Situation: A nurse cares for a male client with a diagnosis of ulcerative colitis. The client is scheduled for colostomy.
1. The nurse gives preoperative teaching to the client. To evaluate the effectivity of the preoperative teaching, the nurse expects the client to be able to:
a. accept the surgical treatment
b. apply the colostomy bag properly
c. explain the functions of the colostomy
d. describe the procedure
2. The nurse explains that signing consent before operation is necessary and a standard hospital policy. The most appropriate procedure for signing the operative permit is to:
a. let the client sign the operative permit and then notify the surgeon that the permit has been signed
b. make sure that the surgeon has explained the procedure to the client and answered the client’s questions, then have the client sign the operative permit
c. let the client sign the permit upon admission so client know what procedure is going to be done
d. prepare the client for surgery, administer the pre-operative ? sign the permit before the client goes to sleep
3. After the operation, the nurse teaches the client how to perform a colostomy irrigation. To enhance the effectiveness of the procedure, the nurse instructs the client to:
a. increase fluid intake
b. reduce the amount of irrigation fluid
c. drink something cold
d. massage the abdomen gently
4. The nurse performs a colostomy irrigation on the client. During the procedure, the client complains of abdominal cramps. Which of the following actions is most appropriate?
a. Stop the irrigation temporarily.
b. Increase the height of the irrigation.
c. Notify the surgeon immediately.
d. Administer pain medication and resume irrigation.
5. The client expresses concern about the odor from stool in the ostomy drainage bag. Which of the following foods would the nurse suggest to the client to reduce odor?
a. yogurt
b. broccoli
c. cucumber
d. eggs
Situation: A 65-year old male client is examined by a private physician and is diagnosed as possible pulmonary tuberculosis.
6. The client asks the nurse why the physician thinks he has tuberculosis. The nurse explains that a diagnosis of tuberculosis may take some weeks to confirm. Which of the following statement support the answer of the nurse?
a. a client with a positive smear will have to have a positive culture to confirm the diagnosis
b. a positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis even if one negative sputum is obtained
c. a positive sputum culture would take at least 3 weeks because of the slow reproduction of the TB bacillus
d. Chest x-rays need to be repeated during several consecutive weeks because the small lesions are difficult to detect
7. The nurse is aware that in pulmonary tuberculosis, there is a decreased surface area for gaseous exchange in the lungs. Oxygen and carbon dioxide are exchanged in the lungs by the process of:
a. diffusion
b. filtration
c. active transport
d. osmosis
8. The client begins to expectorate blood. The nurse understands this as
a. hematuria
b. hematumeria
c. hemoptysis
d. hematoma
9. The client asks the nurse how he got infected with pulmonary tuberculosis. The nurse explains that the mode of transmission is one of the following:
a. exposure to tuberculosis cattle by ingestion of unpasteurized milk
b. airborne droplet method through coughing, singing or sneezing
c. contaminated food and water
d. prolonged skin-to-skin contact
10. The physician prescribes an anti-tuberculosis drug to the client. The nurse is aware that one of the drugs listed can cause damage to the eighth cranial nerve. The drug is
a. aminosalicylic acid (PAS)
b. streptomycin sulfate
c. isonizaid (INH)
d. ethambutol hydrochloride (myambutol)
Situation: A nurse is assigned to care for older clients in a health care facility.
11. When an older client is in the hospital, an important safety consideration the nurse keeps in mind is to:
a. assign the client to a double room with another older client
b. restrain the client when in bed
c. keep the bed in high position
d. place upper side rails in UP position when client is alone
12. The nurse plans the care for an older with hearing loss. The nurse is aware that older clients
a. have moist cerumen
b. respond well to low-pitched tones
c. have changes in the middle ear
d. are oftentimes distracted
13. When the nurse communicates with a client who is hearing impaired, the nurse initially
a. obtains an interpreter for sign language
b. pantomimes and writes the client notes
c. stands in front of the client
d. exaggerates lip movement
14. To reduce the risk of aspirating during mealtimes, the nurse positions the client:
a. on the left side of the bed
b. on the right side of the bed
c. low Fower’s position with legs elevated
d. upright on a chair
15. Which of the following situations is an example of ageism?
a. informing an older adult of his or her rights
b. advising older adults to forego aggressive treatment
c. allowing older adults to make decisions
d. accepting differences among older adults
Situation: The nurse performs physical assessment on client seeking admission for a medical condition.
16. The nurse assesses a male client. Which of the following sequences represent the order in which the nurse should assess the client’s abdomen?
a. observe, auscultate, percuss, palpate
b. percuss, palpate, auscultate, observe
c. auscultate, observe, percuss, palpate
d. palpate, percuss, auscultate, observe
17. The nurse auscultates for the client’s breath sounds. The nurse knows that auscultation produces what type of data?
a. subjective
b. objective
c. medical
d. secondary source
18. The nurse palpates the client’s body to detect warmth. What part of the hand should the nurse use?
a. finger pads
b. back or dorsal surface
c. fingertips
d. ulnar surface
19. The nurse assesses the client for gag reflex. Which of the following would be the best method? The nurse should place a tongue blade
a. on the middle of the tongue and ask the client to cough
b. on the front of the tongue and ask the client to say “ahh”
c. lightly on posterior aspect of the tongue
d. on the vulva
20. The nurse takes the body temperature of the client. The client registers a temperature reading of 38 degrees C. This client will most likely demonstrate which of the following?
a. dyspnea
b. precordial pain
c. increased pulse rate
d. elevated blood pressure
Situation: The nurse cares for a male client who suffered a spinal cord injury following a car accident which resulted to paraplegia.
21. In planning care for the client, the client should be turned every two hours. The nurse knows that this measure is necessary to:
a. prevent pressure sores
b. keep the client comfortable
c. prevent flexion contractures in the lower extremities
d. improve circulation in the lower extremities
22. The nurse understands that the least effective method of preventing contractures of the joints of the lower extremities would be
a. providing the client with active exercise instructions
b. passively moving the extremities through ROM several times daily
c. maintaining proper bed position
d. changing position every 2 hours
23. The nurse is aware that a complication a client with paraplegia may encounter is formation of urinary calculi. The factor that contributes to this condition is:
a. increased loss of calcium for the skeletal system
b. inadequate kidney function
c. high fluid intake
d. increased intake of calcium
24. The nurse recognizes that an early major problem of the client with paraplegic will be
a. quadriceps setting
b. use of mechanical aids for ambulation
c. bladder control
d. client education
24. The client is fortunate that the level of his injury did not interrupt his respiratory function. The cord segments involved with maintaining respiratory functions are
a. thoracic level 5 and 6
b. cervical level 3 and 4
c. thoracic level 2 and 3
d. cervical level 7 and 8
Situation: A 50 year old female patient is admitted for treatment of coronary artery disease (CAD). The nurse knows that women may differ from men in symptoms, diagnosis and treatment of CAD.
26. Stress is a risk factor for Coronary Artery Disease especially when:
a. the person has low, constant stress
b. the person perceives high stress and low control
c. the person perceives high control and low stress
d. it is controlled over short periods
27. How does the clinical presentation of Coronary Artery Diseases differ in women and men?
a. clinical presentation in a woman may be atypical
b. the difference are clearly understood
c. a woman’s signs and symptoms of MI are more typical
d. it is the same for both
28. During attacks a woman is more likely than a man to:
a. describe substernal crushing chest pain
b. get a misdiagnosis
c. get follow-up testing
d. have a concurrent ST-segment elevation
29. Which statement about blood pressure in women is correct?
a. low blood pressure is twice as common in oral contraceptive users
b. hypertension doesn’t affect CAD risk as women age
c. weight, age, and oral contraceptive use affect blood pressure
d. twenty percent of women have hypertension before menopause
30. Research findings indicate that a woman with CAD needs:
a. aggressive exercise for 30 minutes three times a week
b. light exercise such as walking for 20 minutes five times a week
c. light to moderate exercise such as walking for 30 minutes five times a week
d. moderate exercise for 20 minutes five times a week
Situation: A 36-year old female is admitted to the medical ward for treatment of bleeding peptic ulcer.
31. The nurse attending to this client expects the stools to be:
a. clay-colored
b. black and tarry
c. bright red in color
d. coffee-ground like
32. The physician describes Cimetidine (Tagamet) per IV. The nurse is aware that the drug must not be administered very rapidly because the drug may cause the client to experience
a. bradycardia
b. bronchospasm
c. tetany
d. hallucination
33. The client asks the nurse the action of the drug Cimetidine. The nurse explains that the drug
a. inhibits production of hydrochloric acid
b. inhibits vagus nerve stimuation
c. reduces output of gastric acid
d. protect the surface of the ulcer
34. The physician prescribes a therapeutic regimen for a client with peptic ulcer that includes a bland diet, antacids and ranitidine or zantac. Before the client is discharge, what instructions should the nurse give?
a. eat a well-balanced meal 3 times a day
b. stop taking Zantac when the symptoms subside
c. avoid taking aspirin and drugs that contain aspirin
d. increase intake of fluids which contain caffeine
35. The nurse is aware that the risk factors for peptic ulcer in the middle-age group especially men are:
a. alcohol abuse, smoking and stress
b. history of hemorrhoids, smoking and stress
c. living a sedentary lifestyle, smoking and stress
alcohol abuse and a history of acute renal failure
Situation: The 30-year old female was diagnosed to have Hodgkin’s disease.
36. The lymph nodes usually affected first in Hodgkin’s disease are in what areas?
a. cervical
b. inguinal
c. axillary
d. mediastinal
37. The nurse is aware that the highest incidence of this disease is in
a. young adults
b. middle-aged person
c. elderly persons
d. children
38. Which of the following findings would the nurse expect the client to develop as a result of whole body irradiation?
a. susceptibility to infection
b. decreased susceptibility to infection
c. increased production of RBC
d. tendency for pathologic fracture
39. The nurse is aware that whole body irradiation injures or destroys bone marrow making the bone marrow unable to function normally. As a result the nurse would expect the client to develop:
a. increased blood viscosity
b. decreased susceptibility to infection
c. increased tendency for fracture
d. decreased number of erythrocytes
40. The apparent paradox of radiation as a cancer-inducing agent as well as therapy for cancer can be clarified when one considers the:
a. nutritional environment of the cells
b. dosage of radiation utilized
c. extent of the body irradiated
d. physical condition of the client
Situation: A 20 year old patient in a Psych-Ward was placed in a 4-point restraint after attempting to harm himself and kicking his watcher.
41. Which nursing measure should be taken next?
a. Keep patient in isolation
b. Give him a warm bath
c. Alternately release restraint every 15 minutes
d. Monitor patient at all times
42. What precaution should be taken while extremities are restrained?
a. checking the pulse rate
b. assessing papillary response
c. noting respiratory rate
d. checking circulation in the extremities
43. Which of the following statement is NOT true for the use of restraints?
a. Restraints refer only to manual/mechanical device to inhibit free movement.
b. Restraints may be pharmacologic in nature.
c. Restraints are used only to ensure the physical safety of the patient and others.
d. Restraints are used only upon written order of the physician.
44. Other than medical indications, what else should be considered in restraining psychiatric patients?
a. Religion
b. Desires of the family
c. Acceptance of the patient
d. Culture
45. A possible legal interpretation for the application of restraint:
a. unwarranted detention
b. assault and battery
c. abuse of authority
d. punishment
Situation: Exasperated, the teacher of Rico a second grader brought him to the clinic for inattention, hyperactivity and impulsivity.
46. Rico is likely to be suffering from:
a. mood disorder
b. organic brain syndrome
c. aggressive behavior
d. attention deficit disorder
47. The nurse explains to the parents the possible cause of Rico’s behavior
a. overprotective parents
b. affluent families
c. poor families
d. retarded superego development
48. What parenting strategies can the nurses discuss with Rico’s parents?
a. buying his favorite Jollibee every meal
b. allowing him to play his play station whenever he wants to
c. providing regular routine for sleeping, eating, working and playing
d. providing him medications to calm him down
49. The parents asked “What are the side effects of Ritalin?” which was prescribed for Rico.
a. insomnia and palpitations
b. crying and uncontrolled eating
c. laziness and sleepiness
d. extreme obedience
50. What should be avoided in the diet of a hyperactive child like Rico?
a. carbohydrates
b. protein
c. caffeine-rich foods
d. fatty foods
Situation: Arnold, 28 years old, is a client who suddenly became blind when he witnessed how his family was massacred. The medical team cannot find an organic basis for his condition.
51. Which psychiatric condition is Arnold experiencing?
a. malingering
b. body dysmorphic disorder
c. hypochondriasis
d. conversion
52. Which defense mechanism contributes much in Arnold’s blindness?
a.suppression
b. repression
c. reaction formation
d. displacement
53. Which of the following is an appropriate nursing intervention for clients like Arnold?
a. discuss the symptoms with Arnold to reduce the level of anxiety
b. focus on the feelings of Arnold about the traumatic incident
c. consider the symptoms of Arnold and its connection with the incident
d. encourage Arnold to look at different colors to restore vision
54. Arnold felt a slight headache. He verbalized, “I think this is a brain tumor.” Which psychiatric condition is he experiencing?
a. malingering
b. psychophysiologic
c. conversion
d. hypochondriasis
55. Arnold’s symptoms are helpful in decreasing his anxiety about the traumatic incident. This is known as
a. tertiary gain
b. superficial gain
c. secondary gain
d. primary gain
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