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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!$A
2009
THE EVER POPULAR LAST MINUTE TIPS FOR
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NURSING LICENSURE EXAMINATIONS
In NP1, Please FOCUS on the following:
1 !ypes of leade"ship: #$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 $nde" 1. days4 !he inte"/entions fo" C?I') #& @
and C
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | +
5 CO<<U*I!A ?,#'!? *USI*D POC,SS: #ssessment& Planning& Implementation and ,/al$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$"ing hypo= and hype"gly%emia
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1+ Ca"e of %lients with hype"= and hypothy"oidism& st$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$%h as FOC,
FI,') #*#'ASIS = !?, )I7I*D #*) !?, ,S!#I*I*D FOC,S& FOCUS = FI*) OD#*IJ,
C'#IFA U*),S!#*) SO'U!IO* !?, P)S# CAC', = P'#* )O S!U)A #C!
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!?, 5 !,C?*IC#' !IPS FO !?, @O#) ,;#<I*#!IO*
1 #%%ept the fa%t that yo$ %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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 5
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 8
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA |
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 9
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$nt& letha"gy and impai"ed memo"y
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 10
CO*!,*!S
FU*)#<,*!#'S OF *USI*D MMMM12
<#!,*I!A *USI*D MMMMMMMMMMM ++
P,)I#!IC *USI*DMMMMMMMMMMMM8
CO<<U*I!A ?,#'!? *USI*D MMMMMMM58
<,)IC#' SUDIC#' *USI*D MMMMMMM 9PSAC?I#!IC *USI*D MMMMMMMM 118
POF,SSIO*#' #)BUS!<,*! MMMMMMM 1.1
',#),S?IP and <#*#D,<,*! MMMMMM 1..
*USI*D ,S,#C? MMMMMMMMMMM15
CO<P,?,*SI7, ,;#<I*#!IO* MMMMMM
18+
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 11
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 12
FUNDAMENTALS OF NURSING PART 1
1 Using the p"in%iples of standa"d p"e%a$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
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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$al to how many lite"sQ
a 1
b 1000
% 10
d 2002+ Hhi%h of the following is the abb"e/iation of d"opsQ
a Dtt
b Dtts
% )p
d )"
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2. !he abb"e/iation fo" mi%"o d"op isM
a gtt
b gtt
% md"
d mgts
2 Hhi%h of the following is the meaning of P*Q
a Hhen ad/i%e
b Immediately% Hhen ne%essa"y
d *ow
25 Hhi%h of the following is the app"op"iate meaning of C@Q
a Ca"dia% @oa"d oom
b Complete @ath"oom
% Complete @ed est
d Complete @oa"d oom
28 1 tsp is e6$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$th
d !wo times a day befo"e meals
+5 @a% Ca"e is best des%"ibe as:
a Ca"ing fo" the ba% by means of massage
b Hashing of the ba%
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1
% #ppli%ation of %old %omp"ess at the ba%
d #ppli%ation of hot %omp"ess at the ba%
+8 It "efe"s to the p"epa"ation of the bed with a new set of linens
a @ed bath
b @ed maing
% @ed shampoo
d @ed lining
+ Hhi%h of the following is the most impo"tant p$"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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 18
FUNDAMENTALS OF NURSING PART 2
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1
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$me whi%h positionQ
a Sitting
b Standing
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 19
% Den$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$t is:
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 20
a 'ess than +0 mlGho$"
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 21
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$"y
b Inse"t an ai"way
% ,le/ate the head of the bed
d Hithd"aw all pain medi%ations
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 22
ANSERS a$% 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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 2+
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
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++ 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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 2
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
FUNDAMENTALS OF NURSING PART 3
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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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 25
% !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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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 28
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:
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 2
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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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 29
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
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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%%$"
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | +1
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
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+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
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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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% 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
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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
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% 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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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
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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
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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
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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
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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
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | .8
.+ 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
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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
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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
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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
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | +
% 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$e`o be%a$se all @atang$e`os 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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | .
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"
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+ @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
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 50
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 51
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
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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
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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
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%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
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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
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+ )' 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
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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
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 59
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#$
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 80
@ ,/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!#$ata+
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 81
@ Pne$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$"se
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 82
in /ital statisti%s& whi%h of the following is notQ
A' C#$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 $sed to monito"
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 8+
pa"ti%$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
# Family t"eatment "e%o"d
@ !a"get Client list
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$tinely t"ansmitted f"om on%e fa%ility
to anothe"
# Family t"eatment "e%o"d
@ !a"get Client list
C' R!*#rti$ #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%$ment thesefindingsQ
A' Fa6i+ tr!at6!$t r!"#r%
@ !a"get Client list
C epo"ting fo"ms
) O$tp$t "e%o"d
55 !he info"mation abo$t <ang a$lKs add"ess&
f$ll name& age& symptoms and diagnosis is
"e%o"ded in
A' Fa6i+ tr!at6!$t r!"#r%
@ !a"get Client list
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 8
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 88
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 8
@ '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$"sing
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 89
) !he wo"th and dignity of man
A$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$t=patient se"/i%es
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22 !he p$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$nity o"gani(ing
in/ol/es t"aining of potential leade"s in the
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1
%omm$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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 2
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | +
.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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | .
%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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA |
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 5
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 8
# !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)
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 9
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
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) #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"
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 92
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
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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
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) 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
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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
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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
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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
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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
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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
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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
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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"
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.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
MEDICAL SURGICAL NURSING Part 2
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:
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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
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 105
% 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":
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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:
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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
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MEDICAL SURGICAL NURSING Part 3
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
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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
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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
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+ 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
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 118
.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
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 119
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 120
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:
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 121
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
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. 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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 12.
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
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.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
PS(CHIATRIC NURSING Part 2
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"
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. 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
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% !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
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+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:
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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
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) !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
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++ 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
PS(CHIATRIC NURSING Part 3
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:
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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$alisti% beha/io"
d esponsi/eness to the pa"ents
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1. <alo$ 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
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% 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
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% 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 $sing a %ogniti/e app"oa%hQ
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a #g"ee with the %lientKs painf$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 $nable to deal
with the abo"tion at this time
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A Pe"sonal inte"nal st"ength and s$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$ld
al"eady now the "eason fo" inpatient admission
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+ A ,-%ess dopamine is tho$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$se of his
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need fo" so%iali(ation sills 7o%ational t"aining gene"ally taes pla%e in a "ehabilitation fa%ilityW the %lient
des%"ibed in this sit$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$p %lients o" playing a team spo"t in the gym may o/e"whelm a se/e"ely withd"awn %lient
Hat%hing !7 is a solita"y a%ti/ity that will "einfo"%e the %lientKs withd"awal f"om othe"s
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PROFESSIONAL ADUSTMENT
1 # n$"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
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) 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
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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$"ge"y is to be done o" not e-emplifies the bioethi%al p"in%iple
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of a$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 $pdates he" nowledge on the theo"ies in
management and leade"ship in o"de" to be%ome effe%ti/e in he" new "ole She lea"ns that some manage"s ha/e low
%on%e"n fo" se"/i%es and high %on%e"n fo" staff Hhi%h style of management "efe"s to thisQ
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# O"gani(ation <an
@ Impo/e"ished <anagement
C Co$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%
@ #$tho"ita"ian
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C 'aisse( fai"e
) @$"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
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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
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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 ^esp"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$ppo"ti/e of one anothe"T
!he p"in%iple of ^esp"it dK %o"psK "efe"s to p"omoting ha"mony in the wo"pla%e& whi%h is essential in maintaining
a %limate %ond$%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
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# 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$st be a/ailable at all times to a%%omplish %e"tain
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p$"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
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.+ 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/$lge
the info"mation to othe"s
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.9 #le-and"a is tased to o"gani(e the new wing of the hospital She was gi/en the a$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$"e is thisQ
# Cent"ali(ed
@ )e%ent"ali(ed
C <at"i-
) Info"mal
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#nswe": @ )e%ent"ali(ed
)e%ent"ali(ed st"$%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$" wees fo" all patient %a"e pe"sonnel
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C #ll patients shall ha/e thei" weights taen "e%o"ded
) Patients shall answe" the e/al$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
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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
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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 $nde"standing the meaning of e-pe"ien%es as those who e-pe"ien%ed the
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phenomenon
1. ?e systemati%ally plans his sampling plan Sho$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
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) 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
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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
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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
)$"ation of sleep is the ^effe%tK dependent /a"iable of %$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$"ge"y patients
She states the signifi%an%e of the "esea"%h p"oblem Hhi%h of the following statements is the <OS! signifi%ant
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fo" this st$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$dy
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) )ete"mine if the meas$"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$lts to an ^effe%tK& whi%h is
%omplian%e to home %a"e "egimen o" the dependent /a"iable
. Sit$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%$la" time
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S$"/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
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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$ltation at the , and do%to"s offi%es
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) Conta%ts of patients with histo"y of fe/e" and %o$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$"ation
C #tt"ition
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) )esign
#nswe": ) )esign
)esign is not a th"eat to inte"nal /alidity of the inst"$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:
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 181
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 182
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$ited fo"
whi%h "esea"%h designQ
a ?isto"i%al
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 18+
b Case st$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
# ) ) @ )
@ @ @ @ #
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 18.
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 18
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$"e of "ef"ige"ato" to maintain poten%y of measles and OP7 /a%%ine is:
a =2 0C to = 0C
b =1 0C to =2 0C
% 1 0C to 2 0C
d 2 0C to 0C
2 )ipthe"ia /a%%ine is a:
a @a%te"ial to-in
b illed ba%te"ia
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 185
% 'i/e atten$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$"sing that was established in the Philippines is:
a Fatima Uni/e"sity
b Fa" ,aste"n Uni/e"sity
% Uni/e"sity of the ,ast
d Uni/e"sity of Sto !omas
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 188
+ Flo"en%e nightingale is bo"n on:
a F"an%e
b @"itain
% US
d Italy
+9 ObEe%ti/e data is also %alled:
a Co/e"t
b O/e"t% Infe"en%e
d ,/al$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$id in the thi"d t"imeste" weighs app"o-imately:
a 2 ilog"ams
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 189
b F"e6$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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 10
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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 11
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"
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 12
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
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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
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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
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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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 15
% !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 &!
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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
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@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:
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#@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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 190
)!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$"e fo" hypotension
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 191
C)ete"mine whethe" an o-yto%i% d"$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
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. # %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
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##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
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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$ing to monito" the /ital signs
@Conta%ting the physi%ian
C#sing the %lient how he feels
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)7omiting and dia""hea
98 !he n$"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$sion "elated to mate"nal position
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CImpai"ed physi%al mobility "elated to fetal=monito"ing e6$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$"se will e-pe%t the neonate to be:
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#?ypogly%emi%& small fo" gestational age
@?ype"gly%emi%& la"ge fo" gestational age
C?ypogly%emi%& la"ge fo" gestational age
)?ype"gly%emi%& small fo" gestational age
120 Hhi%h of the following inst"$%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$"gi%al %lient is to:
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##dministe" a p"es%"ibed antibioti%
@Hash he" hands fo" 2 min$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 $ssells
t"a%tionQ
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#15=yea"=old female with s%oliosis
@12=yea"=old male with a f"a%t$"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
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@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:
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#!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$"s /ia *D
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CCimetadine +00mg PO 6id
)<o"phine mg I< 6 . ho$"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$ght that the medi%ation may:
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#Ca$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
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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$t the day
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 205
)7is$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
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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
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)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
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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$ld:
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 210
#@e inEe%ted into the deltoid m$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
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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$s& answe"s @& C& and ) a"e in%o""e%t
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1 #nswe" # is %o""e%t !he no"mal platelet %o$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
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COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 21+
#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$e p"ima"y %a"e& so answe" ) is in%o""e%t
2 #nswe" @ is %o""e%t !he %lient with ?P7 is at highe" "is fo" %e"/i%al and /aginal %an%e" "elated to this S!I
She is not at highe" "is fo" the othe" %an%e"s mentioned in answe"s #& C& and )& so those a"e in%o""e%t
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+ #nswe" @ is %o""e%t # lesion that is painf$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$t& absen%e of the nee=Ee" "efle-& and de%"eased "espi"ations indi%ate to-i%ity& so
answe"s #& C& and ) a"e in%o""e%t
51 #nswe" ) is %o""e%t If the %lient e-pe"ien%es hypotension afte" an inEe%tion of epid$"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$se it is not the
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p"ima"y "esponsibility fo" the n$"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$l a%t to the %lient o" his belongings and is not indi%ated in this instan%e !he"efo"e& #nswe"s #& C&
and ) a"e in%o""e%t
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9 #nswe" ) is %o""e%t !he %lient at highest "is fo" %ompli%ations is the %lient with m$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$me defi%it In
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answe" #& impai"ed gas e-%hange "elated to hype"/entilation wo$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 $"ina"y t"a%t infe%tion
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12.#nswe" # is %o""e%t Infants of mothe"s who smoe a"e often low in bi"th weight Infants who a"e la"ge fo"
gestational age a"e asso%iated with diabeti% mothe"s& so answe" @ is in%o""e%t P"ete"m bi"ths a"e asso%iated
with smoing& b$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 $n"elated to the stem
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1+9#nswe" # is %o""e%t !he e6$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 )
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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
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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
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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"¬ /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
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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$s&
answe"s #& C& and ) a"e in%o""e%t
212#nswe" # is %o""e%t !he best I7 fl$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&
answe"s #& C& and ) a"e in%o""e%t
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
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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$ld not aspi"ate afte" the inEe%tion o" %lea" the ai" f"om the sy"inge befo"e inEe%tion !he"efo"e&
answe"s #& C& and ) a"e in%o""e%t
2.5#nswe" @ is %o""e%t 7ali$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
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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