %o""e%t P"oton p$mp inhibito"s s$%h as *e-i$m and P"otoni- sho$ld be taen with meals& fo"

optimal effe%t ?istamine=blo%ing agents s$%h as Janta% sho$ld be taen +0 min$tes befo"e meals& so answe"

# is in%o""e%t !agamet %an be taen in a single dose at bedtime& maing answe" C in%o""e%t #nswe" ) does

not t"eat the p"oblem ade6$ately and& the"efo"e& is in%o""e%t

.2 #nswe" # is %o""e%t If the %lient is a th"eat to the staff and to othe" %lients the n$"se sho$ld %all fo" help and

p"epa"e to administe" a medi%ation s$%h as ?aldol to sedate him #nswe" @ is in%o""e%t be%a$se simply telling

the %lient to %alm down will not wo" #nswe" C is in%o""e%t be%a$se telling the %lient that if he %ontin$es he

will be p$nished is a th"eat and may f$"the" ange" him #nswe" ) is in%o""e%t be%a$se if the %lient is left alone

he might ha"m himself

.+ #nswe" # is %o""e%t If the f$nd$s of the %lient is displa%ed to the side& this might indi%ate a f$ll bladde" !he

ne-t a%tion by the n$"se sho$ld be to %he% fo" bladde" distention and %athete"i(e& if ne%essa"y !he answe"s in@& C& and ) a"e a%tions that "elate to postpa"tal hemo""hage

.. #nswe" C is %o""e%t # low=g"ade tempe"at$"e& blood=tinged sp$t$m& fatig$e& and night sweats a"e symptoms

%onsistent with t$be"%$losis If the answe" in # had said pne$mo%ystis pne$monia& answe" # wo$ld ha/e been%onsistent with the symptoms gi/en in the stem& b$t E$st saying pne$monia isnKt spe%ifi% eno$gh to diagnose

the p"oblem #nswe"s @ and ) a"e not di"e%tly "elated to the stem

. #nswe" @ is %o""e%t If the %lient has a histo"y of P"in(metalKs angina& he sho$ld not be p"es%"ibed t"iptan

p"epa"ations be%a$se they %a$se /aso%onst"i%tion and %o"ona"y spasms !he"e is no %ont"aindi%ation fo" taing

t"iptan d"$gs in %lients with diabetes& %an%e"& o" %l$ste" heada%hes maing answe"s #& C& and ) in%o""e%t

.5 #nswe" # is %o""e%t e"nigKs sign is positi/e if pain o%%$"s on fle-ion of the hip and nee !he @"$d(insi

"efle- is positi/e if pain o%%$"s on fle-ion of the head and ne% onto the %hest so answe" @ is in%o""e%t

#nswe"s C and ) might be p"esent b$t a"e not "elated to e"nigKs sign

.8 #nswe" @ is %o""e%t #p"a-ia is the inability to $se obEe%ts app"op"iately #gnosia is loss of senso"y

%omp"ehension& anomia is the inability to find wo"ds& and aphasia is the inability to spea o" $nde"stand so

answe"s #& C& and ) a"e in%o""e%t

. #nswe" C is %o""e%t In%"eased %onf$sion at night is nown as Ls$ndowningL synd"ome !his in%"eased

%onf$sion o%%$"s when the s$n begins to set and %ontin$es d$"ing the night #nswe" # is in%o""e%t be%a$se

fatig$e is not ne%essa"ily p"esent In%"eased %onf$sion at night is not pa"t of no"mal agingW the"efo"e& answe" @

is in%o""e%t # del$sion is a fi"m& fi-ed beliefW the"efo"e& answe" ) is in%o""e%t

.9 #nswe" C is %o""e%t !he %lient who is %onf$sed might fo"get that he ate ea"lie" )onKt a"g$e with the %lient

Simply get him something to eat that will satisfy him $ntil l$n%h #nswe"s # and ) a"e in%o""e%t be%a$se the

n$"se is dismissing the %lient #nswe" @ is /alidating the del$sion0 #nswe" ) is %o""e%t *a$sea and gast"ointestinal $pset a"e /e"y %ommon in %lients taing

a%etyl%holineste"ase inhibito"s s$%h as ,-elon Othe" side effe%ts in%l$de li/e" to-i%ity& di((iness& $nsteadiness&

and %l$msiness !he %lient might al"eady be e-pe"ien%ing $"ina"y in%ontinen%e o" heada%hes& b$t they a"e not

ne%essa"ily asso%iatedW and the %lient with #l(heime"Ks disease is al"eady %onf$sed !he"efo"e& answe"s #& @&

and C a"e in%o""e%t

1 #nswe" @ is %o""e%t #ny lesion sho$ld be "epo"ted to the do%to" !his %an indi%ate a he"pes lesion Clients

with open lesions "elated to he"pes a"e deli/e"ed by Cesa"ean se%tion be%a$se the"e is a possibility of

t"ansmission of the infe%tion to the fet$s with di"e%t %onta%t to lesions It is not eno$gh to do%$ment the

finding& so answe" # is in%o""e%t !he physi%ian m$st mae the de%ision to pe"fo"m a C=se%tion& maing

answe" C in%o""e%t It is not eno$gh to %ontin$e p"ima"y %a"e& so answe" ) is in%o""e%t

2 #nswe" @ is %o""e%t !he %lient with ?P7 is at highe" "is fo" %e"/i%al and /aginal %an%e" "elated to this S!I

She is not at highe" "is fo" the othe" %an%e"s mentioned in answe"s #& C& and )& so those a"e in%o""e%t




+ #nswe" @ is %o""e%t # lesion that is painf$l is most liely a he"peti% lesion # %han%"e lesion asso%iated with

syphilis is not painf$l& so answe" # is in%o""e%t Condylomata lesions a"e painless wa"ts& so answe" ) is

in%o""e%t In answe" C& gono""hea does not p"esent as a lesion& b$t is e-hibited by a yellow dis%ha"ge

. #nswe" C is %o""e%t Flo"es%ent t"eponemal antibody F!# is the test fo" t"eponema pallid$m 7)' and

P a"e s%"eening tests done fo" syphilis& so answe"s # and @ a"e in%o""e%t !he !haye"=<a"tin %$lt$"e is done

fo" gono""hea& so answe" ) is in%o""e%t

#nswe" ) is %o""e%t !he %"ite"ia fo" ?,''P is hemolysis& ele/ated li/e" en(ymes& and low platelet %o$nt In

answe" #& an ele/ated blood gl$%ose le/el is not asso%iated with ?,''P Platelets a"e de%"eased& not ele/ated&in ?,''P synd"ome as stated in answe" @ !he %"eatinine le/els a"e ele/ated in "enal disease and a"e not

asso%iated with ?,''P synd"ome so answe" C is in%o""e%t

5 #nswe" # is %o""e%t #nswe" @ eli%its the t"i%eps "efle-& so it is in%o""e%t #nswe" C eli%its the patella "efle-&

maing it in%o""e%t #nswe" ) eli%its the "adial ne"/e& so it is in%o""e%t

8 #nswe" @ is %o""e%t @"ethine is $sed %a$tio$sly be%a$se it "aises the blood gl$%ose le/els #nswe"s #& C&

and ) a"e all medi%ations that a"e %ommonly $sed in the diabeti% %lient& so they a"e in%o""e%t

#nswe" C is %o""e%t Hhen the 'GS "atio "ea%hes 2:1& the l$ngs a"e %onside"ed to be mat$"e !he infant will

most liely be small fo" gestational age and will not be at "is fo" bi"th t"a$ma& so answe" ) is in%o""e%t !he

'GS "atio does not indi%ate %ongenital anomalies& as stated in answe" #& and the infant is not at "is fo"int"a$te"ine g"owth "eta"dation& maing answe" @ in%o""e%t

9 #nswe" C is %o""e%t Bitte"iness is a sign of sei($"e in the neonate C"ying& waef$lness& and yawning a"e

e-pe%ted in the newbo"n& so answe"s #& @& and ) a"e in%o""e%t50 #nswe" @ is %o""e%t !he %lient is e-pe%ted to be%ome sleepy& ha/e hot flashes& and be letha"gi% #

de%"easing $"ina"y o$tp$t& absen%e of the nee=Ee" "efle-& and de%"eased "espi"ations indi%ate to-i%ity& so


51 #nswe" ) is %o""e%t If the %lient e-pe"ien%es hypotension afte" an inEe%tion of epid$"al anestheti%& the n$"se

sho$ld t$"n he" to the left side& apply o-ygen by mas& and speed the I7 inf$sion If the blood p"ess$"e does

not "et$"n to no"mal& the physi%ian sho$ld be %onta%ted ,pineph"ine sho$ld be ept fo" eme"gen%y

administ"ation #nswe" # is in%o""e%t be%a$se pla%ing the %lient in !"endelenb$"g position head down will

allow the anesthesia to mo/e $p abo/e the "espi"ato"y %ente"& the"eby de%"easing the diaph"agmKs ability to

mo/e $p and down and /entilate the %lient In answe" @& the I7 "ate sho$ld be in%"eased& not de%"eased In

answe" C& the o-ygen sho$ld be applied by mas& not %ann$la

52 #nswe" # is %o""e%t Can%e" of the pan%"eas f"e6$ently leads to se/e"e na$sea and /omiting and alte"ed

n$t"ition !he othe" p"oblems a"e of lesse" %on%e"nW th$s& answe"s @& C& and ) a"e in%o""e%t5+ #nswe" C is %o""e%t <eas$"ing with a pape" tape meas$"e and ma"ing the a"ea that is meas$"ed is the most

obEe%ti/e method of estimating as%ites Inspe%ting and %he%ing fo" fl$id wa/es a"e mo"e s$bEe%ti/e& so

answe"s # and @ a"e in%o""e%t Palpation of the li/e" will not tell the amo$nt of as%itesW th$s& answe" ) isin%o""e%t

5. #nswe" @ is %o""e%t !he /ital signs indi%ate hypo/olemi% sho% !hey do not indi%ate %e"eb"al tiss$e

pe"f$sion& ai"way %lea"an%e& o" senso"y pe"%eption alte"ations& so answe"s #& C& and ) a"e in%o""e%t

5 #nswe" # is %o""e%t !he %lient with osteogenesis impe"fe%ta is at "is fo" pathologi%al f"a%t$"es and is liely

to e-pe"ien%e these f"a%t$"es if he pa"ti%ipates in %onta%t spo"ts !he %lient might e-pe"ien%e symptoms of

hypo-ia if he be%omes dehyd"ated o" deo-ygenatedW e-t"eme e-e"%ise& espe%ially in wa"m weathe"& %an

e-a%e"bate the %ondition #nswe"s @& C& and ) a"e not fa%to"s fo" %on%e"n

55 #nswe" ) is %o""e%t !he %lient with ne$t"openia sho$ld not ha/e f"esh f"$it be%a$se it sho$ld be peeled

andGo" %ooed befo"e eating ?e sho$ld also not eat foods g"own on o" in the g"o$nd o" eat f"om the salad ba"

!he n$"se sho$ld "emo/e potted o" %$t flowe"s f"om the "oom as well #ny so$"%e of ba%te"ia sho$ld be

eliminated& if possible #nswe"s #& @& and C will not help p"e/ent ba%te"ial in/asions

58 #nswe" @ is %o""e%t In %lients who ha/e not had s$"ge"y to the fa%e o" ne%& the answe" wo$ld be answe" #W

howe/e"& in this sit$ation& this %o$ld f$"the" inte"fe"e with the ai"way In%"easing the inf$sion and pla%ing the

%lient in s$pine position wo$ld be bette" #nswe"s C is in%o""e%t be%a$se it is not ne%essa"y at this time and

%o$ld %a$se hyponat"emia and f$"the" hypotension #nswe" ) is not ne%essa"y at this time

5 #nswe" C is %o""e%t If the %lient p$lls the %hest t$be o$t of the %hest& the n$"seKs fi"st a%tion sho$ld be to

%o/e" the inse"tion site with an o%%l$si/e d"essing #fte"wa"d& the n$"se sho$ld %all the do%to"& who will o"de"

a %hest -="ay and possibly "einse"t the t$be #nswe"s #& @& and ) a"e not the fi"st a%tion to be taen59 #nswe" # is %o""e%t !he no"mal P"otime is 12X20 se%onds # P"otime of 120 se%onds indi%ates an

e-t"emely p"olonged P"otime and %an "es$lt in a spontaneo$s bleeding episode #nswe"s @& C& and ) may be

needed at a late" time b$t a"e not the most impo"tant a%tions to tae fi"st

80 #nswe" C is %o""e%t !he food with the most %al%i$m is the yog$"t #nswe"s #& @& and ) a"e good %hoi%es&

b$t not as good as the yog$"t& whi%h has app"o-imately .00mg of %al%i$m

81 #nswe" C is %o""e%t !he %lient "e%ei/ing magnesi$m s$lfate sho$ld ha/e a Foley %athete" in pla%e& and

ho$"ly intae and o$tp$t sho$ld be %he%ed !he"e is no need to "ef"ain f"om %he%ing the blood p"ess$"e in

the "ight a"m # padded tong$e blade sho$ld be ept in the "oom at the bedside& E$st in %ase of a sei($"e& b$t

this is not "elated to the magnesi$m s$lfate inf$sion )a"ening the "oom is $nne%essa"y& so answe"s #& @& and

) a"e in%o""e%t

82 #nswe" ) is %o""e%t If the %lientKs mothe" "ef$ses the blood t"ansf$sion& the do%to" sho$ld be notified

@e%a$se the %lient is a mino"& the %o$"t might o"de" t"eatment #nswe" # is in%o""e%t @e%a$se it is not the




p"ima"y "esponsibility fo" the n$"se to en%o$"age the mothe" to %onsent o" e-plain the %onse6$en%es& so

answe"s @ and C a"e in%o""e%t

8+ #nswe" @ is %o""e%t !he n$"se sho$ld be most %on%e"ned with la"yngeal edema be%a$se of the a"ea of b$"n

!he ne-t p"io"ity sho$ld be answe" #& as well as hyponat"emia and hypoalemia in C and )& b$t these answe"s

a"e not of p"ima"y %on%e"n so a"e in%o""e%t

8. #nswe" ) is %o""e%t !he %lient with ano"e-ia shows the most imp"o/ement by weight gain Sele%ting a

balan%ed diet does little good if the %lient will not eat& so answe" # is in%o""e%t !he hemato%"it might imp"o/e

by se/e"al means& s$%h as blood t"ansf$sion& b$t that does not indi%ate imp"o/ement in the ano"e-i% %onditionWthe"efo"e& answe" @ is in%o""e%t !he tiss$e t$"go" indi%ates fl$id stasis& not imp"o/ement of ano"e-ia& so

answe" C is in%o""e%t

8 #nswe" ) is %o""e%t #t this time& pain beneath the %ast is no"mal !he %lientKs toes sho$ld be wa"m to the

to$%h& and p$lses sho$ld be p"esent Pa"esthesia is not no"mal and might indi%ate %ompa"tment synd"ome

!he"efo"e& #nswe"s #& @& and C a"e in%o""e%t

85 #nswe" @ is %o""e%t It is no"mal fo" the %lient to ha/e a wa"m sensation when dye is inEe%ted #nswe"s #& C&

and ) indi%ate that the n$"se belie/es that the hot feeling is abno"mal& so they a"e in%o""e%t

88 #nswe" ) is %o""e%t It is not ne%essa"y to wea" glo/es to tae the /ital signs of the %lient If the %lient has

a%ti/e infe%tion with methi%illin="esistant staphylo%o%%$s a$"e$s& glo/es sho$ld be wo"n !he health%a"ewo"e"s in answe"s #& @& and C indi%ate nowledge of infe%tion %ont"ol by thei" a%tions

8 #nswe" ) is %o""e%t )$"ing ,C!& the %lient will ha/e a g"and mal sei(e !his indi%ates %ompletion of the

ele%t"o%on/$lsi/e the"apy #nswe"s #& @& and C do not indi%ate that the ,C! has been effe%ti/e& so a"ein%o""e%t

89 #nswe" # is %o""e%t Infe%tion with pinwo"ms begins when the eggs a"e ingested o" inhaled !he eggs hat%h

in the $ppe" intestine and mat$"e in 2X wees !he females then mate and mig"ate o$t the an$s& whe"e they

lay $p to 18&000 eggs !his %a$ses intense it%hing !he mothe" sho$ld be told to $se a flashlight to e-amine the

"e%tal a"ea abo$t 2X+ ho$"s afte" the %hild is asleep Pla%ing %lea" tape on a tong$e blade will allow the eggs to

adhe"e to the tape !he spe%imen sho$ld then be b"o$ght in to be e/al$ated !he"e is no need to s%"ap the sin&

%olle%t a stool spe%imen& o" b"ing a sample of hai"& so answe"s @& C& and ) a"e in%o""e%t

0 #nswe" @ is %o""e%t ,"te"obiasis& o" pinwo"ms& is t"eated with 7e"mo- mebenda(ole o" #ntiminth

py"antel pamoate !he enti"e family sho$ld be t"eated to ens$"e that no eggs "emain @e%a$se a single

t"eatment is $s$ally s$ffi%ient& the"e is $s$ally good %omplian%e !he family sho$ld then be tested again in 2

wees to ens$"e that no eggs "emain #nswe"s #& C& and ) a"e in%o""e%t statements

1 #nswe" # is %o""e%t !he p"egnant n$"se sho$ld not be assigned to any %lient with "adioa%ti/ity p"esent !he%lient "e%ei/ing linea" a%%ele"ato" the"apy t"a/els to the "adi$m depa"tment fo" the"apy !he "adiation stays in

the depa"tment& so the %lient is not "adioa%ti/e !he %lients in answe"s @& C& and ) pose a "is to the p"egnant

n$"se !hese %lients a"e "adioa%ti/e in /e"y small doses& espe%ially $pon "et$"ning f"om the p"o%ed$"es Fo"app"o-imately 82 ho$"s& the %lients sho$ld dispose of $"ine and fe%es in spe%ial %ontaine"s and $se plasti%

spoons and fo"s

2 #nswe" # is %o""e%t !he %lient with C$shingKs disease has ad"eno%o"ti%al hype"se%"etion !his in%"ease in

the le/el of %o"tisone %a$ses the %lient to be imm$ne s$pp"essed In answe" @& the %lient with diabetes poses no

"is to othe" %lients !he %lient in answe" C has an in%"ease in g"owth ho"mone and poses no "is to himself o"

othe"s !he %lient in answe" ) has hype"thy"oidism o" my-edema and poses no "is to othe"s o" himself

+ #nswe" ) is %o""e%t !he n$"se %o$ld be %ha"ged with malp"a%ti%e& whi%h is failing to pe"fo"m& o"

pe"fo"ming an a%t that %a$ses ha"m to the %lient Di/ing the infant an o/e"dose falls into this %atego"y #nswe"s

#& @& and C a"e in%o""e%t be%a$se they apply to othe" w"ongf$l a%ts *egligen%e is failing to pe"fo"m %a"e fo"

the %lientW a to"t is a w"ongf$l a%t %ommitted on the %lient o" thei" belongingsW and assa$lt is a /iolent physi%al

o" /e"bal atta%

. #nswe" ) is %o""e%t !he li%ensed p"a%ti%al n$"se sho$ld not be assigned to begin a blood t"ansf$sion !he

li%ensed p"a%ti%al n$"se %an inse"t a Foley %athete"& dis%ontin$e a nasogast"i% t$be& and %olle%t sp$t$m

spe%imenW the"efo"e& answe"s #& @& and C a"e in%o""e%t

#nswe" @ is %o""e%t !he /ital signs a"e abno"mal and sho$ld be "epo"ted immediately Contin$ing to

monito" the /ital signs %an "es$lt in dete"io"ation of the %lientKs %ondition& maing answe" # in%o""e%t #sing

the %lient how he feels in answe" C will only p"o/ide s$bEe%ti/e data& and the n$"se in answe" ) is not the best

n$"se to assign be%a$se this %lient is $nstable5 #nswe" @ is %o""e%t !he n$"se with + yea"s of e-pe"ien%e in labo" and deli/e"y nows the most abo$t

possible %ompli%ations in/ol/ing p"ee%lampsia !he n$"se in answe" # is a new n$"se to the $nit& and the

n$"ses in answe"s C and ) ha/e no e-pe"ien%e with the postpa"t$m %lient

8 #nswe" @ is %o""e%t !he Boint Commission on #%%"editation of ?ospitals will p"obably be inte"ested in the

p"oblems in answe"s # and C !he fail$"e of the n$"sing assistant to %a"e fo" the %lient with hepatitis might

"es$lt in te"mination& b$t is not of inte"est to the Boint Commission

#nswe" @ is %o""e%t !he ne-t a%tion afte" dis%$ssing the p"oblem with the n$"se is to do%$ment the in%ident

by filing a fo"mal "ep"imand If the beha/io" %ontin$es o" if ha"m has "es$lted to the %lient& the n$"se may be

te"minated and "epo"ted to the @oa"d of *$"sing& b$t these a"e not the fi"st a%tions "e6$ested in the stem # to"t

is a w"ongf$l a%t to the %lient o" his belongings and is not indi%ated in this instan%e !he"efo"e& #nswe"s #& C&

and ) a"e in%o""e%t




9 #nswe" ) is %o""e%t !he %lient at highest "is fo" %ompli%ations is the %lient with m$ltiple s%le"osis who is

being t"eated with %o"tisone /ia the %ent"al line !he othe"s a"e mo"e stable <S# is methi%illin="esistant

staphylo%o%%$s a$"e$s 7an%omy%in is the d"$g of %hoi%e and is gi/en at s%hed$led times to maintain blood

le/els of the d"$g !he %lients in answe"s #& @& and C a"e mo"e stable and %an be seen late"

90 #nswe" @ is %o""e%t !he p"egnant %lient and the %lient with a b"oen a"m and fa%ial la%e"ations a"e the best

%hoi%es fo" pla%ing in the same "oom !he %lients in answe"s #& C& and ) need to be pla%ed in sepa"ate "ooms

d$e to the se"io$s nat$"es of thei" inE$"ies

91 #nswe" # is %o""e%t @efo"e instilling eyed"ops& the n$"se sho$ld %leanse the a"ea with wate" # 5=yea"=old%hild is not de/elopmentally "eady to instill his own eyed"ops& so answe" @ is in%o""e%t #ltho$gh the mothe"

of the %hild %an instill the eyed"ops& the a"ea m$st be %leansed befo"e administ"ation& maing answe" C

in%o""e%t #ltho$gh the eye might appea" to be %lea"& the n$"se sho$ld instill the eyed"ops& as o"de"ed& so

answe" ) is in%o""e%t

92 #nswe" C is %o""e%t emembe" the #@Cs ai"way& b"eathing& %i"%$lation when answe"ing this 6$estion

#nswe" C is %o""e%t be%a$se a hotdog is the si(e and shape of the %hildKs t"a%hea and poses a "is of aspi"ation

#nswe"s #& @& and C a"e in%o""e%t be%a$se white g"ape E$i%e& a g"illed %heese sandwi%h& and i%e %"eam do not

pose a "is of aspi"ation fo" a %hild

9+ #nswe" C is %o""e%t !he n$"se sho$ld en%o$"age "ooming=in to p"omote pa"ent=%hild atta%hment It is oayfo" the pa"ents to be in the "oom fo" assessment of the %hild #llowing the %hild to ha/e items that a"e familia"

to him is allowed and en%o$"agedW the"efo"e& answe"s # and @ a"e in%o""e%t #nswe" ) is not pa"t of the

n$"seKs "esponsibilities9. #nswe" @ is %o""e%t !he hea"ing aid sho$ld be sto"ed in a wa"m& d"y pla%e It sho$ld be %leaned daily b$t

sho$ld not be moldy& so answe" # is in%o""e%t # toothpi% is inapp"op"iate to $se to %lean the aidW the

toothpi% might b"ea off in the hea"ing aide& maing answe" C in%o""e%t Changing the batte"ies weely& as in

answe" )& is not ne%essa"y

9 #nswe" C is %o""e%t #lways "emembe" yo$" #@Cs ai"way& b"eathing& %i"%$lation when sele%ting an

answe" #ltho$gh answe"s @ and ) might be app"op"iate fo" this %hild& answe" C sho$ld ha/e the highest

p"io"ity #nswe" # does not apply fo" a %hild who has $nde"gone a tonsille%tomy

95 #nswe" # is %o""e%t If the %hild has ba%te"ial pne$monia& a high fe/e" is $s$ally p"esent @a%te"ial

pne$monia $s$ally p"esents with a p"od$%ti/e %o$gh& not a nonp"od$%ti/e %o$gh& maing answe" @ in%o""e%t

hinitis is often seen with /i"al pne$monia& and /omiting and dia""hea a"e $s$ally not seen with pne$monia& so

answe"s C and ) a"e in%o""e%t

98 #nswe" @ is %o""e%t Fo" a %hild with epiglottis and the possibility of %omplete obst"$%tion of the ai"way&eme"gen%y t"a%heostomy e6$ipment sho$ld always be ept at the bedside Int"a/eno$s s$pplies& fl$id& and

o-ygen will not t"eat an obst"$%tionW the"efo"e& answe"s #& C& and ) a"e in%o""e%t

9 #nswe" C is %o""e%t ,-ophthalmos p"ot"$sion of eyeballs often o%%$"s with hype"thy"oidism !he %lientwith hype"thy"oidism will often e-hibit ta%hy%a"dia& in%"eased appetite& and weight lossW the"efo"e& answe"s #&

@& and ) a"e in%o""e%t

99 #nswe" ) is %o""e%t !he %hild with %elia% disease sho$ld be on a gl$ten=f"ee diet #nswe"s #& @& and C all

%ontain gl$ten& while answe" ) gi/es the only %hoi%e of foods that does not %ontain gl$ten

100#nswe" C is %o""e%t emembe" the #@Cs ai"way& b"eathing& %i"%$lation when answe"ing this 6$estion

@efo"e notifying the physi%ian o" assessing the p$lse& o-ygen sho$ld be applied to in%"ease the o-ygen

sat$"ation& so answe"s # and ) a"e in%o""e%t !he no"mal o-ygen sat$"ation fo" a %hild is 92VX100V& maing

answe" @ in%o""e%t

101#nswe" @ is %o""e%t #n amniotomy is an a"tifi%ial "$pt$"e of memb"anes and no"mal amnioti% fl$id is st"aw=

%olo"ed and odo"less Fetal hea"t tones of 150 indi%ate ta%hy%a"dia& and g"eenish fl$id is indi%ati/e of

me%oni$m& so answe"s # and C a"e in%o""e%t If the n$"se notes the $mbili%al %o"d& the %lient is e-pe"ien%ing a

p"olapsed %o"d& so answe" ) is in%o""e%t and wo$ld need to be "epo"ted immediately

102#nswe" ) is %o""e%t )ilation of 2%m ma"s the end of the latent phase of labo" #nswe" # is a /ag$e

answe"& answe" @ indi%ates the end of the fi"st stage of labo"& and answe" C indi%ates the t"ansition phase

10+#nswe" @ is %o""e%t !he no"mal fetal hea"t "ate is 120X150bpmW 100X110bpm is b"ady%a"dia !he fi"st

a%tion wo$ld be to t$"n the %lient to the left side and apply o-ygen #nswe" # is not indi%ated at this time

#nswe" C is not the best a%tion fo" %lients e-pe"ien%ing b"ady%a"dia !he"e is no data to indi%ate the need to

mo/e the %lient to the deli/e"y "oom at this time10.#nswe" ) is %o""e%t !he e-pe%ted effe%t of Pito%in is %e"/i%al dilation Pito%in %a$ses mo"e intense

%ont"a%tions& whi%h %an in%"ease the pain& maing answe" # in%o""e%t Ce"/i%al effa%ement is %a$sed by

p"ess$"e on the p"esenting pa"t& so answe" @ is in%o""e%t #nswe" C is opposite the a%tion of Pito%in

10#nswe" @ is %o""e%t #pplying a fetal hea"t monito" is the %o""e%t a%tion at this time !he"e is no need to

p"epa"e fo" a Caesa"ean se%tion o" to pla%e the %lient in Den$ Pe%to"al position nee=%hest& so answe"s # and

C a"e in%o""e%t #nswe" ) is in%o""e%t be%a$se the"e is no need fo" an $lt"aso$nd based on the finding

105#nswe" @ is %o""e%t !he n$"se de%ides to apply an e-te"nal monito" be%a$se the memb"anes a"e inta%t

#nswe"s #& C& and ) a"e in%o""e%t !he %e"/i- is dilated eno$gh to $se an inte"nal monito"& if ne%essa"y #n

inte"nal monito" %an be applied if the %lient is at 0=station Cont"a%tion intensity has no bea"ing on the

appli%ation of the fetal monito"

108#nswe" ) is %o""e%t Clients admitted in labo" a"e told not to eat d$"ing labo"& to a/oid na$sea and /omiting

I%e %hips may be allowed& b$t this amo$nt of fl$id might not be s$ffi%ient to p"e/ent fl$id /ol$me defi%it In




answe" #& impai"ed gas e-%hange "elated to hype"/entilation wo$ld be indi%ated d$"ing the t"ansition phase

#nswe"s @ and C a"e not %o""e%t in "elation to the stem

10#nswe" ) is %o""e%t !his info"mation indi%ates a late de%ele"ation !his type of de%ele"ation is %a$sed by

$te"opla%ental la% of o-ygen #nswe" # has no "elation to the "eadings& so itKs in%o""e%tW answe" @ "es$lts in a

/a"iable de%ele"ationW and answe" C is indi%ati/e of an ea"ly de%ele"ation

109#nswe" C is %o""e%t !he initial a%tion by the n$"se obse"/ing a late de%ele"ation sho$ld t$"n the %lient to the

sideYp"efe"ably& the left side #dministe"ing o-ygen is also indi%ated #nswe" # might be ne%essa"y b$t not

befo"e t$"ning the %lient to he" side #nswe" @ is not ne%essa"y at this time #nswe" ) is in%o""e%t be%a$sethe"e is no data to indi%ate that the monito" has been applied in%o""e%tly

110#nswe" ) is %o""e%t #%%ele"ations with mo/ement a"e no"mal #nswe"s #& @& and C indi%ate omino$s

findings on the fetal hea"t monito"

111#nswe" C is %o""e%t ,pid$"al anesthesia de%"eases the $"ge to /oid and sensation of a f$ll bladde" # f$ll

bladde" will de%"ease the p"og"ession of labo" #nswe"s #& @& and ) a"e in%o""e%t fo" the stem

112#nswe" @ is %o""e%t '$teni(ing ho"mone "eleased by the pit$ita"y is "esponsible fo" o/$lation #t abo$t day

1.& the %ontin$ed in%"ease in est"ogen stim$lates the "elease of l$teni(ing ho"mone f"om the ante"io" pit$ita"y

!he '? s$"ge is "esponsible fo" o/$lation& o" the "elease of the dominant folli%le in p"epa"ation fo" %on%eption&

whi%h o%%$"s within the ne-t 10X12 ho$"s afte" the '? le/els pea #nswe"s #& C& and ) a"e in%o""e%t be%a$seest"ogen le/els a"e high at the beginning of o/$lation& the endomet"ial lining is thi%& not thin& and the

p"ogeste"one le/els a"e high& not low

11+#nswe" C is %o""e%t !he s$%%ess of the "hythm method of bi"th %ont"ol is dependent on the %lientKs menses being "eg$la" It is not dependent on the age of the %lient& f"e6$en%y of inte"%o$"se& o" "ange of the %lientKs

tempe"at$"eW the"efo"e& answe"s #& @& and ) a"e in%o""e%t

11.#nswe" C is %o""e%t !he best method of bi"th %ont"ol fo" the %lient with diabetes is the diaph"agm #

pe"manent int"a$te"ine de/i%e %an %a$se a %ontin$ing inflammato"y "esponse in diabeti%s that sho$ld be

a/oided& o"al %ont"a%epti/es tend to ele/ate blood gl$%ose le/els& and %ont"a%epti/e sponges a"e not good at

p"e/enting p"egnan%y !he"efo"e& answe"s #& @& and ) a"e in%o""e%t

11#nswe" ) is %o""e%t !he signs of an e%topi% p"egnan%y a"e /ag$e $ntil the fallopian t$be "$pt$"es !he %lient

will %omplain of s$dden& stabbing pain in the lowe" 6$ad"ant that "adiates down the leg o" $p into the %hest

Painless /aginal bleeding is a sign of pla%enta p"e/ia& abdominal %"amping is a sign of labo"& and th"obbing

pain in the $ppe" 6$ad"ant is not a sign of an e%topi% p"egnan%y& maing answe"s #& @& and C in%o""e%t

115#nswe" C is %o""e%t #ll of the %hoi%es a"e tasty& b$t the p"egnant %lient needs a diet that is balan%ed and has

in%"eased amo$nts of %al%i$m #nswe" # is la%ing in f"$its and mil #nswe" @ %ontains the potato %hips&whi%h %ontain a la"ge amo$nt of sodi$m #nswe" C %ontains meat& f"$it& potato salad& and yog$"t& whi%h has

abo$t +50mg of %al%i$m #nswe" ) is not the best diet be%a$se it la%s /egetables and mil p"od$%ts

118#nswe" @ is %o""e%t !he %lient with hype"emesis has pe"sistent na$sea and /omiting Hith /omiting %omesdehyd"ation Hhen the %lient is dehyd"ated& she will ha/e metaboli% a%idosis #nswe"s # and C a"e in%o""e%t

be%a$se they a"e "espi"ato"y dehyd"ation #nswe" ) is in%o""e%t be%a$se the %lient will not be in alalosis with

pe"sistent /omiting

11#nswe" @ is %o""e%t !he most definiti/e diagnosis of p"egnan%y is the p"esen%e of fetal hea"t tones !he

signs in answe"s #& C& and ) a"e s$bEe%ti/e and might be "elated to othe" medi%al %onditions #nswe"s # and C

may be "elated to a hydatidifo"m mole& and answe" ) is often p"esent befo"e menses o" with the $se of o"al

%ont"a%epti/es

119#nswe" C is %o""e%t !he infant of a diabeti% mothe" is $s$ally la"ge fo" gestational age #fte" bi"th& gl$%ose

le/els fall "apidly d$e to the absen%e of gl$%ose f"om the mothe" #nswe" # is in%o""e%t be%a$se the infant will

not be small fo" gestational age #nswe" @ is in%o""e%t be%a$se the infant will not be hype"gly%emi% #nswe" )

is in%o""e%t be%a$se the infant will be la"ge& not small& and will be hypogly%emi%& not hype"gly%emi%

120#nswe" @ is %o""e%t Hhen the %lient is taing o"al %ont"a%epti/es and begins antibioti%s& anothe" method of

bi"th %ont"ol sho$ld be $sed #ntibioti%s de%"ease the effe%ti/eness of o"al %ont"a%epti/es #pp"o-imately X10

po$nds of weight gain is not $n$s$al& so answe" # is in%o""e%t If the %lient misses a bi"th %ont"ol pill& she

sho$ld be inst"$%ted to tae the pill as soon as she "emembe"s the pill #nswe" C is in%o""e%t If she misses

two& she sho$ld tae twoW if she misses mo"e than two& she sho$ld tae the missed pills b$t $se anothe" method

of bi"th %ont"ol fo" the "emainde" of the %y%le #nswe" ) is in%o""e%t be%a$se %hanges in menst"$al flow a"e

e-pe%ted in %lients $sing o"al %ont"a%epti/es Often these %lients ha/e lighte" menses121#nswe" @ is %o""e%t Clients with ?I7 sho$ld not b"eastfeed be%a$se the infe%tion %an be t"ansmitted to the

baby th"o$gh b"east mil !he %lients in answe"s #& C& and )Ythose with diabetes& hype"tension& and thy"oid

diseaseY%an be allowed to b"eastfeed

122#nswe" # is %o""e%t !he symptoms of painless /aginal bleeding a"e %onsistent with pla%enta p"e/ia

#nswe"s @& C& and ) a"e in%o""e%t Ce"/i%al %he% fo" dilation is %ont"aindi%ated be%a$se this %an in%"ease the

bleeding Che%ing fo" fi"mness of the $te"$s %an be done& b$t the fi"st a%tion sho$ld be to %he% the fetal hea"t

tones # detailed histo"y %an be done late"

12+#nswe" ) is %o""e%t !he %lient sho$ld be ad/ised to %ome to the labo" and deli/e"y $nit when the

%ont"a%tions a"e e/e"y min$tes and %onsistent She sho$ld also be told to "epo"t to the hospital if she

e-pe"ien%es "$pt$"e of memb"anes o" e-t"eme bleeding She sho$ld not wait $ntil the %ont"a%tions a"e e/e"y 2

min$tes o" $ntil she has bloody dis%ha"ge& so answe"s # and @ a"e in%o""e%t #nswe" C is a /ag$e answe" and

%an be "elated to a $"ina"y t"a%t infe%tion




12.#nswe" # is %o""e%t Infants of mothe"s who smoe a"e often low in bi"th weight Infants who a"e la"ge fo"

gestational age a"e asso%iated with diabeti% mothe"s& so answe" @ is in%o""e%t P"ete"m bi"ths a"e asso%iated

with smoing& b$t not with app"op"iate si(e fo" gestation& maing answe" C in%o""e%t D"owth "eta"dation is

asso%iated with smoing& b$t this does not affe%t the infant lengthW the"efo"e& answe" ) is in%o""e%t

12#nswe" # is %o""e%t !o p"o/ide p"ote%tion against antibody p"od$%tion& hoDam sho$ld be gi/en within 82

ho$"s !he answe"s in @& C& and ) a"e too late to p"o/ide antibody p"ote%tion hoDam %an also be gi/en

d$"ing p"egnan%y

125#nswe" @ is %o""e%t Hhen the memb"anes "$pt$"e& the"e is often a t"ansient d"op in the fetal hea"t tones !hehea"t tones sho$ld "et$"n to baseline 6$i%ly #ny alte"ation in fetal hea"t tones& s$%h as b"ady%a"dia o"

ta%hy%a"dia& sho$ld be "epo"ted #fte" the fetal hea"t tones a"e assessed& the n$"se sho$ld e/al$ate the %e"/i%al

dilation& /ital signs& and le/el of dis%omfo"t& maing answe"s #& C& and ) in%o""e%t

128#nswe" # is %o""e%t !he a%ti/e phase of labo" o%%$"s when the %lient is dilated .X8%m !he latent o" ea"ly

phase of labo" is f"om 1%m to +%m in dilation& so answe"s @ and ) a"e in%o""e%t !he t"ansition phase of labo"

is X10%m in dilation& maing answe" C in%o""e%t

12#nswe" @ is %o""e%t !he infant of an addi%ted mothe" will $nde"go withd"awal Sn$gly w"apping the infant

in a blanet will help p"e/ent the m$s%le i""itability that these babies often e-pe"ien%e !ea%hing the mothe" to

p"o/ide ta%tile stim$lation o" p"o/ide fo" ea"ly infant stim$lation a"e in%o""e%t be%a$se he is i""itable and needs6$iet and little stim$lation at this time& so answe"s # and ) a"e in%o""e%t Pla%ing the infant in an infant seat in

answe" C is in%o""e%t be%a$se this will also %a$se mo/ement that %an in%"ease m$s%le i""itability

129#nswe" C is %o""e%t Following epid$"al anesthesia& the %lient sho$ld be %he%ed fo" hypotension and signsof sho% e/e"y min$tes fo" 1 min$tes !he %lient %an be %he%ed fo" %e"/i%al dilation late" afte" she is

stable !he %lient sho$ld not be positioned s$pine be%a$se the anesthesia %an mo/e abo/e the "espi"ato"y %ente"

and the %lient %an stop b"eathing Fetal hea"t tones sho$ld be assessed afte" the blood p"ess$"e is %he%ed

!he"efo"e& answe"s #& @& and ) a"e in%o""e%t

1+0#nswe" @ is %o""e%t !he best way to p"e/ent post=ope"ati/e wo$nd infe%tion is hand washing Use of

p"es%"ibed antibioti%s will t"eat infe%tion& not p"e/ent infe%tions& maing answe" # in%o""e%t Hea"ing a mas

and asing the %lient to %o/e" he" mo$th a"e good p"a%ti%es b$t will not p"e/ent wo$nd infe%tionsW the"efo"e&

answe"s C and ) a"e in%o""e%t

1+1#nswe" @ is %o""e%t !he %lient with a hip f"a%t$"e will most liely ha/e disalignment #nswe"s #& C& and )

a"e in%o""e%t be%a$se all f"a%t$"es %a$se pain& and %oolness of the e-t"emities and absen%e of p$lses a"e

indi%ati/e of %ompa"tment synd"ome o" pe"iphe"al /as%$la" disease

1+2#nswe" @ is %o""e%t #fte" menopa$se& women la% ho"mones ne%essa"y to abso"b and $tili(e %al%i$m)oing weight=bea"ing e-e"%ises and taing %al%i$m s$pplements %an help to p"e/ent osteopo"osis b$t a"e not

%a$ses& so answe"s # and C a"e in%o""e%t @ody types that f"e6$ently e-pe"ien%e osteopo"osis a"e thin

Ca$%asian females& b$t they a"e not most liely "elated to osteopo"osis& so answe" ) is in%o""e%t1++#nswe" @ is %o""e%t !he infantKs hips sho$ld be off the bed app"o-imately 1R in @"yantKs t"a%tion #nswe"

# is in%o""e%t be%a$se this does not indi%ate that the t"a%tion is wo"ing %o""e%tly& no" does C #nswe" ) is

in%o""e%t be%a$se @"yantKs t"a%tion is a sin t"a%tion& not a seletal t"a%tion

1+.#nswe" # is %o""e%t @alan%ed seletal t"a%tion $ses pins and s%"ews # Steinman pin goes th"o$gh la"ge

bones and is $sed to stabili(e la"ge bones s$%h as the fem$" #nswe" @ is in%o""e%t be%a$se only the affe%ted

leg is in t"a%tion i"s%hne" wi"es a"e $sed to stabili(e small bones s$%h as finge"s and toes& as in answe" C

#nswe" ) is in%o""e%t be%a$se this type of t"a%tion is not $sed fo" f"a%t$"ed hips

1+#nswe" # is %o""e%t @leeding is a %ommon %ompli%ation of o"thopedi% s$"ge"y !he blood=%olle%tion de/i%e

sho$ld be %he%ed f"e6$ently to ens$"e that the %lient is not hemo""haging !he %lientKs pain sho$ld be

assessed& b$t this is not life=th"eatening Hhen the %lient is in less dange"& the n$t"itional stat$s sho$ld be

assessed and an immobili(e" is not $sedW th$s& answe"s @& C& and ) a"e in%o""e%t

1+5#nswe" # is %o""e%t !he %lientKs family membe" sho$ld be ta$ght to fl$sh the t$be afte" ea%h feeding and

%lamp the t$be !he pla%ement sho$ld be %he%ed befo"e feedings& and indigestion %an o%%$" with the P,D

t$be& E$st as it %an o%%$" with any %lient& so answe"s @ and C a"e in%o""e%t <edi%ations %an be o"de"ed fo"

indigestion& b$t it is not a "eason fo" ala"m # pe"%$taneo$s endos%opy gast"ostomy t$be is $sed fo" %lients

who ha/e e-pe"ien%ed diffi%$lty swallowing !he t$be is inse"ted di"e%tly into the stoma%h and does not

"e6$i"e swallowingW the"efo"e& answe" ) is in%o""e%t

1+8#nswe" C is %o""e%t !he %lient with a total nee "epla%ement sho$ld be assessed fo" anemia # hemato%"it of25V is e-t"emely low and might "e6$i"e a blood t"ansf$sion @leeding of 2%m on the d"essing is not e-t"eme

Ci"%le and date and time the bleeding and monito" fo" %hanges in the %lientKs stat$s # low=g"ade tempe"at$"e

is not $n$s$al afte" s$"ge"y ,ns$"e that the %lient is well hyd"ated& and "e%he% the tempe"at$"e in 1 ho$" If

the tempe"at$"e is abo/e 101RF& "epo"t this finding to the do%to" !ylenol will p"obably be o"de"ed 7oiding

afte" s$"ge"y is also not $n%ommon and no need fo" %on%e"nW the"efo"e answe"s #& @& and ) a"e in%o""e%t

1+#nswe" @ is %o""e%t Pl$mbism is lead poisoning One fa%to" asso%iated with the %ons$mption of lead is

eating f"om potte"y made in Cent"al #me"i%a o" <e-i%o that is $nfi"ed !he %hild li/es in a ho$se b$ilt afte"

1985 this is when lead was taen o$t of paint& and the pa"ents mae stained glass as a hobby Stained glass is

p$t togethe" with lead& whi%h %an d"op on the wo" a"ea& whe"e the %hild %an %ons$me the lead beads #nswe"

# is in%o""e%t be%a$se simply t"a/eling o$t of the %o$nt"y does not in%"ease the "is In answe" C& the ho$se

was b$ilt afte" the lead was "emo/ed with the paint #nswe" ) is $n"elated to the stem




1+9#nswe" # is %o""e%t !he e6$ipment that %an help with a%ti/ities of daily li/ing is the high=seat %ommode

!he hip sho$ld be ept highe" than the nee !he "e%line" is good be%a$se it p"e/ents 90R fle-ion b$t not daily

a%ti/ities # !,*S !"ans%$taneo$s ,le%t"i%al *e"/e Stim$lation $nit helps with pain management and an

abd$%tion pillow is $sed to p"e/ent add$%tion of the hip and possibly dislo%ation of the p"osthesisW the"efo"e&

answe"s @& C& and ) a"e in%o""e%t

1.0#nswe" @ is %o""e%t *a"%an is the antidote fo" na"%oti% o/e"dose If hypo-ia o%%$"s& the %lient sho$ld ha/e

o-ygen administe"ed by mas& not %ann$la !he"e is no data to s$ppo"t the administ"ation of blood p"od$%ts o"

%a"dio"es$s%itation& so answe"s #& C& and ) a"e in%o""e%t1.1#nswe" @ is %o""e%t !he 5=yea"=old sho$ld ha/e a "oommate as %lose to the same age as possible& so the 12=

yea"=old is the best mat%h !he 10=yea"=old with sa"%oma has %an%e" and will be t"eated with %hemothe"apy

that maes him imm$ne s$pp"essed& the 5=yea"=old with osteomylitis is infe%ted& and the %lient in answe" # is

too old and is femaleW the"efo"e& answe"s #& C& and ) a"e in%o""e%t

1.2#nswe" @ is %o""e%t Co- II inhibito"s ha/e been asso%iated with hea"t atta%s and st"oes #ny %hanges in

%a"dia% stat$s o" signs of a st"oe sho$ld be "epo"ted immediately& along with any %hanges in bowel o" bladde"

habits be%a$se bleeding has been lined to $se of Co- II inhibito"s !he %lient does not ha/e to tae the

medi%ation with mil& "emain $p"ight& o" allow 5 wees fo" optimal effe%t& so answe"s #& C& and ) a"e

in%o""e%t1.+#nswe" ) is %o""e%t # plaste"=of=Pa"is %ast taes 2. ho$"s to d"y& and the %lient sho$ld not bea" weight fo"

2. ho$"s !he %ast sho$ld be handled with the palms& not the finge"tips& so answe" # is in%o""e%t Petaling a

%ast is %o/e"ing the end of the %ast with %ast batting o" a so%& to p"e/ent sin i""itation and flaing of the sin$nde" the %ast& maing answe" @ in%o""e%t !he %lient sho$ld be told not to d"y the %ast with a hai" d"ye"

be%a$se this %a$ses hot spots and %o$ld b$"n the %lient !his also %a$ses $ne6$al d"yingW th$s& answe" C is

in%o""e%t

1..#nswe" # is %o""e%t !he"e is no "eason that the %lientKs f"iends sho$ld not be allowed to a$tog"aph the %astW

it will not ha"m the %ast in any way& so answe"s @& C& and ) a"e in%o""e%t

1.#nswe" # is %o""e%t !he n$"se is pe"fo"ming the pin %a"e %o""e%tly when she $ses ste"ile glo/es and >=tips

# li%ensed p"a%ti%al n$"se %an pe"fo"m pin %a"e& the"e is no need to %lean the weights& and the n$"se %an help

with opening the pa%ages b$t it isnKt "e6$i"edW the"efo"e& answe"s @& C& and ) a"e in%o""e%t

1.5#nswe" # is %o""e%t # body %ast o" spi%a %ast e-tends f"om the $ppe" abdomen to the nees o" below

@owel so$nds sho$ld be %he%ed to ens$"e that the %lient is not e-pe"ien%ing a pa"alyti% ille$s Che%ing the

blood p"ess$"e is a t"eatment fo" any %lient& offe"ing pain medi%ation is not %alled fo"& and %he%ing fo"

swelling isnKt spe%ifi% to the stem& so answe"s @& C& and ) a"e in%o""e%t1.8#nswe" C is %o""e%t ?alo t"a%tion will be o"de"ed fo" the %lient with a %e"/i%al f"a%t$"e $ssellKs t"a%tion is

$sed fo" bones of the lowe" e-t"emities& as is @$%Ks t"a%tion C"$%hfield tongs a"e $sed while in the hospital

and the %lient is immobileW the"efo"e& answe"s #& @& and ) a"e in%o""e%t1.#nswe" @ is %o""e%t !he %ont"olle" fo" the %ontin$o$s passi/e=motion de/i%e sho$ld be pla%ed away f"om

the %lient <any %lients %omplain of pain while ha/ing t"eatments with the CP<& so they might t$"n off the

ma%hine !he CP< fle-es and e-tends the leg !he %lient is in the bed d$"ing CP< the"apy& so answe" # is

in%o""e%t #nswe" C is in%o""e%t be%a$se %lients will e-pe"ien%e pain with the t"eatment Use of the CP< does

not alle/iate the need fo" physi%al the"apy& as s$ggested in answe" )

1.9#nswe" # is %o""e%t !he %lientKs palms sho$ld "est lightly on the handles !he elbows sho$ld be fle-ed no

mo"e than +0R b$t sho$ld not be e-tended #nswe" @ is in%o""e%t be%a$se 0R is not a "ela-ed angle fo" the

elbows and will not fa%ilitate %o""e%t wale" $se !he %lient sho$ld wal to the middle of the wale"& not to the

f"ont of the wale"& maing answe" C in%o""e%t !he %lient sho$ld be ta$ght not to %a""y the wale" be%a$se this

wo$ld not p"o/ide stabilityW th$s& answe" ) is in%o""e%t

10#nswe" C is %o""e%t !he %lient with a p"olapsed %o"d sho$ld be t"eated by ele/ating the hips and %o/e"ing

the %o"d with a moist& ste"ile saline ga$(e !he n$"se sho$ld $se he" finge"s to p$sh $p on the p"esenting pa"t

$ntil a %esa"ean se%tion %an be pe"fo"med #nswe"s #& @& and ) a"e in%o""e%t !he n$"se sho$ld not attempt to

"epla%e the %o"d& t$"n the %lient on the side& o" %o/e" with a d"y ga$(e

11#nswe" @ is %o""e%t Chest t$bes wo" to "einflate the l$ng and d"ain se"o$s fl$id !he t$be does not e6$ali(e

e-pansion of the l$ngs Pain is asso%iated with %ollapse of the l$ng& and inse"tion of %hest t$bes is painf$l& so

answe"s # and C a"e in%o""e%t #nswe" ) is t"$e& b$t this is not the p"ima"y "ationale fo" pe"fo"ming %hest t$be

inse"tion12#nswe" ) is %o""e%t S$%%ess with b"eastfeeding depends on many fa%to"s& b$t the most dependable "eason

fo" s$%%ess is desi"e and willingness to %ontin$e the b"eastfeeding $ntil the infant and mothe" ha/e time to

adapt !he ed$%ational le/el& the infantKs bi"th weight& and the si(e of the mothe"Ks b"east ha/e nothing to do

with s$%%ess& so answe"s #& @& and C a"e in%o""e%t

1+#nswe" C is %o""e%t D"een=tinged amnioti% fl$id is indi%ati/e of me%oni$m staining !his finding indi%ates

fetal dist"ess !he p"esen%e of s%ant bloody dis%ha"ge is no"mal& as a"e f"e6$ent $"ination and mode"ate $te"ine

%ont"a%tions& maing answe"s #& @& and ) in%o""e%t

1.#nswe" C is %o""e%t )$"ation is meas$"ed f"om the beginning of one %ont"a%tion to the end of the same

%ont"a%tion #nswe" # "efe"s to f"e6$en%y #nswe" @ is in%o""e%t be%a$se we do not meas$"e f"om the end of

one %ont"a%tion to the beginning of the ne-t %ont"a%tion )$"ation is not meas$"ed f"om the pea of the

%ont"a%tion to the end& as stated in )




1#nswe" @ is %o""e%t !he %lient "e%ei/ing Pito%in sho$ld be monito"ed fo" de%ele"ations !he"e is no

asso%iation with Pito%in $se and hypogly%emia& mate"nal hype""efle-ia& o" fetal mo/ementW the"efo"e& answe"s

#& C& and ) a"e in%o""e%t

15#nswe" ) is %o""e%t Fetal de/elopment depends on ade6$ate n$t"ition and ins$lin "eg$lation Ins$lin needs

in%"ease d$"ing the se%ond and thi"d t"imeste"s& ins$lin "e6$i"ements do not mode"ate as the p"egnan%y

p"og"esses& and ele/ated h$man %ho"ioni% gonadot"ophin ele/ates ins$lin needs& not de%"eases themW the"efo"e&

answe"s #& @& and C a"e in%o""e%t

18#nswe" # is %o""e%t # %alm en/i"onment is needed to p"e/ent sei($"e a%ti/ity #ny stim$lation %an p"e%ipitate sei($"es Obtaining a diet histo"y sho$ld be done late"& and administe"ing an analgesi% is not

indi%ated be%a$se the"e is no data in the stem to indi%ate pain !he"efo"e& answe"s @ and C a"e in%o""e%t

#ssessing the fetal hea"t tones is impo"tant& b$t this is not the highest p"io"ity in this sit$ation as stated in

answe" )

1#nswe" # is %o""e%t !he %lient who is age .2 is at "is fo" fetal anomalies s$%h as )own synd"ome and

othe" %h"omosomal abe""ations #nswe"s @& C& and ) a"e in%o""e%t be%a$se the %lient is not at highe" "is fo"

"espi"ato"y dist"ess synd"ome o" pathologi%al Ea$ndi%e& and !$"ne"Ks synd"ome is a geneti% diso"de"

19#nswe" C is %o""e%t !he %lient with a missed abo"tion will ha/e ind$%tion of labo" P"ostin , is a fo"m of

p"ostaglandin $sed to soften the %e"/i- <agnesi$m s$lfate is $sed fo" p"ete"m labo" and p"ee%lampsia& %al%i$mgl$%onate is the antidote fo" magnesi$m s$lfate& and Pa"del is a dopamine "e%epto" stim$lant $sed to t"eat

Pa"insonKs diseaseW the"efo"e& answe"s #& @& and ) a"e in%o""e%t Pa"del was $sed at one time to d"y b"east

mil150#nswe" # is %o""e%t !he %lientKs blood p"ess$"e and $"ina"y o$tp$t a"e within no"mal limits !he only

alte"ation f"om no"mal is the de%"eased deep tendon "efle-es !he n$"se sho$ld %ontin$e to monito" the blood

p"ess$"e and %he% the magnesi$m le/el !he the"ape$ti% le/el is .X95mgGd' #nswe"s @& C& and ) a"e

in%o""e%t !he"e is no need to stop the inf$sion at this time o" slow the "ate Cal%i$m gl$%onate is the antidote

fo" magnesi$m s$lfate& b$t the"e is no data to indi%ate to-i%ity

151#nswe" C is %o""e%t #$tosomal "e%essi/e diso"de"s %an be passed f"om the pa"ents to the infant If both

pa"ents pass the t"ait& the %hild will get two abno"mal genes and the disease "es$lts Pa"ents %an also pass the

t"ait to the infant #nswe" # is in%o""e%t be%a$se& to ha/e an affe%ted newbo"n& the pa"ents m$st be %a""ie"s

#nswe" @ is in%o""e%t be%a$se both pa"ents m$st be %a""ie"s #nswe" ) is in%o""e%t be%a$se the pa"ents might

ha/e affe%ted %hild"en

152#nswe" ) is %o""e%t #lpha fetop"otein is a s%"eening test done to dete%t ne$"al t$be defe%ts s$%h as spina

bifida !he test is not mandato"y& as stated in answe" # It does not indi%ate %a"dio/as%$la" defe%ts& and themothe"Ks age has no bea"ing on the need fo" the test& so answe"s @ and C a"e in%o""e%t

15+#nswe" @ is %o""e%t )$"ing p"egnan%y& the thy"oid gland t"iples in si(e !his maes it mo"e diffi%$lt to

"eg$late thy"oid medi%ation #nswe" # is in%o""e%t be%a$se the"e %o$ld be a need fo" thy"oid medi%ationd$"ing p"egnan%y #nswe" C is in%o""e%t be%a$se the thy"oid f$n%tion does not slow Fetal g"owth is not

a""ested if thy"oid medi%ation is %ontin$ed& so answe" ) is in%o""e%t

15.#nswe" C is %o""e%t Cyanosis of the feet and hands is a%"o%yanosis !his is a no"mal finding 1 min$te afte"

bi"th #n api%al p$lse sho$ld be 120X150& and the baby sho$ld ha/e m$s%le tone& maing answe"s # and @

in%o""e%t Ba$ndi%e immediately afte" bi"th is pathologi%al Ea$ndi%e and is abno"mal& so answe" ) is in%o""e%t

15#nswe" # is %o""e%t Clients with si%le %ell %"ises a"e t"eated with heat& hyd"ation& o-ygen& and pain "elief

Fl$ids a"e in%"eased& not de%"eased @lood t"ansf$sions a"e $s$ally not "e6$i"ed& and the %lient %an be deli/e"ed

/aginallyW th$s& answe"s @& C& and ) a"e in%o""e%t

155#nswe" # is %o""e%t @efo"e $lt"asonog"aphy& the %lient sho$ld be ta$ght to d"in plenty of fl$ids and not

/oid !he %lient may amb$late& an enema is not needed& and the"e is no need to withhold food fo" ho$"s

!he"efo"e& answe"s @& C& and ) a"e in%o""e%t

158#nswe" ) is %o""e%t @y 1 yea" of age& the infant is e-pe%ted to t"iple his bi"th weight #nswe"s #& @& and C

a"e in%o""e%t be%a$se they a"e too low

15#nswe" @ is %o""e%t # nonst"ess test is done to e/al$ate pe"iodi% mo/ement of the fet$s It is not done to

e/al$ate l$ng mat$"ity as in answe" # #n o-yto%in %hallenge test shows the effe%t of %ont"a%tions on fetal

hea"t "ate and a nonst"ess test does not meas$"e ne$"ologi%al well=being of the fet$s& so answe"s C and ) a"e

in%o""e%t

159#nswe" @ is %o""e%t ?ypospadia is a %ondition in whi%h the"e is an opening on the do"sal side of the penis#nswe" # is in%o""e%t be%a$se hypospadia does not %on%e"n the $"eth"al opening #nswe" C is in%o""e%t

be%a$se the si(e of the penis is not affe%ted #nswe" ) is in%o""e%t be%a$se the opening is on the do"sal side&

not the /ent"al side

180#nswe" # is %o""e%t !"ansition is the time d$"ing labo" when the %lient loses %on%ent"ation d$e to intense

%ont"a%tions Potential fo" inE$"y "elated to p"e%ipitate deli/e"y has nothing to do with the dilation of the %e"/i-&

so answe" @ is in%o""e%t !he"e is no data to indi%ate that the %lient has had anesthesia o" fl$id /ol$me defi%it&

maing answe"s C and ) in%o""e%t

181#nswe" C is %o""e%t 7a"i%ella is %hi%en po- !his he"pes /i"$s is t"eated with anti/i"al medi%ations !he

%lient is not t"eated with antibioti%s o" anti%oag$lants as stated in answe"s # and ) !he %lient might ha/e a

fe/e" befo"e the "ash appea"s& b$t when the "ash appea"s& the tempe"at$"e is $s$ally gone& so answe" @ is

in%o""e%t




182#nswe" @ is %o""e%t Clients with %hest pain %an be t"eated with nit"ogly%e"in& a beta blo%e" s$%h as

p"opanolol& o" 7a"apamil !he"e is no indi%ation fo" an antibioti% s$%h as #mpi%illin& so answe"s #& C& and )

a"e in%o""e%t

18+#nswe" @ is %o""e%t #nti=inflammato"y d"$gs sho$ld be taen with meals to a/oid stoma%h $pset #nswe"s

#& C& and ) a"e in%o""e%t Clients with "he$matoid a"th"itis sho$ld e-e"%ise& b$t not to the point of pain

#lte"nating hot and %old is not ne%essa"y& espe%ially be%a$se wa"m& moist soas a"e mo"e $sef$l in de%"easing

pain Height=bea"ing a%ti/ities s$%h as waling a"e $sef$l b$t is not the best answe" fo" the stem

18.#nswe" ) is %o""e%t <o"phine is %ont"aindi%ated in %lients with gallbladde" disease and pan%"eatitis be%a$semo"phine %a$ses spasms of the Sphente" of Oddi <epe"idine& <ylanta& and Cimetadine a"e o"de"ed fo"

pan%"eatitis& maing answe"s #& @& and C in%o""e%t

18#nswe" @ is %o""e%t ?all$%inogeni% d"$gs %an %a$se hall$%inations Contin$o$s obse"/ation is o"de"ed to

p"e/ent the %lient f"om ha"ming himself d$"ing withd"awal #nswe"s #& C& and ) a"e in%o""e%t be%a$se

hall$%inogeni% d"$gs donKt %"eate both stim$lant and dep"essant effe%ts o" p"od$%e se/e"e "espi"ato"y

dep"ession ?owe/e"& they do p"od$%e psy%hologi%al dependen%e "athe" than physi%al dependen%e

185#nswe" @ is %o""e%t @a"bit$"ates %"eate a sedati/e effe%t Hhen the %lient stops taing ba"bit$"ates& he will

e-pe"ien%e ta%hy%a"dia& dia""hea& and ta%hpnea #nswe" # is in%o""e%t e/en tho$gh dep"ession and s$i%idal

ideation go along with ba"bit$"ate $seW it is not the p"io"ity <$s%le %"amps and abdominal pain a"e /ag$esymptoms that %o$ld be asso%iated with othe" p"oblems !a%hy%a"dia is asso%iated with stopping ba"bit$"ates&

b$t e$pho"ia is not

188#nswe" # is %o""e%t If the fetal hea"t tones a"e hea"d in the "ight $ppe" abdomen& the infant is in a b"ee%h p"esentation If the infant is positioned in the "ight o%%ipital ante"io" p"esentation& the F?!s will be lo%ated in

the "ight lowe" 6$ad"ant& so answe" @ is in%o""e%t If the fet$s is in the sa%"al position& the F?!s will be lo%ated

in the %ente" of the abdomen& so answe" C is in%o""e%t If the F?!s a"e hea"d in the left lowe" abdomen& the

infant is most liely in the left o%%ipital t"ans/e"se position& maing answe" ) in%o""e%t

18#nswe" ) is %o""e%t #sthma is the p"esen%e of b"on%hiola" spasms !his spasm %an be b"o$ght on by

alle"gies o" an-iety #nswe" # is in%o""e%t be%a$se the p"ima"y physiologi%al alte"ation is not inflammation

#nswe" @ is in%o""e%t be%a$se the"e is the p"od$%tion of abno"mally /is%o$s m$%$s& not a p"ima"y alte"ation

#nswe" C is in%o""e%t be%a$se infe%tion is not p"ima"y to asthma

189#nswe" # is %o""e%t !he %lient with mania is seldom sitting long eno$gh to eat and b$"ns many %alo"ies fo"

ene"gy #nswe" @ is in%o""e%t be%a$se the %lient sho$ld be t"eated the same as othe" %lients Small meals a"e

not a %o""e%t option fo" this %lient #llowing he" into the it%hen gi/es he" p"i/ileges that othe" %lients do not

ha/e and sho$ld not be allowed& so answe" ) is in%o""e%t10#nswe" @ is %o""e%t @"yantKs t"a%tion is $sed fo" f"a%t$"ed fem$"s and dislo%ated hips !he hips sho$ld be

ele/ated 1R off the bed #nswe" # is in%o""e%t be%a$se the hips sho$ld not be "esting on the bed #nswe" C is

in%o""e%t be%a$se the hips sho$ld not be abo/e the le/el of the body #nswe" ) is in%o""e%t be%a$se the hipsand legs sho$ld not be flat on the bed

11#nswe" @ is %o""e%t ?e"pes (oste" is shingles Clients with shingles sho$ld be pla%ed in %onta%t p"e%a$tions

Hea"ing glo/es d$"ing %a"e will p"e/ent t"ansmission of the /i"$s Co/e"ing the lesions with a ste"ile ga$(e is

not ne%essa"y& antibioti%s a"e not p"es%"ibed fo" he"pes (oste"& and o-ygen is not ne%essa"y fo" shinglesW

the"efo"e& answe"s #& C& and ) a"e in%o""e%t

12#nswe" @ is %o""e%t # t"o$gh le/el sho$ld be d"awn +0 min$tes befo"e the thi"d o" fo$"th dose !he times in

answe"s #& C& and ) a"e in%o""e%t times to d"aw blood le/els

1+#nswe" @ is %o""e%t !he %lient $sing a diaph"agm sho$ld eep the diaph"agm in a %ool lo%ation #nswe"s #&

C& and ) a"e in%o""e%t She sho$ld "ef"ain f"om lea/ing the diaph"agm in longe" than ho$"s& not . ho$"s She

sho$ld ha/e the diaph"agm "esi(ed when she gains o" loses 10 po$nds o" has abdominal s$"ge"y

1.#nswe" C is %o""e%t <othe"s who plan to b"eastfeed sho$ld d"in plenty of li6$ids& and fo$" glasses is not

eno$gh in a 2.=ho$" pe"iod Hea"ing a s$ppo"t b"a is a good p"a%ti%e fo" the mothe" who is b"eastfeeding as

well as the mothe" who plans to bottle=feed& so answe" # is in%o""e%t ,-p"essing mil f"om the b"east will

stim$late mil p"od$%tion& maing answe" @ in%o""e%t #llowing the wate" to "$n o/e" the b"east will also

fa%ilitate Lletdown&L when the mil begins to be p"od$%edW th$s& answe" ) is in%o""e%t

1#nswe" # is %o""e%t !he fa%ial ne"/e is %"anial ne"/e 7II If damage o%%$"s& the %lient will e-pe"ien%e fa%ial

pain !he a$dito"y ne"/e is "esponsible fo" hea"ing loss and tinnit$s& eye mo/ement is %ont"olled by the

!"o%hea" o" C I7& and the olfa%to"y ne"/e %ont"ols smellW the"efo"e& answe"s @& C& and ) a"e in%o""e%t15#nswe" @ is %o""e%t Clients taing Py"idi$m sho$ld be ta$ght that the medi%ation will t$"n the $"ine o"ange

o" "ed It is not asso%iated with dia""hea& mental %onf$sion& o" %hanges in tasteW the"efo"e& answe"s #& C& and )

a"e in%o""e%t Py"idi$m %an also %a$se a yellowish %olo" to sin and s%le"a if taen in la"ge doses

18#nswe" @ is %o""e%t #%%$tane is %ont"aindi%ated fo" $se by p"egnant %lients be%a$se it %a$ses te"atogeni%

effe%ts Cal%i$m le/els& api%al p$lse& and %"eatinine le/els a"e not ne%essa"yW the"efo"e& answe"s #& C& and )

a"e in%o""e%t

1#nswe" ) is %o""e%t Clients taing #%y%lo/i" sho$ld be en%o$"aged to d"in plenty of fl$ids be%a$se "enal

impai"ment %an o%%$" 'imiting a%ti/ity is not ne%essa"y& no" is eating a high=%a"bohyd"ate diet Use of an

in%enti/e spi"omete" is not spe%ifi% to %lients taing #%y%lo/i"W the"efo"e& answe"s #& @& and C a"e in%o""e%t

19#nswe" # is %o""e%t Clients who a"e p"egnant sho$ld not ha/e an <I be%a$se "adioa%ti/e isotopes a"e

$sed ?owe/e"& %lients with a titani$m hip "epla%ement %an ha/e an <I& so answe" @ is in%o""e%t *o




antibioti%s a"e $sed with this test and the %lient sho$ld "emain still only when inst"$%ted& so answe"s C and )

a"e not spe%ifi% to this test

190#nswe" ) is %o""e%t Clients taing #mphote"i%in @ sho$ld be monito"ed fo" li/e"& "enal& and bone ma""ow

f$n%tion be%a$se this d"$g is to-i% to the idneys and li/e"& and %a$ses bone ma""ow s$pp"ession Ba$ndi%e is a

sign of li/e" to-i%ity and is not spe%ifi% to the $se of #mphote"i%in @ Changes in /ision a"e not "elated& and

na$sea is a side effe%t& not a sign of to-i%ityW no" is $"ina"y f"e6$en%y !h$s& answe"s #& @& and C a"e in%o""e%t

191#nswe" C is %o""e%t !he %lient with %hest pain sho$ld be seen fi"st be%a$se this %o$ld indi%ate a myo%a"dial

infa"%tion !he %lient in answe" # has a blood gl$%ose within no"mal limits !he %lient in answe" @ ismaintained on blood p"ess$"e medi%ation !he %lient in answe" ) is in no dist"ess

192#nswe" @ is %o""e%t Pan%"eati% en(ymes sho$ld be gi/en with meals fo" optimal effe%ts !hese en(ymes

assist the body in digesting needed n$t"ients #nswe"s #& C& and ) a"e in%o""e%t methods of administe"ing

pan%"eati% en(ymes

19+#nswe" C is %o""e%t !he lens allows light to pass th"o$gh the p$pil and fo%$s light on the "etina !he lens

does not stim$late the "etina& assist with eye mo/ement& o" magnify small obEe%ts& so answe"s #& @& and ) a"e

in%o""e%t

19.#nswe" C is %o""e%t <ioti% eyed"ops %onst"i%t the p$pil and allow a6$eo$s h$mo" to d"ain o$t of the Canal

of S%hlemm !hey do not anestheti(e the %o"nea& dilate the p$pil& o" pa"aly(e the m$s%les of the eye& mainganswe"s #& @& and ) in%o""e%t

19#nswe" # is %o""e%t Hhen $sing eyed"ops& allow min$tes between the two medi%ationsW the"efo"e& answe"

@ is in%o""e%t !hese medi%ations %an be $sed by the same %lient b$t it is not ne%essa"y to $se a %y%lopegi%with these medi%ations& maing answe"s C and ) in%o""e%t

195#nswe" @ is %o""e%t Clients with %olo" blindness will most liely ha/e p"oblems disting$ishing /iolets&

bl$es& and g"een !he %olo"s in answe"s #& C& and ) a"e less %ommonly affe%ted

198#nswe" ) is %o""e%t !he %lient with a pa%emae" sho$ld be ta$ght to %o$nt and "e%o"d his p$lse "ate

#nswe"s #& @& and C a"e in%o""e%t #nle edema is a sign of "ight=sided %ongesti/e hea"t fail$"e #ltho$gh this

is not no"mal& it is often p"esent in %lients with hea"t disease If the edema is p"esent in the hands and fa%e& it

sho$ld be "epo"ted Che%ing the blood p"ess$"e daily is not ne%essa"y fo" these %lients !he %lient with a

pa%emae" %an $se a mi%"owa/e o/en& b$t he sho$ld stand abo$t feet f"om the o/en while it is ope"ating

19#nswe" # is %o""e%t Clients who a"e being "et"ained fo" bladde" %ont"ol sho$ld be ta$ght to withhold fl$ids

afte" abo$t 8 pm& o" 1 !he times in answe"s @& C& and ) a"e too ea"ly in the day

199#nswe" ) is %o""e%t C"anbe""y E$i%e is mo"e alaline and& when metaboli(ed by the body& is e-%"eted with

a%idi% $"ine @a%te"ia does not g"ow f"eely in a%idi% $"ine In%"easing intae of meats is not asso%iated with$"ina"y t"a%t infe%tions& so answe" # is in%o""e%t !he %lient does not ha/e to a/oid %it"$s f"$its and pe"i%a"e

sho$ld be done& b$t hyd"ogen pe"o-ide is d"ying& so answe"s @ and C a"e in%o""e%t

200#nswe" C is %o""e%t *P? ins$lin peas in X12 ho$"s& so a sna% sho$ld be offe"ed at that time *P?ins$lin onsets in 90X120 min$tes& so answe" # is in%o""e%t #nswe" @ is $nt"$e be%a$se *P? ins$lin is time

"eleased and does not $s$ally %a$se s$dden hypogly%emia #nswe" ) is in%o""e%t& b$t the %lient sho$ld eat a

bedtime sna%

201#nswe" ) is %o""e%t <ethot"e-ate is a foli% a%id antagonist 'e$%o/o"in is the d"$g gi/en fo" to-i%ity to this

d"$g It is not $sed to t"eat i"on=defi%ien%y anemia& %"eate a syne"gisti% effe%ts& o" in%"ease the n$mbe" of

%i"%$lating ne$t"ophils !he"efo"e& answe"s #& @& and C a"e in%o""e%t

202#nswe" @ is %o""e%t !he %lient who is alle"gi% to dogs& eggs& "abbits& and %hi%en feathe"s is most liely

alle"gi% to the "$bella /a%%ine !he %lient who is alle"gi% to neomy%in is also at "is !he"e is no dange" to the

%lient if he has an o"de" fo" a !@ sin test& ,'IS# test& o" %hest -="ayW th$s& answe"s #& C& and ) a"e in%o""e%t

20+#nswe" @ is %o""e%t Janta% "antidine is a histamine blo%e" that sho$ld be gi/en with meals fo" optimal

effe%t& not befo"e meals ?owe/e"& !agamet %imetidine is a histamine blo%e" that %an be gi/en in one dose at

bedtime *eithe" of these d"$gs sho$ld be gi/en befo"e o" afte" meals& so answe"s # and ) a"e in%o""e%t

20.#nswe" C is %o""e%t !he p"o-imal end of the do$ble=ba""el %olostomy is the end towa"d the small intestines

!his end is on the %lientKs "ight side !he distal end& as in answe"s #& @& and )& is on the %lientKs left side

20#nswe" # is %o""e%t If the n$"se %he%s the f$nd$s and finds it to be displa%ed to the "ight o" left& this is an

indi%ation of a f$ll bladde" !his finding is not asso%iated with hypotension o" %lots& as stated in answe" @

O-yto-i% d"$gs Pito%in a"e d"$gs $sed to %ont"a%t the $te"$s& so answe" C is in%o""e%t It has nothing to do

with displa%ement of the $te"$s #nswe" ) is in%o""e%t be%a$se displa%ement is asso%iated with a f$ll bladde"&not /aginal bleeding

205#nswe" C is %o""e%t Clients with an inte"nal defib"illato" o" a pa%emae" sho$ld not ha/e an <I be%a$se it

%an %a$se dys"hythmias in the %lient with a pa%emae" If the %lient has a need fo" o-ygen& is %la$st"ophobi%& o"

is deaf& he %an ha/e an <I& b$t p"o/isions s$%h as e-tension t$bes fo" the o-ygen& sedati/es& o" a signal

system sho$ld be made to a%%ommodate these p"oblems !he"efo"e& answe"s #& @& and ) a"e in%o""e%t

208#nswe" C is %o""e%t # 5=month=old is too old fo" the %olo"f$l mobile ?e is too yo$ng to play with the

ele%t"oni% game o" the +0=pie%e Eigsaw p$((le !he best toy fo" this age is the %a"s in a plasti% %ontaine"& so

answe"s #& @& and ) a"e in%o""e%t

20#nswe" C is %o""e%t !he %lient with polio has m$s%le weaness Pe"iods of "est th"o$gho$t the day will

%onse"/e the %lientKs ene"gy # hot bath %an %a$se b$"nsW howe/e"& a wa"m bath wo$ld be helpf$l& so answe" #

is in%o""e%t St"en$o$s e-e"%ises a"e not ad/isable& maing answe" @ in%o""e%t 7is$al dist$"ban%es a"e di"e%tly

asso%iated with polio and %annot be %o""e%ted with glassesW the"efo"e& answe" ) is in%o""e%t




209#nswe" @ is %o""e%t !he %lient with a p"otoepisiotomy will need stool softene"s s$%h as do%$sate sodi$m

S$pposito"ies a"e gi/en only with an o"de" f"om the do%to"& <ethe"gine is a d"$g $sed to %ont"a%t the $te"$s&

and Pa"lodel is an anti=Pa"insonian d"$gW the"efo"e& answe"s #& C& and ) a"e in%o""e%t

210#nswe" C is %o""e%t !otal Pa"ente"al *$t"ition is a high=gl$%ose sol$tion !his the"apy often %a$ses the

gl$%ose le/els to be ele/ated @e%a$se this is a %ommon %ompli%ation& ins$lin might be o"de"ed #nswe"s #& @&

and ) a"e in%o""e%t !P* is $sed to t"eat negati/e nit"ogen balan%eW it will not lead to negati/e nit"ogen

balan%e !otal Pa"ente"al *$t"ition %an be managed with o"al hypogly%emi% d"$gs& b$t it is diffi%$lt to do so

!otal Pa"ente"al *$t"ition will not lead to f$"the" pan%"eati% disease211#nswe" @ is %o""e%t !he %lient who is 10 wees p"egnant sho$ld be assessed to dete"mine how she feels

abo$t the p"egnan%y It is too ea"ly to dis%$ss p"ete"m labo"& too late to dis%$ss whethe" she was $sing a

method of bi"th %ont"ol& and afte" the %lient deli/e"s& a dis%$ssion of f$t$"e %hild"en sho$ld be instit$ted !h$s&


212#nswe" # is %o""e%t !he best I7 fl$id fo" %o""e%tion of dehyd"ation is no"mal saline be%a$se it is most lie

no"mal se"$m )e-t"ose p$lls fl$id f"om the %ell& la%tated inge"Ks %ontains mo"e ele%t"olytes than the %lientKs

se"$m& and de-t"ose with no"mal saline will also alte" the int"a%ell$la" fl$id !he"efo"e& answe"s @& C& and )

a"e in%o""e%t

21+#nswe" # is %o""e%t # thy"oid s%an $ses a dye& so the %lient sho$ld be assessed fo" alle"gies to iodine !he%lient will not ha/e a bol$s of fl$id& will not be asleep& and will not ha/e a $"ina"y %athete" inse"ted& so answe"s

@& C& and ) a"e in%o""e%t

21.#nswe" @ is %o""e%t hoDam is $sed to p"e/ent fo"mation of h antibodies It does not p"o/ide imm$nity toh isoen(ymes& eliminate %i"%$lating h antibodies& o" %on/e"t the h fa%to" f"om negati/e to positi/eW th$s&


21#nswe" @ is %o""e%t # %lient with a f"a%t$"ed foot often has a sho"t leg %ast applied to stabili(e the f"a%t$"e

# spi%a %ast is $sed to stabili(e a f"a%t$"ed pel/is o" /e"teb"al f"a%t$"e i"s%hne" wi"es a"e $sed to stabili(e

small bones s$%h as toes and the %lient will most liely ha/e a %ast o" immobili(e"& so answe"s #& C& and ) a"e

in%o""e%t

215#nswe" # is %o""e%t I"idi$m seeds %an be e-pelled d$"ing $"ination& so the %lient sho$ld be ta$ght to st"ain

his $"ine and "epo"t to the do%to" if any of the seeds a"e e-pelled In%"easing fl$ids& "epo"ting $"ina"y

f"e6$en%y& and a/oiding p"olonged sitting a"e not ne%essa"yW the"efo"e& answe"s @& C& and ) a"e in%o""e%t

218#nswe" C is %o""e%t Imm$nos$pp"essants a"e $sed to p"e/ent antibody fo"mation #nti/i"als& antibioti%s&

and analgesi%s a"e not $sed to p"e/ent antibody p"od$%tion& so answe"s #& @& and ) a"e in%o""e%t

21#nswe" # is %o""e%t @efo"e %ata"a%t "emo/al& the %lient will ha/e <yd"iati% d"ops instilled to dilate the p$pil !his will fa%ilitate "emo/al of the lens <ioti%s %onst"i%t the p$pil and a"e not $sed in %ata"a%t %lients #

lase" is not $sed to smooth and "eshape the lensW the diseased lens is "emo/ed Sili%one oil is not inEe%ted in this

%lientW th$s& answe"s @& C& and ) a"e in%o""e%t219#nswe" C is %o""e%t Pla%ing simple signs that indi%ate the lo%ation of "ooms whe"e the %lient sleeps& eats&

and bathes will help the %lient be mo"e independent P"o/iding mi""o"s and pi%t$"es is not "e%ommended with

the %lient who has #l(heime"Ks disease be%a$se mi""o"s and pi%t$"es tend to %a$se agitation& and alte"nating

health%a"e wo"e"s %onf$ses the %lientW the"efo"e& answe"s #& @& and ) a"e in%o""e%t

220#nswe" C is %o""e%t # Ba%son=P"att d"ain is a se"$m=%olle%tion de/i%e %ommonly $sed in abdominal

s$"ge"y # Ba%son=P"att d"ain will not p"e/ent the need fo" d"essing %hanges& "ed$%e edema of the in%ision& o"

eep the %ommon bile d$%t open& so answe"s #& @& and ) a"e in%o""e%t # t=t$be is $sed to eep the %ommon

bile d$%t open

221#nswe" C is %o""e%t !he infant who is +2 wees gestation will not be able to %ont"ol his head& so head lag

will be p"esent <ongolian spots a"e %ommon in #f"i%an #me"i%an infants& not Ca$%asian infantsW the %lient at

+2 wees will ha/e s%"otal "$gae o" "edness b$t will not ha/e /e"ni- %aseosa& the %heesy appea"ing %o/e"ing

fo$nd on most f$ll=te"m infants !he"efo"e& answe"s #& @& and ) a"e in%o""e%t

222#nswe" # is %o""e%t ?emat$"ia in a %lient with a pel/i% f"a%t$"e %an indi%ate t"a$ma to the bladde" o"

impending bleeding diso"de"s It is not $n$s$al fo" the %lient to %omplain of m$s%les spasms with m$ltiple

f"a%t$"es& so answe" @ is in%o""e%t )i((iness %an be asso%iated with blood loss and is nonspe%ifi%& maing

answe" C in%o""e%t *a$sea& as stated in answe" )& is also %ommon in the %lient with m$ltiple t"a$mas

22+#nswe" C is %o""e%t !he %lientKs statement L!hey a"e t"ying to ill meL indi%ates pa"anoid del$sions !he"e

is no data to indi%ate that the %lient is hea"ing /oi%es o" is into-i%ated& so answe"s # and ) a"e in%o""e%t)el$sions of g"ande$" a"e fi-ed beliefs that the %lient is s$pe"io" o" pe"haps a famo$s pe"son& maing answe" @

in%o""e%t

22.#nswe" @ is %o""e%t @e%a$se the n$"se is $nawa"e of when the bottle was opened o" whethe" the saline is

ste"ile& it is safest to obtain a new bottle #nswe"s #& C& and ) a"e not safe p"a%ti%es

22#nswe" C is %o""e%t Infants with an #pga" of 9 at min$tes most liely ha/e a%"yo%yanosis& a no"mal

physiologi% adaptation to bi"th It is not "elated to the infant being %old& e-pe"ien%ing b"ady%a"dia& o" being

letha"gi%W th$s& answe"s #& @& and ) a"e in%o""e%t

225#nswe" # is %o""e%t apid %ontin$o$s "ewa"ming of a f"ostbite p"ima"ily lessens %ell$la" damage It does

not p"e/ent fo"mation of bliste"s It does p"omote mo/ement& b$t this is not the p"ima"y "eason fo" "apid

"ewa"ming It might in%"ease pain fo" a sho"t pe"iod of time as the feeling %omes ba% into the e-t"emityW

the"efo"e& answe"s @& C& and ) a"e in%o""e%t




228#nswe" ) is %o""e%t ?emodialysis wo"s by $sing a dialy(ing memb"ane to filte" waste that has

a%%$m$lated in the blood It does not pass wate" th"o$gh a dialy(ing memb"ane no" does it eliminate plasma

p"oteins o" lowe" the p?& so answe"s #& @& and C a"e in%o""e%t

22#nswe" @ is %o""e%t !he %lient who is imm$ne=s$pp"essed and is e-posed to measles sho$ld be t"eated with

medi%ations to boost his imm$nity to the /i"$s #n antibioti% o" anti/i"al will not p"ote%t the %lient and it is too

late to pla%e the %lient in isolation& so answe"s #& C& and ) a"e in%o""e%t

229#nswe" ) is %o""e%t !he %lient with <S# sho$ld be pla%ed in isolation Dlo/es& a gown& and a mas

sho$ld be $sed when %a"ing fo" the %lient and hand washing is /e"y impo"tant !he doo" sho$ld "emain %losed& b$t a negati/e=p"ess$"e "oom is not ne%essa"y& so answe"s # and @ a"e in%o""e%t <S# is sp"ead by %onta%t

with blood o" body fl$id o" by to$%hing the sin of the %lient It is %$lt$"ed f"om the nasal passages of the

%lient& so the %lient sho$ld be inst"$%ted to %o/e" his nose and mo$th when he snee(es o" %o$ghs It is not

ne%essa"y fo" the %lient to wea" the mas at all timesW the n$"se sho$ld wea" the mas& so answe" C is in%o""e%t

2+0#nswe" @ is %o""e%t Pain "elated to phantom limb synd"ome is d$e to pe"iphe"al ne"/o$s system

inte""$ption #nswe" # is in%o""e%t be%a$se phantom limb pain %an last se/e"al months o" indefinitely #nswe"

C is in%o""e%t be%a$se it is not psy%hologi%al It is also not d$e to infe%tions& as stated in answe" )

2+1#nswe" # is %o""e%t )$"ing a Hhipple p"o%ed$"e the head of the pan%"eas& whi%h is a pa"t of the stoma%h&

the EeE$n$m& and a po"tion of the stoma%h a"e "emo/ed and "eanastomosed #nswe" @ is in%o""e%t be%a$se the p"o-imal thi"d of the small intestine is not "emo/ed !he enti"e stoma%h is not "emo/ed& as in answe" C& and in

answe" )& the esophag$s is not "emo/ed

2+2#nswe" C is %o""e%t Peppe" is not p"o%essed and %ontains ba%te"ia #nswe"s #& @& and ) a"e in%o""e%t be%a$se f"$its sho$ld be %ooed o" washed and peeled& and salt and et%h$p a"e allowed

2++#nswe" # is %o""e%t Co$madin is an anti%oag$lant One of the tests fo" bleeding time is a P"otime !his test

sho$ld be done monthly ,ating mo"e f"$its and /egetables is not ne%essa"y& and da"=g"een /egetables %ontain

/itamin & whi%h in%"eases %lotting& so answe" @ is in%o""e%t )"ining mo"e li6$ids and a/oiding %"owds is

not ne%essa"y& so answe"s C and ) a"e in%o""e%t

2+.#nswe" # is %o""e%t !he %lient who is ha/ing a %ent"al /eno$s %athete" "emo/ed sho$ld be told to hold his

b"eath and bea" down !his p"e/ents ai" f"om ente"ing the line #nswe"s @& C& and ) will not fa%ilitate

"emo/al

2+#nswe" @ is %o""e%t Clients with a histo"y of st"epto%o%%al infe%tions %o$ld ha/e antibodies that "ende" the

st"eptoinase ineffe%ti/e !he"e is no "eason to assess the %lient fo" alle"gies to pineapples o" bananas& the"e is

no %o""elation to the $se of phenytoin and st"eptoinase& and a histo"y of al%ohol ab$se is also not a fa%to" in

the o"de" fo" st"eptoinaseW the"efo"e& answe"s #& C& and ) a"e in%o""e%t2+5#nswe" @ is %o""e%t !he %lient who is imm$ne=s$pp"essed and has bone ma""ow s$pp"ession sho$ld be

ta$ght not to floss his teeth be%a$se platelets a"e de%"eased Using oils and %"eam=based soaps is allowed& as is

eating salt and $sing an ele%t"i% "a(o"W the"efo"e& answe"s #& C& and ) a"e in%o""e%t2+8#nswe" # is %o""e%t !he best method and safest way to %hange the ties of a t"a%heotomy is to apply the new

ones befo"e "emo/ing the old ones ?a/ing a helpe" is good& b$t the helpe" might not p"e/ent the %lient f"om

%o$ghing o$t the t"a%heotomy #nswe" C is not the best way to p"e/ent the %lient f"om %o$ghing o$t the

t"a%heotomy #sing the do%to" to s$t$"e the t"a%heotomy in pla%e is not app"op"iate

2+#nswe" ) is %o""e%t !he o$tp$t of +00m' is indi%ati/e of hemo""hage and sho$ld be "epo"ted immediately

#nswe" # does nothing to help the %lient <iling the t$be is done only with an o"de" and will not help in this

sit$ation& and slowing the int"a/eno$s inf$sion is not %o""e%tW th$s& answe"s @ and C a"e in%o""e%t

2+9#nswe" # is %o""e%t !he infant with tet"ology of falot has fi/e hea"t defe%ts ?e will be t"eated with digo-in

to slow and st"engthen the hea"t ,pineph"ine& aminophyline& and at"opine will speed the hea"t "ate and a"e not

$sed in this %lientW the"efo"e& answe"s @& C& and ) a"e in%o""e%t

2.0!he %o""e%t answe" is ma"ed by an ; in the diag"am !he !ail of Spen%e is lo%ated in the $ppe" o$te"

6$ad"ant of the b"east

2.1#nswe" # is %o""e%t !he toddle" with a /ent"i%$la" septal defe%t will ti"e easily ?e will not g"ow no"mally

b$t will not need mo"e %alo"ies ?e will be s$s%eptible to ba%te"ial infe%tion& b$t he will be no mo"e s$s%eptible

to /i"al infe%tions than othe" %hild"en !he"efo"e& answe"s @& C& and ) a"e in%o""e%t

2.2#nswe" @ is %o""e%t # nonst"ess test dete"mines pe"iodi% mo/ement of the fet$s It does not dete"mine l$ng

mat$"ity& show %ont"a%tions& o" meas$"e ne$"ologi%al well=being& maing answe"s #& C& and ) in%o""e%t

2.+#nswe" C is %o""e%t !he monito" indi%ates /a"iable de%ele"ations %a$sed by %o"d %omp"ession If Pito%in isinf$sing& the n$"se sho$ld t$"n off the Pito%in Inst"$%ting the %lient to p$sh is in%o""e%t be%a$se p$shing %o$ld

in%"ease the de%ele"ations and be%a$se the %lient is %m dilated& maing answe" # in%o""e%t Pe"fo"ming a

/aginal e-am sho$ld be done afte" t$"ning off the Pito%in& and pla%ing the %lient in a semi=Fowle"Ks position is

not app"op"iate fo" this sit$ationW the"efo"e& answe"s @ and ) a"e in%o""e%t

2..#nswe" C is %o""e%t !he g"aph indi%ates /ent"i%$la" ta%hy%a"dia !he answe"s in #& @& and ) a"e not noted

on the ,CD st"ip

2.#nswe" @ is %o""e%t 'o/eno- inEe%tions sho$ld be gi/en in the abdomen& not in the deltoid m$s%le !he

%lient sho$ld not aspi"ate afte" the inEe%tion o" %lea" the ai" f"om the sy"inge befo"e inEe%tion !he"efo"e&


2.5#nswe" @ is %o""e%t 7ali$m is not gi/en in the same sy"inge with othe" medi%ations& so answe" # is

in%o""e%t !hese medi%ations %an be gi/en to the same %lient& so answe" ) is in%o""e%t In answe" C& it is not




ne%essa"y to wait to inEe%t the se%ond medi%ation 7ali$m is an antian-iety medi%ation& and Phene"gan is $sed

as an antiemeti%

2.8#nswe" @ is %o""e%t 7oiding e/e"y + ho$"s p"e/ents stagnant $"ine f"om %olle%ting in the bladde"& whe"e

ba%te"ia %an g"ow )o$%hing is not "e%ommended and obtaining a $"inalysis monthly is not ne%essa"y& maing

answe"s # and C in%o""e%t !he %lient sho$ld p"a%ti%e wiping f"om f"ont to ba% afte" /oiding and bowel

mo/ements& so answe" ) is in%o""e%t

2.#nswe" C is %o""e%t Of these %lients& the one who sho$ld be assigned to the %a"e of the n$"sing assistant is

the %lient with dementia Only an * o" the physi%ian %an pla%e the %lient in se%l$sion& so answe" # isin%o""e%t !he n$"se sho$ld empty the Foley %athete" of the p"ee%lampti% %lient be%a$se the %lient is $nstable&

maing answe" @ in%o""e%t # n$"se o" physi%al the"apist sho$ld amb$late the %lient with a f"a%t$"ed hip& so

answe" ) is in%o""e%t

2.9#nswe" # is %o""e%t !he %lient who has "e%ently had a thy"oide%tomy is at "is fo" t"a%heal edema # padded

tong$e blade is $sed fo" sei($"es and not fo" the %lient with t"a%heal edema& so answe" @ is in%o""e%t If the

%lient e-pe"ien%es t"a%heal edema& the endot"a%heal t$be o" ai"way will not %o""e%t the p"oblem& so answe"s C

and ) a"e in%o""e%t

20#nswe" ) is %o""e%t ?istoplasmosis is a f$ng$s %a""ied by bi"ds It is not t"ansmitted to h$mans by %ats&

dogs& o" t$"tles !he"efo"e& answe"s #& @& and C a"e in%o""e%t

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Nursing Review Exam

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