DEPARTMENT OF NURSING

NURSING PRACTICE IV - Care of Clients with Physiologic and Psychosocial Alterations SET A - PREBOARDS

GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test items.
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
3. AVOID ERASURES. Write the subject title “NURSING PRACTICE IV” on the box provided.
4. Shade the appropriate set.
5. Use only lead Pencil No. 2 for shading.

1. You see a nurse in the emergency department (ED) remove meperidine from the medication cart and replace it with saline.
She then pockets the syringe. Your eyes make contact with her, and she panics, begging you to not report her because
she could lose her job. You’re deeply troubled and speak with the charge nurse about this incident. She points out that
the ED is so short-staffed right now, it can’t afford to lose this nurse. The charge nurse suggests that it would be best to let
this incident drop because no harm has been done and she’s confident that the nurse won’t repeat this behavior now that
she has been caught. What’s your responsibility in this situation?
A. Inform the charge nurse that you feel bad about the situation, but this incident can’t be overlooked; if she doesn’t
address it, you’ll go to the next person in the chain of command
B. Assume the charge nurse will report it if it happens again
C. Comply with the charge nurse’s wishes
D. Consider that it’s none of your business

Answer: A. If you, who witnessed the incident, believe that it’s a mandatory reportable event, it’s your responsibility to report it to
the next authority in the chain of command, even if the charge nurse disagrees. Nurse and charge nurse share equal
responsibility in this situation.

2. You’re a staff nurse, setting up a quality improvement project for the emergency department (ED) to have 100% compliance in
consistent, thorough documentation of pain assessment after analgesic administration. Which would be the best for you to
choose as an outcome indicator?
A. Attendance at the mandatory inservice is accomplished by 100% of the nursing staff
B. An audit of department charts 1 month later reveals a 20% improvement in documentation
C. Random selection from one nurse’s charts shows complete documentation for that client
D. The ED physicians unanimously agree that the documentation has improved
Answer: B. The best indicator that learning has taken place is a change in behavior. Evidence for that is an actual improvement
in the desired requirement. Attending a class doesn’t necessarily mean learning took place or that attendees are now able to
apply the new information. Although one nurse may achieve the desired goal, that isn’t indicative of the rest of the staff or of an
improvement from before the project. Opinions lack objectivity and can be wrong.

3. The nurse manager announces that the emergency department (ED) will begin benchmarking results from client
satisfaction surveys. Which is the best understanding of that concept?
A. The ED will compare its current scores with its previous scores
B. The ED will compare the ED nurses’ scores with the ED physicians’ scores
C. The ED will compare its scores with the best in the field
D. The ED will compare its scores with other departments’ scores
Answer: C. Benchmarking is measuring against those renowned in the industry for implementing best practices. Looking for
improvement from internal previous scores is quality improvement; comparison of internal components of the score might help
determine the reasons for the department’s current scores, but isn’t benchmarking. Internal benchmarking is done only for similar
processes such as laboratory turnaround time. Although facilities may make comparisons, that isn’t benchmarking.

4. You’re the triage nurse in a busy emergency department There are no rooms available in the treatment area for noncritical
cases at the present time. As you’re taking a client with chest pain and shortness of breath to the treatment area, a client
previously triaged starts screaming at you, “We were here first; I demand to be seen now!” What’s the best response for
you to make?
A. “Because you’re so upset, I’ll take you back now. Try to control yourself.”
B. “We’re doing the best we can. There are many sick people here today.”
C. “If you don’t sit down and be quiet, I’ll call security to escort you outside.”
D. “I know that you’re upset. We’ll get you into the treatment area as soon as we can.”
Answer: D. The client is becoming agitated, possibly from feeling ignored. Acknowledge his feelings, but calmly repeat the facts.
Rewarding that behavior by taking the client back will signal to everyone else who’s waiting that they should behave similarly.
Besides, the purpose of triage is that the person with the highest need goes first. The client is too upset to absorb information
and think rationally. Taking an authoritative stance and removing the client will only escalate the client’s frustration and agitation
as well as possibly result in inadequate medical care for his need.

5. A staff nurse made a medication error this morning and reported it to you, the charge nurse. What’s the best initial response
for you to make?
A. Inquire about the client’s physiologic response to the error
B. Remind the nurse about the importance of medication safety
C. Write up an incident report
D. Discuss process changes with the nurse manager
Answer: A. Client safety is always the greatest concern; first do whatever is necessary to minimize harm to the client. The nurse
is probably already aware of the importance of medication safety; that’s why she’s reporting the incident. Although an incident
report or process changes may be required, it can be done after ensuring that the client is all right.
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6. You and the other emergency department nurses believe that you have inadequate staff for the current client census. Which
are the most appropriate data for you to consider in preparing your request for additional staff?
A. Client acuity and length of stay
B. Consensus of the physicians’ and the nurses’ opinions
C. Amount of nursing staff overtime and unfilled positions
D. Number of frequency of client complaints
Answer: A. The new Emergency Nurses Association Guidelines for Determining Emergency Department Nurse Staffing include
client census, client acuity, client length-of-stay, nursing time for interventions, skill mix, and adjustment factor for the nonclient
care time. Although the other options may represent supportive information, the objective criteria from the national professional
organization, backed by research, is more meaningful. Different factors than staffing numbers may also be influencing or causing
the other options, such as new and inexperienced staff or rude staff.

7. Which is the best way for the charge nurse to handle the staff’s reaction at the end-of-shift report after the staff was verbally
abused by a client’s wife?
A. Encourage the staff to deal with the report privately to prevent compromising client confidentiality
B. Hold a group discussion session so that the staff can share their thoughts and feelings
C. Invite the staff out for drinks to help distract them from the disturbing event
D. Ask pastoral care to offer prayers for the client’s recovery next week
Answer: B. To avoid posttraumatic stress syndrome, it’s advisable to have a Critical Incident Stress Debriefing. This involves
expressing personal feelings, discussion, and working on unresolved emotional issues. Private discussions among caregivers
doesn’t breech client confidentiality. Denying and blunting emotions through avoidance or numbing with drinking only leads to
delayed reactions. A prayer service is an option, but shouldn’t be the only action; it involves a time delay and may not be
consistent with some of the staff’s personal values.

8. The emergency department (ED) director indicates that he wants to promote evidence-based emergency nursing practice.
Which is the best example of that concept?
A. The nurse reassesses the client 1 hour after analgesic administration
B. The ED triage procedure for a client who’s wheezing is modified based on several research
C. The ED attending physician preferences are implemented into the new ED protocol for the client with chest pain
D. Data regarding the ED client length-of-stay are systematically gathered and reviewed

Answer: B. Evidence-based practice involves collecting data and validating results before making a change; research studies can
validate a planned change. Reassessment is part of the nursing process or evaluation of just one client’s response. Physician
preference is opinion-based, not necessarily evidence-based. Data collection and review is part of evidence-based practice, but
not the complete concept.

9. In anticipation of a nursing shortage, the nursing management in a facility is investigating a nursing care delivery model that
involves the division of tasks, with one nurse assuming the responsibility for particular tasks. This model is called
A. Total patient care C. Team nursing
B. Functional nursing D. Primary nursing
Answer: B. Functional nursing is task focused, not client focused. In this model, tasks are divided, with one nurse assuming
responsibility for specific tasks. (Option A) Total patient care is a model of care where an RN is responsible for all aspects of care
for one or more clients. The RN may delegate aspects of care, but retains accountability for care of all assigned clients. (Option
C) In team nursing, an RN leads a team that is composed of other RNs, LPNs or LVNs, and nurse assistants or technicians. The
team members provide direct client care to groups of clients, under the direction of the RN team leader. Nurse assistants are
given client assignments rather than being assigned particular tasks. (Option D) Primary nursing is a model of care delivery
whereby an RN assumes responsibility for a caseload of clients over time. Typically the RN selects the clients for his or her
caseload and cares for the same clients during their hospitalization or stay in the health care setting.

10. The medical center has changed its overall management philosophy from centralized to decentralized management. One
advantage of a decentralized management structure for the nursing units over a centralized structure is that:
A. Staff is not responsible for defining their roles
B. Managers handle the difficult decisions
C. Communication pathways are simplified
D. Each staff member is accountable for evaluating the plan of care.
Answer: D. In decentralized management, decision making is moved down to the level of staff. It requires workers to be
empowered to accept greater responsibility for the quality of client care provided. This means that each staff member is
accountable for evaluating the plan of care. (Option A) If decentralized decision making is in place, professional staff has a voice
in identifying the RN role. Each RN on the work team is responsible for knowing his or her role and how it is to be implemented
on the nursing unit. (Option B) In decentralized management, autonomy exists (freedom to decide and act). The nurse manager
does not necessarily handle the difficult decisions. Those staff members who are best informed about a problem or issue make
decisions on the basis of knowledge. (Option C) Communication pathways are not simplified.

11. In gathering information, as a nurse these are the reliable sources except:21
A. Interview
B. Observation
C. Grapevine
D. Records

Answer: C. Grapevine – Rumours are not reliable sources of information. The other items would guarantee reliable results.
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12. As a nurse educator, you want to know the reasons behind the leave of absences of student nurses. These tools can be used
except?22
A. Interview
B. Records
C. Pre-Test & Post-Test
D. Questionnaire

Answer: C. Pre-Test & Post-Test – This is not an appropriate tool in gathering the needed data. Since this type of research is
descriptive in nature, the other three options can be utilized.

13. Upon gathering the data, which of the following can describe the most number of reasons for leave of absence?23
A. Median
B. Mode
C. Frequency
D. Deviance

B. Mode – This is a numerical value in a distribution that occurs frequently.

14. If you want to know the average age of the nursing students who has the most number of leave of absence you will need:24
A. Median
B. Mode
C. Mean
D. Deviance
Answer: C. Mean – The point on the scale that is equal to the sum of scores divided by the number of scores

15. After all the data presented, what part of descriptive statistics will you use in order to place a systematic arrangement of
numerical values from lowest to highest?25
A. Deviance
B. Central Tendency
C. Mode
D. Frequency Distribution

Answer: D. Frequency Distribution – Deviance shows how to disperse a group of samples can from the middle value. Central
tendency shows how clustered groups can be in a middle value; mode is an example of central tendency

16. Which nursing intervention would be most appropriate if a male client develop orthostatic hypotension while taking
amitriptyline (Elavil)?
a. Consulting with the physician about substituting a different type of antidepressant.
b. Advising the client to sit up for 1 minute before getting out of bed.
c. Instructing the client to double the dosage until the problem resolves.
d. Informing the client that this adverse reaction should disappear within 1 week.
Answer: (B) Advising the client to sit up for 1 minute before getting out of bed.
Rationale: To minimize the effects of amitriptyline-induced orthostatic hypotension, the nurse should advise the client to sit up for
1 minute before getting out of bed. Orthostatic hypotension commonly occurs with tricyclic antidepressant therapy. In these cases,
the dosage may be reduced or the physician may prescribe nortriptyline, another tricyclic antidepressant. Orthostatic hypotension
disappears only when the drug is discontinued.

17. Mr. Cruz visits the physician's office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia,
fatigue, low selfesteem, poor concentration, and difficulty making decisions. The client states that these symptoms began
at least 2 years ago. Based on
this report, the nurse Tyfany suspects:
a. Cyclothymic disorder.
b. Atypical affective disorder.
c. Major depression.
d. Dysthymic disorder.

Answer: (D) Dysthymic disorder.

Rationale: Dysthymic disorder is marked by feelings of depression lasting at least 2 years, accompanied by at least two of the
following symptoms: sleep disturbance, appetite disturbance, low energy or fatigue, low selfesteem, poor concentration, difficulty
making decisions, and hopelessness. These symptoms may be relatively continuous or separated by intervening periods of
normal mood that last a few days to a few weeks. Cyclothymic disorder is a chronic mood disturbance of at least 2 years' duration
marked by numerous periods of depression and hypomania. Atypical affective disorder is characterized by manic signs and
symptoms. Major depression is a recurring, persistent sadness or loss of interest or pleasure in almost all activities, with signs and
symptoms recurring for at least 2 weeks.

18. After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes
activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse
verifies the dosage ordered. What is the
usual minimum dose of activated charcoal?
a. 5 g mixed in 250 ml of water
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b. 15 g mixed in 500 ml of water
c. 30 g mixed in 250 ml of water
d. 60 g mixed in 500 ml of water

Answer: (C) 30 g mixed in 250 ml of water

Rationale: The usual adult dosage of activated charcoal is 5 to 10 times the estimated weight of the drug or chemical ingested, or
a minimum dose of 30 g, mixed in 250 ml of water. Doses less than this will be ineffective; doses greater than this can increase
the risk of adverse reactions, although toxicity doesn't occur with activated charcoal, even at the maximum dose.

19. .What herbal medication for depression, widely used in Europe, is now being prescribed in the United States?
a. Ginkgo biloba
b. Echinacea
c. St. John's wort
d. Ephedra

Answer: (C) St. John's wort

Rationale: St. John's wort has been found to have serotonin-elevating properties, similar to prescription antidepressants. Ginkgo
biloba is prescribed to enhance mental acuity. Echinacea has immunestimulating properties. Ephedra is a naturally occurring
stimulant that is similar to ephedrine.

20. .Cely with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this
medication?
a. Calcium
b. Sodium
c. Chloride
d. Potassium

Answer: (B) Sodium

Rationale: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be
reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should
drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions but sodium is most
important to the absorption of lithium.

21. Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true?
a. It's characterized by an acute onset and lasts about 1 month.
b. It's characterized by a slowly evolving onset and lasts about 1 week.
c. It's characterized by a slowly evolving onset and lasts about 1 month.
d. It's characterized by an acute onset and lasts hours to a number of days.

Answer: (D) It's characterized by an acute onset and lasts hours to a number of days

22. Edward, a 66 year old client with slight memory impairment and poor concentration is diagnosed with primary degenerative
dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from
social interactions. To assess
for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for:
a. Occasional irritable outbursts.
b. Impaired communication.
c. Lack of spontaneity.
d. Inability to perform self-care activities.

Answer: (B) Impaired communication.

Rationale: Initially, memory impairment may be the only cognitive deficit in a client with Alzheimer's disease. During the early
stage of this disease, subtle personality changes may also be present. However, other than occasional irritable outbursts and lack
of spontaneity, the client is usually cooperative and exhibits socially appropriate behavior. Signs of advancement to the middle
stage of Alzheimer's disease include exacerbated cognitive impairment with obvious personality changes and impaired
communication, such as inappropriate conversation, actions, and responses.
During the late stage, the client can't perform self-care activities and may become mute.

23. Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the
client that:
a. This medication may be habit forming and will be discontinued as soon as the client feels
better.
b. This medication has no serious adverse effects.
c. The client should avoid eating such foods as aged cheeses, yogurt, and chicken livers while
taking the medication.
d. This medication may initially cause tiredness, which should become less bothersome over
time.

Answer: (D) This medication may initially cause tiredness, which should become less bothersome over time.
Rationale: Sedation is a common early adverse effect of imipramine, a tricyclic antidepressant, and usually decreases as
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tolerance develops. Antidepressants aren't habit forming and don't cause physical or psychological dependence. However, after a
long course of high-dose therapy, the dosage should be decreased gradually to avoid mild withdrawal symptoms. Serious adverse
effects, although rare, include myocardial infarction, heart failure, and tachycardia. Dietary restrictions, such as avoiding aged
cheeses, yogurt, and chicken livers, are necessary for a client taking a monoamine oxidase inhibitor, not a tricyclic
antidepressant.

24. Kathleen is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the
nurse should plan to:
a. Severely restrict the client's physical activities.
b. Weigh the client daily, after the evening meal.
c. Monitor vital signs, serum electrolyte levels, and acid-base balance.
d. Instruct the client to keep an accurate record of food and fluid intake.

Answer: (C) Monitor vital signs, serum electrolyte levels, and acid-base balance.
Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of
arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore,
monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial. Option A may worsen anxiety. Option
B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D
would reward the client with attention for not eating and reinforce the control issues that are central to the underlying
psychological problem; also, the client may record food and fluid intake inaccurately.

25. Celia with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after
admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects
that the client is going
through which of the following withdrawals?
a. Alcohol withdrawal
b. Cannabis withdrawal
c. Cocaine withdrawal
d. Opioid withdrawal

Answer: (D) Opioid withdrawal

Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no
real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

26. Mr. Garcia, an attorney who throws books and furniture around the office after losing a case is referred to the psychiatric
nurse in the law firm's employee assistance program. Nurse Beatriz knows that the client's behavior most likely represents
the use of which defense mechanism?
a. Regression
b. Projection
c. Reaction-formation
d. Intellectualization

Answer: (A) Regression

Rationale: An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is
appropriate at a younger age. In projection, the client blames someone or something other than the source. In reaction formation,
the client acts in opposition to his feelings. In intellectualization, the client overuses rational explanations or abstract thinking to
decrease the significance of a feeling or event.

27. Nurse Anne is caring for a client who has been treated long term with antipsychotic medication. During the assessment, Nurse
Anne checks the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most likely observe:
a. Abnormal movements and involuntary movements of the mouth, tongue, and face.
b. Abnormal breathing through the nostrils accompanied by a “thrill.”
c. Severe headache, flushing, tremors, and ataxia.
d. Severe hypertension, migraine headache,

Answer: (A) Abnormal movements and involuntary movements of the mouth, tongue, and face.
Rationale: Tardive dyskinesia is a severe reaction associated with long term use of antipsychotic medication. The clinical
manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue (fly catcher tongue),
and face.

28. Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or
symptoms?
a. Weakness
b. Diarrhea
c. Blurred vision
d. Fecal incontinence

. Answer: (C) Blurred vision

Rationale: At lithium levels of 2 to 2.5 mEq/L the client will experienced blurred vision, muscle twitching, severe hypotension, and
persistent nausea and vomiting. With levels between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea, muscle
weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal
incontinence occurs, as well as seizures, cardiac dysrythmias, peripheral vascular collapse, and death.

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29. Nurse Jannah is monitoring a male client who has been placed inrestraints because of violent behavior. Nurse determines that
it will be safe to remove the restraints when:
a. The client verbalizes the reasons for the violent behavior.
b. The client apologizes and tells the nurse that it will never happen again.
c. No acts of aggression have been observed within 1 hour after the release of two of the
extremity restraints.
d. The administered medication has taken effect.

(Answer: (C) No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.
Rationale: The best indicator that the behavior is controlled, if the client exhibits no signs of aggression after partial release of
restraints. Options A, B, and D do not ensure that the client has controlled the behavior.

30. Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by
the nurse:
a. Increased attention span and concentration
b. Increase in appetite
c. Sleepiness and lethargy
d. Bradycardia and diarrhea

Answer: (A) increased attention span and concentration

Rationale: The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D.
Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability.

31. .Kitty, a 9 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have
Mental retardation of this classification:
a. Profound
b. Mild
c. Moderate
d. Severe

Answer: (C) Moderate

Rationale: The child with moderate mental retardation has an I.Q. of 35- 50 Profound Mental retardation has an I.Q. of below 20;
Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35

32. The therapeutic approach in the care of Armand an autistic child include the following EXCEPT:
a. Engage in diversionary activities when acting -out
b. Provide an atmosphere of acceptance
c. Provide safety measures
d. Rearrange the environment to activate the child

Answer: (D) Rearrange the environment to activate the child

Rationale: The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry
outburst can be re-channeling through safe activities. B. Acceptance enhances a trustingrelationship. C. Ensure safety from self-
destructive behaviors like head banging and hair pulling

33. Jeremy is brought to the emergency room by friends who state that he took something an hour ago. He is actively
hallucinating, agitated, with irritated nasal septum.
a. Heroin
b. Cocaine
c. LSD
d. Marijuana

68. Answer: (B) cocaine

Rationale: The manifestations indicate intoxication with cocaine, a CNS stimulant.

A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary
constriction.

B. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs

D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal,
impaired judgment and hallucinations.

34. .Nurse Pauline is aware that Dementia unlike delirium is characterized by:
a. Slurred speech
b. Insidious onset
c. Clouding of consciousness
d. Sensory perceptual change

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Answer: (B) insidious onset
Rationale: Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive
disturbances. A,C and D are all characteristics of delirium.

35. A 35 year old female has intense fear of riding an elevator. She claims “ As if I will die inside.” The client is suffering from:
a. Agoraphobia
b. Social phobia
c. Claustrophobia
d. Xenophobia

Answer: (C) Claustrophobia

Rationale: Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is
difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D.
Xenophobia is fear of strangers.

36. .Nurse Myrna develops a counter-transference reaction. This is evidenced by:

a. Revealing personal information to the client
b. Focusing on the feelings of the client.
c. Confronting the client about discrepancies in verbal or non-verbal behavior
d. The client feels angry towards the nurse who resembles his mother.

Answer: (A) Revealing personal information to the client

Rationale: Counter-transference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts.
B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the
nurse based on her past.

37. Tristan is on Lithium has suffered from diarrhea and vomiting. What should the nurse incharge do first:
a. Recognize this as a drug interaction
b. Give the client Cogentin
c. Reassure the client that these are common side effects of lithium therapy
d. Hold the next dose and obtain an order for a stat serum lithium level

69. (D) Hold the next dose and obtain an order for a stat serum lithium level
Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is
done to validate the observation.

A. The manifestations are not due to drug interaction.

B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics.
C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia.

38. Nurse Sarah ensures a therapeutic environment for all the client. Which of the following best
describes a therapeutic milieu?
a. A therapy that rewards adaptive behavior
b. A cognitive approach to change behavior
c. A living, learning or working environment.
d. A permissive and congenial environment

70. .Answer: (C) A living, learning or working environment.

Rationale: A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to
provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms; limit setting,
balance and unit modification.

A. Behavioral approach in psychiatric care

is based on the premise that behavior can be learned or unlearned through the use of reward and punishment.
B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive
behaviors.
C. This is not congruent with therapeutic milieu.

39. Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting:
a. Splitting
b. Transference
c. Countertransference
d. Resistance

Answer: (B) Transference

Rationale: Transference is a positive or negative feeling associated with a significant person in the client’s past that are
unconsciously assigned to another

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A. Splitting is a defense mechanism commonly seen in a client with
personality disorder in which the world is perceived as all good or all bad
C.Countert-transference is a
phenomenon where the nurse shifts feelings assigned to someone in her past to the patient
D. Resistance is the client’s refusal to submit himself to the care of the nurse

40. Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother.
Rape is an example of which type of crisis:
a. Situational
b. Adventitious
c. Developmental
d. Internal

Answer: (B) Adventitious

Rationale: Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life.

A. Situational
crisis is from an external source that upset ones psychological equilibrium
C and D. Are the same. They are transitional or developmental periods in life

41. Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental
Disorders, Text Revision (DSM-IV-TR) is:
a. Obesity
b. Borderline personality disorder
c. Major depression
d. Hypertension

Answer: (C) Major depression

Rationale: The DSM-IV-TR classifies major depression as an Axis I disorder. Borderline personality disorder as an Axis II; obesity
and hypertension, Axis III.

42. .Katrina, a newly admitted is extremely hostile toward a staff member she has just met, without apparent reason. According to
Freudian theory, the nurse should suspect that the client is experiencing which of the following phenomena?
a. Intellectualization
b. Transference
c. Triangulation
d. Splitting

Answer: (B) Transference

Rationale: Transference is the unconscious assignment of negative or positive feelings evoked by a significant person in the
client’s past to another person. Intellectualization is a defense mechanism in which the client avoids dealing with emotions by
focusing on facts. Triangulation refers to conflicts involving three family members. Splitting is a defense mechanism commonly
seen in clients with personality disorder in which the world is perceived as all good or all bad.

43. An 83year-old male client is in extended care facility is anxious most of the time and frequently complains of a number of
vague symptoms that interfere with his ability to eat. These symptoms indicate which of the following disorders?
a. Conversion disorder
b. Hypochondriasis
c. Severe anxiety
d. Sublimation

75. Answer: (B) Hypochondriasis

Rationale: Complains of vague physical symptoms that have no apparent medical causes are characteristic of clients with
hypochondriasis. In many cases, the GI system is affected.

Conversion disorders are characterized by one or more neurologic symptoms. The client’s symptoms don’t suggest severe
anxiety. A client experiencing sublimation channels maladaptive feelings or impulses into socially acceptable behavior

44. Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of GI
symptoms before course examinations. Although physical causes have been eliminated, the student continues to express
her belief that she has a serious illness. These symptoms are typically of which of the following disorders?
a. Conversion disorder
b. Depersonalization
c. Hypochondriasis
d. Somatization disorder

76. Answer: (B) Hypochondriasis

Rationale: Complains of vague physical symptoms that have no apparent medical causes are characteristic of clients with
hypochondriasis. In many cases, the GI system is affected.

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Conversion disorders are characterized by one or more neurologic symptoms. The client’s symptoms don’t suggest severe
anxiety. A client experiencing sublimation channels maladaptive feelings or impulses into socially acceptable behavior
79. Answer: (C) Hypochondriasis
Rationale: Hypochodriasis in this case is shown by the client’s belief that she has a serious illness, although pathologic causes
have been eliminated. The disturbance usually lasts at lease 6 with identifiable life stressor such as, in this case, course
examinations.

Conversion disorders are characterized by one or more neurologic

symptoms.

Depersonalization refers to persistent recurrent episodes of feeling detached from one’s self or body.
Somatoform disorders generally have a chronic course with few remissions.

45. Nurse Daisy is aware that the following pharmacologic agents are sedative hypnotic medication is used to induce sleep for a
client experiencing a sleep disorder is:
a. Triazolam (Halcion)
b. Paroxetine (Paxil)\
c. Fluoxetine (Prozac)
d. Risperidone (Risperdal)

Answer: (A) Triazolam (Halcion)

Rationale: Triazolam is one of a group of sedative hypnotic medication that can be used for a limited time because of the risk of
dependence.

Paroxetine is a scrotonin-specific reutake inhibitor used for treatment

of depression panic disorder, and obsessive-compulsive disorder.
Fluoxetine is a scrotonin-specific reuptake inhibitor used for depressive disorders and obsessive-compulsive disorders.
Risperidome is indicated for psychotic disorders.

46. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statement refers to a secondary
gain?
a. It brings some stability to the family
b. It decreases the preoccupation with the physical illness
c. It enables the client to avoid some unpleasant activity
d. It promotes emotional support or attention for the client

Answer: (D) It promotes emotional support or attention for the client

Rationale: Secondary gain refers to the benefits of the illness that allow the client to receive emotional support or attention.

Primary gain enables the client to avoid some unpleasant activity. A dysfunctional family may disregard the real issue, although
some conflict is relieved. Somatoform pain disorder is a preoccupation with pain in the absence of physical disease.

47. Dervid is diagnosed with panic disorder with agoraphobia is talking with the nurse in-charge about the progress made in
treatment. Which of the following statements indicates a positive client response?
a. “I went to the mall with my friends last Saturday”
b. “I’m hyperventilating only when I have a panic attack”
c. “Today I decided that I can stop taking my medication”
d. “Last night I decided to eat more than a bowl of cereal”

Answer: (A) “I went to the mall with my friends last Saturday”

Rationale: Clients with panic disorder tent to be socially withdrawn. Going to the mall is a sign of working on avoidance behaviors.
Hyperventilating is a key symptom of panic disorder. Teaching breathing control is a major intervention for clients with panic
disorder. The client taking medications for panic disorder; such as tricylic antidepressants and benzodiazepines, must be weaned
off these drugs. Most clients with panic disorder with agoraphobia don’t have nutritional problems.

48. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in client with posttraumatic stress disorder can be
demonstrated by which of the following client self –reports?
a. “I’m sleeping better and don’t have nightmares”
b. “I’m not losing my temper as much”
c. “I’ve lost my craving for alcohol”
d. I’ve lost my phobia for water”

Answer: (A) “I’m sleeping better and don’t have nightmares”

Rationale:MAO inhibitors are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individual with
posttraumatic stress disorder. MAO inhibitors aren’t used to help control flashbacks or phobias or to decrease the craving for
alcohol.

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49. Mark, with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). Which of the following
important facts should nurse Betty discuss with the client about discontinuing the medication?
a. Stopping the drug may cause depression
b. Stopping the drug increases cognitive abilities
c. Stopping the drug decreases sleeping difficulties
d. Stopping the drug can cause withdrawal symptoms

Answer: (D) Stopping the drug can cause withdrawal symptoms

Rationale: Stopping antianxiety drugs such as benzodiazepines can cause the client to have withdrawal symptoms. Stopping a
benzodiazepine doesn’t tend to cause depression, increase cognitive abilities, or decrease sleeping difficulties.

84Jennifer, an adolescent who is depressed and reported by his parents as having difficulty in school is brought to the community
mental health center to be evaluated. Which of the following other health problems would the nurse suspect?
a. Anxiety disorder
b. Behavioral difficulties
c. Cognitive impairment
d. Labile moods

85. 8Answer: (B) Behavioral difficulties

Rationale: Adolescents tend to demonstrate severe irritability and behavioral problems rather than simply a depressed mood.
Anxiety disorder is more commonly associated with small children rather than with adolescents. Cognitive impairment is typically
associated with delirium or dementia. Labile mood is more characteristic of a client with cognitive impairment or bipolar disorder.

50. Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic disorder. Which of the following statement about
dysthymic disorder is true?
a. It involves a mood range from moderate depression to hypomania
b. It involves a single manic depression
c. It’s a form of depression that occurs in the fall and winter
d. It’s a mood disorder similar to major depression but of mild to moderate severity

.Answer: (D) It’s a mood disorder similar to major depression but of mild to moderate severity
Rationale: Dysthymic disorder is a mood disorder similar to major depression but it remains mild to moderate in severity.
A - Cyclothymic disorder is a mood disorder characterized by a mood range from moderate depression to hypomania.
B- Bipolar I disorder is characterized by a single manic episode with no past major depressive episodes.
C- C - Seasonal affective disorder is a form of depression occurring in the fall and winter.

51. The nurse is aware that the following ways in vascular dementia different from Alzheimer’s disease is:
a. Vascular dementia has more abrupt onset
b. The duration of vascular dementia is usually brief
c. Personality change is common in vascular dementia
d. The inability to perform motor activities occurs in vascular dementia

Answer: (A) Vascular dementia has more abrupt onset

Rationale: Vascular dementia differs from Alzheimer’s disease in that it has a more abrupt onset and runs a highly variable
course. Personality change is common in Alzheimer’s disease. The duration of delirium is usually brief. The inability to carry out
motor activities is common in Alzheimer’s disease.

52. Loretta, a newly admitted client was diagnosed with delirium and has history of hypertension and anxiety. She had been
taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be related to which of
the following conditions?
a. Infection
b. Metabolic acidosis
c. Drug intoxication
d. Hepatic encephalopathy

Answer: (C) Drug intoxication

Rationale: This client was taking several medications that have a propensity for producing delirium; digoxin (a digitalis glycoxide),
furosemide (a thiazide diuretic), and diazepam (a benzodiazepine). Sufficient supporting data don’t exist to suspect the other
options as causes.

53. Nurse Ron enters a client’s room, the client says, “They’re crawling on my sheets! Get them off my bed!” Which of the
following assessment is the most accurate?
a. The client is experiencing aphasia
b. The client is experiencing dysarthria
c. The client is experiencing a flight of ideas
d. The client is experiencing visual hallucination

88. Answer: (D) The client is experiencing visual hallucination

Rationale: The presence of a sensory stimulus correlates with the definition of a hallucination, which is a false sensory perception.

Aphasia refers to a communication problem.

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Dysarthria is difficulty in speech production.
Flight of ideas is rapid shifting from one topic to another.

54. Which of the following descriptions of a client’s experience and behavior can be assessed as an illusion?
a. The client tries to hit the nurse when vital signs must be taken
b. The client says, “I keep hearing a voice telling me to run away”
c. The client becomes anxious whenever the nurse leaves the bedside
d. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the
wall.

Answer: (D) The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.
Rationale: Minor memory problems are distinguished from dementia by their minor severity and their lack of significant
interference with the client’s social or occupational lifestyle. Other options would be included in the history data but don’t directly
correlate with the client’s lifestyle.

55. During conversation of Nurse John with a client, he observes that the client shift from one topic to the next on a regular basis.
Which of the following terms describes this disorder?
a. Flight of ideas
b. Concrete thinking
c. Ideas of reference
d. Loose association

Answer: (D) Loose association

Rationale: Loose associations are conversations that constantly shift in topic. Concrete thinking implies highly definitive thought
processes. Flight of ideas is characterized by conversation that’s disorganized from the onset. Loose associations don’t
necessarily start in a cogently, then becomes loose.

56. Francis tells the nurse that her coworkers are sabotaging the computer. When the nurse asks questions, the client becomes
argumentative. This behavior shows personality traits associated with which of the following personality disorder?
a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal

Answer: (C) Paranoid

Rationale: Because of their suspiciousness, paranoid personalities ascribe malevolent activities to others and tent to be
defensive, becoming quarrelsome and argumentative. Clients with antisocial personality disorder can also be antagonistic and
argumentative but are less suspicious than paranoid personalities. Clients with histrionic personality disorder are dramatic, not
suspicious and argumentative. Clients with schizoid personality disorder are usually detached from other and tend to have
eccentric behavior.

57. Which of the following interventions is important for a Cely experiencing with paranoid personality disorder taking olanzapine
(Zyprexa)?
a. Explain effects of serotonin syndrome
b. Teach the client to watch for extrapyramidal adverse reaction
c. Explain that the drug is less affective if the client smokes
d. Discuss the need to report paradoxical effects such as euphoria

Answer: (C) Explain that the drug is less affective if the client smokes
Rationale: Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. Serotonin syndrome occurs with clients who
take a combination of antidepressant medications. Olanzapine doesn’t cause euphoria, and extrapyramidal adverse reactions
aren’t a problem. However, the client should be aware of adverse effects such as tardive dyskinesia.

58. Nurse Alexandra notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When
discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his
peers?
a. Lack of honesty
b. Belief in superstition
c. Show of temper tantrums
d. Constant need for attention

Answer: (A) Lack of honesty

Rationale: Clients with antisocial personality disorder tent to engage in acts of dishonesty, shown by lying. Clients with schizotypal
personality disorder tend to be superstitious. Clients with histrionic
personality disorders tend to overreact to frustrations and disappointments, have temper tantrums, and seek attention.

59. Tommy, with dependent personality disorder is working to increase his self-esteem. Which of the following statements by the
Tommy shows teaching was successful?
a. “I’m not going to look just at the negative things about myself”
b. “I’m most concerned about my level of competence and progress”
c. “I’m not as envious of the things other people have as I used to be”
d. “I find I can’t stop myself from taking over things other should be doing”
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Answer: (A) “I’m not going to look just at the negative things about myself”
Rationale: As the clients makes progress on improving self-esteem, selfblame and negative self evaluation will decrease. Clients
with dependent personality disorder tend to feel fragile and inadequate and would be extremely unlikely to discuss their level of
competence and progress. These clients focus on self and aren’t envious or jealous. Individuals with dependent personality
disorders don’t take over situations because they see themselves as inept and inadequate.

60. Norma, a 42-year-old client with a diagnosis of chronic undifferentiated schizophrenia lives in a rooming house that has a
weekly nursing clinic. She scratches while she tells the nurse she feels creatures eating away at her skin. Which of the
following interventions should be done first?
a. Talk about his hallucinations and fears
b. Refer him for anticholinergic adverse reactions
c. Assess for possible physical problems such as rash
d. Call his physician to get his medication increased to control his psychosis

Answer: (C) Assess for possible physical problems such as rash

Rationale: Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world.
They need to have as in-depth assessment of physical complaints that may spill over into their delusional symptoms. Talking with
the client won’t provide as assessment of his itching, and itching isn’t as adverse reaction of antipsychotic drugs, calling the
physician to get the client’s medication increased doesn’t address his physical complaints.

61. Ivy, who is on the psychiatric unit is copying and imitating the movements of her primary nurse. During recovery, she says, “I
thought the nurse was my mirror. I felt connected only when I saw my nurse.” This behavior is known by which of the
following terms?
a. Modeling
b. Echopraxia
c. Ego-syntonicity
d. Ritualism

Answer: (B) Echopraxia

Rationale: Echopraxia is the copying of another’s behaviors and is the result of the loss of ego boundaries. Modeling is the
conscious copying of someone’s behaviors. Ego-syntonicity refers to behaviors that correspond with the individual’s sense of self.
Ritualism behaviors are repetitive and compulsive.

62. Jun approaches the nurse and tells that he hears a voice telling him that he’s evil and deserves to die. Which of the following
terms describes the client’s perception?
a. Delusion
b. Disorganized speech
c. Hallucination
d. Idea of reference

Answer: (C) Hallucination

Rationale: Hallucinations are sensory experiences that are misrepresentations of reality or have no basis in reality. Delusions are
beliefs not based in reality. Disorganized speech is characterized by jumping from one topic to the next or using unrelated words.
An idea of reference is a belief that an unrelated situation holds special meaning for the client.

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So A is delusions, B is illusions, C is illusion also, and D is hallucinations

Delusions

There are many types of delusions:

 Delusions of influence (Believe that their thought and actions are controlled by outside force)

 Delusions of persecution (Believe that others are trying to harm)

 Delusions of reference (Believe that some events in the environment have special meaning to, and directed at the patient)

 Grandiose delusions (The patient’s feelings of having special power and knowledge or special relationships with important
figures)

 Somatic delusions (Feelings that the body has been manipulated by outside forces)

 Delusion of love (Belive that he has a special romantic relationship with a public famous figure)

 Nihilism (Patient believe that the self world and even time has been lost or destroyed)

Illusions

Illusions may occur more often when attention is not focused on the sensory modality, or when ther is strong affective state. For
example, in a dark, a frightened person is more likely to perceive the outline of a bush as that of an attacker.

Hallucinations

Hallucinations are not restricted to the mentally ill. A few normal people experience them, especially when tired, also occur in
healthy people during transition between sleep and waking; they are called hypnagogic while falling asleep or hypnapompic while
awaking.

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Auditory hallucinations is the most common type of hallucinations in psychiatric disorders. May be noises or voices, it can be
heard clearly or indistinctly, they may seem to speak words or phrases or sentences. Hallucination may be inferred when the
patient appears to be talking in response to voice and may whisper, mutter to himself incomprehensively, or talk normally or shout
out loudly as occurring in schizophrenics.

NOTE: Auditory hallucinations are one of the diagnostic criteria of schizophrenia and other psychotic disorders.

Visual hallucinations may be elementary or complex. Visual hallucinations are experienced as located outside the field of vision
(eg, behind the head) or involve experience beyond the sensory range (eg, being able to look out the window and see someone in
distant city). Visual hallucinations are seen in dissociation and conversion disorder, severe affective disorder, organic mental
conditions, substance abuse and schizophrenia, but the contents of the visual hallucination are of little diagnostic significance.

NOTE: isolated visual hallucinations should always raise the possibility of an organic cause (medical disorder or drug abuse) and
investigations should be done.

Tactile hallucinations or haptic hallucinations generally are of little diagnostic significance. Examples like sensation of being
touched, sensation of insects moving under the skin occurs in cocaine abuse and occasionally in schizophrenia.

Hallucinations of taste and smell are infrequent. They may occur in schizophrenia and severe depressive disorders, but they may
suggest temporal lobe epilepsy or irritation of the olfactory bulb or pathways by tumor, so their presence indicate medical
investigation.

Hallucination of deep sensation may occur as feelings of the viscera being pulled upon or distended, or of sexual stimulation.

63. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense
mechanisms is probably used by mike?
a. Projection
b. Rationalization
c. Regression
d. Repression

Answer: (C) Regression

Rationale: Regression, a return to earlier behavior to reduce anxiety, is the basic defense mechanism in schizophrenia.

Projection is a defense mechanism in which one blames others and attempts to justify actions; it’s used primarily by people with
paranoid schizophrenia and delusional disorder.

Rationalization is a defense mechanism used to justify one’s action.

Repression is the basic defense mechanism in the neuroses; it’s an involuntary exclusion of painful
thoughts, feelings, or experiences from awareness.

64. Rocky has started taking haloperidol (Haldol). Which of the following instructions is most appropriate for Ricky before taking
haloperidol?
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a. Should report feelings of restlessness or agitation at once
b. Use a sunscreen outdoors on a year-round basis
c. Be aware you’ll feel increased energy taking this drug
d. This drug will indirectly control essential hypertension

Answer: (A) Should report feelings of restlessness or agitation at once

Rationale: Agitation and restlessness are adverse effect of haloperidol and can be treated with antocholinergic drugs. Haloperidol
isn’t likely to cause photosensitivity or control essential hypertension. Although the client may experience increased concentration
and activity, these effects are due to a decreased in symptoms, not the drug itself.

65. Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection
A. Sudden weight loss
B. Polyuria
C. Hypertension
D. Shock

66. The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is
to decrease:
A. Pain
B. Weight
C. Hematuria
D. Hypertension

67. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is
aware that this medication is given to:
A. Decrease the total basal metabolic rate.
B. Maintain the function of the parathyroid glands.
C. Block the formation of thyroxine by the thyroid gland.
D. Decrease the size and vascularity of the thyroid gland.

68. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who
is diagnosed with:
A. Liver disease
B. Hypertension
C. Type 2 diabetes
D. Hyperthyroidism

69. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for
the systemic side effect of:
A. Ascites
B. Nystagmus
C. Leukopenia
D. Polycythemia

70. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should
suggest that the client plan to:
A. Eliminate foods high in cellulose. .C. Avoid foods that in the past caused flatus.
B. Decrease fluid intake at meal times. D. Adhere to a bland diet prior to social events.

71. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions
were understood when the client states, “I should:
A. Lie on my left side while instilling the irrigating solution.”
B. Keep the irrigating container less than 18 inches above the stoma.”
C. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.”
D. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”

72. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is
somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this
electrolyte imbalance, the nurse would expect to:
A. Administer Kayexalate
B. Restrict foods high in protein
C. Increase oral intake of cheese and milk.
D. Administer large amounts of normal saline via I.V.

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73. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The
drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
A. 18 gtt/min
B. 28 gtt/min
C. 32 gtt/min
D. 36 gtt/min

74. Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?
A. Face and neck
B. Right upper arm and penis
C. Right thigh and penis
D. Upper trunk

75. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When
assessing the client, the nurse would be most concerned if the assessment revealed:
A. Reactive pupils
B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature

76. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse
shows her knowledge deficit about the artificial cardiac pacemaker?
A. take the pulse rate once a day, in the morning upon awakening
B. May be allowed to use electrical appliances
C. Have regular follow up care
D. May engage in contact sports

77. The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is
A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
C. Oxygen is administered best using a non-rebreathing mask
D. Blood gases are monitored using a pulse oximeter.

78. Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal
drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler’s position on either
his right side or on his back. The nurse is aware that this position:
A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous retur

79. .Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse’s highest priority of
information would be:
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.

80. Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions,
and sodium bicarbonate to be used to treat:
A. hypernatremia.
B. hypokalemia.
C. hyperkalemia.
D. hypercalcemia.

81. Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual
intercourse.
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D. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.

82. Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When
palpating the her kidneys, the nurse should keep which anatomical fact in mind?
A. The left kidney usually is slightly higher than the right one.
B. The kidneys are situated just above the adrenal glands.
C. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾” to 1-1/8″) wide.
D. The kidneys lie between the 10th and 12th thoracic vertebrae

83. Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are
consistent with CRF if the result is:
A. Increased pH with decreased hydrogen ions.
B. Increased serum levels of potassium, magnesium, and calcium.
C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.

84. Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the
room, Katrina asks what dysplasia means. Which definition should the nurse provide?
A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin.
B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found.
D. Alteration in the size, shape, and organization of differentiated cells

85. During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs
and symptoms of cancer. What is the most common AIDS-related cancer?
A. Squamous cell carcinoma
B. Multiple myeloma
C. Leukemia
D. Kaposi’s sarcoma

86. Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery.
In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client
require special positioning for this type of anesthesia?
A. To prevent confusion
B. To prevent seizures
C. To prevent cerebrospinal fluid (CSF) leakage
D. To prevent cardiac arrhythmias

87. .A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing
action should be to:
A. Auscultate bowel sounds.
B. Palpate the abdomen.
C. Change the client’s position.
D. Insert a rectal tube.

88. Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position
the client for this test initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor

89. A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that
the client’s stoma appears dusky. How should the nurse interpret this finding?
A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.

90. Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
A. Applying knee splints
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B. Elevating the foot of the bed
C. Hyperextending the client’s palms
D. Performing shoulder range-of-motion exercises

91. Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding
indicates a potential problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).

92. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid
pressure ulcers, Nurse Celia should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.

93. .Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How
should the nurse apply this topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the affected area
C. In long, even, outward, and downward strokes in the direction of hair growth
D. In long, even, outward, and upward strokes in the direction opposite hair growth

94. Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking
catecholamines and sympathetic nerve stimulation is:
A. Beta -adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates

95. .A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate
reading of jugular vein distention?
A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position

96. The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart
failure by increasing ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents

97. A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level.
Which of the following dietary modifications is not appropriate for this client?
A. Fiber intake of 25 to 30 g daily
B. Less than 30% of calories form fat
C. Cholesterol intake of less than 300 mg daily
D. Less than 10% of calories from saturated fat

98. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which
of the following actions would breach the client confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
B. The CCU nurse notifies the on-call physician about a change in the client’s condition
C. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.
D. At the client’s request, the CCU nurse updates the client’s wife on his condition

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 DEPARTMENT OF NURSING
99. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are
giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in
compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse.
Which of the following actions should the nurse take first?
A. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.
B. Check endotracheal tube placement.
C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.

100. Mrs. Catty Perry is to receive an IV infusion at 800am: of 3Li of Dextrise and Normal Saline over 24 hours period. Nurse
Jennifer Lupez, observes that the rate is 150 ml per hour. If the said IV solution runs continuously at this given rate. The IV
therapy or infusion will be completed at:
A. 5am
B. 8am
C. 6am
D. 4am

Answer : D
Rationale : The total amount to be given, 3,000 ml, divided by the hourly rate, 150 ml"hour,euals the length of the infusion or, in
this case, 20 hours. 8am - 4am.

-------------------------------------------------------------------------------------- END OF EXAM ----------------------------------------------------------------

Prepared by Reviewed by

Nelson J. Moleta Jr., RN, RM, LPT, M.Ed,MSN Marilen F. Pacis, RN, RM, MAN
Faculty Program Chair, Nursing

Approved by:

Ma. Reina Rose D. Gulmatico, RN, MSN

Dean, College of Allied Health

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