1. A. Furadantin antimicrobial activity is more potent in an acid urine. Ascorbic acid or vitamin C tablets acidify the urine.

2. A. These signs, in addition to laryngeal edema, are characteristic of an allergic reaction that is, less spe- cifically, a transfusion reaction. Chills, increased temp- erature, and pain in the kidney region are indications of a hemolytic reaction.

3. B. Coumadin therapy is contraindicated in the pregnant woman because it crosses the placenta. The pregnant client should be taught heparin administration with a heparin lock if anticoagulation therapy must be continued. The arthritic client (2) may take aspirin or NSAIDs, which potentiate the effects of Coumadin, and should be watched for gastrointestinal bleed, as should the client with ulcer disease (4).

4. D. Alterations in vital signs could be an indication of side effects of nebulizer medication. The client should be in sitting position, either in the bed or in a chair. Postural drainage would not be done before IPPB therapy. The nurse would not leave the client during this treatment.

5. B. Maintaining neutropenic precautions is the most important implementation for this client. The client is at risk for infection. Low neutrophil and white blood cell counts are often found in clients with aplastic anemia or malignancies or in clients who have received cytotoxic therapy. These low blood counts are most likely due to the Prevacid, trazadone, and Zoloft. Administration of blood (1) is not indicated; frequent vital signs (2) is important, but not the highest priority; continuing the medications that are the most likely cause of the low blood count (4) will only make the situation worse.

6. A. These side effects may be present with this medication, but may be alleviated by taking the drug in the evening. Often, taking one dose in the evening will minimize the sedation. The nurse needs to follow up with this client and report to the physician.

7. B. Short-acting insulin is withdrawn first in order to prevent possible contamination of the short-_acting insulin bottle by the longer-acting insulin.

8. A. A blood transfusion should be started slowly (from 25 to 50 drops per minute) for the first 15 minutes because slow administration allows time to observe for an adverse reaction. Most reactions occur in the first 15 minutes. Continuing rate is 100 mL/hr.

9. B. Aspirin impedes clotting by blocking prosta-glandin synthesis, which can lead to bleeding. A side effect of prednisone is gastric irritation, also leading to bleeding. Tarry stools indicate bleeding in the upper GI system.

10. D. Dicumarol is an anticoagulant drug and one of the dangers involved is bleeding. Using a safety razor can lead to bleeding through cuts. The drug should be given at the same time daily but not related to meals (1). Due to danger of bleeding, missed doses (3) should not be made up.

11. B. If dopamine has a positive effect, it will cause vasoconstriction peripherally, but increase renal perfusion and the blood pressure will rise. The cardiac index will also rise and the PCWP should decrease.

12. C. Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed. This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KCl is also added to the infusion.

13. B. Foods high in oxalate include spinach, green and wax beans, beets, and chocolate.

14. B. Mydriatic drugs are used preoperatively so that the pupil is widely dilated. Either atropine sulfate or epinephrine HCl is commonly used. Pilocarpine (3) and carbamylcholine (2) are miotics used for glaucoma and certain types of lens implants. Timolol maleate (4) is a beta blocker used for glaucoma.

15. D. Beta blockers act to decrease heart rate and force of contraction and reduce vasoconstriction by antagonizing Beta receptors in the myocardium and vasculature. Choices (1) and (2) refer to the action of nitrates as well as Calcium Channel Blockers such as Diltiazem. Choice (3) is not applicable.

1.       Answer: (A) Identify the source of the conflict and understand the points of friction
This involves a problem solving approach, which addresses the root cause of the problem.

2.       Answer: (B) Is not beneficial; hence it should be prevented at all times
Conflicts are beneficial because it surfaces out issues in the open and can be solved right away. Likewise, members of the team become more conscientious with their work when they are aware that other members of the team are watching them.

3.       Answer: (C) Avoidance
This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect the problem remains unsolved and both parties are in a lose-lose situation.

4.       Answer: (D) Let the staff ventilate her feelings and ask how she can be of help.
Reaching out and helping the staff is the most effective strategy in dealing with burn out. Knowing that someone is ready to help makes the staff feel important; hence her self-worth is enhanced.

5.       Answer: (D) Focusing activity on the correction of identified behavior.
Performance appraisal deal with both positive and negative performance; is not meant to be a fault-finding activity

6.       Answer: (C) Patients are the best source of information regarding personnel appraisal.
The patient can be a source of information about the performance of the staff but it is never the best source. Directly observing the staff is the best source of information for personnel appraisal.

7.       Answer: (C) The evaluation is focused on objective data systematically.
Collecting objective data systematically can not be achieved in an informal appraisal. It is focused on what actually happens in the natural work setting.

8.       Answer: (D) The session is private between the two members.
The session is private between the manager and the staff and remains to be so when the two parties do not divulge the information to others.

9.       Answer: (B) Consultative
A consultative manager is almost like a participative manager. The participative manager has complete trust and confidence in the subordinate, always uses the opinions and ideas of subordinates and communicates in all directions.

10.    Answer: (D) Unity of direction
Unity of direction is a management principle, not an element of an organizational structure.

11.    Answer: (A) Staffing
Staffing is a management function involving putting the best people to accomplish tasks and activities to attain the goals of the organization.

12.    Answer: (B) Record of related learning experience (RLE)
Record of RLE is not required for employment purposes but it is required for the nurse’s licensure examination.

13.    Answer: (B) Induction
This step in the recruitment process gives time for the staff to submit all the documentary requirements for employment.

14.    Answer: (B) Decentralized
Decentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow.

15.    Answer: (C) Rightmost box
The leftmost box is occupied by the highest authority while the lowest level worker occupies the rightmost box.

16.    Answer: (D) Promotes better interpersonal relationship
Decentralized structures allow the staff to solve decisions by themselves, involve them in decision making; hence they are always given opportunities to interact with one another.

17.    Answer: (B) Provides care to a group of patients together with a group of nurses
This function is done in team nursing where the nurse is a member of a team that provides care for a group of patients.

18.    Answer: (B) Modular nursing
Modular nursing is a variant of team nursing. The difference lies in the fact that the members in modular nursing are paraprofessional workers.

19.    Answer: (B) Identify the values of the department
Identify the values of the department will set the guiding principles within which the department will operate its activities 

20.    Answer: (B) Rotation of duty will be done every four weeks for all patient care personnel.
Structure standards include management system, facilities, equipment, materials needed to deliver care to patients. Rotation of duty is a management system.

21.    Answer: (A) Process
Process standards include care plans, nursing procedure to be done to address the needs of the patients.

22.    Answer: (D) Identify possible courses of action
This is a step in a quality control process and not a basic step in the control process.

23.    Answer: (B) Characteristics used to measure the level of nursing care
Criteria are specific characteristics used to measure the standard of care.

24.    Answer: (A) Instructing the members of the standards committee to prepare policies
Instructing the members involves a directing function.

25.    Answer: (C) Patients’ reports 95% satisfaction rate prior to discharge from the hospital.
This refers to an outcome standard, which is a result of the care that is rendered to the patient.

26.    Answer: (A) The things that were planned are done
Controlling is defined as seeing to it that what is planned is done.

27.    Answer: (A) Span of control
Span of control refers to the number of workers who report directly to a manager.

28.    Answer: (B) Initiate a group interaction
Initiate a group interaction will be an opportunity to discuss the problem in the open.

29.    Answer: (C) Age of patients
An extraneous variable is not the primary concern of the researcher but has an effect on the results of the study. Adult patients may be young, middle or late adult.

30.    Answer: (B) Sr. Callista Roy
Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode

31.    Answer: (C) Most accurate and valid method of data gathering
The most serious disadvantage of this method is accuracy and validity of information gathered

32.    Answer: (B) “Turnaround Time in Emergency Rooms”
The article is for pediatric patients and may not be relevant for adult patients.

33.    Answer: (C) Salary of nurses
Salary of staff nurses is not an indicator of patient satisfaction, hence need not be included as a variable in the study.

34.    Answer: (A) degree of agreement and disagreement
Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study.

35.    Answer: (B) Reliability
Reliability is repeatability of the instrument; it can elicit the same responses even with varied administration of the instrument

36.    Answer: (A) Sensitivity
Sensitivity is an attribute of the instrument that allow the respondents to distinguish differences of the options where to choose from

37.    Answer: (A) Validity
Validity is ensuring that the instrument contains appropriate questions about the research topic

38.    Answer: (A) Random
Random sampling gives equal chance for all the elements in the population to be picked as part of the sample.

39.    Answer: (B) Ethnography
Ethnography is focused on patterns of behavior of selected people within a culture

40.    Answer: (B) Madeleine Leininger
Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture

1. Answer: (A) What is causing you to become agitated?
   In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. B. Pacing is a tension relieving measure for an agitated client. C. This is a threatening statement that can heighten the client’s tension. D. Seclusion is used when less restrictive measures have failed.
2. Answer: (D) Initiate confinement measures
   The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. . When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. A, B and C are appropriate approaches during the escalation phase of aggression.
3. Answer: (B) A mature experienced nurse
   The unstable, aggressive client should be assigned to the most experienced nurse. A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient.
4. Answer: (A) Taking a directive role in verbalizing feelings
   Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. B. A confrontational approach can be threatening and adds to the client’s tension. C and D. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful.
5. Answer: (D) The staff carried out less restrictive measures but were unsuccessful.
   This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior.
6. Answer: (C) manifest enduring patterns of inflexible behaviors
   Personality disorders are characterized by inflexible traits and characteristics that are lifelong. A and D. This disorder is manifested by life-long patterns of behavior. The client with this disorder will not likely present himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic intervention. B. Medications are generally not recommended for personality disorders.
7. Answer: (D) Antisocial
   These are the characteristics of an individual with antisocial personality. A. Narcissistic personality disorder is characterized by grandiosity and a need for constant admiration from others. B. Individuals with paranoid personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as threatening. C. Individuals with histrionic have excessive emotionality, and attention-seeking behaviors.
8. Answer: (B) reaction formation
   Reaction formation is the adoption of behavior or feelings that are exactly opposite of one’s true emotions. A. Denial is refusal to accept a painful reality. C. Rationalization is attempting to justify one’s behavior by presenting reasons that sounds logical. D. Projection is attributing of one’s behaviors and feelings to another person.
9. Answer: (A) Lack of self esteem, strong dependency needs and impulsive behavior
   These are the characteristics of client with borderline personality. B. This describes the avoidant personality. C. These are the characteristics of a client with paranoid personality D. This describes the obsessive compulsive personality
10. Answer: (D) Ensuring she adheres to certain restrictions
    The client is manipulative. The client must be informed about the policies, expectations, rules and regulation upon admission. A. Limits should be firmly and consistently implemented. Flexibility and bargaining are not therapeutic in dealing with a manipulative client. B. There is no specific medication prescribed for this condition. C. This is not part of the care plan. Interaction with other clients are allowed but the client should be observed and given limits in her attempt to manipulate and dominate others.
11. Answer: (D) Ego integrity vs. despair
    The client belongs to the middle adulthood stage (30 to 65 yrs.) The developmental task generativity is characterized by concern and care for others. It is a productive and creative stage. (A) Infancy stage (0 – 18 mos.) is concerned with gratification of oral needs (B) School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies and social skills (C) Late adulthood ( 60 and above) Concerned with reflection on the past and his contributions to others and face the future.
12. Answer: (B) to deal with feelings and thoughts that are not acceptable
    Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to reduce anxiety. A. This is not true in all instances of projection C and D. This focuses on the self rather than others
13. Answer: (C) “I don’t know anything about that. You are afraid of being harmed.”
    This presents reality and acknowledges the clients feeling A and B. are not therapeutic responses because these disagree with the client’s false belief and makes the client feel challenged D. unnecessary exploration of the false
14. Answer: (B) Pseudoparkinsonism
    Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by mask-like facies, pill rolling tremors, muscle rigidity A. Tardive dyskinesia is manifested by lip smacking, wormlike movement of the tongue C. Akinesia is characterized by feeling of weakness and muscle fatigue D. Dystonia is manifested by torticollis and rolling back of the eyes
15. Answer: (B) Transference
    Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another 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. Counterttransference 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
16. Answer: (B) Adventitious
    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
17. Answer: (B) Touch the client to show acceptance and empathy
    The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed.
18. Answer: (C) She postpones the physical assessment until the client is calm
    The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher
19. Answer: (D) Help her return to her pre-rape level of function
    The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal
20. Answer: (D) Post traumatic disorder
    Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months
21. Answer: (C) Severe
    The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization
22. Answer: (B) a subjectively perceived threat
    Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression
23. Answer: (A) Give specific instructions using speak in concise statements.
    The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus.
24. Answer: (B) Valium
    Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic
25. Answer: (B) Take the medication after meals.
    Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.

1. Answer: (C) He learns to verbalize his feelings and concerns
   C. The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors. A. The client is encouraged to acknowledge feelings rather than being indifferent to her feelings. B. Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success. D. Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor, not as irrational.
2. Answer: (B) “I haven’t been able to open the door and go into my baby’s room “
   This indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful use of denial is dysfunctional. A. This indicates acknowledgement of the loss. Expressing feelings openly is acceptable. C. This indicates the stage of depression in the grieving process. D. Remembering both positive and negative aspects of the deceased love one signals successful mourning.
3. Answer: (C) Low esteem related to failure in role performance
   This indicates the client’s negative self evaluation. A sense of worthlessness may accompany depression. A,B and D are not relevant. The cues do not indicate inability to use coping resources, decreased ability to transmit/process symbols, nor insufficient quality of social exchange
4. Answer: (D) Zyprexa
   This is an antipsychotic. A. This is a SSRI antidepressant. B. This antidepressant belongs to the Tricyclic group. C. This is a MAOI antidepressant.
5. Answer: (B) Monitor respiratory status
   A side effect of ECT which is life threatening is respiratory arrest. A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority.
6. Answer: (A) set realistic limits to the client’s behavior
   The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety. B. Clear, concise directions are given because of the distractibility of the client but this is not the priority. C. The manic client tend to externalize hostile feelings, however only non-destructive methods of expression should be allowed D. Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic.
7. Answer: (D) cleaning
   The client’s excess energy can be rechanelled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension. A. Tennis is a competitive activity which can stimulate the client.
8. Answer: (A) Agree on a consistent approach among the staff assigned to the client.
   A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed. B. This is not therapeutic because the client tends to control and dominate others. C. Limits are set for interaction time. D. Allowing the client to negotiate may reinforce manipulative behavior.
9. Answer: (A) Taking a directive role in verbalizing feelings
   The client has the right to be free from unnecessary restraints. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger. B. This is a threatening approach. C and D. Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger.
10. Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level
    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.
11. Answer: (C) anger
    Anger is experienced as reality sets in. This may either be directed to God, the deceased or displaced on others. A. Depression is a painful stage where the individual mourns for what was lost. B. Denial is the first stage of the grieving process evidenced by the statement “No, it can’t be true.” The individual does not acknowledge that the loss has occurred to protect self from the psychological pain of the loss. D. In bargaining the individual holds out hope for additional alternatives to forestall the loss, evidenced by the statement “If only…”
12. Answer: (D) ”It must really be frustrating for you. How can I best help you?”
    This response reflects the pain due to loss. A helping relationship can be forged by showing empathy and concern. A. This is not therapeutic since it passes the buck or responsibility to the clergy. B. This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts. C. This statement passes judgment on the client.
13. Answer: (D) giving broad opening
    Broad opening technique allows the client to take the initiative in introducing the topic. A,B and C are all therapeutic techniques but these are not exemplified by the nurse’s statement.
14. Answer: (B) suicidal ideation
    The client’s statement is a verbal cue of suicidal ideation not anxiety. While suicide is common among clients with major depression, this occurs when their depression starts to lift. Hopelessness indicates no alternatives available and may lead to suicide, the statement and non verbal cue of the client indicate suicide.
15. Answer: (A) Remove all potentially harmful items from the client’s room.
    Accessibility of the means of suicide increases the lethality. Allowing patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients bur not specifically for suicide.
16. Answer: (A) Establishing relationship with the opposite sex and career planning.
    The client belongs to the adolescent stage. The adolescent establishes his sense of identity by making decisions regarding familial, occupational and social roles. The adolescent emancipates himself from the family and decides what career to pursue, what set of friends to have and what value system to uphold. B. This refers to the middle adulthood stage concerned with transmitting his values to the next generation to ensure his immortality through the perpetuation of his culture. C. This reflects school age which is concerned with the pursuit of knowledge and skills to deal with the environment both in the present and in the future. D. The stage of young adulthood is concerned with development of intimate relationship with the opposite sex, establishment of a safe and congenial family environment and building of one’s lifework.
17. Answer: (B) dependent
    A client with dependent personality is predisposed to develop asthma. A. The conforming non-assertive client is predisposed to develop hypertension because of the tendency to repress rage. C. The perfectionist and compulsive tend to develop migraine. D. The masochistic, self sacrificing type are prone to develop rheumatoid arthritis.
18. Answer: (C) A living, learning or working environment.
    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. D. This is not congruent with therapeutic milieu.
19. Answer: (C) Place in semi-fowlers position and render O2 inhalation as ordered
    Since psychopysiologic disorder has organic basis, priority intervention is directed towards disease-specific management. Failure to address the medical condition of the client may be a life threat. A and B. The client has physical symptom that is adversely affected by psychological factors. Verbalization of feelings in a non threatening environment and involvement in relaxing activities are adaptive way of dealing with stressors. However, these are not the priority. D. Helping the client connect the physical symptoms with the emotional problems can be done when the client is ready.
20. Answer: (C) “You seem to have concerns about going home.”
    This statement reflects how the client feels. Showing empathy can encourage the client to talk which is important as an alternative more adaptive way of coping with stressors.. A. Giving false reassurance is not therapeutic. B. While this technique explores plans after discharge, it does not focus on expression of feelings. D. This close ended question does not encourage verbalization of feelings.
21. Answer: (C) Comfort with one’s sexuality
    The nurse must be accepting, empathetic and non-judgmental to patients who disclose concerns regarding sexuality. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. A,B and D are important considerations but these are not the priority.
22. Answer: (D) It is the desire to live or involve in reactions of the opposite sex
    Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This refers to masochism. C. This describes exhibitionism.
23. Answer: (B) Sexual arousal
    Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. A. Sexual Desire refers to the ability, interest or willingness for sexual stimulation. C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. D. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state.
24. Answer: (B) Sexual Arousal Disorder
    This describes sexual arousal disorder. A. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. D. Sexual Pain Disorder is characterized by genital pain before, during or after sexual intercourse.
25. Answer: (D) “I only need access to your arm. Putting up your sleeve is fine.”
    The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. A and B. These responses are not therapeutic because they are challenging and rejecting. C. Threatening the client is not therapeutic.

1. Answer: (B) tolerance
   tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.
2. Answer: (A) delirium tremens
   Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination.
3. Answer: (A) Monitoring his vital signs every hour
   Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety.
4. Answer: (B) cocaine
   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. C. 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.
5. Answer: (B) Narcan (Naloxone)
   Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroine
6. Answer: (C) agnosia
   This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory.
7. Answer: (C) “This must be difficult for you and your mother.”
   This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings.
8. Answer: (C) remains in a safe and secure environment
   Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently
9. Answer: (A) “Your husband is dead. Let me serve you your breakfast.”
   The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation.
10. Answer: (B) insidious onset
    Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.
11. Answer: (B) fluid volume deficit
    Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority.
12. Answer: (C) Approach the nurse and talk out her feelings
    The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother.
13. Answer: (B) Weight gain
    Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. (C) Attending an activity does not indicate improvement in nutritional state. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement.
14. Answer: (A) have episodic binge eating and purging
    Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. B and C are characteristics of a client with anorexia nervosa D. Low esteem is noted in both eating disorders
15. Answer: (A) Patient will learn problem solving skills
    if the client learns problem solving skills she will gain a sense of control over her life. (B) Anxiety is caused by powerlessness. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority.
16. Answer: (B) Discuss their eating behavior.
    The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship
17. Answer: (C) Claustrophobia
    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.
18. Answer: (D) Accept her fears without criticizing.
    The client cannot control her fears although the client knows its silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions.
19. Answer: (A) Revealing personal information to the client
    A. Countertransference 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.
20. Answer: (D) The client will be able to overcome his disabling fear.
    The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization.
21. Answer: (A) Avoid taking CNS depressant like alcohol.
    Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium.
22. Answer: (C) The conversion symptom has symbolic meaning to the client
    the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety.
23. Answer: (D) “How do you feel about being pressured into sex by your boyfriend?”
    Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause.
24. Answer: (B) It is a deliberate effort to handle upsetting events
    Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder.
25. Answer: (C) stress management techniques
    Stree management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best.

1.       Answer: (B) A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.
Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. A. This describes the ego function reality testing. C. This is the definition of Mental Health and Psychiatric Nursing. D. Mental health is not just the absence of mental illness.

2.       Answer: (A) Administers medications to a schizophrenic patient.
Administration of medications and treatments, assessment, documentation are the activities of the nurse as a technician. B. Activities as a parent surrogate. C. Refers to the ward manager role. D. Role as a teacher.

3.       Answer: (A) Subconscious
Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled spontaneously and voluntarily. B. This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in the environment. C. The largest potion of the mind that contains the memories of one’s past particularly the unpleasant. It is difficult to recall the unconscious content. D. The conscious self that deals and tests reality.

4.       Answer: (D) The censoring portion of the mind.
The critical censoring portion of one’s personality; the conscience. A. This refers to the ego function that protects itself from anything that threatens it.. B. The Id is composed of the untamed, primitive drives and impulses. C. This refers to the ego that acts as the moderator of the struggle between the id and the superego.

5.       Answer: (C) Teaching the client stress management techniques
Primary level of prevention refers to the promotion of mental health and prevention of mental illness. This can be achieved by rendering health teachings such as modifying ones responses to stress. A. This is tertiary level of prevention that deals with rehabilitation. B and D. Secondary level of prevention which involves reduction of actual illness through early detection and treatment of illness.

6.       Answer: (A) “Are you being threatened or hurt by your partner?
The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse.

7.       Answer: (A) Sexual desire disorder
Has little or no sexual desire or has distaste for sex. B. Failure to maintain the physiologic requirements for sexual intercourse. C. Persistent and recurrent inability to achieve an orgasm. D. Also called dyspareunia. Individuals with this disorder suffer genital pain before, during and after sexual intercourse.

8.       Answer: (A) “Here’s the number of a crisis center that you can call for help .”
Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. B. Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However discuss options available. C. The victim tends to isolate from friends and family. D. This is judgmental. Avoid in anyway implying that she is at fault.

9.       Answer: (B) “When I tell my child to do something once, I don’t expect to have to tell"
Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old.

10.    Answer: (C) Ensure the safety of the victim
The priority consideration is the safety of the victim. Attend to the physical injuries to ensure the physiologic safety and integrity of the child. Reporting suspected case of abuse may deter recurrence of abuse. A,B and D may be addressed later.

11.    Answer: (D) Somatoform Pain Disorder
This is characterized by severe and prolonged pain that causes significant distress. A. This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. B. This is an unrealistic preoccupation with a fear of having a serious illness. C. Characterized by alteration or loss in sensory or motor function resulting from a psychological conflict.

12.    Answer: (B) Conflict between id and superego
Freud explains anxiety as due to opposing action drives between the id and the superego. A. Sullivan identified 2 types of needs, satisfaction and security. Failure to gratify these needs may result in anxiety. C. Biomedical perspective of anxiety. D. Explanation of anxiety using the behavioral model.

13.    Answer: (D) Impaired social interaction
The client may not have difficulty in social exchange. The cues do not support this diagnosis. A. The client maladaptively uses body symptoms to manage anxiety. B. The client will have discomfort due to pain. C. The client may fail to meet environmental expectations due to pain.

14.    Answer: (C) Expression of conflicts through bodily symptoms
Bodily symptoms are used to handle conflicts. A. Manifestations do not have an organic basis. B. This occurs unconsciously. D. Medical treatment is not used because the disorder does not have a structural or organic basis.

15.    Answer: (A) “I know the feeling is real tests revealed negative results.”
Shows empathy and offers information. B. This is a demeaning statement. C. This belittles the client’s feelings. D. Giving undue attention to the physical symptom reinforces the complaint.

16.    Answer: (A) provide as much structure as possible for the child
Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non –confrontational approach and setting limit to time allotted for activities. B. The child will not benefit from a lenient approach. C. Dissipate energy through safe activities. D. This indicates that the classroom environment lacks structure.

17.    Answer: (D) Serious violations of age related norms.
This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression, vandalism, stealing, lying and truancy. A. This is characteristic of attention deficit disorder. B and C. These are noted among children with autistic disorder.

18.    Answer: (A) increased attention span and concentration
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.

19.    Answer: (A) Returning the child to the school immediately with family support.
Exposure to the feared situation can help in overcoming anxiety. A. This will not help in relieving the anxiety due separation from a significant other. C. and C. Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable. D. This will not help the child overcome the fear

20.    Answer: (C) Moderate
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.

21.    Answer: (A) overprotection of the child
The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. B,C, and D Children with mental retardation have learning difficulty. They should be taught with patience and repetition, start from simple to complex, use visuals and compliment them for motivation. Realistic expectations should be set and optimize their capability.

22.    Answer: (B) altered parenting role
Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. This is reflected in the parent’s inability to care for the child. A. This refers to lack of choices or inability to mobilize one’s resources. C. Refers to change in family relationship and function. D. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources

23.    Answer: (B) intolerance to change, disturbed relatedness, stereotypes
These are manifestations of autistic disorder. A. These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. C. These are manifestations of Attention Deficit Disorder D. These are the manifestations of Conduct Disorder

24.    Answer: (D) Rearrange the environment to activate the child
The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be rechannelled through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling.

25.    Answer: (C) Pre-operational
Pre-operational stage (2-7 years) is the stage when the use of language, the use of symbols and the concept of time occur. A. Sensory-motor stage (0-2 years) is the stage when the child uses the senses in learning about the self and the environment through exploration. B. Concrete operations (7-12 years) when inductive reasoning develops. D. Formal operations (2 till adulthood) is when abstract thinking and deductive reasoning develop.

1.       Answer: (B) protecting the client from infection
Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.

2.       Answer: (A) 25 gtt/min
To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20)

3.       Answer: (B) Eating habits are altered
For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued

4.       Answer: (A) Increase her lean body mass
Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.

5.       Answer: (A) Exercising the triceps, finger flexors, and elbow extensors
These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.

6.       Answer: (C) The palms of her hands
The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)

7.       Answer: (C) 12 minims
Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate

8.       Answer: (B) Relieves pain and decreases level of anxiety
Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand.

9.       Answer: (C) Supports combustion
The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.

10.    Answer: (C) CK-MB
The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage.

11.    Answer: (B) Elevated STsegments
This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.

12.    Answer: (B) Refocus the conversation on his fears, frustrations and anger about his condition
This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.

13.    Answer: (D) Increased pulse rate
Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.

14.    Answer: (C) Avoid giving him direct information and help him explore his feelings
To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs.

15.    Answer: (C) Absorb vitamin B12
Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.

16.    Answer: (D) 2.0 ml
First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.

17.    Answer: (C) IM injections once a month will maintain control
Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow

18.    Answer: (D) For the rest of her life
Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life.

19.    Answer: (D) Projection
Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.

20.    Answer: (A) When the client would have normally had a bowel movement
Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.

21.    Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid insertion
The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.

22.    Answer: (B) Difficulty in inserting the irrigating tube
Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.

23.    Answer: (B) A difficult time accepting reality and is in a state of denial.
As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported

24.    Answer: (B) Everything he ate before the operation but will avoid those foods that cause gas
There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.

25.    Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and presence of pulses
Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished

26.    Answer: (C) Assess his response to the equipment
It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding

27.    Answer: (B) Milk the tube toward the collection container as ordered
This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber

28.    Answer: (A) Increased breath sounds
The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function

29.    Answer: (A) Urinary output is 30 ml in an hour
A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.

30.    Answer: (D) Presence of abdominal drains for several days after surgery
Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.

31.    Answer: (B) Encourage frequent coughing and deep breathing
This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.

32.    Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving
The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.

33.    Answer: (D) Client’s perception of the change
It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.

34.    Answer: (C) Intellectualization
People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.

35.    Answer: (D) Use a soft toothbrush and electric razor
Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.

36.    Answer: (C) A hemolytic transfusion reaction
This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.

37.    Answer: (D) “Does it help you to joke about your illness?”
This non-judgmentally on the part of the nurse points out the client’s behavior.

38.    Answer: (C) Allow the denial but be available to discuss death
This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.

39.    Answer: (C) +235 ml
The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake

40.    Answer: (B) Dyspnea on exertion
Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.

41.    Answer: (D) Ascending limb of the loop of Henle
This is the site of action of Lasix being a potent loop diuretic.

42.    Answer: (C) 2.0 L
One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.

43.    Answer: (D) Cardiac glycoside
A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.

44.    Answer: (B) 2000 calories
There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein

45.    Answer: (B) Sodium
Restriction of sodium reduces the amount of water retention that reduces the cardiac workload

46.    Answer: (A) The medications he has been taking
Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use

47.    Answer: (B) Regular meals and snacks to limit gastric discomfort
Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.

48.    Answer: (B) Decreasing PCO2
Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.

49.    Answer: (B) 600 Kilocalories
Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.

50.    Answer: (D) Performing active-assistive leg exercises
Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon

51.    Answer: (C) Maintaining the ordered hydration
Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection

52.    Answer: (D) Dorsiflexion, plantar flexion, eversion and inversion
These movements include all possible range of motion for the ankle joint

53.    Answer: (A) 30 degrees
Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores.

54.    Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours
An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.

55.    Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis
Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis

56.    Answer: (B) Hemorrhage
After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.

57.    Answer: (B) Provide hemostasis
The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.

58.    Answer: (B) Milk the catheter tubing
Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.

59.    Answer: (B) Call the physician if my urinary stream decreases
Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.

60.    Answer: (C) Weight loss, exopthalmos and restlessness
Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.

61.    Answer: (B) A small part of the gland is left intact
Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.

62.    Answer: (B) A tracheostomy set and oxygen
Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.

63.    Answer: (C) Asking her to state her name out loud
If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.

64.    Answer: (B) Dry skin and fatigue
Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.

65.    Answer: (C) Avoid using a sleeping mask at night
The mask may irritate or scratch the eye if the client turns and lies on it during the night.

66.    Answer: (D) 22.5%
The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%

67.    Answer: (A) Inhibit bacterial growth
Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes

68.    Answer: (B) 28 gtt/min
This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)

69.    Answer: (C) Relieve pain and promote rapid epithelialization
The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.

70.    Answer: (C) Orthopneic position
The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion

71.    Answer: (C) Rapid but brief symptomatic improvement
Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.

72.    Answer: (C) Maintain the present muscle strength
Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy

73.    Answer: (D) Respiratory exchange and ability to swallow
Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration

74.    Answer: (C) Evaluate the client’s muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.

75.    Answer: (D) Coordinate her meal schedule with the peak effect of her medication, Mestinon
Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.

1.       Answer: (A) Hyponatremia
The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting

2.       Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained.

3.       Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm.
In the client with an external shunt, don’t use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.

4.       Answer: (D) He will be pain free.
Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.

5.       Answer: (C) right lower quadrant
To be exact, the appendix is anatomically located at the Mc Burney’s point at the right iliac area of the right lower quadrant.

6.       Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks
The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case.

7.       Answer: (C) 31%
Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% – head; 9% – each upper extremity; 18%- front chest and abdomen; 18% – entire back; 18% – each lower extremity and 1% – perineum.

8.       Answer: (D) Fluid shift from intravascular space to the interstitial space
This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.

9.       Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea
Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern.

10.    Answer: (D) Helping the client to rest in the position of maximal comfort
Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications.

11.    Answer: (D) fluid and electrolyte monitoring
Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight.

12.    Answer: (D) Aluminum hydroxide
Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects.

13.    Answer: (A) 0.45% NaCl
Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood.

14.    Answer: (A) hypertension
In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria.

15.    Answer: (B) assessing Maria’s expectations and doubts
Assessing the client’s expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed.

16.    Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the grieving process
A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient’s feelings and encourage verbalization.

17.    Answer: (B) it affects both normal and tumor cells
Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression.

18.    Answer: (C) CTscanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor
CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors.

19.    Answer: (D) frequently elevating the arm of the affected side above the level of the heart.
Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling.

20.    Answer: (B) “My 7 year old twins should not come to visit me while I’m receiving treatment.”
Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself.

21.    Answer: (B) Rapid cell catabolism
One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure.

22.    Answer: (C) Low residue diet
It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions

23.    Answer: (A) Avoid BP measurement and constricting clothing on the affected arm
A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm

24.    Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels.
The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur.

25.    Answer: (A) A rapid pulse and increased RR
The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival.

26.    Answer: (D) assessing her VS especially her RR
Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications.

27.    Answer: (B) Urine output of 30 to 50 ml/hr.
Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance.

28.    Answer: (D) Pericardial tamponade
Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.

29.    Answer: (A) administering an irritant that will stimulate vomiting
Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed.

30.    Answer: (C) Palpable carotid pulse
Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after.

31.    Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water
Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done.

32.    Answer: (A) Force air out of the lungs
The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material.

33.    Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely
Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another.

34.    Answer: (C) relax the bronchial smooth muscle
Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles.

35.    Answer: (C) lower half of the sternum
The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration.

36.    Answer: (B) “As one ages, visual changes are noted as part of degenerative changes. This is normal.”
Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision.

37.    Answer: (D) sexual intercourse
To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP.

38.    Answer: (C) Speak clearly in a loud voice or shout to be heard
Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly.

39.    Answer: (D) Force fluids before and after the procedure.
LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure.

40.    Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding.
Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site.

41.    Answer: (D) progression from restlessness to confusion and disorientation to lethargy
The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially manifested by restlessness.

42.    Answer: (D) Aspirin is used in the acute management of a completed stroke.
The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding.

43.    Answer: (D) Encourage the client to speak at every possible opportunity.
Expressive or motor aphasia is a result of damage in the Broca’s area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively.

44.    Answer: (C) altered cerebral tissue perfusion
The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage.

45.    Answer: (D) Ineffective airway clearance related to muscle weakness
Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation.

46.    Answer: (C) Test for glucose
The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage.

47.    Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb.
The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow.

48.    Answer: (D) Place items so that it is necessary to bend or stretch to reach them.
Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient.

49.    Answer: (D) Ensure an intake of at least 3000 ml of fluid per day.
Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones.

50.    Answer: (B) Before log rolling, remove the pillow from under the client’s head and use no pillows between the client’s legs.
Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing.

View the questions of NCLEX Practice Test for Medical Surgical Nursing.

1.       Answer: (C) “With a pillow, apply pressure against the incision.”
Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.

2.       Answer: (C) experience reduced sensory perception
Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.

3.       Answer: (C) This is normal side-effect of AtSO4
Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.

4.       Answer: (D) Administer Demerol 50mg IM q4h
Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse.

5.       Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?"
The client is showing signs of anxiety reaction to a stressful event. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns.

6.       Answer: (C) Check the patency of the nasogastric tube for any obstruction.
Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention.

7.       Answer: (C) Handle him gently when assisting with required care
Patients with cancer and bone metastasis experience severe pain especially when moving. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. During nursing care, the patient needs to be supported and handled gently.

8.       Answer: (B) Take his vital signs again in 15 minutes.
Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring.

9.       Answer: (C) Bleeding from ears
The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation

10.    Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.”
Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention.

11.    Answer: (B) The positive inotropic effect will decrease urine output
Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output.

12.    Answer: (A) Use of stool softeners.
Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver.

13.    Answer: (D) may engage in contact sports
The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.

14.    Answer: (D) “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved.
Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention.

15.    Answer: (B) Canned sardines
Canned foods are generally rich in sodium content as salt is used as the main preservative.

16.    Answer: (C) Instruct the client about the need for bed rest.
In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.

17.    Answer: (B) It prevents conversion of factors that are needed in the formation of clots.
Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.

18.    Answer: (D) Cough or change in a chronic cough
Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection.

19.    Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive.

20.    Answer: (C) Suction until the client indicates to stop or no longer than 20 second
One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning.

21.    Answer: (D) Delay resistance and increase the tuberculostatic effect
Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance.

22.    Answer: (B) Facilitate ventilation of the left lung.
Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.

23.    Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug.
If the client breathes out through the mouth with pursed lips, this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness.

24.    Answer: (A) Food and fluids will be withheld for at least 2 hours.
Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.

25.    Answer: (C) Lower the oxygen rate.
The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR.

26.    Answer: (C) Impaired gas exchange.
Pneumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess.

27.    Answer: (D) posterior neck fat pad and thin extremities
“ Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. All these are noted in a client with Cushing’s syndrome.

28.    Answer: (B) “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.”
The possible side effects of steroid administration are hypokalemia, increase tendency to infection and poor wound healing. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis

29.    Answer: (C) Blood pressure
Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.

30.    Answer: (D) Give the guest a glass of orange juice
In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious client, he should be given immediately carbohydrates in the form of fruit juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV.

31.    Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s disease.”
Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease.

32.    Answer: (A) Checking the back and sides of the operative dressing
Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry and clear of drainage.

33.    Answer: (C) Progressive weight gain
Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.

34.    Answer: (C) Lipodystrophic areas can result, causing erratic insulin absorption rates from these
Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions.

35.    Answer: (C) Keep legs elevated on 2 pillows while sleeping
The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.

36.    Answer: (B) Assess gag reflex prior to administration of fluids
The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.

37.    Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake.

38.    Answer: (B) Notify the MD of your findings
The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.

39.    Answer: (A) Sit upright for at least 30 minutes after meals
The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome.

40.    Answer: (A) Treatment will include Ranitidine and Antibiotics
One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer.

41.    Answer: (B) Empty bladder before procedure
Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure.

42.    Answer: (A) “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia production.

43.    Answer: (C) Meperidine
Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.

44.    Answer: (B) encouraging the client to cough and deep breathe
Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications.

45.    Answer: (A) Deflate the esophageal balloon
When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction

46.    Answer: (B) Ulcerative colitis
Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem.

47.    Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test
Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema.

48.    Answer: (D) “I will include more fresh fruits and vegetables in my diet.”
Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer.

49.    Answer: (A) Cover the wound with sterile, moist saline dressing
Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process.

50.    Answer: (B) Ambulate.
Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination.