PNLE Nursing
PNLE Nursing
A. I.V
B. I.M
C. Oral
D. S.C
3. Dr. Garcia writes the following order for the client who has been recently
admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how
should the nurse document this order onto the medication administration
record?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypervolemia
11.She finds out that some managers have benevolent-authoritative style of
management. Which of the following behaviors will she exhibit most likely?
A. Increased appetite
B. Loss of urge to defecate
C. Hard, brown, formed stools
D. Liquid or semi-liquid stools
15.Nurse Linda prepares to perform an otoscopic examination on a female
client. For proper visualization, the nurse should position the client’s ear by:
A. Constipation
B. Diarrhea
C. Risk for infection
D. Deficient knowledge
24.A male client is receiving total parenteral nutrition suddenly demonstrates
signs and symptoms of an air embolism. What is the priority action by the
nurse?
A. Autocratic.
B. Laissez-faire.
C. Democratic.
D. Situational
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The
nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc.
How many cc’s of KCl will be added to the IV solution?
A. .5 cc
B. 5 cc
C. 1.5 cc
D. 2.5 cc
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The
IV drip factor is 60. The IV rate that will deliver this amount is:
A. 50 cc/ hour
B. 55 cc/ hour
C. 24 cc/ hour
D. 66 cc/ hour
28.The nurse is aware that the most important nursing action when a client
returns from surgery is:
A. Assess the IV for type of fluid and rate of flow.
B. Assess the client for presence of pain.
C. Assess the Foley catheter for patency and urine output
D. Assess the dressing for drainage.
29. Which of the following vital sign assessments that may indicate
cardiogenic shock after myocardial infarction?
A. Assessment
B. Evaluation
C. Implementation
D. Planning and goals
32.Which of the following item is considered the single most important factor
in assisting the health professional in arriving at a diagnosis or determining
the person’s needs?
A. Trochanter roll extending from the crest of the ileum to the midthigh.
B. Pillows under the lower legs.
C. Footboard
D. Hip-abductor pillow
34.Which stage of pressure ulcer development does the ulcer extend into the
subcutaneous tissue?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
35.When the method of wound healing is one in which wound edges are not
surgically approximated and integumentary continuity is restored by
granulations, the wound healing is termed
A. Hypothermia
B. Hypertension
C. Distended neck veins
D. Tachycardia
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours
as needed, to control a client’s postoperative pain. The package insert is
“Meperidine, 100 mg/ml.” How many milliliters of meperidine should the
client receive?
A. 0.75
B. 0.6
C. 0.5
D. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement
correctly describes an insulin unit?
A. 40.1 °C
B. 38.9 °C
C. 48 °C
D. 38 °C
40.The nurse is assessing a 48-year-old client who has come to the
physician’s office for his annual physical exam. One of the first physical signs
of aging is:
A. 30 drops/minute
B. 32 drops/minute
C. 20 drops/minute
D. 18 drops/minute
44.If a central venous catheter becomes disconnected accidentally, what
should the nurse in-charge do immediately?
A. Fingertips
B. Finger pads
C. Dorsal surface of the hand
D. Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and
learning process?
A. Summative
B. Informative
C. Formative
D. Retrospective
48.A 45 year old client, has no family history of breast cancer or other risk
factors for this disease. Nurse John should instruct her to have mammogram
how often?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
50.Nurse Len refers a female client with terminal cancer to a local hospice.
What is the goal of this referral?
A. Knee
B. Ankle
C. Lower thigh
D. Foot
53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and
receives a continuous insulin infusion. Which condition represents the
greatest risk to this child?
A. Hypernatremia
B. Hypokalemia
C. Hyperphosphatemia
D. Hypercalcemia
54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly
admitted client. Immediately afterward, the client may experience:
A. Wiping the port with an alcohol swab before inserting the syringe.
B. Aspirating a sample from the port on the drainage bag.
C. Clamping the tubing of the drainage bag.
D. Obtaining the specimen from the urinary drainage bag.
59.Nurse Meredith is in the process of giving a client a bed bath. In the middle
of the procedure, the unit secretary calls the nurse on the intercom to tell the
nurse that there is an emergency phone call. The appropriate nursing action is
to:
A. Immediately walk out of the client’s room and answer the phone call.
B. Cover the client, place the call light within reach, and answer the phone
call.
C. Finish the bed bath before answering the phone call.
D. Leave the client’s door open so the client can be monitored and the
nurse can answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity
testing from a client who has a productive cough. Nurse Janah plans to
implement which intervention to obtain the specimen?
A. Ask the client to expectorate a small amount of sputum into the emesis
basin.
B. Ask the client to obtain the specimen after breakfast.
C. Use a sterile plastic container for obtaining the specimen.
D. Provide tissues for expectoration and obtaining the specimen.
61. Nurse Ron is observing a male client using a walker. The nurse determines
that the client is using the walker correctly if the client:
A. Puts all the four points of the walker flat on the floor, puts weight on the
hand pieces, and then walks into it.
B. Puts weight on the hand pieces, moves the walker forward, and then
walks into it.
C. Puts weight on the hand pieces, slides the walker forward, and then
walks into it.
D. Walks into the walker, puts weight on the hand pieces, and then puts all
four points of the walker flat on the floor.
62.Nurse Amy has documented an entry regarding client care in the client’s
medical record. When checking the entry, the nurse realizes that incorrect
information was documented. How does the nurse correct this error?
A. Crutches
B. Single straight-legged cane
C. Quad cane
D. Walker
66.A male client with a right pleural effusion noted on a chest X-ray is being
prepared for thoracentesis. The client experiences severe dizziness when
sitting upright. To provide a safe environment, the nurse assists the client to
which position for the procedure?
A. Validity
B. Specificity
C. Sensitivity
D. Reliability
68.Harry knows that he has to protect the rights of human research subjects.
Which of the following actions of Harry ensures anonymity?
A. Interview schedule
B. Questionnaire
C. Use of laboratory data
D. Observation
71.Monica is aware that there are times when only manipulation of study
variables is possible and the elements of control or randomization are not
attendant. Which type of research is referred to this?
A. Field study
B. Quasi-experiment
C. Solomon-Four group design
D. Post-test only design
72.Cherry notes down ideas that were derived from the description of
an investigation written by the person who conducted it. Which type
of reference source refers to this?
A. Footnote
B. Bibliography
C. Primary source
D. Endnotes
73.When Nurse Trish is providing care to his patient, she must remember
that her duty is bound not to do doing any action that will cause the
patient harm. This is the meaning of the bioethical principle:
A. Non-maleficence
B. Beneficence
C. Justice
D. Solidarity
74.When a nurse in-charge causes an injury to a female patient and the
injury caused becomes the proof of the negligent act, the presence of the
injury is said to exemplify the principle of:
A. Force majeure
B. Respondeat superior
C. Res ipsa loquitor
D. Holdover doctrine
75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial
power. An example of this power is:
A. The Board can issue rules and regulations that will govern the practice
of nursing
B. The Board can investigate violations of the nursing law and code
of ethics
C. The Board can visit a school applying for a permit in collaboration with
CHED
D. The Board prepares the board examinations
76. When the license of nurse Krina is revoked, it means that she:
A. Is no longer allowed to practice the profession for the rest of her life
B. Will never have her/his license re-issued since it has been revoked
C. May apply for re-issuance of his/her license based on certain conditions
stipulated in RA 9173
D. Will remain unable to practice professional nursing
77.Ronald plans to conduct a research on the use of a new method of
pain assessment scale. Which of the following is the second step in
the conceptualizing phase of the research process?
A. Florence Nightingale
B. Madeleine Leininger
C. Albert Moore
D. Sr. Callista Roy
81.Marion is aware that the sampling method that gives equal chance to
all units in the population to get picked is:
A. Random
B. Accidental
C. Quota
D. Judgment
82.John plans to use a Likert Scale to his study to determine the:
A. Madeleine Leininger
B. Sr. Callista Roy
C. Florence Nightingale
D. Jean Watson
84.Ms. Garcia is responsible to the number of personnel reporting to her.
This principle refers to:
A. Span of control
B. Unity of command
C. Downward communication
D. Leader
85.Ensuring that there is an informed consent on the part of the patient before
a surgery is done, illustrates the bioethical principle of:
A. Beneficence
B. Autonomy
C. Veracity
D. Non-maleficence
86.Nurse Reese is teaching a female client with peripheral vascular
disease about foot care; Nurse Reese should include which instruction?
A. Lithotomy
B. Supine
C. Prone
D. Sims’ left lateral
89.Nurse Marian is preparing to administer a blood transfusion. Which
action should the nurse take first?
A. Independent
B. Dependent
C. Interdependent
D. Intradependent
91.A female client is to be discharged from an acute care facility
after treatment for right leg thrombophlebitis. The Nurse Betty notes that
the client’s leg is pain-free, without redness or edema. The nurse’s
actions reflect which step of the nursing process?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
92.Nursing care for a female client includes removing elastic stockings
once per day. The Nurse Betty is aware that the rationale for this intervention?
A. Do nothing.
B. Invert the vial and let it stand for 3 to 5 minutes.
C. Shake the vial vigorously.
D. Roll the vial gently between the palms.
96.Which intervention should the nurse Trish use when administering
oxygen by face mask to a female client?
A. 6 hours
B. 4 hours
C. 3 hours
D. 2 hours
98.Nurse Monique is monitoring the effectiveness of a client’s drug
therapy. When should the nurse Monique obtain a blood sample to measure
the trough drug level?
A. Observations
B. Restating
C. Exploring
D. Focusing
2. Tony refuses his evening dose of Haloperidol (Haldol), then becomes
extremely agitated in the dayroom while other clients are watching television.
He begins cursing and throwing furniture. Nurse Oliver first action is to:
A. Check the client’s medical record for an order for an as-needed I.M.
dose of medication for agitation.
B. Place the client in full leather restraints.
C. Call the attending physician and report the behavior.
D. Remove all other clients from the dayroom.
3. Tina who is manic, but not yet on medication, comes to the drug treatment
center. The nurse would not let this client join the group session because:
A. Inform the mother that she and the father can work through this
problem themselves.
B. Refer the mother to the hospital social worker.
C. Agree to talk with the mother and the father together.
D. Suggest that the father and son work things out.
5. What is Nurse John likely to note in a male client being admitted for alcohol
withdrawal?
A. Perceptual disorders.
B. Impending coma.
C. Recent alcohol intake.
D. Depression with mutism.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that
it “doesn’t help” and refuses to take it. What should the nurse say or do?
A. Id
B. Ego
C. Superego
D. Oedipal complex
8. In preparing a female client for electroconvulsive therapy (ECT), Nurse
Michelle knows that succinylcoline (Anectine) will be administered for which
therapeutic effect?
A. Short-acting anesthesia
B. Decreased oral and respiratory secretions.
C. Skeletal muscle paralysis.
D. Analgesia.
9. Nurse Gina is aware that the dietary implications for a client in manic phase
of bipolar disorder is:
A. Serve the client a bowl of soup, buttered French bread, and apple slices.
B. Increase calories, decrease fat, and decrease protein.
C. Give the client pieces of cut-up steak, carrots, and an apple.
D. Increase calories, carbohydrates, and protein.
10.What parental behavior toward a child during an admission procedure
should cause Nurse Ron to suspect child abuse?
A. Flat affect
B. Expressing guilt
C. Acting overly solicitous toward the child.
D. Ignoring the child.
11.Nurse Lynnette notices that a female client with obsessive-compulsive
disorder washes her hands for long periods each day. How should the nurse
respond to this compulsive behavior?
A. “You’ve developed this paralysis so you can stay with your parents. You
must deal with this conflict if you want to walk again.”
B. “It must be awful not to be able to move your legs. You may feel better if
you realize the problem is psychological, not physical.”
C. “Your problem is real but there is no physical basis for it. We’ll work on
what is going on in your life to find out why it’s happened.”
D. “It isn’t uncommon for someone with your personality to develop
a conversion disorder during times of stress.”
14.Nurse Krina knows that the following drugs have been known to
be effective in treating obsessive-compulsive disorder (OCD):
A. Antidepressants
B. Anticholinergics
C. Antipsychotics
D. Mood stabilizers
18.A client seeks care because she feels depressed and has gained
weight. To treat her atypical depression, the physician prescribes
tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day. When this
drug is used to treat atypical depression, what is its onset of action?
A. 1 to 2 days
B. 3 to 5 days
C. 6 to 8 days
D. 10 to 14 days
19. A 65 years old client is in the first stage of Alzheimer’s disease.
Nurse Patricia should plan to focus this client’s care on:
A. Barbiturates
B. Amphetamines
C. Methadone
D. Benzodiazepines
23.Nurse Cristina is caring for a client who experiences false
sensory perceptions with no basis in reality. These perceptions are known as:
A. Delusions
B. Hallucinations
C. Loose associations
D. Neologisms
24. Nurse Marco is developing a plan of care for a client with
anorexia nervosa. Which action should the nurse include in the plan?
A. Restricts visits with the family and friends until the client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which will reduce her anxiety.
25.Tim is admitted with a diagnosis of delusions of grandeur. The nurse
is aware that this diagnosis reflects a belief that one is:
A. Withdrawal
B. Logical thinking
C. Repression
D. Denial
28.Richard is admitted with a diagnosis of schizotypal personality
disorder. Which signs would this client exhibit during social situations?
A. Aggressive behavior
B. Paranoid thoughts
C. Emotional affect
D. Independence needs
29. Nurse Mickey is caring for a client diagnosed with bulimia. The
most appropriate initial goal for a client diagnosed with bulimia is to:
A. “It is the voice of your conscience, which only you can control.”
B. “No, I do not hear your voices, but I believe you can hear them”.
C. “The voices are coming from within you and only you can hear them.”
D. “Oh, the voices are a symptom of your illness; don’t pay any attention to
them.”
32.The nurse is aware that the side effect of electroconvulsive therapy that
a client may experience:
A. Loss of appetite
B. Postural hypotension
C. Confusion for a time after treatment
D. Complete loss of memory for a time
33.A dying male client gradually moves toward resolution of
feelings regarding impending death. Basing care on the theory of Kubler-
Ross, Nurse Trish plans to use nonverbal interventions when
assessment reveals that the client is in the:
A. Anger stage
B. Denial stage
C. Bargaining stage
D. Acceptance stage
34.The outcome that is unrelated to a crisis state is:
A. Driving at night
B. Staying in the sun
C. Ingesting wines and cheeses
D. Taking medications containing aspirin
36.Jen a nursing student is anxious about the upcoming board
examination but is able to study intently and does not become distracted by
a roommate’s talking and loud music. The student’s ability to
ignore distractions and to focus on studying demonstrates:
A. Mild-level anxiety
B. Panic-level anxiety
C. Severe-level anxiety
D. Moderate-level anxiety
37.When assessing a premorbid personality characteristics of a client with
a major depression, it would be unusual for the nurse to find that this
client demonstrated:
A. Rigidity
B. Stubbornness
C. Diverse interest
D. Over meticulousness
38.Nurse Krina recognizes that the suicidal risk for depressed client
is greatest:
A. Privacy
B. Respect
C. Empathy
D. Presence
43.When establishing an initial nurse-client relationship, Nurse Hazel
should explore with the client the:
A. 1 to 2 weeks
B. 4 to 6 weeks
C. 4 to 6 months
D. 6 to 12 months
46. Nurse Judy knows that statistics show that in adolescent
suicide behavior:
A. phenelzine (Nardil)
B. chlordiazepoxide (Librium)
C. lithium carbonate (Lithane)
D. imipramine (Tofranil)
49.Which information is most important for the nurse Trinity to include in
a teaching plan for a male schizophrenic client taking clozapine (Clozaril)?
A. Tardive dyskinesia.
B. Dystonia.
C. Neuroleptic malignant syndrome.
D. Akathisia.
51.Which nursing intervention would be most appropriate if a male
client develop orthostatic hypotension while taking amitriptyline (Elavil)?
A. Cyclothymic disorder.
B. Atypical affective disorder.
C. Major depression.
D. Dysthymic disorder.
53. After taking an overdose of phenobarbital (Barbita), Mario is admitted
to the emergency department. Dr. Trinidad prescribes activated
charcoal (Charcocaps) to be administered by mouth immediately.
Before administering the dose, the nurse verifies the dosage ordered. What is
the usual minimum dose of activated charcoal?
A. Ginkgo biloba
B. Echinacea
C. St. John’s wort
D. Ephedra
55.Cely with manic episodes is taking lithium. Which electrolyte level
should the nurse check before administering this medication?
A. Calcium
B. Sodium
C. Chloride
D. Potassium
56.Nurse Josefina is caring for a client who has been diagnosed with delirium.
Which statement about delirium is true?
A. Alcohol withdrawal
B. Cannibis withdrawal
C. Cocaine withdrawal
D. Opioid withdrawal
61.Mr. Garcia, an attorney who throws books and furniture around the
office after losing a case is referred to the psychiatric nurse in the law
firm’s employee assistance program. Nurse Beatriz knows that the
client’s behavior most likely represents the use of which defense mechanism?
A. Regression
B. Projection
C. Reaction-formation
D. Intellectualization
62.Nurse Anne is caring for a client who has been treated long term
with antipsychotic medication. During the assessment, Nurse Anne checks
the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse
Anne would most likely observe:
A. Weakness
B. Diarrhea
C. Blurred vision
D. Fecal incontinence
64.Nurse Jannah is monitoring a male client who has been placed
inrestraints because of violent behavior. Nurse determines that it will be safe
to remove the restraints when:
A. Profound
B. Mild
C. Moderate
D. Severe
67.The therapeutic approach in the care of Armand an autistic child
include the following EXCEPT:
A. Heroin
B. Cocaine
C. LSD
D. Marijuana
69.Nurse Pauline is aware that Dementia unlike delirium is characterized by:
A. Slurred speech
B. Insidious onset
C. Clouding of consciousness
D. Sensory perceptual change
70.A 35 year old female has intense fear of riding an elevator. She claims “ As
if I will die inside.” The client is suffering from:
A. Agoraphobia
B. Social phobia
C. Claustrophobia
D. Xenophobia
71.Nurse Myrna develops a counter-transference reaction. This is
evidenced by:
A. Splitting
B. Transference
C. Countertransference
D. Resistance
75.Marielle, 17 years old was sexually attacked while on her way home
from school. She is brought to the hospital by her mother. Rape is an
example of which type of crisis:
A. Situational
B. Adventitious
C. Developmental
D. Internal
76. Nurse Greta is aware that the following is classified as an Axis I
disorder by the Diagnosis and Statistical Manual of Mental Disorders,
Text Revision (DSM-IV-TR) is:
A. Obesity
B. Borderline personality disorder
C. Major depression
D. Hypertension
77.Katrina, a newly admitted is extremely hostile toward a staff member
she has just met, without apparent reason. According to Freudian theory,
the nurse should suspect that the client is experiencing which of the
following phenomena?
A. Intellectualization
B. Transference
C. Triangulation
D. Splitting
78.An 83year-old male client is in extended care facility is anxious most of
the time and frequently complains of a number of vague symptoms
that interfere with his ability to eat. These symptoms indicate which of
the following disorders?
A. Conversion disorder
B. Hypochondriasis
C. Severe anxiety
D. Sublimation
79. Charina, a college student who frequently visited the health center during
the past year with multiple vague complaints of GI symptoms before
course examinations. Although physical causes have been eliminated, the
student continues to express her belief that she has a serious illness. These
symptoms are typically of which of the following disorders?
A. Conversion disorder
B. Depersonalization
C. Hypochondriasis
D. Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents
are sedative hypnotic medication is used to induce sleep for a client
experiencing a sleep disorder is:
A. Triazolam (Halcion)
B. Paroxetine (Paxil)\
C. Fluoxetine (Prozac)
D. Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which
of the following statement refers to a secondary gain?
A. Anxiety disorder
B. Behavioral difficulties
C. Cognitive impairment
D. Labile moods
86. Ricardo, an outpatient in psychiatric facility is diagnosed with
dysthymic disorder. Which of the following statement about dysthymic
disorder is true?
A. Infection
B. Metabolic acidosis
C. Drug intoxication
D. Hepatic encephalopathy
89. Nurse Ron enters a client’s room, the client says, “They’re crawling on
my sheets! Get them off my bed!” Which of the following assessment is the
most accurate?
A. The client tries to hit the nurse when vital signs must be taken
B. The client says, “I keep hearing a voice telling me to run away”
C. The client becomes anxious whenever the nurse leaves the bedside
D. The client looks at the shadow on a wall and tells the nurse she sees
frightening faces on the wall.
91. During conversation of Nurse John with a client, he observes that the
client shift from one topic to the next on a regular basis. Which of the
following terms describes this disorder?
A. Flight of ideas
B. Concrete thinking
C. Ideas of reference
D. Loose association
92. Francis tells the nurse that her coworkers are sabotaging the
computer. When the nurse asks questions, the client becomes argumentative.
This behavior shows personality traits associated with which of the
following personality disorder?
A. Antisocial
B. Histrionic
C. Paranoid
D. Schizotypal
93. Which of the following interventions is important for a Cely experiencing
with paranoid personality disorder taking olanzapine (Zyprexa)?
A. Lack of honesty
B. Belief in superstition
C. Show of temper tantrums
D. Constant need for attention
95. Tommy, with dependent personality disorder is working to increase his
selfesteem. Which of the following statements by the Tommy shows teaching
was successful?
A. “I’m not going to look just at the negative things about myself”
B. “I’m most concerned about my level of competence and progress”
C. “I’m not as envious of the things other people have as I used to be”
D. “I find I can’t stop myself from taking over things other should be doing”
96. Norma, a 42-year-old client with a diagnosis of chronic
undifferentiated schizophrenia lives in a rooming house that has a weekly
nursing clinic. She scratches while she tells the nurse she feels creatures
eating away at her skin. Which of the following interventions should be done
first?
A. Modeling
B. Echopraxia
C. Ego-syntonicity
D. Ritualism
98. Jun approaches the nurse and tells that he hears a voice telling him that
he’s evil and deserves to die. Which of the following terms describes the
client’s perception?
A. Delusion
B. Disorganized speech
C. Hallucination
D. Idea of reference
99. Mike is admitted to a psychiatric unit with a diagnosis of
undifferentiated schizophrenia. Which of the following defense mechanisms
is probably used by mike?
A. Projection
B. Rationalization
C. Regression
D. Repression
100. Rocky has started taking haloperidol (Haldol). Which of the
following instructions is most appropriate for Ricky before taking haloperidol?
A. resign on the spot from the nursing position and apply for a position
that does not require floating
B. Inform the nursing supervisor and the charge nurse on the pediatric
floor about the nurse’s lack of skill and feelings of hesitations and request
assistance
C. Ask several other nurses how they feel about pediatrics and find
someone else who is willing to accept the assignment
D. Refuse the assignment and leave the unit requesting a vacation a day
8. An experienced nurse who voluntarily trained a less experienced nurse with
the intention of enhancing the skills and knowledge and promoting
professional advancement to the nurse is called a:
A. mentor
B. team leader
C. case manager
D. change agent
9. The pediatrics unit is understaffed and the nurse manager informs the
nurses in the obstetrics unit that she is going to assign one nurse to float in
the pediatric units. Which statement by the designated float nurse may put her
job at risk?
A. “I do not get along with one of the nurses on the pediatrics unit”
B. “I have a vacation day coming and would like to take that now”
C. “I do not feel competent to go and work on that area”
D. “ I am afraid I will get the most serious clients in the unit”
10. The newly hired staff nurse has been working on a medical unit for 3
weeks. The nurse manager has posted the team leader assignments for the
following week. The new staff knows that a major responsibility of the team
leader is to:
A. The Physician
B. The Registered Nurse caring for the client
C. The 15-year-old mother of the baby boy
D. The mother of the girl
12. A nurse caring to a client with Alzheimer’s disease overheard a family
member say to the client, “if you pee one more time, I won’t give you any more
food and drinks”. What initial action is best for the nurse to take?
A. Take no action because it is the family member saying that to the client
B. Talk to the family member and explain that what she/he has said is not
appropriate for the client
C. Give the family member the number for an Elder Abuse Hot line
D. Document what the family member has said
13. Which is true about informed consent?
A. Notify the pediatric team that the mother has refused resuscitation and
any treatment for the baby and take the baby to the mother
B. Get a court order making the baby a ward of the court
C. Record the statement of the mother, notify the pediatric team, and
observe carefully for signs of impaired bonding and neglect as a
reasonable suspicion of child abuse
D. Do nothing except record the mother’s statement in the medical record
15. The hospitalized client with a chronic cough is scheduled for
bronchoscopy. The nurse is tasks to bring the informed consent document
into the client’s room for a signature. The client asks the nurse for details of
the procedure and demands an explanation why the process of informed
consent is necessary. The nurse responds that informed consent means:
A. The patient releases the physician from all responsibility for the
procedure.
B. The immediate family may make decision against the patient’s will.
C. The physician must give the client or surrogates enough information to
make health care judgments consistent with their values and goals.
D. The patient agrees to a procedure ordered by the physician even if the
client does not understand what the outcome will be.
16. A hospitalized client with severe necrotizing ulcer of the lower leg is
schedule for an amputation. The client tells the nurse that he will not sign the
consent form and he does not want any surgery or treatment because of
religious beliefs about reincarnation. What is the role of the RN?
A. Normal Saline
B. Heparinized normal saline
C. 5% dextrose in water
D. Lactated Ringer’s solution
22. The nurse is caring to a client who is hypotensive. Following a large
hematemesis, how should the nurse position the client?
A. “Your baby eats too rapidly and overfills the stomach, which causes
vomiting
B. “Your baby can’t empty the formula that is in the stomach into the
bowel”
C. “The vomiting is due to the nausea that accompanies pyloric stenosis”
D. “Your baby needs to be burped more thoroughly after feeding”
39. A 70-year-old client with suspected tuberculosis is brought to the geriatric
care facilities. An intradermal tuberculosis test is schedule to be done. The
client asks the nurse what is the purpose of the test. Which of the following
would be the best rationale for this?
A. Picture windows
B. Unwashed dishes in the sink
C. Clear and shiny floors
D. Brightly lit rooms
42. After a birth, the physician cut the cord of the baby, and before the baby is
given to the mother, what would be the initial nursing action of the nurse?
A. pruritus
B. pus in the urine
C. WBC in the urine
D. Dysuria
46. Which of the following would be the most important goal in the nursing
care of an infant client with eczema?
A. preventing infection
B. maintaining the comfort level
C. providing for adequate nutrition
D. decreasing the itching
47. The nurse is making a discharge instruction to a client receiving
chemotherapy. The client is at risk for bone marrow depression. The nurse
gives instructions to the client about how to prevent infection at home. Which
of the following health teaching would be included?
A. Isopropyl alcohol
B. Hexachlorophene (Phisohex)
C. Soap and water
D. Chlorhexidine gluconate (CHG) (Hibiclens)
49. The mother of the client tells the nurse, “ I’m not going to have my baby
get any immunization”. What would be the best nursing response to the
mother?
A. “My child might need an extra capsule if the meal is high in fat”
B. “I’ll give the enzyme capsule before every snack”
C. “I’ll give the enzyme capsule before every meal”
D. “My child hates to take pills, so I’ll mix the capsule into a cup of hot
chocolate
3. The mother brought her child to the clinic for follow-up check up. The
mother tells the nurse that 14 days after starting an oral iron supplement, her
child’s stools are black. Which of the following is the best nursing response to
the mother?
A. “I will notify the physician, who will probably decrease the dosage
slightly”
B. “This is a normal side effect and means the medication is working”
C. “You sound quite concerned. Would you like to talk about this further?”
D. “I will need a specimen to check the stool for possible bleeding”
4. An 8-year-old boy with asthma is brought to the clinic for check up. The
mother asks the nurse if the treatment given to her son is effective. What
would be the appropriate response of the nurse?
A. I will review first the child’s height on a growth chart to know if the
treatment is working
B. I will review first the child’s weight on a growth chart to know if the
treatment is working
C. I will review first the number of prescriptions refills the child has
required over the last 6 months to give you an accurate answer
D. I will review first the number of times the child has seen the pediatrician
during the last 6 months to give you an accurate answer
5. The nurse is caring to a child client who is receiving tetracycline. The nurse
is aware that in taking this medication, it is very important to:
A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch
9. A 9-year-old boy is admitted to the hospital. The boy is being treated with
salicylates for the migratory polyarthritis accompanying the diagnosis of
rheumatic fever. Which of the following activities performed by the child
would give a best sign that the medication is effective?
A. After meals
B. Between meals
C. After medication
D. Around the child’s play schedule
13. The nurse is providing health teaching about the breastfeeding and family
planning to the client who gave birth to a healthy baby girl. Which of the
following statement would alert the nurse that the client needs further
teaching?
A. The toddler did not bond well with the maternal figure
B. The blanket is an important transitional object
C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions
15. The nurse has knowledge about the developmental task of the child. In
caring a 3-year-old-client, the nurse knows that the suited developmental task
of this child is to:
A. The older daughter be given more responsibility and assure her “that
she is a big girl now, and doesn’t need Mommy as much”
B. The older daughter not have interaction with the baby at the hospital,
because she may harm her new sibling
C. The older daughter stay with her grandmother for a few days until the
parents and new baby are settled at home
D. The mother spend time alone with her older daughter when the baby is
sleeping
17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed
to go to the playroom. Which of the following is an appropriate toy would the
nurse select for the child:
A. Puzzle
B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
18. Which of the following clients is at high risk for developmental problem?
A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers
22. A 5-year-old boy client is scheduled for hernia surgery. The nurse is
preparing to do preoperative teaching with the child. The nurse should knows
that the 5-year-old would:
A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming staff
development meeting
D. Listening to a compact disc
24. The parent of a 16-year-old boy tells the nurse that his son is driving a
motorbike very fast and with one hand. “It is making me crazy!” What would
be the best explanation of the nurse to the behavior of the boy?
A. “I should check the diaphragm carefully for holes every time I use it.”
B. “The diaphragm must be left in place for at least 6 hours after
intercourse.”
C. “I really need to use the diaphragm and jelly most during the middle of
my menstrual cycle
D. “I may need a different size diaphragm if I gain or lose more than 20
pounds”
28. The client visits the clinic for prenatal check-up. While waiting for the
physician, the nurse decided to conduct health teaching to the client. The
nurse informed the client that primigravida mother should go to the hospital
when which patter is evident?
A. cushioned footstool
B. bedside wood table
C. kitchen countertop
D. living room sofa
31. The nurse in the health center is making an assessment to the infant
client. The nurse notes some rashes and small fluid-filled bumps in the skin.
The nurse suspects that the infant has eczema. Which of the following is the
most important nursing goal:
A. Preventing infection
B. Providing for adequate nutrition
C. Decreasing the itching
D. Maintaining the comfort level
32. The nurse in the health center is providing immunization to the children.
The nurse is carefully assessing the condition of the children before giving the
vaccines. Which of the following would the nurse note to withhold the infant’s
scheduled immunizations?
A. a dry cough
B. a skin rash
C. a low-grade fever
D. a runny nose
33. A mother brought her child in the health center for hepatitis B vaccination
in a series. The mother informs the nurse that the child missed an
appointment last month to have the third hepatitis B vaccination. Which of the
following statements is the appropriate nursing response to the mother?
A. “During treatment for yeast, avoid vaginal intercourse for one week”
B. “Wear loose-fitting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water solution”
38. During immunization week in the health center, the parent of a 6-month-
old infant asks the health nurse, “Why is our baby going to receive so many
immunizations over a long time period?” The best nursing response would be:
A. “The number of immunizations your baby will receive shows how many
pediatric communicable and infectious diseases can now be prevented.”
B. “You need to ask the physician”
C. “The number of immunizations your baby will receive is determined by
your baby’s health history and age”
D. “It is easier on your baby to receive several immunizations rather than
one at a time”
39. The community health nurse is conducting a health teaching about
nutrition to a group of pregnant women who are anemic and are lactose
intolerant. Which of the following foods should the nurse especially
encourage during the third trimester?
A. Cheese, yogurt, and fish for protein and calcium needs plus prenatal
vitamins and iron supplements
B. Prenatal iron and calcium supplements plus a regular adult diet
C. Red beans, green leafy vegetables, and fish for iron and calcium needs
plus prenatal vitamins and iron supplements
D. Red meat, milk and eggs for iron and calcium needs plus prenatal
vitamins and iron supplements
40. A woman with active tuberculosis (TB) and has visited the health center
for regular therapy for five months wants to become pregnant. The nurse
knows that further information is necessary when the woman states:
A. “Spontaneous abortion may occur in one out of five women who are
infected”
B. “Pulmonary TB may jeopardize my pregnancy”
C. “I know that I may not be able to have close contact with my baby until
contagious is no longer a problem
D. “I can get pregnant after I have been free of TB for 6 months”
41. The Department of Health is alarmed that almost 33 million people suffer
from food poisoning every year. Salmonella enteritis is responsible for almost
4 million cases of food poisoning. One of the major goals is to promote proper
food preparation. The community health nurse is tasks to conduct health
teaching about the prevention of food poisoning to a group of mother
everyday. The nurse can help identify signs and symptoms of specific
organisms to help patients get appropriate treatment. Typical symptoms of
salmonella include:
A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples
45. The City health department conducted a medical mission in Barangay
Marulas. Majority of the children in the Barangay Marulas were diagnosed
with pinworms. The community health nurse should anticipate that the
children’s chief complaint would be:
A. Lack of appetite
B. Severe itching of the scalp
C. Perianal itching
D. Severe abdominal pain
46. The mother brought her daughter to the health center. The child has head
lice. The nurse anticipates that the nursing diagnosis most closely correlated
with this is:
A. Flexion of the hips when the neck is flexed from a lying position
B. Calf pain when the foot is dorsiflexed
C. Inability of the child to extend the legs fully when lying supine
D. Pain when the chin is pulled down to the chest
48. A community health nurse makes a home visit to a child with an infectious
and communicable disease. In planning care for the child, the nurse must
determine that the primary goal is that the:
A. Tripod gait
B. Two-point gait
C. Four-point gait
D. Three-point gait
6. The client is transferred to the nursing care unit from the operating room
after a transurethral resection of the prostate. The client is complaining of
pain in the abdomen area. The nurse suspects of bladder spasms, which of
the following is the best nursing action to minimize the pain felt by the client?
A. NPO
B. Small feedings of bland food
C. A regular diet given frequently in small amounts
D. Frequent feedings of clear liquids
8. The nurse is going to insert a Miller-Abbott tube to the client. Before
insertion of the tube, the balloon is tested for patency and capacity and then
deflated. Which of the following nursing measure will ease the insertion to the
tube?
A. Orange juice.
B. Whole milk.
C. Ginger ale.
D. Black coffee.
10. Mr. Bean, a 70-year-old client is admitted in the hospital for almost one
month. The nurse understands that prolonged immobilization could lead to
decubitus ulcers. Which of the following would be the least appropriate
nursing intervention in the prevention of decubitus?
A. Administer an enema
B. Perform range-of-motion exercise to all extremities
C. Ensure maximum fluid intake (3000ml/day)
D. Put the client on the bedpan every 2 hours
17. John is diagnosed with Addison’s disease and admitted in the hospital.
What would be the appropriate nursing care for John?
A. 5 minutes
B. 60 seconds
C. 30 seconds
D. 2 minutes
26. The nurse encourages the client to wear compression stockings. What is
the rationale behind in using compression stockings?
A. Compression stockings promote venous return
B. Compression stockings divert blood to major vessels
C. Compression stockings decreases workload on the heart
D. Compression stockings improve arterial circulation
27. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which
is the best nursing intervention is most likely to assist the client?
A. Periorbital edema
B. Increased specific gravity of urine
C. A urinary output of 50mL/hr
D. Daily weight gain of 2 lb or more
29. A nurse is completing an assessment to a client with cirrhosis. Which of
the following nursing assessment is important to notify the physician?
A. Expanding ecchymosis
B. Ascites and serum albumin of 3.2 g/dl
C. Slurred speech
D. Hematocrit of 37% and hemoglobin of 12g/dl
30. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes
mellitus. After the game, the client complains of becoming diaphoretic and
light-headedness. The client asks the nurse how to avoid this reaction. The
nurse will recommend to:
A. Allow plenty of time after the insulin injection and before beginning the
match
B. Eat a carbohydrate snack before and during the badminton match
C. Drink plenty of fluids before, during, and after bed time
D. Take insulin just before starting the badminton match
31. A client is rushed to the emergency room due to serious vehicle accident.
The nurse is suspecting of head injury. Which of the following assessment
findings would the nurse report to the physician?
A. CVP of 5mmHa
B. Glasgow Coma Scale score of 13
C. Polyuria and dilute urinary output
D. Insomnia
32. Mrs. Moore, 62-year-old, with diabetes is in the emergency department.
She stepped on a sharp sea shells while walking barefoot along the beach.
Mrs. Moore did not notice that the object pierced the skin until later that
evening. What problem does the client most probably have?
A. Nephropathy
B. Macroangiopathy
C. Carpal tunnel syndrome
D. Peripheral neuropathy
33. A client with gangrenous foot has undergone a below-knee amputation.
The nurse in the nursing care unit knows that the priority nursing intervention
in the immediate post operative care of this client is:
A. “You will probably have to eat six meals a day for the rest of your life.”
B. “Eating six meals a day can be a bother, can’t it?”
C. “Some clients can tolerate three meals a day by the time they leave the
hospital. Maybe it will be a little longer for you.”
D. “ It varies from client to client, but generally in 6-12 months most clients
can return to their previous meal patterns”
43. A male client with cirrhosis is complaining of belly pain, itchiness and his
breasts are getting larger and also the abdomen. The client is so upset
because of the discomfort and asks the nurse why his breast and abdomen
are getting larger. Which of the following is the appropriate nursing response?
A. “How much of a difference have you noticed”
B. “It’s part of the swelling your body is experiencing”
C. “It’s probably because you have been less physically active”
D. “Your liver is not destroying estrogen hormones that all men produce”
44. A client is diagnosed with detached retina and scheduled for surgery.
Preoperative teaching of the nurse to the client includes:
A. Wash the catheter with soap and water after each use
B. Lubricate the catheter with Vaseline
C. Perform the Valsalva maneuver to promote insertion
D. Replace the catheter with a new one every 24 hour
47. The nurse in the nursing care unit is assigned to care to a client who is
Immunocompromised. The client tells the nurse that his chest is painful and
the blisters are itchy. What would be the nursing intervention to this client?
A. Visual hallucinations.
B. Receptive aphasia.
C. Hemiparesis.
D. Personality changes.
5. A client with Addison’s disease has a blood pressure of 65/60. The nurse
understands that decreased blood pressure of the client with Addison’s
disease involves a disturbance in the production of:
A. Androgens
B. Glucocorticoids
C. Mineralocorticoids
D. Estrogen
6. The nurse is planning to teach the client about a spontaneous
pneumothorax. The nurse would base the teaching on the understanding that:
A. Inspired air will move from the lung into the pleural space.
B. There is greater negative pressure within the chest cavity.
C. The heart and great vessels shift to the affected side.
D. The other lung will collapse if not treated immediately.
7. During an assessment, the nurse recognizes that the client has an
increased risk for developing cancer of the tongue. Which of the following
health history will be a concern?
A. Advise the client to refrain from vigorous brushing of teeth and hair.
B. Instruct the client to avoid driving for 2 weeks.
C. Encourage eye exercises to strengthen the ocular musculature.
D. Teach the client coughing and deep-breathing techniques.
17. A client with AIDS develops bacterial pneumonia is admitted in the
emergency department. The client’s arterial blood gases is drawn and the
result is PaO2 80mmHg. then arterial blood gases are drawn again and the
level is reduced from 80 mmHg to 65 mmHg. The nurse should;
A. Furosemide (Lasix)
B. Hydrochlorothiazide (HydroDIURIL)
C. Metolazone (Zaroxolyn)
D. Spironolactone (Aldactone)
27. The physician prescribed Albuterol (Proventil) to the client with severe
asthma. After the administration of the medication the nurse should monitor
the client for:
A. Palpitation
B. Visual disturbance
C. Decreased pulse rate
D. Lethargy
28. A client is receiving diltiazem (Cardizem). What should the nurse include in
a teaching plan aimed at reducing the side effects of this medication?
A. The triglycerides
B. The INR
C. Chest pain
D. Blood pressure
30. A client is taking nitroglycerine tablets, the nurse should teach the client
the importance of:
A. Muscle strength
B. Symptoms
C. Blood pressure
D. Consciousness
36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in
the management of trigeminal neuralgia by monitoring the client’s:
A. Seizure activity
B. Liver function
C. Cardiac output
D. Pain relief
37. Administration of potassium iodide solution is ordered to the client who
will undergo a subtotal thyroidectomy. The nurse understands that this
medication is given to:
A. Arterial blood pH
B. Pulse rate
C. Serum glucose
D. Intake and output
40. A client with recurrent urinary tract infections is to be discharged. The
client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at
home. The nurse provides discharge instructions to the client. Which of the
following instructions will be correct?
A. Bone marrow
B. Liver
C. Lymph nodes
D. Blood
42. The physician reduced the client’s Dexamethasone (Decadron) dosage
gradually and to continue a lower maintenance dosage. The client asks the
nurse about the change of dosage. The nurse explains to the client that the
purpose of gradual dosage reduction is to allow:
A. Return of cortisone production by the adrenal glands.
B. Production of antibodies by the immune system
C. Building of glycogen and protein stores in liver and muscle
D. Time to observe for return of increases intracranial pressure
43. The nurse is assigned to care for a client with diarrhea. Excessive fluid
loss is expected. The nurse is aware that fluid deficit can most accurately be
assessed by:
A. Potassium
B. Sodium
C. Chloride
D. Calcium
45. Which of the following client has a high risk for developing hyperkalemia?
A. Crohn’s disease
B. End-Stage renal disease
C. Cushing’s syndrome
D. Chronic heart failure
46. The nurse is reviewing the laboratory result of the client. The client’s
serum potassium level is 5.8 mEq/L. Which of the following is the initial
nursing action?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answers and Rationales
1. A. Clients in the early stage of spinal cord damage experience an atonic
bladder, which is characterized by the absence of muscle tone, an
enlarged capacity, no feeling of discomfort with distention, and overflow
with a large residual. This leads to urinary stasis and infection. High fluid
intake limits urinary stasis and infection by diluting the urine and
increasing urinary output.
2. D. The temperature of 102 ºF (38.8ºC) or greater lead to an increased
metabolism and cardiac workload.
3. B. Dysuria, nocturia, and urgency are all signs an irritable bladder after
radiation therapy.
4. A. The occipital lobe is involve with visual interpretation.
5. C. Mineralocorticoids such as aldosterone cause the kidneys to retain
sodium ions. With sodium, water is also retained, elevating blood
pressure. Absence of this hormone thus causes hypotension.
6. B. As a person with a tear in the lung inhales, air moves through that
opening into the intrapleural and causes partial or complete collapse of
the lungs.
7. A. Heavy alcohol ingestion predisposes an individual to the
development of oral cancer.
8. D. The greater the density of compact bone makes it stronger than the
cancellous bone. Compact bone forms from cancellous bone by the
addition of concentric rings of bones substances to the marrow spaces of
cancellous bone. The large marrow spaces are reduced to haversian
canals.
9. A. Viscosity, a measure of a fluid’s internal resistance to flow, is
increased as the number of red cells suspended in plasma.
10. C. Hemiparesis creates instability. Using a cane provides a wider base
of support and, therefore greater stability.
11. D. Manual stretching exercises will assist in keeping the muscles and
tendons supple and pliable, reducing the traumatic consequences of
repetitive activity.
12. C. The length of the urethra is shorter in females than in males;
therefore microorganisms have a shorter distance to travel to reach the
bladder. The proximity of the meatus to the anus in females also
increases this incidence.
13. D. Temperature may increase within the first 24 hours and persist as
long as a week.
14. C. The hips are in extension when the client is prone; this keeps the hips
from flexing.
15. C. Steroids have an anti-inflammatory effect that can reduce arthritic
pannus formation.
16. A. Activities such as rigorous brushing of hair and teeth cause
increased intraocular pressure and may lead to hemorrhage in the anterior
chamber.
17. C. This decrease in PaO2 indicates respiratory failure; it warrants
immediate medical evaluation.
18. C. This is truthful and provides basic information that may prompt
recollection of what happened; it is a starting point.
19. D. Clients adapting to illness frequently feel afraid and helpless and
strike out at health team members as a way of maintaining control or
denying their fear.
20. C. There are few physical restraints on activity postoperatively, but the
client may have emotional problems resulting from the body image
changes.
21. B. Clients need to be prepared emotionally for the body image changes
that occur after bariatric surgery. Clients generally experience excessive
abdominal skin folds after weight stabilizes, which may require a
panniculectomy. Body image disturbance often occurs in response to
incorrectly estimating one’s size; it is not uncommon for the client to still
feel fat no matter how much weight is lost.
22. D. Surgery on the bowel has no direct anatomic or physiologic effect on
sexual performance. However, the nurse should encourage verbalization.
23. C. Osteoporosis is not restricted to women; it is a potential major health
problem of all older adults; estimates indicate that half of all women have
at least one osteoporitic fracture and the risk in men is estimated between
13% and 25%; a bone mineral density measurement assesses the mass of
bone per unit volume or how tightly the bone is packed.
24. A. Around-the-clock administration of analgesics is recommended for
acute pain in the older adult population; this help to maintain a therapeutic
blood level of pain medication.
25. C. Generally, female voices have a higher pitch than male voices; older
adults with presbycusis (hearing loss caused by the aging process) have
more difficulty hearing higher-pitched sounds.
26. D. Aldactone is a potassium-sparing diuretic; hyperkalemia is an
adverse effect.
27. A. Albuterol’s sympathomimetic effect causes cardiac stimulation that
may cause tachycardia and palpitation.
28. D. Changing positions slowly will help prevent the side effect of
orthostatic hypotension.
29. A. Therapeutic effects of simvastatin include decreased serum
triglyceries, LDL and cholesterol.
30. C. Nitroglycerine is sensitive to light and moisture ad must be stored in
a dark, airtight container.
31. A. Visual disturbance are a sign of toxicity because retinopathy can
occur with this drug.
32. B. Toxic levels of Lanoxin stimulate the medullary chemoreceptor
trigger zone, resulting in nausea and subsequent anorexia.
33. B. Warfarin derivatives cause an increase in the prothrombin time and
INR, leading to an increased risk for bleeding. Any abnormal or excessive
bleeding must be reported, because it may indicate toxic levels of the
drug.
34. B. Levodopa is the metabolic precursor of dopamine. It reduces
sympathetic outflow by limiting vasoconstriction, which may result in
orthostatic hypotension.
35. A. Tensilon, an anticholinesterase drug, causes temporary relief of
symptoms of myasthenia gravis in client who have the disease and is
therefore an effective diagnostic aid.
36. D. Carbamazepine ( Tegretol) is administered to control pain by
reducing the transmission of nerve impulses in clients with trigeminal
neuralgia.
37. C. Potassium iodide, which aids in decreasing the vascularity of the
thyroid gland, decreases the risk for hemorrhage.
38. C. Hydrocortisone is a glucocorticoid that has anti-inflammatory action
and aids in metabolism of carbohydrate, fat, and protein, causing elevation
of blood glucose. Thus it enables the body to adapt to stress.
39. D. DDAVP replaces the ADH, facilitating reabsorption of water and
consequent return of normal urine output and thirst.
40. B. To prevent crystal formation, the client should have sufficient intake
to produce 1000 to 1500 mL of urine daily while taking this drug.
41. A. Prolonged chemotherapy may slow the production of leukocytes in
bone marrow, thus suppressing the activity of the immune system.
Antibiotics may be required to help counter infections that the body can
no longer handle easily.
42. A. Any hormone normally produced by the body must be withdrawn
slowly to allow the appropriate organ to adjust and resume production.
43. B. Dehydration is most readily and accurately measured by serial
assessment of body weight; 1 L of fluid weighs 2.2 pounds.
44. A. The concentration of potassium is greater inside the cell and is
important in establishing a membrane potential, a critical factor in the
cell’s ability to function.
45. B. The kidneys normally eliminate potassium from the body;
hyperkalemia may necessitate dialysis.
46. C. Vital signs monitor cardiorespiratory status; hyperkalemia causes
serious cardiac dysrhythmias.
47. A. Once treatment with insulin for diabetic ketoacidosis is begun,
potassium ions reenter the cell, causing hypokalemia; therefore
potassium, along with the replacement fluid, is generally supplied.
48. C. Potassium, the major intracellular cation, functions with sodium and
calcium to regulate neuromuscular activity and contraction of muscle
fibers, particularly the heart muscle. In hypokalemia these symptoms
develop.
49. A. Because IV solutions enter the body’s internal environment, all
solutions and medications utilizing this route must be sterile to prevent
the introduction of microbes.
50. A. A low pH and bicarbonate level are consistent with metabolic
acidosis.
A. Oedipal complex
B. Superego
C. Id
D. Ego
2. A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the
best nursing response to this cient?
A. Depression
B. Withdrawal
C. Apathy
D. Anger
9. A client in the psychiatric unit is shouting out loud and tells the nurse,
“Please, help me. They are coming to get me.” What would be the appropriate
nursing response?
A. “What do you think is the connection between your not getting enough
love and overeating?”
B. “Tell me what you think the therapist means.”
C. “You need to ask your therapist.”
D. “ We are here to deal with your diet, not with your psychological
problems.”
11. After the discussion about the procedure the physician scheduled the
client for mastectomy. The client tells the nurse, “If my breasts will be
removed, I’m afraid my husband will not love me anymore and maybe he will
never touch me.” What should the nurse’s response?
A. competitive play
B. nonverbal play
C. cooperative play
D. solitary play
15. The client is telling the nurse in the psychiatric ward, “I hate them.” Which
of the following is the most appropriate nursing response to the client?
A. Identification.
B. Rationalization.
C. Denial.
D. Compensation.
17. A male client is quiet when the physician told him that he has stage IV
cancer and has 4 months to live. The nurse determines that this reaction may
be an example of:
A. Indifference
B. Denial
C. Resignation
D. Anger
18. A nurse is caring to a female client with five young children. The family
member told the client that her ex-husband has died 2 days ago. The reaction
of the client is stunned silence, followed by anger that the ex-husband left no
insurance money for their young children. The nurse should understand that:
A. The children and the injustice done to them by their father’s death are
the woman’s main concern.
B. To explain the woman’s reaction, the nurse needs more information
about the relationship and breakup.
C. The woman is not reacting normally to the news.
D. The woman is experiencing a normal bereavement reaction.
19. A client who is manic comes to the outpatient department. The nurse is
assigning an activity for the client. What activity is best for the nurse to
encourage for a client in a manic phase?
A. Isocarboxazid (Marplan)
B. Chlorpromazine HCI (Thorazine)
C. Trihexyphenidyl HCI (Artane)
D. Trifluoperazine HCI (Stelazine)
22. The nurse is caring to an 80-year-old client with dementia? What is the
most important psychosocial need for this client?
A. Delusion.
B. Hallucination.
C. Negativism.
D. Illusion.
24. A client is admitted in the hospital. On assessment, the nurse found out
that the client had several suicidal attempts. Which of the following is the
most important nursing action?
A. Acknowledge that the word has some special meaning for the client.
B. Try to interpret what the client means.
C. Divert the client’s attention to an aspect of reality.
D. State that what the client is saying has not been understood and then
divert attention to something that is really bound.
27. A male client diagnosed with depression tells the nurse, “I don’t want to
look weak and I don’t even cry because my wife and my kids can’t bear it.” The
nurse understands that this is an example of:
A. Repression.
B. Suppression.
C. Undoing.
D. Rationalization.
28. A female client tells the nurse that she is afraid to go out from her room
because she thinks that the other client might kill her. The nurse is aware that
this behavior is related to:
A. Hallucination.
B. Ideas of reference.
C. Delusion of persecution.
D. Illusion.
29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and
shows less awareness of the physical body. What problem would the nurse be
most concerned?
A. Nausea.
B. Gait disturbances.
C. Bowel movements.
D. Voiding.
30. A 6-year-old client dies in the nursing unit. The parents want to see the
child. What is the most appropriate nursing action?
A. Tremor, drowsiness.
B. Seizures, suicidal tendencies.
C. Visual disturbance, headache.
D. Excessive diaphoresis, diarrhea.
32. A nurse is assigned to activate a client who is withdrawn, hears voices and
negativistic. What would be the best nursing approach?
A. Hypertensive crisis.
B. Diet restrictions.
C. Taking medication with meals.
D. Exposure to sunlight.
35. A 16-year-old girl is admitted for treatment of a fracture. The client shares
to the nurse caring to her that her step-father has made sexual advances to
her. She got the chance to tell it to her mother but refuses to believe. What is
the most therapeutic action of the nurse would be:
A. Suggest the teen meet with a counselor to discuss his feelings about
his girlfriend.
B. Tell the teen that his feelings are normal, and recommend that he find
another girlfriend to take his mind off the problem.
C. Recall the teenage boys often say things they really do not mean and
ignore the comment.
D. Regard the comment seriously and notify the teen’s primary health care
provider and parents
38. Which of the following person will be at highest risk for suicide?
A. Touch her and tell her exactly what was done for her baby.
B. Allow the mother to continue her present behavior while sitting quietly
with her.
C. “No, all clients are given the same good care.”
D. “Yes, you’re probably right. Your son did not get better care.”
42. The nurse is interacting to a client with an antisocial personality disorder.
What would be the most therapeutic approach of the nurse to an antisocial
behavior?
A. Diuretics
B. Antihypertensive
C. Steroids
D. Anticonvulsants
2. Halfway through the administration of blood, the female client complains of
lumbar pain. After stopping the infusion Nurse Hazel should:
A. Raw carrots
B. Apple juice
C. Whole wheat bread
D. Cottage cheese
5. Kenneth who has diagnosed with uremic syndrome has the potential to
develop complications. Which among the following complications should the
nurse anticipates:
A. Right atrium
B. Superior vena cava
C. Aorta
D. Pulmonary
10. A client has been diagnosed with hypertension. The nurse priority nursing
diagnosis would be:
A. dairy products
B. vegetables
C. Grains
D. Broccoli
15. Karen has been diagnosed with aplastic anemia. The nurse monitors for
changes in which of the following physiologic functions?
A. Bowel function
B. Peripheral sensation
C. Bleeding tendencies
D. Intake and out put
16. Lydia is scheduled for elective splenectomy. Before the clients goes to
surgery, the nurse in charge final assessment would be:
A. signed consent
B. vital signs
C. name band
D. empty bladder
17. What is the peak age range in acquiring acute lymphocytic leukemia
(ALL)?
A. 4 to 12 years.
B. 20 to 30 years
C. 40 to 50 years
D. 60 60 70 years
18. Marie with acute lymphocytic leukemia suffers from nausea and
headache. These clinical manifestations may indicate all of the following
except
A. effects of radiation
B. chemotherapy side effects
C. meningeal irritation
D. gastric distension
19. A client has been diagnosed with Disseminated Intravascular Coagulation
(DIC). Which of the following is contraindicated with the client?
A. Administering Heparin
B. Administering Coumadin
C. Treating the underlying cause
D. Replacing depleted blood products
20. Which of the following findings is the best indication that fluid
replacement for the client with hypovolemic shock is adequate?
A. Stomatitis
B. Airway obstruction
C. Hoarseness
D. Dysphagia
22. Karina a client with myasthenia gravis is to receive immunosuppressive
therapy. The nurse understands that this therapy is effective because it:
A. Buttocks
B. Ears
C. Face
D. Abdomen
28. Nurse Katrina would recognize that the demonstration of crutch walking
with tripod gait was understood when the client places weight on the:
A. Hypovolemia
B. renal failure
C. metabolic acidosis
D. hyperkalemia
32. Nurse Judith obtains a specimen of clear nasal drainage from a client with
a head injury. Which of the following tests differentiates mucus from
cerebrospinal fluid (CSF)?
A. Protein
B. Specific gravity
C. Glucose
D. Microorganism
33. A 22 year old client suffered from his first tonic-clonic seizure. Upon
awakening the client asks the nurse, “What caused me to have a
seizure? Which of the following would the nurse include in the primary cause
of tonic clonic seizures in adults more the 20 years?
A. Electrolyte imbalance
B. Head trauma
C. Epilepsy
D. Congenital defect
34. What is the priority nursing assessment in the first 24 hours after
admission of the client with thrombotic CVA?
A. “Practice using the mechanical aids that you will need when future
disabilities arise”.
B. “Follow good health habits to change the course of the disease”.
C. “Keep active, use stress reduction strategies, and avoid fatigue.
D. “You will need to accept the necessity for a quiet and inactive lifestyle”.
36. The nurse is aware the early indicator of hypoxia in the unconscious client
is:
A. Cyanosis
B. Increased respirations
C. Hypertension
D. Restlessness
37. A client is experiencing spinal shock. Nurse Myrna should expect the
function of the bladder to be which of the following?
A. Normal
B. Atonic
C. Spastic
D. Uncontrolled
38. Which of the following stage the carcinogen is irreversible?
A. Progression stage
B. Initiation stage
C. Regression stage
D. Promotion stage
39. Among the following components thorough pain assessment, which is the
most significant?
A. Effect
B. Cause
C. Causing factors
D. Intensity
40. A 65 year old female is experiencing flare up of pruritus. Which of the
client’s action could aggravate the cause of flare ups?
A. 67-year-old client
B. 49-year-old client
C. 33-year-old client
D. 15-year-old client
43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia.
Which of the following would the nurse assess next?
A. Headache
B. Bladder distension
C. Dizziness
D. Ability to move legs
44. Nurse Katrina should anticipate that all of the following drugs may be
used in the attempt to control the symptoms of Meniere’s disease except:
A. Antiemetics
B. Diuretics
C. Antihistamines
D. Glucocorticoids
45. Which of the following complications associated with tracheostomy tube?
A. Psychotherapy
B. Alcoholics anonymous (A.A.)
C. Total abstinence
D. Aversion Therapy
2. Nurse Hazel is caring for a male client who experience false
sensory perceptions with no basis in reality. This perception is known as:
A. Hallucinations
B. Delusions
C. Loose associations
D. Neologisms
3. Nurse Monet is caring for a female client who has suicidal tendency. When
accompanying the client to the restroom, Nurse Monet should…
A. Being Killed
B. Highly famous and important
C. Responsible for evil world
D. Connected to client unrelated to oneself
7. A 20 year old client was diagnosed with dependent personality
disorder. Which behavior is not likely to be evidence of ineffective individual
coping?
A. Paranoid thoughts
B. Emotional affect
C. Independence need
D. Aggressive behavior
9. Nurse Claire is caring for a client diagnosed with bulimia. The
most appropriate initial goal for a client diagnosed with bulimia is?
A. Respiratory difficulties
B. Nausea and vomiting
C. Dizziness
D. Seizures
12.A 75 year old client is admitted to the hospital with the diagnosis
of dementia of the Alzheimer’s type and depression. The symptom that
is unrelated to depression would be?
A. Increasing stimulation
B. limiting unnecessary interaction
C. increasing appropriate sensory perception
D. ensuring constant client and staff contact
16.A 39 year old mother with obsessive-compulsive disorder has
become immobilized by her elaborate hand washing and walking rituals.
Nurse Trish recognizes that the basis of O.C. disorder is often:
A. Depensiveness
B. Embarrassment
C. Shame
D. Remorsefulness
20.Which of the following approaches would be most appropriate to use
with a client suffering from narcissistic personality disorder when
discrepancies exist between what the client states and what actually exist?
A. Rationalization
B. Supportive confrontation
C. Limit setting
D. Consistency
21.Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis
and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm.
Which of the medications would the nurse expect to administer?
A. Naloxone (Narcan)
B. Benzlropine (Cogentin)
C. Lorazepam (Ativan)
D. Haloperidol (Haldol)
22.Which of the following foods would the nurse Trish eliminate from the
diet of a client in alcohol withdrawal?
A. Milk
B. Orange Juice
C. Soda
D. Regular Coffee
23.Which of the following would Nurse Hazel expect to assess for a
client who is exhibiting late signs of heroin withdrawal?
A. Have more positive relation with the father than the mother
B. Cling to mother & cry on separation
C. Be able to develop only superficial relation with the others
D. Have been physically abuse
27.When teaching parents about childhood depression Nurse Trina
should say?
A. Scanning speech
B. Speech lag
C. Shuttering
D. Echolalia
29.A 60 year old female client who lives alone tells the nurse at
the community health center “I really don’t need anyone to talk to”. The TV
is my best friend. The nurse recognizes that the client is using the
defense mechanism known as?
A. Displacement
B. Projection
C. Sublimation
D. Denial
30.When working with a male client suffering phobia about black cats,
Nurse Trish should anticipate that a problem for this client would be?
A. Flight of ideas
B. Associative looseness
C. Confabulation
D. Concretism
34.Nurse Joey is aware that the signs & symptoms that would be
most specific for diagnosis anorexia are?
A. Multiple stimuli
B. Routine Activities
C. Minimal decision making
D. Varied Activities
37.To further assess a client’s suicidal potential. Nurse Katrina should
be especially alert to the client expression of:
A. Neologisms
B. Echolalia
C. Flight of ideas
D. Loosening of association
42.A long term goal for a paranoid male client who has unjustifiably
accused his wife of having many extramarital affairs would be to help the
client develop:
A. Neuroleptic medication
B. Short term seclusion
C. Psychosurgery
D. Electroconvulsive therapy
50.Mario is admitted to the emergency room with drug-included
anxiety related to over ingestion of prescribed antipsychotic medication. The
most important piece of information the nurse in charge should obtain initially
is the:
A. Nightingale
B. Benner
C. Swanson
D. King
3. For her, Nursing is a theoretical system of knowledge that prescribes a
process of analysis and action related to care of the ill person
A. King
B. Henderson
C. Roy
D. Leininger
4. According to her, Nursing is a helping or assistive profession to persons
who are wholly or partly dependent or when those who are supposedly caring
for them are no longer able to give care.
A. Henderson
B. Orem
C. Swanson
D. Neuman
5. Nursing is a unique profession, Concerned with all the variables affecting
an individual’s response to stressors, which are intra, inter and extra personal
in nature.
A. Neuman
B. Johnson
C. Watson
D. Parse
6. The unique function of the nurse is to assist the individual, sick or well, in
the performance of those activities contributing to health that he would
perform unaided if he has the necessary strength, will and knowledge, and do
this in such a way as to help him gain independence as rapidly as possible.
A. Henderson
B. Abdellah
C. Levin
D. Peplau
7. Caring is the essence and central unifying, a dominant domain that
distinguishes nursing from other health disciplines. Care is an essential
human need.
A. Benner
B. Watson
C. Leininger
D. Swanson
8. Caring involves 5 processes, KNOWING, BEING WITH, DOING FOR,
ENABLING and MAINTAINING BELIEF.
A. Benner
B. Watson
C. Leininger
D. Swanson
9. Caring is healing, it is communicated through the consciousness of the
nurse to the individual being cared for. It allows access to higher human spirit.
A. Benner
B. Watson
C. Leininger
D. Swanson
10. Caring means that person, events, projects and things matter to people. It
reveals stress and coping options. Caring creates responsibility. It is an
inherent feature of nursing practice. It helps the nurse assist clients to recover
in the face of the illness.
A. Benner
B. Watson
C. Leininger
D. Swanson
11. Which of the following is NOT TRUE about profession according to Marie
Jahoda?
A. Education
B. Theory
C. Caring
D. Autonomy
14. This is the distinctive individual qualities that differentiate a person to
another
A. Philosophy
B. Personality
C. Charm
D. Character
15. Refers to the moral values and beliefs that are used as guides to personal
behavior and actions
A. Philosophy
B. Personality
C. Charm
D. Character
16. As a nurse manager, which of the following best describes this function?
A. Change agent
B. Client advocate
C. Case manager
D. Collaborator
19. These are nursing intervention that requires knowledge, skills and
expertise of multiple health professionals.
A. Dependent
B. Independent
C. Interdependent
D. Intradependent
20. What type of patient care model is the most common for student nurses
and private duty nurses?
A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
22. This patient care model works best when there are plenty of patient but
few nurses
A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
23. RN assumes 24 hour responsibility for the client to maintain continuity of
care across shifts, days or visits.
A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
24. Who developed the first theory of nursing?
A. Hammurabi
B. Alexander
C. Fabiola
D. Nightingale
25. She introduces the NATURE OF NURSING MODEL.
A. Henderson
B. Nightingale
C. Parse
D. Orlando
26. She described the four conservation principle.
A. Levin
B. Leininger
C. Orlando
D. Parse
27. Proposed the HEALTH CARE SYSTEM MODEL.
A. Henderson
B. Orem
C. Parse
D. Neuman
28. Conceptualized the BEHAVIORAL SYSTEM MODEL
A. Orem
B. Johnson
C. Henderson
D. Parse
29. Developed the CLINICAL NURSING – A HELPING ART MODEL
A. Swanson
B. Hall
C. Weidenbach
D. Zderad
30. Developed the ROLE MODELING and MODELING theory
A. Erickson,Tomlin,Swain
B. Neuman
C. Newman
D. Benner and Wrubel
31. Proposed the GRAND THEORY OF NURSING AS CARING
A. Erickson, Tomlin, Swain
B. Peterson,Zderad
C. Bnner,Wrubel
D. Boykin,Schoenhofer
32. Postulated the INTERPERSONAL ASPECT OF NURSING
A. Travelbee
B. Swanson
C. Zderad
D. Peplau
33. He proposed the theory of morality that is based on MUTUAL TRUST
A. Freud
B. Erikson
C. Kohlberg
D. Peters
34. He proposed the theory of morality based on PRINCIPLES
A. Freud
B. Erikson
C. Kohlberg
D. Peters
35. Freud postulated that child adopts parental standards and traits through
A. Imitation
B. Introjection
C. Identification
D. Regression
36. According to them, Morality is measured of how people treat human being
and that a moral child strives to be kind and just
A. Zderad and Peterson
B. Benner and Wrubel
C. Fowler and Westerhoff
D. Schulman and Mekler
37. Postulated that FAITH is the way of behaving. He developed four theories
of faith and development based on his experience.
A. Giligan
B. Westerhoff
C. Fowler
D. Freud
38. He described the development of faith. He suggested that faith is a
spiritual dimension that gives meaning to a persons life. Faith according to
him, is a relational phenomenon.
A. Giligan
B. Westerhoff
C. Fowler
D. Freud
39. Established in 1906 by the Baptist foreign mission society of America.
Miss rose nicolet, was it’s first superintendent.
A. St. Paul Hospital School of nursing
B. Iloilo Mission Hospital School of nursing
C. Philippine General Hospital School of nursing
D. St. Luke’s Hospital School of nursing
40. Anastacia Giron-Tupas was the first Filipino nurse to occupy the position
of chief nurse in this hospital.
A. St. Paul Hospital
B. Iloilo Mission Hospital
C. Philippine General Hospital
D. St. Luke’s Hospital
41. She was the daughter of Hungarian kings, who feed 300-900 people
everyday in their gate, builds hospitals, and care of the poor and sick herself.
A. Elizabeth
B. Catherine
C. Nightingale
D. Sairey Gamp
42. She dies of yellow fever in her search for truth to prove that yellow fever is
carried by a mosquitoes.
A. Clara louise Maas
B. Pearl Tucker
C. Isabel Hampton Robb
D. Caroline Hampton Robb
43. He was called the father of sanitation.
A. Abraham
B. Hippocrates
C. Moses
D. Willam Halstead
44. The country where SHUSHURUTU originated
A. China
B. Egypt
C. India
D. Babylonia
45. They put girls clothes on male infants to drive evil forces away
A. Chinese
B. Egyptian
C. Indian
D. Babylonian
46. In what period of nursing does people believe in TREPHINING to drive evil
forces away?
A. Dark period
B. Intuitive period
C. Contemporary period
D. Educative period
47. This period ended when Pastor Fliedner, build Kaiserwerth institute for the
training of Deaconesses
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period
48. Period of nursing where religious Christian orders emerged to take care of
the sick
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period
49. Founded the second order of St. Francis of Assisi
A. St. Catherine
B. St. Anne
C. St. Clare
D. St. Elizabeth
50. This period marked the religious upheaval of Luther, Who questions the
Christian faith.
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period
51. According to the Biopsychosocial and spiritual theory of Sister Callista
Roy, Man, As a SOCIAL being is
A. Like all other men
B. Like some other men
C. Like no other men
D. Like men
52. She conceptualized that man, as an Open system is in constant interaction
and transaction with a changing environment.
A. Roy
B. Levin
C. Neuman
D. Newman
53. In a CLOSED system, which of the following is true?
A. Affected by matter
B. A sole island in vast ocean
C. Allows input
D. Constantly affected by matter, energy, information
54. Who postulated the WHOLISTIC concept that the totality is greater than
sum of its parts?
A. Roy
B. Rogers
C. Henderson
D. Johnson
55. She theorized that man is composed of sub and supra systems.
Subsystems are cells, tissues, organs and systems while the suprasystems
are family, society and community.
A. Roy
B. Rogers
C. Henderson
D. Johnson
56. Which of the following is not true about the human needs?
A. Certain needs are common to all people
B. Needs should be followed exactly in accordance with their hierarchy
C. Needs are stimulated by internal factors
D. Needs are stimulated by external factors
57. Which of the following is TRUE about the human needs?
A. May not be deferred
B. Are not interrelated
C. Met in exact and rigid way
D. Priorities are alterable
58. According to Maslow, which of the following is NOT TRUE about a self
actualized person?
A. Understands poetry, music, philosophy, science etc.
B. Desires privacy, autonomous
C. Follows the decision of the majority, uphold justice and truth
D. Problem centered
59. According to Maslow, which of the following is TRUE about a self
actualized person?
A. Makes decision contrary to public opinion
B. Do not predict events
C. Self centered
D. Maximum degree of self conflict
60. This is the essence of mental health
A. Self awareness
B. Self actualization
C. Self esteem
D. Self worth
61. Florence nightingale is born in
A. Germany
B. Britain
C. France
D. Italy
62. Which is unlikely of Florence Nightingale?
A. Born May 12, 1840
B. Built St. Thomas school of nursing when she was 40 years old
C. Notes in nursing
D. Notes in hospital
63. What country did Florence Nightingale train in nursing?
A. Belgium
B. US
C. Germany
D. England
64. Which of the following is recognized for developing the concept of HIGH
LEVEL WELLNESS?
A. Erikson
B. Madaw
C. Peplau
D. Dunn
65. One of the expectations is for nurses to join professional association
primarily because of
A. Promotes advancement and professional growth among its members
B. Works for raising funds for nurse’s benefit
C. Facilitate and establishes acquaintances
D. Assist them and securing jobs abroad
66. Founder of the PNA
A. Julita Sotejo
B. Anastacia Giron Tupas
C. Eufemia Octaviano
D. Anesia Dionisio
67. Which of the following provides that nurses must be a member of a
national nurse organization?
A. R.A 877
B. 1981 Code of ethics approved by the house of delegates and the PNA
C. Board resolution No. 1955 Promulgated by the BON
D. RA 7164
68. Which of the following best describes the action of a nurse who
documents her nursing diagnosis?
A. She documents it and charts it whenever necessary
B. She can be accused of malpractice
C. She does it regularly as an important responsibility
D. She charts it only when the patient is acutely ill
69. Which of the following does not govern nursing practice?
A. RA 7164
B. RA 9173
C. BON Res. Code Of Ethics
D. BON Res. Scope of Nursing Practice
70. A nurse who is maintaining a private clinic in the community renders
service on maternal and child health among the neighborhood for a fee is:
A. Primary care nurse
B. Independent nurse practitioner
C. Nurse-Midwife
D. Nurse specialist
71. When was the PNA founded?
A. September 22, 1922
B. September 02, 1920
C. October 21, 1922
D. September 02, 1922
72. Who was the first president of the PNA ?
A. Anastacia Giron-Tupas
B. Loreto Tupas
C. Rosario Montenegro
D. Ricarda Mendoza
73. Defines health as the ability to maintain internal milieu. Illness according
to him/her/them is the failure to maintain internal environment.
A. Cannon
B. Bernard
C. Leddy and Pepper
D. Roy
74. Postulated that health is a state and process of being and becoming an
integrated and whole person.
A. Cannon
B. Bernard
C. Dunn
D. Roy
75. What regulates HOMEOSTASIS according to the theory of Walter Cannon?
A. Positive feedback
B. Negative feedback
C. Buffer system
D. Various mechanisms
76. Stated that health is WELLNESS. A termed define by the culture or an
individual.
A. Roy
B. Henderson
C. Rogers
D. King
77. Defined health as a dynamic state in the life cycle, and Illness as
interference in the life cycle.
A. Roy
B. Henderson
C. Rogers
D. King
78. She defined health as the soundness and wholness of developed human
structure and bodily mental functioning.
A. Orem
B. Henderson
C. Neuman
D. Clark
79. According to her, Wellness is a condition in which all parts and subparts of
an individual are in harmony with the whole system.
A. Orem
B. Henderson
C. Neuman
D. Johnson
80. Postulated that health is reflected by the organization, interaction,
interdependence and integration of the subsystem of the behavioral system.
A. Orem
B. Henderson
C. Neuman
D. Johnson
81. According to them, Well being is a subjective perception of BALANCE,
HARMONY and VITALITY
A. Leavell and Clark
B. Peterson and Zderad
C. Benner and Wruber
D. Leddy and Pepper
82. He describes the WELLNESS-ILLNESS Continuum as interaction of the
environment with well being and illness.
A. Cannon
B. Bernard
C. Dunn
D. Clark
83. An integrated method of functioning that is oriented towards maximizing
one’s potential within the limitation of the environment.
A. Well being
B. Health
C. Low level Wellness
D. High level Wellness
84. What kind of illness precursor, according to DUNN is cigarette smoking?
A. Heredity
B. Social
C. Behavioral
D. Environmental
85. According to DUNN, Overcrowding is what type of illness precursor?
A. Heredity
B. Social
C. Behavioral
D. Environmental
86. Health belief model was formulated in 1975 by who?
A. Becker
B. Smith
C. Dunn
D. Leavell and Clark
87. In health belief model, Individual perception matters. Which of the
following is highly UNLIKELY to influence preventive behavior?
A. Perceived susceptibility to an illness
B. Perceived seriousness of an illness
C. Perceived threat of an illness
D. Perceived curability of an illness
88. Which of the following is not a PERCEIVED BARRIER in preventive action?
A. Difficulty adhering to the lifestyle
B. Economic factors
C. Accessibility of health care facilities
D. Increase adherence to medical therapies
89. Conceptualizes that health is a condition of actualization or realization of
person’s potential. Avers that the highest aspiration of people is fulfillment
and complete development actualization.
A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model
90. Views people as physiologic system and Absence of sign and symptoms
equates health.
A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model
91. Knowledge about the disease and prior contact with it is what type of
VARIABLE according to the health belief model?
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
92. It includes internal and external factors that leads the individual to seek
help
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
93. Influence from peers and social pressure is included in what variable of
HBM?
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
94. Age, Sex, Race etc. is included in what variable of HBM?
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
95. According to Leavell and Clark’s ecologic model, All of this are factors that
affects health and illness except
A. Reservoir
B. Agent
C. Environment
D. Host
96. Is a multi dimensional model developed by PENDER that describes the
nature of persons as they interact within the environment to pursue health
A. Ecologic Model
B. Health Belief Model
C. Health Promotion Model
D. Health Prevention Model
97. Defined by Pender as all activities directed toward increasing the level of
well being and self actualization.
A. Health prevention
B. Health promotion
C. Health teaching
D. Self actualization
98. Defined as an alteration in normal function resulting in reduction of
capacities and shortening of life span.
A. Illness
B. Disease
C. Health
D. Wellness
99. Personal state in which a person feels unhealthy
A. Illness
B. Disease
C. Health
D. Wellness
100. According to her, Caring is defined as a nurturant way of responding to a
valued client towards whom the nurse feels a sense of commitment and
responsibility.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answers and Rationales
1. D. Person, Environment, Nursing, Health. This is an actual board exam
question and is a common board question. Theorist always describes The
nursing profession by first defining what is NURSING, followed by the
PERSON, ENVIRONMENT and HEALTH CONCEPT. The most popular
theory was perhaps Nightingale’s. She defined nursing as the utilization of
the persons environment to assist him towards recovery. She defined the
person as somebody who has a reparative capabilities mediated and
enhanced by factors in his environment. She describes the environment as
something that would facilitate the person’s reparative process and
identified different factors like sanitation, noise, etc. that affects a
person’s reparative state.
2. A. Nightingale. Florence nightingale do not believe in the germ theory,
and perhaps this was her biggest mistake. Yet, her theory was the first in
nursing. She believed that manipulation of environment that includes
appropriate noise, nutrition, hygiene, light, comfort, sanitation etc. could
provide the client’s body the nurturance it needs for repair and recovery.
3. C. Roy. Remember the word “ THEOROYTICAL “ For Callista Roy,
Nursing is a theoretical body of knowledge that prescribes analysis and
action to care for an ill person. She introduced the ADAPTATION MODEL
and viewed person as a BIOSPSYCHOSOCIAL BEING. She believed that by
adaptation, Man can maintain homeostasis.
4. B. Orem. In self care deficit theory, Nursing is defined as A helping or
assistive profession to person who are wholly or partly dependent or when
people who are to give care to them are no longer available. Self care, are
the activities that a person do for himself to maintain health, life and well
being.
5. A. Neuman. Neuman divided stressors as either intra, inter and extra
personal in nature. She said that NURSING is concerned with eliminating
these stressors to obtain a maximum level of wellness. The nurse helps
the client through PRIMARY, SECONDARY AND TERTIARY prevention
modes. Please do not confuse this with LEAVELL and CLARK’S level of
prevention.
6. A. Henderson. This was an actual board question. Remember this
definition and associate it with Virginia Henderson. Henderson also
describes the NATURE OF NURSING theory. She identified 14 basic needs
of the client. She describes nursing roles as SUBSTITUTIVE : Doing
everything for the client, SUPPLEMENTARY : Helping the client and
COMPLEMENTARY : Working with the client. Breathing normally,
Eliminating waste, Eating and drinking adquately, Worship and Play are
some of the basic needs according to her.
7. C. Leininger. There are many theorist that describes nursing as CARE.
The most popular was JEAN WATSON’S Human Caring Model. But this
question pertains to Leininger’s definition of caring. CUD I LIE IN GER?
[ Could I Lie In There ] Is the Mnemonics I am using not to get confused. C
stands for CENTRAL , U stands for UNIFYING, D stands for DOMINANT
DOMAIN. I emphasize on this matter due to feedback on the last June
2006 batch about a question about CARING.
8. D. Swanson . Caring according to Swanson involves 5 processes.
Knowing means understanding the client. Being with emphasizes the
Physical presence of the nurse for the patient. Doing for means doing
things for the patient when he is incapable of doing it for himself. Enabling
means helping client transcend maturational and developmental stressors
in life while Maintaining belief is the ability of the Nurse to inculcate
meaning to these events.
9. B. Watson. The deepest and spiritual definition of Caring came from
Jean watson. For her, Caring expands the limits of openess and allows
access to higher human spirit.
10. A. Benner. I think of CARE BEAR to facilitate retainment of BENNER. As
in, Care Benner. For her, Caring means being CONNECTED or making
things matter to people. Caring according to Benner give meaning to
illness and re establish connection.
11. B. It serves specific interest of a group.Believe it or not, you should know
the definition of profession according to Jahoda because it is asked in the
Local boards. A profession should serve the WHOLE COMMUNITY and not
just a specific intrest of a group. Everything else, are correct.
12. A. Concerned with quantity. A professional is concerned with QUALITY
and not QUANTITY. In nursing, We have methods of quality assurance and
control to evaluate the effectiveness of nursing care. Nurses, are never
concerned with QUANTITY of care provided.
13. C. Caring. Caring and caring alone, is the most unique quality of the
Nursing Profession. It is the one the delineate Nursing from other
professions.
14. B. Personality. Personality are qualities that make us different from each
other. These are impressions that we made, or the footprints that we leave
behind. This is the result of the integration of one’s talents, behavior,
appearance, mood, character, morals and impulses into one harmonious
whole. Philosophy is the basic truth that fuel our soul and give our life a
purpose, it shapes the facets of a person’s character. Charm is to attract
other people to be a change agent. Character is our moral values and
belief that guides our actions in life.
15. D. Character.Rationale: Refer to number 14
16. D. Provide in service education programs, Use accurate nursing audit,
formulate philosophy and vision of the institution . A refers to being a change
agent. B is a role of a patient advocate. C is a case manager while D
basically summarized functions of a nurse manager. If you haven’t read
Lydia Venzon’s Book : NURSING MANAGEMENT TOWARDS QUALITY
CARE, I suggest reading it in advance for your management subjects in the
graduate school. Formulating philosophy and vision is in PLANNING.
Nursing Audit is in CONTROLLING, In service education programs are
included in DIRECTING. These are the processes of Nursing Management,
I just forgot to add ORGANIZING which includes formulating an
organizational structure and plans, Staffing and developing qualifications
and job descriptions.
17. A. Determine client’s need.You can never provide nursing care if you don’t
know what are the needs of the client. How can you provide an effective
postural drainage if you do not know where is the bulk of the client’s
secretion. Therefore, the best description of a care provider is the
accurate and prompt determination of the client’s need to be able to
render an appropriate nursing care.
18. B. Client advocate. As a client’s advocate, Nurses are to protect the
client’s right and promotes what is best for the client. Knowing that
Morphine causes spasm of the sphincter of Oddi and will lead to further
increase in the client’s pain, The nurse knew that the best treatment option
for the client was not provided and intervene to provide the best possible
care.
19. C. Interdependent. Interdependent functions are those that needs
expertise and skills of multiple health professionals. Example is when A
child was diagnosed with nephrotic syndrome and the doctor ordered a
high protein diet, Budek then work together with the dietician about the
age appropriate high protein foods that can be given to the child, Including
the preparation to entice the child into eating the food. NOTE : It is still
debated if the diet in NS is low, moderate or high protein, In the U.S,
Protein is never restricted and can be taken in moderate amount. As far as
the local examination is concerned, answer LOW PROTEIN HIGH CALORIC
DIET.
20. A. Total patient care. This is also known as case nursing. It is a method of
nursing care wherein, one nurse is assigned to one patient for the delivery
of total care. These are the method use by Nursing students, Private duty
nurses and those in critical or isolation units.
21. D. Total patient care .Total patient care works best if there are many
nurses but few patients.
22. A. Functional nursing. Functional nursing is task oriented, One nurse is
assigned on a particular task leading to task expertise and efficiency. The
nurse will work fast because the procedures are repetitive leading to task
mastery. This care is not recommended as this leads fragmented nursing
care.
23. C. Primary nursing. Your keyword in Primary nursing is the 24 hours. This
does not necessarily means the nurse is awake for 24 hours, She can have
a SECONDARY NURSES that will take care of the patient in shifts where
she is not arround.
24. D. Nightingale . Refer to question # 2. Hammurabi is the king of babylon
that introduces the LEX TALIONES law, If you kill me, you should be killed…
If you rob me, You should be robbed, An eye for an eye and a tooth for a
tooth. Alexander the great was the son of King Philip II and is from
macedonia but he ruled Greece including Persia and Egypt. He is known to
use a hammer to pierce a dying soldier’s medulla towards speedy death
when he thinks that the soldier will die anyway, just to relieve their
suffering. Fabiola was a beautiful roman matron who converted her house
into a hospital.
25. A. Henderson. Refer to question # 6.
26. A. Levin. Myra Levin described the 4 Conservation principles which are
concerned with the Unity and Integrity of an individual. These are
ENERGY : Our output to facilitate meeting of our needs. STRUCTURAL
INTEGRITY : We mus maintain the integrity of our organs, tissues and
systems to be able to function and prevent harmful agents entering our
body. PERSONAL INTEGRITY : These refers to our self esteem, self worth,
self concept, identify and personality. SOCIAL INTEGRITY : Reflects our
societal roles to our society, community, family, friends and fellow
individuals.
27. D. Neuman . Betty Neuman asserted that nursing is a unique profession
and is concerned with all the variables affecting the individual’s response
to stressors. These are INTRA or within ourselves, EXTRA or outside the
individual, INTER means between two or more people. She proposed the
HEALTH CARE SYSTEM MODEL which states that by PRIMARY,
SECONDARY and TERTIARY prevention, The nurse can help the client
maintain stability against these stressors.
28. B. Johnson. According to Dorothy Johnson, Each person is a behavioral
system that is composed of 7 subsystems. Man adjust or adapt to
stressors by a using a LEARNED PATTERN OF RESPONSE. Man uses his
behavior to meet the demands of the environment, and is able to modified
his behavior to support these demands.
29. C. Weidenbach.Just remember ERNESTINE WEIDENBACHLINICAL.
30. A. Erickson,Tomlin,Swain
31. D. Boykin,Schoenhofer . This theory was called GRAND THEORY because
boykin and schoenofer thinks that ALL MAN ARE CARING, And that
nursing is a response to this unique call. According to them, CARING IS A
MORAL IMPERATIVE, meaning, ALL PEOPLE will tend to help a man who
fell down the stairs even if he is not trained to do so.
32. A. Travelbee. Travelbee’s theory was referred to as INTERPERSONAL
theory because she postulated that NURSING is to assist the individual
and all people that affects this individual to cope with illness, recover and
FIND MEANING to this experience. For her, Nursing is a HUMAN TO
HUMAN relationship that is formed during illness. To her, an individual is a
UNIQUE and irreplaceable being in continuous process of becoming,
evolving and changing. PLEASE do remember, that it is PARSE who
postulated the theory of HUMAN BECOMING and not TRAVELBEE, for I
read books that say it was TRAVELBEE and not PARSE.
33. C. Kohlberg. Kohlber states that relationships are based on mutual trust.
He postulated the levels of morality development. At the first stage called
the PREMORAL or preconventional, A child do things and label them as
BAD or GOOD depending on the PUNISHMENT or REWARD they get. They
have no concept of justice, fairness and equity, for them, If I punch this kid
and mom gets mad, thats WRONG. But if I dance and sing, mama smiles
and give me a new toy, then I am doing something good. In the
Conventional level, The individual actuates his act based on the response
of the people around him. He will follow the rules, regulations, laws and
morality the society upholds. If the law states that I should not resuscitate
this man with a DNR order, then I would not. However, in the Post
conventional level or the AUTONOMOUS level, the individual still follows
the rules but can make a rule or bend part of these rules according to his
own MORALITY. He can change the rules if he thinks that it is needed to
be changed. Example is that, A nurse still continue resuscitating the client
even if the client has a DNR order because he believes that the client can
still recover and his mission is to save lives, not watch patients die.
34. D. Peters . Remember PETERS for PRINCIPLES. P is to P. He believes
that morality has 3 components : EMOTION or how one feels,
JUDGEMENT or how one reason and BEHAVIOR or how one actuates his
EMOTION and JUDGEMENT. He believes that MORALITY evolves with the
development of PRINCPLES or the person’s vitrue and traits. He also
believes in AUTOMATICITY of virtues or he calls HABIT, like kindness,
charity, honesty, sincerity and thirft which are innate to a person and
therfore, will be performed automatically.
35. C. Identification. A child, according to Freud adopts parental standards,
traits, habits and norms through identication. A good example is the
corned beef commercial ” WALK LIKE A MAN, TALK LIKE A MAN ” Where
the child identifies with his father by wearing the same clothes and doing
the same thing.
36. D. Schulman and Mekler . According to Schulman and Mekler, there are 2
components that makes an action MORAL : The intention should be good
and the Act must be just. A good example is ROBIN HOOD, His intention is
GOOD but the act is UNJUST, which makes his action IMMORAL.
37. B. Westerhoff. There are only 2 theorist of FAITH that might be asked in
the board examinations. Fowler and Westerhoff. What differs them is that,
FAITH of fowler is defined abstractly, Fowler defines faith as a FORCE that
gives a meaning to a person’s life while Westerhoff defines faith as a
behavior that continuously develops through time.
38. C. Fowler. Rationale: Refer to # 37
39. B. Iloilo Mission Hospital School of nursing
40. C. Philippine General Hospital
41. A. Elizabeth.Saint Elizabeth of Hungary was a daughter of a King and is
the patron saint of nurses. She build hospitals and feed hungry people
everyday using the kingdom’s money. She is a princess, but devoted her
life in feeding the hungry and serving the sick.
42. A. Clara louise Maas. Clara Louise Maas sacrificed her life in research of
YELLOW FEVER. People during her time do not believe that yellow fever
was brought by mosquitoes. To prove that they are wrong, She allowed
herself to be bitten by the vector and after days, She died.
43. C. Moses
44. C. India
45. A. Chinese. Chinese believes that male newborns are demon magnets.
To fool those demons, they put female clothes to their male newborn.
46. B. Intuitive period.Egyptians believe that a sick person is someone with
an evil force or demon that is inside their heads. To release these evil
spirits, They would tend to drill holes on the patient’s skull and it is called
TREPHINING.
47. A. Apprentice period.What dilineates apprentice period among others is
that, it ENDED when formal schools were established. During the
apprentice period, There is no formal educational institution for nurses.
Most of them receive training inside the convent or church. Some of them
are trained just for the purpose of nursing the wounded soldiers. But
almost all of them are influenced by the christian faith to serve and nurse
the sick. When Fliedner build the first formal school for nurses, It marked
the end of the APPRENTICESHIP period.
48. A. Apprentice period. Apprentice period is marked by the emergence of
religious orders the are devoted to religious life and the practice of
nursing.
49. C. St. Clare. The poor clares, is the second order of St. Francis of assisi.
The first order was founded by St. Francis himself. St. Catherine of Siena
was the first lady with the lamp. St. Anne is the mother of mama mary. St.
Elizabeth is the patron saint of Nursing.
50. B. Dark period. Protestantism emerged with Martin Luther questions the
Pope and Christianity. This started the Dark period of nursing when the
christian faith was smeared by controversies. These leads to closure of
some hospital and schools run by the church. Nursing became the work of
prostitutes, slaves, mother and least desirable of women.
51. B. Like some other men.According to ROY, Man as a social being is like
some other man. As a spiritual being and Biologic being, Man are all alike.
As a psychologic being, No man thinks alike. This basically summarized
her BIOPSYHOSOCIAL theory which is included in our licensure exam
coverage.
52. A. Roy. OPEN system theory is ROY. As an open system, man
continuously allows input from the environment. Example is when you tell
me Im good looking, I will be happy the entire day, Because I am an open
system and continuously interact and transact with my environment. A
close system is best exemplified by a CANDLE. When you cover the candle
with a glass, it will die because it will eventually use all the oxygen it needs
inside the glass for combustion. A closed system do not allow inputs and
output in its environment.
53. B. A sole island in vast ocean
54. B. Rogers. The wholistic theory by Martha Rogers states that MAN is
greater than the sum of all its parts and that his dignity and worth will not
be lessen even if one of this part is missing. A good example is ANNE
BOLEYN, The mother of Queen Elizabeth and the wife of King Henry VIII.
She was beheaded because Henry wants to mary another wife and that
his divorce was not approved by the pope. Outraged, He insisted on the
separation of the Church and State and divorce Anne himself by making
everyone believe that Anne is having an affair to another man. Anne was
beheaded while her lips is still saying a prayer. Even without her head,
People still gave respect to her diseased body and a separate head. She
was still remembered as Anne boleyn, Mother of Elizabeth who lead
england to their GOLDEN AGE.
55. B. Rogers. According to Martha Rogers, Man is composed of 2 systems :
SUB which includes cells, tissues, organs and system and SUPRA which
includes our famly, community and society. She stated that when any of
these systems are affected, it will affect the entire individual.
56. B. Needs should be followed exactly in accordance with their hierarchy.Needs
can be deferred. I can urinate later as not to miss the part of the movie’s
climax. I can save my money that are supposedly for my lunch to watch
my idols in concert. The physiologic needs can be meet later for some
other needs and need not be strictly followed according to their hierarchy.
57. D. Priorities are alterable. Refer to question # 56.
58. C. Follows the decision of the majority, uphold justice and truth. A,B and D
are all qualities of a self actualized person. A self actualized person do not
follow the decision of majority but is self directed and can make decisions
contrary to a popular opinion.
59. A. Makes decision contrary to public opinion. Refer to question # 58.
60. B. Self actualization. The peak of maslow’s hierarchy is the essence of
mental health.
61. D. Italy. Florence Nightingale was born in Florence, Italy, May 12, 1820.
Studied in Germany and Practiced in England.
62. A. Born May 12, 1840
63. C. Germany
64. D. Dunn. According to Dunn, High level wellness is the ability of an
individual to maximize his full potential with the limitations imposed by his
environment. According to him, An individual can be healthy or ill in both
favorable and unfavorable environment.
65. A. Promotes advancement and professional growth among its members
66. B. Anastacia Giron Tupas
67. C. Board resolution No. 1955 Promulgated by the BON. This is an old board
resolution. The new Board resolution is No. 220 series of 2004 also known
as the Nursing Code Of ethics which states that [ SECTION 17, A ] A nurse
should be a member of an accredited professional organization which is
the PNA.
68. C. She does it regularly as an important responsibility
69. A. RA 7164. 7164 is an old law. This is the 1991 Nursing Law which was
repealed by the newer 9173.
70. B. Independent nurse practitioner
71. D. September 02, 1922. According to the official PNA website, they are
founded September 02, 1922.
72. C. Rosario Montenegro. Anastacia Giron Tupas founded the FNA, the
former name of the PNA but the first President was Rosario Montenegro.
73. B. Bernard. According to Bernard, Health is the ability to maintain and
Internal Milieu and Illness is the failure to maintain the internal
environment.
74. D. Roy. According to ROY, Health is a state and process of becoming a
WHOLE AND INTEGRATED Person.
75. B. Negative feedback. The theory of Health as the ability to maintain
homeostasis was postulated by Walter Cannon. According to him, There
are certain FEEDBACK Mechanism that regulates our Homeostasis. A
good example is that when we overuse our arm, it will produce pain. PAIN
is a negative feedback that signals us that our arm needs a rest.
76. C. Rogers. Martha Rogers states that HEALTH is synonymous with
WELLNESS and that HEALTH and WELLNESS is subjective depending on
the definition of one’s culture.
77. D. King .Emogene King states that health is a state in the life cycle and
Illness is any interference on this cycle. I enjoyed the Movie LION KING
and like what Mufasa said that they are all part of the CIRCLE OF LIFE, or
the Life cycle.
78. A. Orem. Orem defined health as the SOUNDNESS and WHOLENESS of
developed human structure and of bodily and mental functioning.
79. C. Neuman. Neuman believe that man is composed of subparts and
when this subparts are in harmony with the whole system, Wellness
results. Please do not confuse this with the SUB and SUPRA systems of
martha rogers.
80. D. Johnson . Once you see the phrase BEHAVIORAL SYSTEM, answer
Dorothy Johnson.
81. D. Leddy and Pepper .According to Leddy and Pepper, Wellness is
subjective and depends on an individuals perception of balance, harmony
and vitality. Leavell and Clark postulared the ecologic model of health and
illness or the AGENT-HOST-ENVIRONMENT model. Peterson and Zderad
developed the HUMANISTIC NURSING PRACTICE theory while Benner and
Wruber postulate the PRIMACY OF CARING MODEL.
82. C. Dunn
83. D. High level Wellness
84. C. Behavioral. Behavioral precursors includes smoking, alcoholism, high
fat intake and other lifestyle choices. Environmental factors involved poor
sanitation and over crowding. Heridity includes congenital and diseases
acquired through the genes. There are no social precursors according to
DUNN.
85. D. Environmental
86. A. Becker. According to Becker, The belief of an individual greatly affects
his behavior. If a man believes that he is susceptible to an illness, He will
alter his behavior in order to prevent its occurence. For example, If a man
thinks that diabetes is acquired through high intake of sugar and simple
carbohydrates, then he will limit the intake of foods rich in these
components.
87. D. Perceived curability of an illness . If a man think he is susceptibe to a
certain disease, thinks that the disease is serious and it is a threat to his
life and functions, he will use preventive behaviors to avoid the occurence
of this threat.
88. A. Difficulty adhering to the lifestyle and B. Economic factors. Perceived
barriers are those factors that affects the individual’s health preventive
actions. Both A and B can affect the individual’s ability to prevent the
occurence of diseases. C and D are called Preventive Health Behaviors
which enhances the individual’s preventive capabilities.
89. D. Eudaemonistic Model . Smith formulated 5 models of health. Clinical
model simply states that when people experience sign and symptoms,
they would think that they are unhealthy therefore, Health is the absence
of clinical sign and symptoms of a disease. Role performance model
states that when a person does his role and activities without deficits, he
is healthy and the inability to perform usual roles means that the person is
ill. Adaptive Model states that if a person adapts well with his
environment, he is healthy and maladaptation equates illness.
Eudaemonistic Model of health according to smith is the actualization of a
person’s fullest potential. If a person functions optimally and develop self
actualization, then, no doubt that person is healthy.
90. A. Clinical Model. Rationale: Refer to question # 89.
91. C. Structural. Modifying variables in Becker’s health belief model
includes DEMOGRAPHIC : Age, sex, race etc. SOCIOPSYCHOLOGIC :
Social and Peer influence. STRUCTURAL : Knowledge about the disease
and prior contact with it and CUES TO ACTION : Which are the sign and
symptoms of the disease or advice from friends, mass media and others
that forces or makes the individual seek help.
92. D. Cues to action . Refer to question # 91.
93. B. Sociopsychologic. Refer to question # 91.
94. A. Demographic. Refer to question # 91.
95. A. Reservoir. According to L&C’s Ecologic model, there are 3 factors that
affect health and illness. These are the AGENT or the factor the leads to
illness, either a bacteria or an event in life. HOST are persons that may or
may not be affected by these agents. ENVIRONMENT are factors external
to the host that may or may not predispose him to the AGENT.
96. C. Health Promotion Model. Pender developed the concept of HEALTH
PROMOTION MODEL which postulated that an individual engages in
health promotion activities to increase well being and attain self
actualization. These includes exercise, immunization, healthy lifestyle,
good food, self responsibility and all other factors that minimize if not
totally eradicate risks and threats of health.
97. B. Health promotion. Refer to question # 96.
98. B. Disease. Disease are alteration in body functions resulting in reduction
of capabilities or shortening of life span.
99. A. Illness. Illness is something PERSONAL. Unlike disease, Illness are
personal state in which person feels unhealthy. An old person might think
he is ILL but in fact, he is not due, to diminishing functions and
capabilities, people might think they are ILL. Disease however, is
something with tangible basis like lab results, X ray films or clinical sign
and symptoms.
100. B. Watson. This is Jean Watson’s definition of Nursing as caring. This
was asked word per word last June 06′ NLE. Benner defines caring as
something that matters to people. She postulated the responsibility
created by Caring in nursing. She was also responsible for the PRIMACY
OF CARING MODEL. Leininger defind the 4 conservation principle while
Swanson introduced the 5 processes of caring.
A. The client will not urinate due to relaxation of the detrusor muscle
B. The client will be restless and alert
C. Clients BP will increase, there will be vasodilation
D. There will be increase glycogenolysis, Pancrease will decrease insulin
secretion
3. State in which a person’s physical, emotional, intellectual and social
development or spiritual functioning is diminished or impaired compared with
a previous experience.
A. Illness
B. Disease
C. Health
D. Wellness
4. This is the first stage of illness wherein, the person starts to believe that
something is wrong. Also known as the transition phase from wellness to
illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
5. In this stage of illness, the person accepts or rejects a professionals
suggestion. The person also becomes passive and may regress to an earlier
stage.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
6. In this stage of illness, The person learns to accept the illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
7. In this stage, the person tries to find answers for his illness. He wants his
illness to be validated, his symptoms explained and the outcome reassured or
predicted
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
8. The following are true with regards to aspect of the sick role except
A. Predisposing factor
B. Etiology
C. Risk factor
D. Modifiable Risks
10. Refers to the degree of resistance the potential host has against a certain
pathogen
A. Susceptibility
B. Immunity
C. Virulence
D. Etiology
11. A group of symptoms that sums up or constitute a disease
A. Syndrome
B. Symptoms
C. Signs
D. Etiology
12. A woman undergoing radiation therapy developed redness and burning of
the skin around the best. This is best classified as what type of disease?
A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic
13. The classification of CANCER according to its etiology Is best described
as:
1. Nosocomial
2. Idiopathic
3. Neoplastic
4. Traumatic
5. Congenital
6. Degenrative
A. 5 and 2
B. 2 and 3
C. 3 and 4
D. 3 and 5
14. Term to describe the reactiviation and recurrence of pronounced
symptoms of a disease
A. Remission
B. Emission
C. Exacerbation
D. Sub acute
15. A type of illness characterized by periods of remission and exacerbation
A. Chronic
B. Acute
C. Sub acute
D. Sub chronic
16. Diseases that results from changes in the normal structure, from
recognizable anatomical changes in an organ or body tissue is termed as
A. Functional
B. Occupational
C. Inorganic
D. Organic
17. It is the science of organism as affected by factors in their environment. It
deals with the relationship between disease and geographical environment.
A. Epidemiology
B. Ecology
C. Statistics
D. Geography
18. This is the study of the patterns of health and disease. Its occurrence and
distribution in man, for the purpose of control and prevention of disease.
A. Epidemiology
B. Ecology
C. Statistics
D. Geography
19. Refers to diseases that produced no anatomic changes but as a result
from abnormal response to a stimuli.
A. Functional
B. Occupational
C. Inorganic
D. Organic
20. In what level of prevention according to Leavell and Clark does the nurse
support the client in obtaining OPTIMAL HEALTH STATUS after a disease or
injury?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
21. In what level of prevention does the nurse encourage optimal health and
increases person’s susceptibility to illness?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
22. Also known as HEALTH MAINTENANCE prevention.
A. Primary
B. Secondary
C. Tertiary
D. None of the above
23. PPD In occupational health nursing is what type of prevention?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
24. BCG in community health nursing is what type of prevention?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
25. A regular pap smear for woman every 3 years after establishing normal
pap smear for 3 consecutive years Is advocated. What level of prevention
does this belongs?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
26. Self monitoring of blood glucose for diabetic clients is on what level of
prevention?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
27. Which is the best way to disseminate information to the public?
A. Newspaper
B. School bulletins
C. Community bill boards
D. Radio and Television
28. Who conceptualized health as integration of parts and subparts of an
individual?
A. Newman
B. Neuman
C. Watson
D. Rogers
29. The following are concept of health:
A. Bernard
B. Selye
C. Cannon
D. Rogers
31. Excessive alcohol intake is what type of risk factor?
A. Genetics
B. Age
C. Environment
D. Lifestyle
32. Osteoporosis and degenerative diseases like Osteoarthritis belongs to
what type of risk factor?
A. Genetics
B. Age
C. Environment
D. Lifestyle
33. Also known as STERILE TECHNIQUE
A. Surgical Asepsis
B. Medical Asepsis
C. Sepsis
D. Asepsis
34. This is a person or animal, who is without signs of illness but harbors
pathogen within his body and can be transferred to another
A. Host
B. Agent
C. Environment
D. Carrier
35. Refers to a person or animal, known or believed to have been exposed to a
disease.
A. Carrier
B. Contact
C. Agent
D. Host
36. A substance usually intended for use on inanimate objects, that destroys
pathogens but not the spores.
A. Sterilization
B. Disinfectant
C. Antiseptic
D. Autoclave
37. This is a process of removing pathogens but not their spores
A. Sterilization
B. Auto claving
C. Disinfection
D. Medical asepsis
38. The third period of infectious processes characterized by development of
specific signs and symptoms
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
39. A child with measles developed fever and general weakness after being
exposed to another child with rubella. In what stage of infectious process
does this child belongs?
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
40. A 50 year old mailman carried a mail with anthrax powder in it. A minute
after exposure, he still hasn’t developed any signs and symptoms of anthrax.
In what stage of infectious process does this man belongs?
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
41. Considered as the WEAKEST LINK in the chain of infection that nurses can
manipulate to prevent spread of infection and diseases
A. Etiologic/Infectious agent
B. Portal of Entry
C. Susceptible host
D. Mode of transmission
42. Which of the following is the exact order of the infection chain?
1. Susceptible host
2. Portal of entry
3. Portal of exit
4. Etiologic agent
5. Reservoir
6. Mode of transmission
A. 1,2,3,4,5,6
B. 5,4,2,3,6,1
C. 4,5,3,6,2,1
D. 6,5,4,3,2,1
43. Markee, A 15 year old high school student asked you. What is the mode of
transmission of Lyme disease. You correctly answered him that Lyme disease
is transmitted via
A. Pathogenicity
B. Virulence
C. Invasiveness
D. Non Specificity
45. Contact transmission of infectious organism in the hospital is usually
cause by
A. Urinary catheterization
B. Spread from patient to patient
C. Spread by cross contamination via hands of caregiver
D. Cause by unclean instruments used by doctors and nurses
46. Transmission occurs when an infected person sneezes, coughs or laugh
that is usually projected at a distance of 3 feet.
A. Droplet transmission
B. Airborne transmission
C. Vehicle transmission
D. Vector borne transmission
47. Considered as the first line of defense of the body against infection
A. Skin
B. WBC
C. Leukocytes
D. Immunization
48. All of the following contributes to host susceptibility except
A. Creed
B. Immunization
C. Current medication being taken
D. Color of the skin
49. Graciel has been injected TT5, her last dosed for tetanus toxoid
immunization. Graciel asked you, what type of immunity is TT Injections? You
correctly answer her by saying Tetanus toxoid immunization is a/an
A. Cleaning
B. Disinfecting
C. Sterilizing
D. Handwashing
52. This is considered as the most important aspect of handwashing
A. Time
B. Friction
C. Water
D. Soap
53. In handwashing by medical asepsis, Hands are held ….
A. Above the elbow, The hands must always be above the waist
B. Above the elbow, The hands are cleaner than the elbow
C. Below the elbow, Medical asepsis do not require hands to be above the
waist
D. Below the elbow, Hands are dirtier than the lower arms
54. The suggested time per hand on handwashing using the time method is
A. 5 seconds
B. 10 seconds
C. 15 seconds
D. 30 seconds
56. How many ml of liquid soap is recommended for handwashing procedure?
A. 1-2 ml
B. 2-3 ml
C. 2-4 ml
D. 5-10 ml
57. Which of the following is not true about sterilization, cleaning and
disinfection?
A. Equipment with small lumen are easier to clean
B. Sterilization is the complete destruction of all viable microorganism
including spores
C. Some organism are easily destroyed, while other, with coagulated
protein requires longer time
D. The number of organism is directly proportional to the length of time
required for sterilization
58. Karlita asked you, How long should she boil her glass baby bottle in water?
You correctly answered her by saying
A. Boiling Water
B. Gas sterilization
C. Steam under pressure
D. Radiation
60. A TB patient was discharged in the hospital. A UV Lamp was placed in the
room where he stayed for a week. What type of disinfection is this?
A. Concurrent disinfection
B. Terminal disinfection
C. Regular disinfection
D. Routine disinfection
61. Which of the following is not true in implementing medical asepsis
A. Green trashcan
B. Black trashcan
C. Orange trashcan
D. Yellow trashcan
65. Needles, scalpels, broken glass and lancets are considered as injurious
wastes. As a nurse, it is correct to put them at disposal via a/an
A. Using a long forceps, Push it back towards the cervix then call the
physician
B. Wear gloves, remove it gently and place it on a lead container
C. Using a long forceps, Remove it and place it on a lead container
D. Call the physician, You are not allowed to touch, re insert or remove it
67. After leech therapy, Where should you put the leeches?
A. In a room with positive air pressure and atleast 3 air exchanges an hour
B. In a room with positive air pressure and atleast 6 air exchanges an hour
C. In a room with negative air pressure and atleast 3 air exchanges an hour
D. In a room with negative air pressure and atleast 6 air exchanges an hour
70. A client has been diagnosed with RUBELLA. What precaution is used for
this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
71. A client has been diagnosed with MEASLES. What precaution is used for
this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
72. A client has been diagnosed with IMPETIGO. What precaution is used for
this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
73. The nurse is to insert an NG Tube when suddenly, she accidentally dip the
end of the tube in the client’s glass containing distilled drinking water which is
definitely not sterile. As a nurse, what should you do?
A. Autoclaved linens and gowns are considered sterile for about 4 months
as long as the bagging is intact
B. Surgical technique is a sole effort of each nurse
C. Sterile conscience, is the best method to enhance sterile technique
D. If a scrubbed person leaves the area of the sterile field, He/she must do
handwashing and gloving again, but the gown need not be changed.
76. In putting sterile gloves, Which should be gloved first?
A. Slipping gloved hand with all fingers when picking up the second glove
B. Grasping the first glove by inserting four fingers, with thumbs up
underneath the cuff
C. Putting the gloves into the dominant hand first
D. Adjust only the fitting of the gloves after both gloves are on
79. Which gloves should you remove first?
A. 1 inch
B. 3 inches
C. 6 inches
D. 10 inches
83. The tip of the sterile forceps is considered sterile. It is used to manipulate
the objects in the sterile field using the non sterile hands. How should the
nurse hold a sterile forceps?
A. Hans Selye
B. Walter Cannon
C. Claude Bernard
D. Martha Rogers
89. Which of the following is NOT TRUE with regards to the concept of
Modern Stress Theory?
A. Stress is essential
B. Man does not encounter stress if he is asleep
C. A single stress can cause a disease
D. Stress always leads to distress
91. Which of the following is TRUE in the stage of alarm of general adaptation
syndrome?
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
93. Stage of GAS Characterized by adaptation
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
94. Stage of GAS wherein, the Level of resistance are decreased
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
95. Where in stages of GAS does a person moves back into HOMEOSTASIS?
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
96. Stage of GAS that results from prolonged exposure to stress. Here, death
will ensue unless extra adaptive mechanisms are utilized
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
97. All but one is a characteristic of adaptive response
A. Vasoconstriction
B. Vasodilatation
C. Decreases force of contractility
D. Decreases cardiac output
2. What stress response can you expect from a patient with blood sugar of 50
mg / dl?
A. Body will try to decrease the glucose level
B. There will be a halt in release of sex hormones
C. Client will appear restless
D. Blood pressure will increase
3. All of the following are purpose of inflammation except
A. Immediate Vasodilation
B. Transient Vasoconstriction
C. Immediate Vasoconstriction
D. Transient Vasodilation
5. The last expected process in the stages of inflammation is characterized by
A. Serous
B. Serosanguinous
C. Purulent
D. Sanguinous
7. The first manifestation of inflammation is
A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes
9. Which of the following WBC component proliferates in cases of
Anaphylaxis?
A. Neutrophils
B. Basophils
C. Eosinophil
D. Monocytes
10. Icheanne, ask you, her Nurse, about WBC Components. She got an injury
yesterday after she twisted her ankle accidentally at her gymnastic class. She
asked you, which WBC Component is responsible for proliferation at the
injured site immediately following an injury. You answer:
A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes
11. Icheanne then asked you, what is the first process that occurs in the
inflammatory response after injury, You tell her:
A. Phagocytosis
B. Emigration
C. Pavementation
D. Chemotaxis
12. Icheanne asked you again, What is that term that describes the magnetic
attraction of injured tissue to bring phagocytes to the site of injury?
A. First intention
B. Second intention
C. Third intention
D. Fourth intention
14. Type of healing when scars are minimal due to careful surgical incision
and good healing
A. First intention
B. Second intention
C. Third intention
D. Fourth intention
15. Imelda, was slashed and hacked by an unknown suspects. She suffered
massive tissue loss and laceration on her arms and elbow in an attempt to
evade the criminal. As a nurse, you know that the type of healing that will most
likely occur to Miss Imelda is
A. First intention
B. Second intention
C. Third intention
D. Fourth intention
16. Imelda is in the recovery stage after the incident. As a nurse, you know
that the diet that will be prescribed to Miss Imelda is
1. Constipation
2. Urinary frequency
3. Hyperglycemia
4. Increased blood pressure
A. 3,4
B. 1,3,4
C. 1,2,4
D. 1,4
20. The client is on NPO post midnight. Which of the following, if done by the
client, is sufficient to cancel the operation in the morning?
A. Low BP
B. Decrease Urine output
C. Warm, flushed, dry skin
D. Low serum sodium levels
22. Which of the following is true about therapeutic relationship?
A. Roy
B. Peplau
C. Rogers
D. Travelbee
24. In what phase of Nurse patient relationship does a nurse review the
client’s medical records thereby learning as much as possible about the
client?
A. Pre Orientation
B. Orientation
C. Working
D. Termination
25. Nurse Aida has seen her patient, Roger for the first time. She establish a
contract about the frequency of meeting and introduce to Roger the expected
termination. She started taking baseline assessment and set interventions
and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?
A. Pre Orientation
B. Orientation
C. Working
D. Termination
26. Roger has been seen agitated, shouting and running. As Nurse Aida
approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger
“That is an unacceptable behavior Roger, Stop and go to your room now.” The
situation is most likely in what phase of NPR?
A. Pre Orientation
B. Orientation
C. Working
D. Termination
27. Nurse Aida, in spite of the incident, still consider Roger as worthwhile
simply because he is a human being. What major ingredient of a therapeutic
communication is Nurse Aida using?
A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness
28. Nurse Irma saw Roger and told Nurse Aida “ Oh look at that psychotic
patient “ Nurse Aida should intervene and correct Nurse Irma because her
statement shows that she is lacking?
A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness
29. Which of the following statement is not true about stress?
A. It is a nervous energy
B. It is an essential aspect of existence
C. It has been always a part of human experience
D. It is something each person has to cope
30. Martina, a Tennis champ was devastated after many new competitors
outpaced her in the Wimbledon event. She became depressed and always
seen crying. Martina is clearly on what kind of situation?
A. Mild
B. Moderate
C. Severe
D. Panic
33. Elton, 21 year old nursing student is taking the board examination. She is
sweating profusely, has decreased awareness of his environment and is
purely focused on the exam questions characterized by his selective
attentiveness. What anxiety level is Elton exemplifying?
A. Mild
B. Moderate
C. Severe
D. Panic
34. You noticed the patient chart : ANXIETY +3 What will you expect to see in
this client?
A. When anxiety is +1
B. When the client starts to have a narrow perceptual field and selective
inattentiveness
C. When problem solving is not possible
D. When the client is immobile and disorganized
36. Which of the following behavior is not a sign or a symptom of Anxiety?
A. Offer choices
B. Provide a quiet and calm environment
C. Provide detailed explanation on each and every procedures and
equipments
D. Bring anxiety down to a controllable level
38. Which of the following statement, if made by the nurse, is considered not
therapeutic?
A. Biofeedback
B. Massage
C. Autogenic training
D. Visualization and Imagery
41. This is also known as Self-suggestion or Self-hypnosis
A. Biofeedback
B. Meditation
C. Autogenic training
D. Visualization and Imagery
42. Which among these drugs is NOT an anxiolytic?
A. Valium
B. Ativan
C. Milltown
D. Luvox
43. Kenneth, 25 year old diagnosed with HIV felt that he had not lived up with
God’s expectation. He fears that in the course of his illness, God will be
punitive and not be supportive. What kind of spiritual crisis is Kenneth
experiencing?
1. Spiritual Pain
2. Spiritual Anxiety
3. Spiritual Guilt
4. Spiritual Despair
A. 1,2
B. 2,3
C. 3,4
D. 1,4
44. Grace, believes that her relationship with God is broken. She tried to go to
church to ask forgiveness everyday to remedy her feelings. What kind of
spiritual distress is Grace experiencing?
A. Spiritual Pan
B. Spiritual Alienation
C. Spiritual Guilt
D. Spiritual Despair
45. Remedios felt “EMPTY” She felt that she has already lost God’s favor and
love because of her sins. This is a type of what spiritual crisis?
A. Spiritual Anger
B. Spiritual Loss
C. Spiritual Despair
D. Spiritual Anxiety
46. Budek is working with a schizophrenic patient. He noticed that the client is
agitated, pacing back and forth, restless and experiencing Anxiety +3. Budek
said “You appear restless” What therapeutic technique did Budek used?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
48. Rommel told Budek, “Do you think Im crazy?” Budek responded, “Do you
think your crazy?” Budek uses what example of therapeutic communication?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
49. Myra, 21 year old nursing student has difficulty sleeping. She told Nurse
Budek “I really think a lot about my x boyfriend recently” Budek told Myra “And
that causes you difficulty sleeping?” Which therapeutic technique is used in
this situation?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
50. Myra told Budek “I cannot sleep, I stay away all night” Budek told her “You
have difficulty sleeping” This is what type of therapeutic communication
technique?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
51. Myra said “I saw my dead grandmother here at my bedside a while ago”
Budek responded “Really? That is hard to believe, How do you feel about it?”
What technique did Budek used?
A. Disproving
B. Disagreeing
C. Voicing Doubt
D. Presenting Reality
52. Which of the following is a therapeutic communication in response to “I
am a GOD, bow before me Or ill summon the dreaded thunder to burn you and
purge you to pieces!”
A. “You are not a GOD, you are Professor Tadle and you are a PE Teacher,
not a Nurse. I am Glen, Your nurse.”
B. “Oh hail GOD Tadle, everyone bow or face his wrath!”
C. “Hello Mr. Tadle, You are here in the hospital, I am your nurse and you
are a patient here”
D. “How can you be a GOD Mr. Tadle? Can you tell me more about it?”
53. Erik John Senna, Told Nurse Budek “ I don’t want to that, I don’t want that
thing.. that’s too painful!” Which of the following response is NON
THERAPEUTIC
A. “ This must be difficult for you, But I need to inject you this for your own
good”
B. “ You sound afraid”
C. “Are you telling me you don’t want this injection?”
D. “Why are you so anxious? Please tell me more about your feelings Erik”
54. Legrande De Salvaje Y Cobrador La Jueteng, was caught by the bacolod
police because of his illegal activities. When he got home after paying for the
bail, He shouted at his son. What defense mechanism did Mr. La Jueteng
used?
A. Restitution
B. Projection
C. Displacement
D. Undoing
55. Later that day, he bought his son ice cream and food. What defense
mechanism is Legrande unconsciously doing?
A. Restitution
B. Conversion
C. Redoing
D. Reaction formation
56. Crisis is a sudden event in ones life that disturbs a person’s homeostasis.
Which of the following is NOT TRUE in crisis?
A. Situational
B. Maturational
C. Social
D. Phenomenal
59. Estrada, The Philippine president, has been unexpectedly impeached and
was out of office before the end of his term. He is in what type of crisis?
A. Situational
B. Maturational
C. Social
D. Phenomenal
60. The tsunami in Thailand and Indonesia took thousands of people and
change million lives. The people affected by the Tsunami are saddened and
do not know how to start all over again. What type of crisis is this?
A. Situational
B. Maturational
C. Social
D. Phenomenal
61. Which of the following is the BEST goal for crisis intervention?
A. Behavior therapy
B. Gestalt therapy
C. Cognitive therapy
D. Milieu Therapy
63. Therapeutic nurse client relationship is describes as follows
A. Verbal communication
B. Non verbal communication
C. Written communication
D. Oral communication
69. Represents inner feeling that a person do not like talking about.
A. Overt communication
B. Covert communication
C. Verbal communication
D. Non verbal communication
70. Which of the following is NOT a characteristic of an effective Nurse-Client
relationship?
A. POMR
B. POR
C. Traditional
D. Resource oriented
72. Type of recording that integrates all data about the problem, gathered by
members of the health team.
A. POMR
B. Traditional
C. Resource oriented
D. Source oriented
73. These are data that are monitored by using graphic charts or graphs that
indicated the progression or fluctuation of client’s Temperature and Blood
pressure.
A. Progress notes
B. Kardex
C. Flow chart
D. Flow sheet
74. Provides a concise method of organizing and recording data about the
client. It is a series of flip cards kept in portable file used in change of shift
reports.
A. Kardex
B. Progress Notes
C. SOAPIE
D. Change of shift report
75. You are about to write an information on the Kardex. There are 4 available
writing instruments to use. Which of the following should you use?
A. Mongol #2
B. Permanent Ink
C. A felt or fountain pen
D. Pilot Pentel Pen marker
76. The client has an allergy to Iodine based dye. Where should you put this
vital information in the client’s chart?
A. As desired
B. Before meals
C. After meals
D. Before bed time
80. The physician ordered, Maalox, 2 hours p.c, what does p.c means?
A. As desired
B. Before meals
C. After meals
D. Before bed time
81. The physician ordered, Maxitrol, Od. What does Od means?
A. Left eye
B. Right eye
C. Both eye
D. Once a day
82. The physician orderd, Magnesium Hydroxide cc Aluminum Hydroxide.
What does cc means?
A. without
B. with
C. one half
D. With one half dose
83. Physician ordered, Paracetamol tablet ss. What does ss means?
A. without
B. with
C. one half
D. With one half dose
84. Which of the following indicates that learning has been achieved?
A. Matuts starts exercising every morning and eating a balance diet after
you taught her mag HL tayo program
B. Donya Delilah has been able to repeat the steps of insulin
administration after you taught it to her
C. Marsha said “ I understand “ after you a health teaching about family
planning
D. John rated 100% on your given quiz about smoking and alcoholism
85. In his theory of learning as a BEHAVIORISM, he stated that transfer of
knowledge occurs if a new situation closely resembles an old one.
A. Bloom
B. Lewin
C. Thorndike
D. Skinner
86. Which of the following is TRUE with regards to learning?
A. Cognitive
B. Affective
C. Psychomotor
D. Motivative
88. Which domains of learning is responsible for making John and Marsha
understand the different kinds of family planning methods?
A. Cognitive
B. Affective
C. Psychomotor
D. Motivative
89. Which of the following statement clearly defines therapeutic
communication?
A. The nurse must fully understand the patient’s feelings, perception and
reactions before goals can be established
B. The nurse must be a role model for health fostering behavior
C. The nurse must recognize that the patient may manifest maladaptive
behavior after illness
D. The nurse should understand that patients might test her before trust is
established
91. Which of the following communication skill is most effective in dealing
with covert communication?
A. Validation
B. Listening
C. Evaluation
D. Clarification
92. Which of the following are qualities of a good recording?
1. Brevity
2. Completeness and chronology
3. Appropriateness
4. Accuracy
A. 1,2
B. 3,4
C. 1,2,3
D. 1,2,3,4
93. All of the following chart entries are correct except
A. Detailed explanation
B. Demonstration
C. Use of pamphlets
D. Film showing
95. What is the most important characteristic of a nurse patient relationship?
A. It is growth facilitating
B. Based on mutual understanding
C. Fosters hope and confidence
D. Involves primarily emotional bond
96. Which of the following nursing intervention is needed before teaching a
client post spleenectomy deep breathing and coughing exercises?
A. Tell the patient that deep breathing and coughing exercises is needed to
promote good breathing, circulation and prevent complication
B. Tell the client that deep breathing and coughing exercises is needed to
prevent Thrombophlebitis, hydrostatic pneumonia and atelectasis
C. Medicate client for pain
D. Tell client that cooperation is vital to improve recovery
97. The client has an allergy with penicillin. What is the best way to
communicate this information?
A. Nightingale
B. Johnson
C. Rogers
D. Hall
2. The American Nurses association formulated an innovation of the Nursing
process. Today, how many distinct steps are there in the nursing process?
A. APIE – 4
B. ADPIE – 5
C. ADOPIE – 6
D. ADOPIER – 7
3. They are the first one to suggest a 4 step nursing process which are : APIE ,
or assessment, planning, implementation and evaluation.
1. Yura
2. Walsh
3. Roy
4. Knowles
A. 1,2
B. 1,3
C. 3,4
D. 2,3
4. Which characteristic of nursing process is responsible for proper utilization
of human resources, time and cost resources?
A. Actual
B. Probable
C. Possible
D. Risk
10. Nurse Angela is about to make a diagnosis but very unsure because the
S/S the client is experiencing is not specific with her diagnosis of
POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She
then focus on gathering data to refute or prove her diagnosis but her plans
and interventions are already ongoing for the diagnosis. Which type of
Diagnosis is this?
A. Actual
B. Probable
C. Possible
D. Risk
11. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an
operation with an incision near the diaphragm. She knew that this will
contribute to some complications later on. She then should develop what type
of Nursing diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk
12. Which of the following Nursing diagnosis is INCORRECT?
A. Dizziness
B. Chest pain
C. Anxiety
D. Blue nails
18. A patient’s chart is what type of data source?
A. Primary
B. Secondary
C. Tertiary
D. Can be A and B
19. All of the following are characteristic of the Nursing process except
A. Dynamic
B. Cyclical
C. Universal
D. Intrapersonal
20. Which of the following is true about the NURSING CARE PLAN?
A. It is nursing centered
B. Rationales are supported by interventions
C. Verbal
D. Atleast 2 goals are needed for every nursing diagnosis
21. A framework for health assessment that evaluates the effects of stressors
to the mind, body and environment in relation with the ability of the client to
perform ADL.
A. Convection
B. Conduction
C. Radiation
D. Evaporation
25. Which of the following is TRUE about temperature?
A. 40 degree Celsius
B. 39 degree Celsius
C. 100 degree Fahrenheit
D. 105.8 degree Fahrenheit
27. Tympanic temperature is taken from John, A client who was brought
recently into the ER due to frequent barking cough. The temperature reads
37.9 Degrees Celsius. As a nurse, you conclude that this temperature is
A. High
B. Low
C. At the low end of the normal range
D. At the high end of the normal range
28. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and
go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever
is John having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
29. John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a
normal temperature of 36.5 degrees. Today, his temperature surges to 40
degrees. What type of fever is John having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
30. John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago,
He has a fever with a temperature of 38.9 Degrees. Right now, his temperature
is back to normal. Which of the following best describe the fever john is
having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
31. The characteristic fever in Dengue Virus is characterized as:
A. Tricyclic
B. Bicyclic
C. Biphasic
D. Triphasic
32. When John has been given paracetamol, his fever was brought down
dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10
minutes. The nurse would assess this event as:
A. The goal of reducing john’s fever has been met with full satisfaction of
the outcome criteria
B. The desired goal has been partially met
C. The goal is not completely met
D. The goal has been met but not with the desired outcome criteria
33. What can you expect from Marianne, who is currently at the ONSET stage
of fever?
A. Hot, flushed skin
B. Increase thirst
C. Convulsion
D. Pale,cold skin
34. Marianne is now at the Defervescence stage of the fever, which of the
following is expected?
A. Delirium
B. Goose flesh
C. Cyanotic nail beds
D. Sweating
35. Considered as the most accessible and convenient method for
temperature taking
A. Oral
B. Rectal
C. Tympanic
D. Axillary
36. Considered as Safest and most non invasive method of temperature
taking
A. Oral
B. Rectal
C. Tympanic
D. Axillary
37. Which of the following is NOT a contraindication in taking ORAL
temperature?
A. Quadriplegic
B. Presence of NGT
C. Dyspnea
D. Nausea and Vomitting
38. Which of the following is a contraindication in taking RECTAL
temperature?
A. Unconscious
B. Neutropenic
C. NPO
D. Very young children
39. How long should the Rectal Thermometer be inserted to the clients anus?
A. 1 to 2 inches
B. 5 to 1.5 inches
C. 3 to 5 inches
D. 2 to 3 inches
40. In cleaning the thermometer after use, The direction of the cleaning to
follow Medical Asepsis is :
A. 3 minutes
B. 4 minutes
C. 7 minutes
D. 10 minutes
42. Which of the following statement is TRUE about pulse?
A. Apical rate
B. Cardiac rate
C. Pulse deficit
D. Pulse pressure
45. Which of the following completely describes PULSUS PARADOXICUS?
A. I:E 2:1
B. I:E : 4:3
C. I:E 1:1
D. I:E 1:2
47. Contains the pneumotaxic and the apneutic centers
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
48. Which of the following is responsible for deep and prolonged inspiration
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
49. Which of the following is responsible for the rhythm and quality of
breathing?
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
50. The primary respiratory center
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
51. Which of the following is TRUE about the mechanism of action of the
Aortic and Carotid bodies?
A. Hydrocodone decreases RR
B. Stress increases RR
C. Increase temperature of the environment, Increase RR
D. Increase altitude, Increase RR
53. When does the heart receives blood from the coronary artery?
A. Systole
B. Diastole
C. When the valves opens
D. When the valves closes
54. Which of the following is more life threatening?
A. BP = 180/100
B. BP = 160/120
C. BP = 90/60
D. BP = 80/50
55. Refers to the pressure when the ventricles are at rest
A. Diastole
B. Systole
C. Preload
D. Pulse pressure
56. Which of the following is TRUE about the blood pressure determinants?
A. Hypervolemia lowers BP
B. Hypervolemia increases GFR
C. HCT of 70% might decrease or increase BP
D. Epinephrine decreases BP
57. Which of the following do not correctly correlates the increase BP of Ms.
Aida, a 70 year old diabetic?
A. 5
B. 10
C. 15
D. 30
59. Too narrow cuff will cause what change in the Client’s BP?
A. If the eye level is higher than the level of the meniscus, it will cause a
false high reading
B. If the eye level is higher than the level of the meniscus, it will cause a
false low reading
C. If the eye level is lower than the level of the meniscus, it will cause a
false low reading
D. If the eye level is equal to that of the level of the upper meniscus, the
reading is accurate
63. How many minute/s is/are allowed to pass before making a re-reading
after the first one?
A. 1
B. 5
C. 15
D. 30
64. Which of the following is TRUE about the auscultation of blood pressure?
A. RUQ,RLQ,LUQ,LLQ
B. RLQ,RUQ,LLQ,LUQ
C. RUQ,RLQ,LLQ,LUQ
D. RLQ,RUQ,LUQ,LLQ
67. In inspecting the abdomen, which of the following is NOT DONE?
A. Supine
B. Dorsal recumbent
C. Sitting
D. Lithotomy
71. When is the best time to collect urine specimen for routine urinalysis and
C/S?
A. Early morning
B. Later afternoon
C. Midnight
D. Before breakfast
72. Which of the following is among an ideal way of collecting a urine
specimen for culture and sensitivity?
A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included
the urine in the 24 hour urine specimen
B. The nurse discards the Friday 9:00 A M urine of the client
C. The nurse included the Saturday 9:00 A.M urine of the client to the
specimen collection
D. The nurse added preservatives as per protocol and refrigerates the
specimen
74. This specimen is required to assess glucose levels and for the presence of
albumin the the urine
A. During meals
B. In between meals
C. Before meals
D. 2 Hours after meals
76. In collecting a urine from a catheterized patient, Which of the following
statement indicates an accurate performance of the procedure?
A. Clamp above the port for 30 to 60 minutes before drawing the urine
from the port
B. Clamp below the port for 30 to 60 minutes before drawing the urine
from the port
C. Clamp above the port for 5 to 10 minutes before drawing the urine from
the port
D. Clamp below the port for 5 to 10 minutes before drawing the urine from
the port
77. A community health nurse should be resourceful and meet the needs of
the client. A villager ask him, Can you test my urine for glucose? Which of the
following technique allows the nurse to test a client’s urine for glucose
without the need for intricate instruments.
A. The nurse added the Urine as the 2/3 part of the solution
B. The nurse heats the test tube after adding 1/3 part acetic acid
C. The nurse heats the test tube after adding 2/3 part of Urine
D. The nurse determines abnormal result if she noticed that the test tube
becomes cloudy
79. Which of the following is incorrect with regards to proper urine testing
using Benedict’s Solution?
A. Heat around 5ml of Benedict’s solution together with the urine in a test
tube
B. Add 8 to 10 drops of urine
C. Heat the Benedict’s solution without the urine to check if the solution is
contaminated
D. If the color remains BLUE, the result is POSITIVE
80. +++ Positive result after Benedicts test is depicted by what color?
A. Blue
B. Green
C. Yellow
D. Orange
81. Clinitest is used in testing the urine of a client for glucose. Which of the
following, If committed by a nurse indicates error?
A. The nurse scoop the specimen specifically at the site with blood and
mucus
B. She took around 1 inch of specimen or a teaspoonful
C. Ask the client to call her for the specimen after the client wiped off his
anus with a tissue
D. Ask the client to defecate in a bedpan, Secure a sterile container
84. In a routine sputum analysis, Which of the following indicates proper
nursing action before sputum collection?
A. The nurse
B. Medical technologist
C. Physician
D. Physical therapist
86. David, 68 year old male client is scheduled for Serum Lipid analysis. Which
of the following health teaching is important to ensure accurate reading?
A. Tell the patient to eat fatty meals 3 days prior to the procedure
B. NPO for 12 hours pre procedure
C. Ask the client to drink 1 glass of water 1 hour prior to the procedure
D. Tell the client that the normal serum lipase level is 50 to 140 U/L
87. The primary factor responsible for body heat production is the
A. Metabolism
B. Release of thyroxin
C. Muscle activity
D. Stress
88. The heat regulating center is found in the
A. Medulla oblongata
B. Thalamus
C. Hypothalamus
D. Pons
89. A process of heat loss which involves the transfer of heat from one
surface to another is
A. Radiation
B. Conduction
C. Convection
D. Evaporation
90. Which of the following is a primary factor that affects the BP?
A. Obesity
B. Age
C. Stress
D. Gender
91. The following are social data about the client except
A. Patient’s lifestyle
B. Religious practices
C. Family home situation
D. Usual health status
92. The best position for any procedure that involves vaginal and cervical
examination is
A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy
93. Measure the leg circumference of a client with bipedal edema is best done
in what position?
A. Dorsal recumbent
B. Sitting
C. Standing
D. Supine
94. In palpating the client’s abdomen, Which of the following is the best
position for the client to assume?
A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy
95. Rectal examination is done with a client in what position?
A. Dorsal recumbent
B. Sims position
C. Supine
D. Lithotomy
96. Which of the following is a correct nursing action when collecting urine
specimen from a client with an Indwelling catheter?
A. Standing
B. Sitting
C. Side lying
D. Prone
100. In assessing the client’s chest, which position best show chest
expansion as well as its movements?
A. Sitting
B. Prone
C. Sidelying
D. Supine
Answers
1. D. Hall
2. C. ADOPIE – 6
3. A. 1,2
4. C. Efficient
5. B. Humanistic
6. D. Effective
7. B. 2,3
8. A. Actual
9. D. Risk
10. C. Possible
11. D. Risk
12. B. High risk for injury R/T Absence of side rails
13. D. Client is cyanotic
14. D. The client is thirsty and dehydrated
15. B. They are general and broadly stated
16. D. Reestablishes a normal pattern of elimination
17. D. Blue nails
18. B. Secondary
19. D. Intrapersonal
20. A. It is nursing centered
21. A. Functional health framework
22. C. Body system framework
23. B. The bulb used in Rectal temperature reading is pear shaped or round
24. A. Convection
25. A. The highest temperature usually occurs later in a day, around 8 P.M to 12
M.N
26. D. 105.8 degree Fahrenheit
27. D. At the high end of the normal range
28. C. Remittent
29. A. Relapsing
30. B. Intermittent
31. C. Biphasic
32. D. The goal has been met but not with the desired outcome criteria
33. D. Pale,cold skin
34. D. Sweating
35. A. Oral
36. D. Axillary
37. A. Quadriplegic
38. B. Neutropenic
39. B. .5 to 1.5 inches
40. B. From stem to bulb
41. C. 7 minutes
42. A. Young person have higher pulse than older persons
43. B. Use the thumb to palpate the artery
44. D. Pulse pressure
45. B. A greater-than-normal decrease in systolic blood pressure with inspiration
46. D. I:E 1:2
47. B. Pons
48. B. Pons
49. B. Pons
50. A. Medulla oblongata
51. B. If the BP is elevated, the RR decreases
52. C. Increase temperature of the environment, Increase RR
53. B. Diastole
54. B. BP = 160/120
55. A. Diastole
56. D. Epinephrine decreases BP
57. A. Females, after the age 65 tends to have lower BP than males
58. D. 30
59. C. False high reading
60. D. The left arm
61. A. Read the mercury at the upper meniscus, preferably at the eye level to
prevent error of parallax
62. B. If the eye level is higher than the level of the meniscus, it will cause a false
low reading
63. A. 1
64. B. The bell of the stethoscope is use in auscultating BP
65. A. Inspection, Auscultation, Percussion, Palpation
66. D. RLQ,RUQ,LUQ,LLQ
67. B. Knees and legs are straighten to relax the abdomen
68. D. Darken the room to provide better illumination
69. D. To ensure that the procedure is done in an ethical manner
70. A. Supine
71. A. Early morning
72. B. Discard the first flow of urine to ensure that the urine is not contaminated
73. A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the
urine in the 24 hour urine specimen
74. D. Second voided urine
75. C. Before meals
76. B. Clamp below the port for 30 to 60 minutes before drawing the urine from the
port
77. C. Benedict’s test
78. B. The nurse heats the test tube after adding 1/3 part acetic acid
79. D. If the color remains BLUE, the result is POSITIVE
80. D. Orange
81. A. Specimen is collected after meals
82. A. Avoid turnips, radish and horseradish 3 days before procedure
83. C. Ask the client to call her for the specimen after the client wiped off his anus
with a tissue
84. C. Rinse the client’s mouth with Listerine after collection
85. B. Medical technologist
86. B. NPO for 12 hours pre procedure
87. A. Metabolism
88. C. Hypothalamus
89. B. Conduction
90. C. Stress
91. A. Patient’s lifestyle
92. D. Lithotomy
93. A. Dorsal recumbent
94. A. Dorsal recumbent
95. B. Sims position
96. C. Use sterile syringe to aspirate urine specimen from the drainage port
97. C. Collect 5 to 10 ml for urine
98. A. At the client’s back
99. A. Standing
100. A. Sitting
PNLE: FON Practice Exam for
Oxygenation and Nutrition
1. Which one of the following is NOT a function of the Upper airway?
A. Cilia
B. Nares
C. Carina
D. Vibrissae
3. This is the paranasal sinus found between the eyes and the nose that
extends backward into the skull
A. Ehtmoid
B. Sphenoid
C. Maxillary
D. Frontal
4. Which paranasal sinus is found over the eyebrow?
A. Ehtmoid
B. Sphenoid
C. Maxillary
D. Frontal
5. Gene De Vonne Katrouchuacheulujiki wants to change her surname to
something shorter, The court denied her request which depresses her and find
herself binge eating. She accidentally aspirate a large piece of nut and it
passes the carina. Probabilty wise, Where will the nut go?
A. Type I pneumocytes
B. Type II pneumocytes
C. Goblet cells
D. Adipose cells
7. How many lobes are there in the RIGHT LUNG?
A. One
B. Two
C. Three
D. Four
8. The presence of the liver causes which anatomical difference of the
Kidneys and the Lungs?
A. Type I pneumocytes
B. Type II pneumocytes
C. Goblet cells
D. Adipose cells
10. The normal L:S Ratio to consider the newborn baby viable is
A. 1:2
B. 2:1
C. 3:1
D. 1:3
11. Refers to the extra air that can be inhaled beyond the normal tidal volume
A. Lungs
B. Intercostal Muscles
C. Diaphragm
D. Pectoralis major
15. Cassandra asked you : How many air is there in the oxygen and how many
does human requires? Which of the following is the best response :
A. God is good, Man requires 21% of oxygen and we have 21% available in
our air
B. Man requires 16% of oxygen and we have 35% available in our air
C. Man requires 10% of oxygen and we have 50% available in our air
D. Human requires 21% of oxygen and we have 21% available in our air
16. Which of the following is TRUE about Expiration?
A. A passive process
B. The length of which is half of the length of Inspiration
C. Stridor is commonly heard during expiration
D. Requires energy to be carried out
17. Which of the following is TRUE in postural drainage?
A. Mucolytic
B. Warm and humidify air
C. Administer medications
D. Promote bronchoconstriction
19. Which of the following is NOT TRUE in steam inhalation?
A. As desired
B. As needed
C. Every 1 hour
D. Every 4 hours
21. Ernest Arnold Hamilton, a 60 year old American client was mobbed by
teen gangsters near New york, Cubao. He was rushed to John John Hopio
Medical Center and was Unconscious. You are his nurse and you are to
suction his secretions. In which position should you place Mr. Hamilton?
A. High fowlers
B. Semi fowlers
C. Prone
D. Side lying
22. You are about to set the suction pressure to be used to Mr. Hamilton. You
are using a Wall unit suction machine. How much pressure should you set the
valve before suctioning Mr. Hamilton?
A. 50-95 mmHg
B. 200-350 mmHg
C. 100-120 mmHg
D. 10-15 mmHg
23. The wall unit is not functioning; You then try to use the portable suction
equipment available. How much pressure of suction equipment is needed to
prevent trauma to mucus membrane and air ways in case of portable suction
units?
A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 15-25 mmHg
24. There are four catheter sizes available for use, which one of these should
you use for Mr. Hamilton?
A. Fr. 18
B. Fr. 12
C. Fr. 10
D. Fr, 5
25. Which of the following, if done by the nurse, indicates incompetence
during suctioning an unconscious client?
1. Tachypnea
2. Tachycardia
3. Cyanosis
4. Pallor
5. Irritability
6. Flaring of NaresA. 1,2
B. 2,5
C. 2,6
D. 3,4
27. Which method of oxygenation least likely produces anxiety and
apprehension?
A. Nasal Cannula
B. Simple Face mask
C. Non Rebreather mask
D. Partial Rebreather mask
28. Which of the following oxygen delivery method can deliver 100% Oxygen at
15 LPM?
A. Nasal Cannula
B. Simple Face mask
C. Non Rebreather mask
D. Partial Rebreather mask
29. Which of the following is not true about OXYGEN?
A. Pancytopenia
B. Anemia
C. Fingers are Club-like
D. Hematocrit of client is decreased
33. The best method of oxygen administration for client with COPD uses:
A. Cannula
B. Simple Face mask
C. Non rebreather mask
D. Venturi mask
34. Mang dagul, a 50 year old chronic smoker was brought to the E.R because
of difficulty in breathing. Pleural effusion was the diagnosis and CTT was
ordered. What does C.T.T Stands for?
A. 2nd ICS
B. 4th ICS
C. 5th ICS
D. 8th ICS
36. There is a continuous bubbling in the water sealed drainage system with
suction. And oscillation is observed. As a nurse, what should you do?
A. Consider this as normal findings
B. Notify the physician
C. Check for tube leak
D. Prepare a petrolatum gauze dressing
37. Which of the following is true about nutrition?
A. It is the process in which food are broken down, for the body to use in
growth and development
B. It is a process in which digested proteins, fats, minerals, vitamins and
carbohydrates are transported into the circulation
C. It is a chemical process that occurs in the cell that allows for energy
production, energy use, growth and tissue repair
D. It is the study of nutrients and the process in which they are use by the
body
38. The majority of the digestion processes take place in the
A. Mouth
B. Small intestine
C. Large intestine
D. Stomach
39. All of the following is true about digestion that occurs in the Mouth except
A. Mouth
B. Esophagus
C. Small intestine
D. Stomach
42. Protein and Fat digestion begins where?
A. Mouth
B. Esophagus
C. Small intestine
D. Stomach
43. All but one is true about digestion that occurs in the Stomach
A. Sucrase
B. Enterokinase
C. Amylase
D. Enterokinase
45. The hormone secreted by the Small intestine that stimulates the
production of pancreatic juice which primarily aids in buffering the acidic
bolus passed by the Stomach
A. Enterogastrone
B. Cholecystokinin
C. Pancreozymin
D. Enterokinase
46. When the duodenal enzyme sucrase acts on SUCROSE, which 2
monosaccharides are formed?
A. Galactose + Galactose
B. Glucose + Fructose
C. Glucose + Galactose
D. Fructose + Fructose
47. This is the enzyme secreted by the pancrease that completes the protein
digestion
A. Trypsin
B. Enterokinase
C. Enterogastrone
D. Amylase
48. The end product of protein digestion or the “Building blocks of Protein” is
what we call
A. Nucleotides
B. Fatty acids
C. Glucose
D. Amino Acids
49. Enzyme secreted by the small intestine after it detects a bolus of fatty
food. This will contract the gallbladder to secrete bile and relax the sphincter
of Oddi to aid in the emulsification of fats and its digestion.
A. Lipase
B. Amylase
C. Cholecystokinin
D. Pancreozymin
50. Which of the following is not true about the Large Intestine?
A. It absorbs around 1 L of water making the feces around 75% water and
25% solid
B. The stool formed in the transverse colon is not yet well formed
C. It is a sterile body cavity
D. It is called large intestine because it is longer than the small intestine
51. This is the amount of heat required to raise the temperature of 1 kg water
to 1 degree Celsius
A. Calorie
B. Joules
C. Metabolism
D. Basal metabolic rate
52. Assuming a cup of rice provides 50 grams of carbohydrates. How many
calories are there in that cup of rice?
A. 150 calories
B. 200 calories
C. 250 calories
D. 400 calories
53. An average adult filipino requires how many calories in a day?
A. 1,000 calories
B. 1,500 calories
C. 2,000 calories
D. 2,500 calories
54. Which of the following is true about an individual’s caloric needs?
A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6
57. Which Vitamin is not given in conjunction with the intake of LEVODOPA in
cases of Parkinson’s Disease due to the fact that levodopa increases its level
in the body?
A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6
58. A vitamin taken in conjunction with ISONIAZID to prevent peripheral
neuritis
A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6
59. The inflammation of the Lips, Palate and Tongue is associated in the
deficiency of this vitamin
A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6
60. Beri beri is caused by the deficiency of which Vitamin?
A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin C
61. Which of the following is the best source of Vitamin E?
A. Zinc
B. Iron
C. Selenium
D. Vanadium
66. Incident of prostate cancer is found to have been reduced on a population
exposed in tolerable amount of sunlight. Which vitamin is associated with this
phenomenon?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
67. Micronutrients are those nutrients needed by the body in a very minute
amount. Which of the following vitamin is considered as a MICRONUTRIENT
A. Phosphorous
B. Iron
C. Calcium
D. Sodium
68. Deficiency of this mineral results in tetany, osteomalacia, osteoporosis
and rickets.
A. Vitamin D
B. Iron
C. Calcium
D. Sodium
69. Among the following foods, which has the highest amount of potassium
per area of their meat?
A. Cantaloupe
B. Avocado
C. Raisin
D. Banana
70. A client has HEMOSIDEROSIS. Which of the following drug would you
expect to be given to the client?
A. Acetazolamide
B. Deferoxamine
C. Calcium EDTA
D. Activated charcoal
71. Which of the following provides the richest source of Iron per area of their
meat?
A. Pork meat
B. Lean read meat
C. Pork liver
D. Green mongo
72. Which of the following is considered the best indicator of nutritional status
of an individual?
A. Height
B. Weight
C. Arm muscle circumference
D. BMI
73. Jose Miguel, a 50 year old business man is 6’0 Tall and weights 179 lbs.
As a nurse, you know that Jose Miguel is :
A. Overweight
B. Underweight
C. Normal
D. Obese
74. Jose Miguel is a little bit nauseous. Among the following beverages,
Which could help relieve JM’s nausea?
A. Coke
B. Sprite
C. Mirinda
D. Orange Juice or Lemon Juice
75. Which of the following is the first sign of dehydration?
A. Tachycardia
B. Restlessness
C. Thirst
D. Poor skin turgor
76. What Specific gravity lab result is compatible with a dehydrated client?
A. 1.007
B. 1.020
C. 1.039
D. 1.029
77. Which hematocrit value is expected in a dehydrated male client?
A. 67%
B. 50%
C. 36%
D. 45%
78. Which of the following statement by a client with prolonged vomiting
indicates the initial onset of hypokalemia?
A. Marinol
B. Dramamine
C. Benadryl
D. Alevaire
80. Which is not a clear liquid diet?
A. Hard candy
B. Gelatin
C. Coffee with Coffee mate
D. Bouillon
81. Which of the following is included in a full liquid diet?
A. Popsicles
B. Pureed vegetable meat
C. Pineapple juice with pulps
D. Mashed potato
82. Which food is included in a BLAND DIET?
A. Steamed broccoli
B. Creamed potato
C. Spinach in garlic
D. Sweet potato
83. Which of the following if done by the nurse, is correct during NGT
Insertion?
A. 250 cc
B. 290 cc
C. 350 cc
D. 310 cc
87. Which of the following if done by a nurse indicates deviation from the
standards of NGT feeding?
A. Do not give the feeding and notify the doctor of residual of the last
feeding is greater than or equal to 50 ml
B. Height of the feeding should be 12 inches about the tube point of
insertion to allow slow introduction of feeding
C. Ask the client to position in supine position immediately after feeding to
prevent dumping syndrome
D. Clamp the NGT before all of the water is instilled to prevent air entry in
the stomach
88. What is the most common problem in TUBE FEEDING?
A. Diarrhea
B. Infection
C. Hyperglycemia
D. Vomiting
89. Which of the following is TRUE in colostomy feeding?
A. Hold the syringe 18 inches above the stoma and administer the feeding
slowly
B. Pour 30 ml of water before and after feeding administration
C. Insert the ostomy feeding tube 1 inch towards the stoma
D. A Pink stoma means that circulation towards the stoma is all well
90. A client with TPN suddenly develops tremors, dizziness, weakness and
diaphoresis. The client said “I feel weak” You saw that his TPN is already
empty and another TPN is scheduled to replace the previous one but its
provision is already 3 hours late. Which of the following is the probable
complication being experienced by the client?
A. Hyperglycemia
B. Hypoglycemia
C. Infection
D. Fluid overload
91. To assess the adequacy of food intake, which of the following
assessment parameters is best used?
A. Medulla Oblongata
B. Pons
C. Hypothalamus
D. Cerebellum
93. The most threatening complication of vomiting in client’s with stroke is
A. Aspiration
B. Dehydration
C. Fluid and electrolyte imbalance
D. Malnutrition
94. Which among this food is the richest source of Iron?
A. Ampalaya
B. Broccoli
C. Mongo
D. Malunggay leaves
95. Which of the following is a good source of Vitamin A?
A. Egg yolk
B. Liver
C. Fish
D. Peanuts
96. The most important nursing action before gastrostomy feeding is
A. Check V/S
B. Assess for patency of the tube
C. Measure residual feeding
D. Check the placement of the tube
97. The primary advantage of gastrostomy feeding is
A. 20
B. 19
C. 15
D. 25
99. Which finding is consistent with PERNICIOUS ANEMIA?
A. Strawberry tongue
B. Currant Jelly stool
C. Beefy red tongue
D. Pale [ HYPOCHROMIC ] RBC
100. The nurse is browsing the chart of the patient and notes a normal serum
lipase level. Which of the following is a normal serum lipase value?
A. 10 U/L
B. 100 U/L
C. 200 U/L
D. 350 U/L
Answers
1. A. For clearance mechanism such as coughing
2. D. Vibrissae
3. A. Ehtmoid
4. D. Frontal
5. A. Right main stem bronchus
6. C. Goblet cells
7. C. Three
8. C. Right kidney lower, Right lung shorter
9. B. Type II pneumocytes
10. B. 2:1
11. A. Inspiratory reserve volume
12. D. Residual volume
13. B. We have 12 pairs of ribs Cassandra
14. C. Diaphragm
15. D. Human requires 21% of oxygen and we have 21% available in our air
16. A. A passive process
17. A. Patient assumes position for 10 to 15 minutes
18. D. Promote bronchoconstriction
19. C. Render steam inhalation for atleast 60 minutes
20. B. As needed
21. D. Side lying
22. C. 100-120 mmHg
23. C. 10-15 mmHg
24. A. Fr. 18
25. A. Measure the length of the suction catheter to be inserted by measuring from
the tip of the nose, to the earlobe, to the xiphoid process
26. B. 2,5
27. A. Nasal Cannula
28. C. Non Rebreather mask
29. D. Excessive oxygen administration results in respiratory acidosis
30. B. Put a non rebreather mask in the patient before opening the oxygen source
31. D. Client is frequently turning from side to side
32. C. Fingers are Club-like
33. A. Cannula
34. C. Closed tube thoracotomy
35. D. 8th ICS
36. A. Consider this as normal findings
37. D. It is the study of nutrients and the process in which they are use by the body
38. B. Small intestine
39. C. The action of ptyalin or the salivary tyrpsin breaks down starches into
maltose
40. D. Coffee with coffee mate, Bacon and Egg
41. A. Mouth
42. D. Stomach
43. C. HCl inhibits absorption of Calcium in the gastric mucosa
44. C. Amylase
45. C. Pancreozymin
46. B. Glucose + Fructose
47. A. Trypsin
48. D. Amino Acids
49. C. Cholecystokinin
50. C. It is a sterile body cavity
51. A. Calorie
52. B. 200 calories
53. C. 2,000 calories
54. C. During cold weather, people need more calories due to increase BMR
55. A. An individual in a long state of gluconeogenesis
56. C. Vitamin B3
57. D. Vitamin B6
58. D. Vitamin B6
59. B. Vitamin B2
60. A. Vitamin B1
61. B. Vegetable oil
62. A. Pork liver and organ meats, Pork
63. D. Organ meats, Green leafy vegetables, Liver, Eggs
64. A. Spinach, Green leafy vegetables, Cabbage, Liver
65. C. Selenium
66. D. Vitamin D
67. B. Iron
68. C. Calcium
69. A. Cantaloupe
70. B. Deferoxamine
71. C. Pork liver
72. B. Weight
73. C. Normal
74. A. Coke
75. C. Thirst
76. C. 1.039
77. A. 67%
78. D. Nurse, help! My legs are cramping
79. D. Alevaire
80. C. Coffee with Coffee mate
81. A. Popsicles
82. B. Creamed potato
83. B. Measure the amount of the tube to be inserted from the Tip of the nose, to
the earlobe, to the xiphoid process
84. A. X-Ray
85. B. Bring the client into a chair
86. D. 310 cc
87. C. Ask the client to position in supine position immediately after feeding to
prevent dumping syndrome
88. A. Diarrhea
89. B. Pour 30 ml of water before and after feeding administration
90. B. Hypoglycemia
91. C. 3 day diet recall
92. A. Medulla Oblongata
93. A. Aspiration
94. C. Mongo
95. B. Liver
96. B. Assess for patency of the tube
97. C. Maintains Gastro esophageal sphincter integrity
98. B. 19
99. C. Beefy red tongue
100. C. 200 U/L
A. Wheezes
B. Rhonchi
C. Gurgles
D. Vesicular
3. The nurse in charge measures a patient’s temperature at 101 degrees F.
What is the equivalent centigrade temperature?
A. 36.3 degrees C
B. 37.95 degrees C
C. 40.03 degrees C
D. 38.01 degrees C
4. Which approach to problem solving tests any number of solutions until one
is found that works for that particular problem?
A. Intuition
B. Routine
C. Scientific method
D. Trial and error
5. What is the order of the nursing process?
A. Accuracy
B. Legibility
C. Concern for privacy
D. Rapid communication
11. The theorist who believes that adaptation and manipulation of stressors
are related to foster change is:
A. Dorothea Orem
B. Sister Callista Roy
C. Imogene King
D. Virginia Henderson
12. Formulating a nursing diagnosis is a joint function of:
A. Cultural belief
B. Personal belief
C. Health belief
D. Superstitious belief
14. Becky is on NPO since midnight as preparation for blood test. Adreno-
cortical response is activated. Which of the following is an expected
response?
A. Manager
B. Caregiver
C. Patient advocate
D. Educator
20. Which data would be of greatest concern to the nurse when completing
the nursing assessment of a 68-year-old woman hospitalized due to
Pneumonia?
A. 30 degrees
B. 90 degrees
C. 45 degrees
D. 0 degree
Answers and Rationales
1. 1. (C) Respiratory rate greater than 20 breaths per minute. A respiratory rate
of greater than 20 breaths per minute is tachypnea. A blood pressure of
140/90 is considered hypertension. Pulse greater than 100 beats per
minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel
sounds.
2. (A) Wheezes. Wheezes are indicated by continuous, lengthy, musical;
heard during inspiration or expiration. Rhonchi are usually coarse breath
sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath
sounds are low pitch, soft intensity on expiration.
4. (D) Trial and error. The trial and error method of problem solving isn’t
systematic (as in the scientific method of problem solving) routine, or
based on inner prompting (as in the intuitive method of problem solving).
5. (C) Assessing, diagnosing, planning, implementing, evaluating. The correct
order of the nursing process is assessing, diagnosing, planning,
implementing, evaluating.
6. (C) Nursing care plan. The outcome, or the product of the planning phase
of the nursing process is a Nursing care plan.
7. (C) Client verbalized, “I feel pain when urinating.”. Subjective data are
those that can be described only by the person experiencing it. Therefore,
only the patient can describe or verify whether he is experiencing pain or
not.
8. (C) “The patient will identify all the high-salt food from a prepared list by
discharge.”. Expected outcomes are specific, measurable, realistic
statements of goal attainment. The phrases “right amount”, “less
nauseated” and “enough sleep” are vague and not measurable.
9. (C) She signs on the medication sheet after administering the medication.A
nurse should record a nursing intervention (ex. Giving medications) after
performing the nursing intervention (not before). Recording should also be
done using a pen, be complete, and signed with the nurse’s full name and
title.
10. (C) Concern for privacy. A patient’s privacy may be violated if security
measures aren’t used properly or if policies and procedures aren’t in place
that determines what type of information can be retrieved, by whom, and
for what purpose.
11. (B) Sister Callista Roy. Sister Roy’s theory is called the adaptation theory
and she viewed each person as a unified biophysical system in constant
interaction with a changing environment. Orem’s theory is called self-care
deficit theory and is based on the belief that individual has a need for self-
care actions. King’s theory is the Goal attainment theory and described
nursing as a helping profession that assists individuals and groups in
society to attain, maintain, and restore health. Henderson introduced the
nature of nursing model and identified the 14 basic needs.
12. (B) Nurse and patient. Although diagnosing is basically the nurse’s
responsibility, input from the patient is essential to formulate the correct
nursing diagnosis.
13. (C) Health belief. Health belief of an individual influences his/her
preventive health behavior.
14. (D) Decreased urine output. Adreno-cortical response involves release of
aldosterone that leads to retention of sodium and water. This results to
decreased urine output.
15. (D) Aspirate urine from the tubing port using a sterile syringe. The nurse
should aspirate the urine from the port using a sterile syringe to obtain a
urine specimen. Opening a closed drainage system increase the risk of
urinary tract infection.
16. (A) Stop the infusion. The sign and symptoms indicate extravasation so
the IVF should be stopped immediately and put warm not cold towel on
the affected site.
17. (B) After few minutes, return to that patient’s room and do not leave until the
patient takes the medication. This is to verify or to make sure that the
medication was taken by the patient as directed.
18. (A) Place the feeding 20 inches above the pint if insertion of NGT. The height
of the feeding is above 12 inches above the point of insertion, bot 20
inches. If the height of feeding is too high, this results to very rapid
introduction of feeding. This may trigger nausea and vomiting.
19. (D) Educator. When teaching a patient about medications before
discharge, the nurse is acting as an educator. A caregiver provides direct
care to the patient. The nurse acts as s patient advocate when making the
patient’s wishes known to the doctor.
20. (C) Capillary refill greater than 3 seconds and buccal cyanosis. Capillary refill
greater than 3 seconds and buccal cyanosis indicate decreased oxygen to
the tissues which requires immediate attention/intervention. Oriented to
date, time and place, hemoglobin of 13 g/dl are normal data.
21. (C) Patient’s NGT was removed 2 hours ago. The change-of-shift report
should indicate significant recent changes in the patient’s condition that
the nurse assuming responsibility for care of the patient will need to
monitor. The other options are not critical enough to include in the report.
22. (A) “The patient will experience decreased frequency of bowel
elimination.” The goal is the opposite, healthy response of the problem
statement of the nursing diagnosis. In this situation, the problem
statement is diarrhea.
23. (C) Making of individualized patient care. To be effective, the nursing care
plan developed in the planning phase of the nursing process must reflect
the individualized needs of the patient.
24. (A) Ineffective breathing pattern related to pain, as evidenced by shortness of
breath.. Physiologic needs (ex. Oxygen, fluids, nutrition) must be met
before lower needs (such as safety and security, love and belongingness,
self-esteem and self-actualization) can be met. Therefore, physiologic
needs have the highest priority.
25. (D) 0 degree. The patient should be positioned with the head of the bed
completely flattened to perform an abdominal examination. If the head of
the bed is elevated, the abdominal muscles and organs can be bunched
up, altering the findings
PNLE: Fundamentals in Nursing
Exam 2
1. A patient is wearing a soft wrist-safety device. Which of the following
nursing assessment is considered abnormal?
A. broccoli
B. sardines
C. cabbage
D. tomatoes
3. Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces of his
formula this morning.” This statement is an example of:
A. Hypethermia
B. Diabetes Mellitus
C. Angina
D. Chronic Renal Failure
5. What is the characteristic of the nursing process?
A. stagnant
B. inflexible
C. asystematic
D. goal-oriented
6. A skin lesion which is fluid-filled, less than 1 cm in size is called:
A. papule
B. vesicle
C. bulla
D. macule
7. During application of medication into the ear, which of the following is
inappropriate nursing action?
A. livor mortis
B. rigor mortis
C. algor mortis
D. none of the above
10. When performing an admission assessment on a newly admitted patient,
the nurse percusses resonance. The nurse knows that resonance heard on
percussion is most commonly heard over which organ?
A. thigh
B. liver
C. intestine
D. lung
11. The nurse is aware that Bell’s palsy affects which cranial nerve?
A. 2nd CN (Optic)
B. 3rd CN (Occulomotor)
C. 4th CN (Trochlear)
D. 7th CN (Facial)
12. Prolonged deficiency of Vitamin B9 leads to:
A. scurvy
B. pellagra
C. megaloblastic anemia
D. pernicious anemia
13. Nurse Cherry is teaching a 72 year old patient about a newly prescribed
medication. What could cause a geriatric patient to have difficulty retaining
knowledge about the newly prescribed medication?
A. Independent
B. Dependent
C. Collaborative
D. Professional
15. Claire is admitted with a diagnosis of chronic shoulder pain. By definition,
the nurse understands that the patient has had pain for more than:
A. 3 months
B. 6 months
C. 9 months
D. 1 year
16. Which of the following statements regarding the nursing process is true?
A. It is useful on outpatient settings.
B. It progresses in separate, unrelated steps.
C. It focuses on the patient, not the nurse.
D. It provides the solution to all patient health problems.
17. Which of the following is considered significant enough to require
immediate communication to another member of the health care team?
A. food preferences
B. regularity of meal times
C. 3-day diet recall
D. eating style and habits
19. Van Fajardo is a 55 year old who was admitted to the hospital with newly
diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo.
What kind of role does the nurse assume?
A. talker
B. teacher
C. thinker
D. doer
20. When providing a continuous enteral feeding, which of the following action
is essential for the nurse to do?
A. depression
B. bargaining
C. denial
D. acceptance
23. Immunization for healthy babies and preschool children is an example of
what level of preventive health care?
A. Primary
B. Secondary
C. Tertiary
D. Curative
24. Which is an example of a subjective data?
A. Temperature of 38 0C
B. Vomiting for 3 days
C. Productive cough
D. Patient stated, “My arms still hurt.”
25. The nurse is assessing the endocrine system. Which organ is part of the
endocrine system?
A. Heart
B. Sinus
C. Thyroid
D. Thymus
Answers and Rationales
1. (D) Bluish fingernails, cool and pale fingers. A safety device on the wrist
may impair blood circulation. Therefore, the nurse should assess the
patient for signs of impaired circulation such as bluish fingernails, cool
and pale fingers. Palpable radial and ulnar pulses, capillary refill within 3
seconds are all normal findings.
2. (B) sardines. The normal serum sodium level is 135 to 145 mEq/L, the
client is having hypernatremia. Pia should avoid food high in sodium like
processed food. Broccoli, cabbage and tomatoes are good source of
Vitamin C.
3. (A) objective data from a secondary source. Jason is the primary source; his
mother is a secondary source. The data is objective because it can be
perceived by the senses, verified by another person observing the same
patient, and tested against accepted standards or norms.
4. (A) Hypethermia. Hyperthermia is a NANDA-approved nursing diagnosis.
Diabetes Mellitus, Angina and Chronic Renal Failure are medical
diagnoses.
5. (D) goal-oriented. The nursing process is goal-oriented. It is also
systematic, patient-centered, and dynamic.
6. (B) vesicle. Vesicle is a circumscribed circulation containing serous fluid
or blood and less than 1 cm (ex. Blister, chicken pox).
7. (B) Instill the medication directly into the tympanic membrane. During the
application of medication it is inappropriate to instill the medication
directly into the tympanic membrane. The right thing to do is instill the
medication along the lateral wall of the auditory canal.
8. (B) Provide opportunity to the client to tell their story. Providing a grieving
person an opportunity to tell their story allows the person to express
feelings. This is therapeutic in assisting the client resolve grief.
9. (C) algor mortis. Algor mortis is the decrease of the body’s temperature
after death. Livor mortis is the discoloration of the skin after death. Rigor
mortis is the stiffening of the body that occurs about 2-4 hours after
death.
10. (D) lung. Resonance is loud, low-pitched and long duration that’s heard
most commonly over an air-filled tissue such as a normal lung.
11. (D) 7th CN (Facial). Bells’ palsy is the paralysis of the motor component
of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid
or the mouth, drooling, flat nasolabial fold and loss of taste on the
affected side of the face.
12. (C) megaloblastic anemia. Prolonged Vitamin B9 deficiency will lead to
megaloblastic anemia while pernicious anemia results in deficiency in
Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and
Pellagra results in deficiency in Vitamin B3.
13. (B) Decreased sensory functions. Decreased in sensory functions could
cause a geriatric patient to have difficulty retaining knowledge about the
newly prescribed medications. Absence of family support and no interest
on learning may affect compliance, not knowledge retention. Decreased
plasma levels do not alter patient’s knowledge about the drug.
14. (A) Independent. Independent nursing interventions involve actions that
nurses initiate based on their own knowledge and skills without the
direction or supervision of another member of the health care team.
15. (B) 6 months. Chronic pain s usually defined as pain lasting longer than 6
months.
16. (C) It focuses on the patient, not the nurse. The nursing process is patient-
centered, not nurse-centered. It can be use in any setting, and the steps
are related. The nursing process can’t solve all patient health problems.
17. (B) Diminished breath sounds in patient with previously normal breath
sounds. Diminished breath sound is a life threatening problem therefore it
is highly priority because they pose the greatest threat to the patient’s
well-being.
18. (C) 3-day diet recall. 3-day diet recall is an example of dietary history.
This is used to indicate the adequacy of food intake of the client.
19. (B) teacher. The nurse will assume the role of a teacher in this
therapeutic relationship. The other roles are inappropriate in this situation.
20. (C) Elevate the head of the bed. Elevating the head of the bed during an
enteral feeding prevents aspiration. The patient may be placed on the right
side to prevent aspiration. Enteral feedings are given at room temperature
to lessen GI distress. The enteral tubing should be changed every 24 hours
to limit microbial growth.
21. (D) Increased rate and depth of respiration. Kussmaul breathing is also
called as hyperventilation. Seen in metabolic acidosis and renal failure.
Option A refers to Biot’s breathing. Option B is apneustic breathing and
option C is the Cheyne-stokes breathing.
22. (C) denial. The client is in denial stage because she is unready to face
the reality that loss is happening and she assumes artificial cheerfulness.
23. (A) Primary. The primary level focuses on health promotion. Secondary
level focuses on health maintenance. Tertiary focuses on rehabilitation.
There is n Curative level of preventive health care problems.
24. (D) Patient stated, “My arms still hurt.”. Subjective data are apparent only
to the person affected and can or verified only by that person.
25. (C) Thyroid. The thyroid is part of the endocrine system. Heart, sinus and
thymus are not.
PNLE: Fundamentals in Nursing
Exam 3
1. Nurse Brenda is teaching a patient about a newly prescribed drug. What
could cause a geriatric patient to have difficulty retaining knowledge about
prescribed medications?
A. Vital signs
B. Laboratory test result
C. Patient’s description of pain
D. Electrocardiographic (ECG) waveforms
4. A male patient has a soft wrist-safety device. Which assessment finding
should the nurse consider abnormal?
A. Frontal plane
B. Sagittal plane
C. Midsagittal plane
D. Transverse plane
6. A female patient with a terminal illness is in denial. Indicators of denial
include:
A. Shock dismay
B. Numbness
C. Stoicism
D. Preparatory grief
7. The nurse in charge is transferring a patient from the bed to a chair. Which
action does the nurse take during this patient transfer?
A. Manager
B. Educator
C. Caregiver
D. Patient advocate
12. A female patient exhibits signs of heightened anxiety. Which response by
the nurse is most likely to reduce the patient’s anxiety?
A. ¼ ml
B. ½ ml
C. ¾ ml
D. 1 ¼ ml
16. The nurse in charge measures a patient’s temperature at 102 degrees F.
what is the equivalent Centigrade temperature?
A. 39 degrees C
B. 47 degrees C
C. 38.9 degrees C
D. 40.1 degrees C
17. To evaluate a patient for hypoxia, the physician is most likely to order
which laboratory test?
A. Within 1 month
B. Within 3 months
C. Within 6 months
D. Within 12 months
20. Which human element considered by the nurse in charge during
assessment can affect drug administration?
A. Ask the child, “Do you want me to start the I.V. now?”
B. Give simple directions shortly before the I.V. therapy is to start
C. Tell the child, “This treatment is for your own good”
D. Inform the child that the needle will be in place for 10 days
22. All of the following parts of the syringe are sterile except the:
A. Barrel
B. Inside of the plunger
C. Needle tip
D. Barrel tip
23. The best way to instill eye drops is to:
A. Instruct the patient to lock upward, and drop the medication into the
center of the lower lid
B. Instruct the patient to look ahead, and drop the medication into the
center of the lower lid
C. Drop the medication into the inner canthus regardless of eye position
D. Drop the medication into the center of the canthus regardless of eye
position
24. The difference between an 18G needle and a 25G needle is the needle’s:
A. Length
B. Bevel angle
C. Thickness
D. Sharpness
25. A patient receiving an anticoagulant should be assessed for signs of:
A. Hypotension
B. Hypertension
C. An elevated hemoglobin count
D. An increased number of erythrocytes
Answers and Rationales
1. (B) Sensory deficits. Sensory deficits could cause a geriatric patient to
have difficulty retaining knowledge about prescribed medications.
Decreased plasma drug levels do not alter the patient’s knowledge about
the drug. A lack of family support may affect compliance, not knowledge
retention. Toilette syndrome is unrelated to knowledge retention.
2. (C) The symptomatic quadrant last. The nurse should systematically
assess all areas of the abdomen, if time and the patient’s condition permit,
concluding with the symptomatic area. Otherwise, the nurse may elicit
pain in the symptomatic area, causing the muscles in other areas to
tighten. This would interfere with further assessment.
3. (C) Patient’s description of pain. Subjective data come directly from the
patient and usually are recorded as direct quotations that reflect the
patient’s opinions or feelings about a situation. Vital signs, laboratory test
result, and ECG waveforms are examples of objective data.
4. (C) Cool, pale fingers. A safety device on the wrist may impair circulation
and restrict blood supply to body tissues. Therefore, the nurse should
assess the patient for signs of impaired circulation, such as cool, pale
fingers. A palpable radial or lunar pulse and pink nail beds are normal
findings.
5. (A) Frontal plane. Frontal or coronal plane runs longitudinally at a right
angle to a sagittal plane dividing the body in anterior and posterior
regions. A sagittal plane runs longitudinally dividing the body into right and
left regions; if exactly midline, it is called a midsagittal plane. A transverse
plane runs horizontally at a right angle to the vertical axis, dividing the
structure into superior and inferior regions.
6. (A) Shock dismay. Shock and dismay are early signs of denial-the first
stage of grief. The other options are associated with depression—a later
stage of grief.
7. (B) Helps the patient dangle the legs. After placing the patient in high
Fowler’s position and moving the patient to the side of the bed, the nurse
helps the patient sit on the edge of the bed and dangle the legs; the nurse
then faces the patient and places the chair next to and facing the head of
the bed.
8. (D) Demonstrating the procedure and having the patient return the
demonstration. Demonstrating by the nurse with a return demonstration by
the patient ensures that the patient can perform wound care correctly.
Patients may claim to understand discharge instruction when they do not.
An interpreter of family member may communicate verbal or written
instructions inaccurately.
9. (A) Discard the syringe to avoid a medication error. As a safety precaution,
the nurse should discard an unlabeled syringe that contains medication.
The other options are considered unsafe because they promote error.
10. (B) Aging-related physiological changes. Aging-related physiological
changes account for the increased frequency of adverse drug reactions in
geriatric patients. Renal and hepatic changes cause drugs to clear more
slowly in these patients. With increasing age, neurons are lost and blood
flow to the GI tract decreases.
11. (B) Educator. When teaching a patient about medications before
discharge, the nurse is acting as an educator. The nurse acts as a
manager when performing such activities as scheduling and making
patient care assignments. The nurse performs the care giving role when
providing direct care, including bathing patients and administering
medications and prescribed treatments. The nurse acts as a patient
advocate when making the patient’s wishes known to the doctor.
12. (D) “Let’s talk about what’s bothering you.” Anxiety may result from feeling
of helplessness, isolation, or insecurity. This response helps reduce
anxiety by encouraging the patient to express feelings. The nurse should
be supportive and develop goals together with the patient to give the
patient some control over an anxiety-inducing situation. Because the other
options ignore the patient’s feeling and block communication, they would
not reduce anxiety.
13. (C) Handling surgical instruments to the surgeon. The scrub nurse assist the
surgeon by providing appropriate surgical instruments and supplies,
maintaining strict surgical asepsis and, with the circulating nurse,
accounting for all gauze, sponges, needles, and instruments. The
circulating nurse assists the surgeon and scrub nurse, positions the
patient, applies appropriate equipment and surgical drapes, assists with
gowning and gloving, and provides the surgeon and scrub nurse with
supplies.
14. (C) Return shortly to the patient’s room and remain there until the patient takes
the medication. The nurse should return shortly to the patient’s room and
remain there until the patient takes the medication to verify that it was
taken as directed. The nurse should never leave medication at the
patient’s bedside unless specifically requested to do so.
15. (C) ¾ ml. The nurse solves the problem as follows: 10,000 units/7,500
units = 1 ml/X 10,000 X = 7,500 X= 7,500/10,000 or ¾ ml
16. (C) 38.9 degrees C. To convert Fahrenheit degrees to centigrade, use this
formula: C degrees = (F degrees – 32) x 5/9 C degrees = (102 – 32) 5/9 +
70 x 5/9 38.9 degrees C
17. (D) Arterial blood gas (ABG) analysis. All of these test help evaluate a
patient with respiratory problems. However, ABG analysis is the only test
evaluates gas exchange in the lungs, providing information about patient’s
oxygenation status.
18. (B) The diaphragm detects high-pitched sounds best. The diaphragm of a
stethoscope detects high-pitched sound best; the bell detects low pitched
sounds best. Palpation detects thrills best.
19. (C) Within 6 months. In most cases, an outpatient must fill a prescription
for a controlled substance within 6 months of the date on which the
prescription was written.
20. (D) The patient’s cognitive abilities. The nurse must consider the patient’s
cognitive abilities to understand drug instructions. If not, the nurse must
find a family member or significant other to take on the responsibility of
administering medications in the home setting. The patient’s ability to
recover, occupational hazards, and socioeconomic status do not affect
drug administration.
21. (B) Give simple directions shortly before the I.V. therapy is to start. Because
a 2-year-old child has limited understanding, the nurse should give simple
directions and explanations of what will occur shortly before the
procedure. She should try to avoid frightening the child with the
explanation and allow the child to make simple choices, such as choosing
the I.V. insertion site, if possible. However, she shouldn’t ask the child if he
wants the therapy, because the answer may be “No!” Telling the child that
the treatment is for his own good is ineffective because a 2-year-old
perceives pain as a negative sensation and cannot understand that a
painful procedure can have position results. Telling the child how long the
therapy will last is ineffective because the 2-year-old doesn’t have a good
understanding of time.
22. (A) Barrel. All syringes have three parts: a tip, which connects the needle
to the syringe; a barrel, the outer part on which the measurement scales
are printed; and a plunger, which fits inside the barrel to expel the
medication. The external part of the barrel and the plunger and (flange)
must be handled during the preparation and administration of the
injection. However, the inside and trip of the barrel, the inside (shaft) of the
plunger, and the needle tip must remain sterile until after the injection.
23. (A) Instruct the patient to lock upward, and drop the medication into the center
of the lower lid. Having the patient look upward reduces blinking and
protects the cornea. Instilling drops in the center of the lower lid promotes
absorption because the drops are less likely to run into the nasolacrimal
duct or out of the eye.
24. (C) Thickness. Gauge is a measure of the needle’s thickness: The higher
the number the thinner the shaft. Therefore, an 18G needle is considerably
thicker than a 25G needle.
25. (A) Hypotension. A major side effect of anticoagulant therapy is bleeding,
which can be identified by hypotension (a systolic blood pressure under
100 mm Hg). Anticoagulants do not result in the other three conditions.
PNLE : Maternal and Child Health
Nursing Exam 1
1. A client asks the nurse what a third degree laceration is. She was informed
that she had one. The nurse explains that this is:
A. frequency
B. dysuria
C. incontinence
D. burning
5. Mrs. Jimenez went to the health center for pre-natal check-up. the student
nurse took her weight and revealed 142 lbs. She asked the student nurse how
much should she gain weight in her pregnancy.
A. 20-30 lbs
B. 25-35 lbs
C. 30- 40 lbs
D. 10-15 lbs
6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the
following key concept should the nurse consider when implementing nursing
care?
A. generalized edema
B. proteinuria 4+
C. blood pressure of 160/110
D. convulsions
8. Nurse Geli explains to the client who is 33 weeks pregnant and is
experiencing vaginal bleeding that coitus:
A. To facilitate elimination
B. To promote uterine contraction
C. To promote analgesia
D. To prevent infection
13. Nurse Luis is assessing the newborn’s heart rate. Which of the following
would be considered normal if the newborn is sleeping?
A. Toddler
B. Preschool
C. School
D. Adolescence
17. Which of the following situations would alert you to a potentially
developmental problem with a child?
A. Tell her that she would not be loved by others is she behaves that way..
B. Withholding giving her toys until she behaves properly.
C. Ignore her behavior as long as she does not hurt herself and others.
D. Ask her what she wants and give it to pacify her.
19. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his
scheduled check-up. By this period, baby Villanueva has already increased his
height by how many inches?
A. 3 inches
B. 4 inches
C. 5 inches
D. 6 inches
20. Alice, 10 years old was brought to the ER because of Asthma. She was
immediately put under aerosol administration of Terbutaline. After sometime,
you observe that the child does not show any relief from the treatment given.
Upon assessment, you noticed that both the heart and respiratory rate are still
elevated and the child shows difficulty of exhaling. You suspect:
A. Bronchiectasis
B. Atelectasis
C. Epiglotitis
D. Status Asthmaticus
21. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of
nephroblastoma. Symptoms the nurse observes that suggest this problem
include:
A. blurred vision
B. nasal stuffiness
C. breast tenderness
D. constipation
23. Nurse Jacob is assessing a 15 month old child with acute otitis media.
Which of the following symptoms would the nurse anticipate finding?
A. Fetal lie
B. Fetal movement
C. Maternal blood pressure
D. Maternal uterine contractions
2. During a 2 hour childbirth focusing on labor and delivery process for
primigravida. The nurse describes the second maneuver that the fetus goes
through during labor progress when the head is the presenting part as which
of the following:
A. Flexion
B. Internal rotation
C. Descent
D. External rotation
3. Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-
fetoprotein. The nurse informed her about the result of the elevation of serum
AFP. The patient asked her what was the test for:
A. 5 weeks of gestation
B. 10 weeks of gestation
C. 15 weeks of gestation
D. 20 weeks of gestation
5. Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The
nurse would explain that this is most probably the result of which of the
following:
A. Thrombophlebitis
B. PIH
C. Pressure on blood vessels from the enlarging uterus
D. The force of gravity pulling down on the uterus
6. Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart
disease lesion. Her pregnancy has just been diagnosed. Her heart disease has
not caused her to limit physical activity in the past. Her cardiac disease and
functional capacity classification is:
A. Class I
B. Class II
C. Class III
D. class IV
7. The client asks the nurse, “When will this soft spot at the top of the head of
my baby will close?” The nurse should instruct the mother that the neonate’s
anterior fontanel will normally close by age:
A. 2-3 months
B. 6-8 months
C. 10-12 months
D. 12-18 months
8. When a mother bleeds and the uterus is relaxed, soft and non-tender, you
can account the cause to:
A. Hematocrit 33.5%
B. WBC 8,000/mm3
C. Rubella titer less than 1:8
D. One hour glucose challenge test 110 g/dL
11. Aling Patricia is a patient with preeclampsia. You advise her about her
condition, which would tell you that she has not really understood your
instructions?
A. Weekly during the 8th month because this is her third pregnancy.
B. During the second trimester, if amniocentesis indicates a problem.
C. To her infant immediately after delivery if the Coomb’s test is positive.
D. Within 72 hours after delivery if infant is found to be Rh positive.
14. A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm.
She has a weak cry, irregular respiration. She was moving all extremities and
only her hands and feet were still slightly blue. The nurse should enter the
APGAR score as:
A. 5
B. 6
C. 7
D. 8
15. Billy is a 4 year old boy who has an IQ of 140 which means:
A. average normal
B. very superior
C. above average
D. genius
16. A newborn is brought to the nursery. Upon assessment, the nurse finds
that the child has short palpebral fissures, thinned upper lip. Based on this
data, the nurse suspects that the newborn is MOST likely showing the effects
of:
A. Chronic toxoplasmosis
B. Lead poisoning
C. Congenital anomalies
D. Fetal alcohol syndrome
17. A priority nursing intervention for the infant with cleft lip is which of the
following:
A. an excess of RBC
B. an excess of WBC
C. a deficiency of clotting factor VIII
D. a deficiency of clotting factor IX
19. Celine, a mother of a 2 year old tells the nurse that her child “cries and has
a fit when I have to leave him with a sitter or someone else.” Which of the
following statements would be the nurse’s most accurate analysis of the
mother’s comment?
A. The child has not experienced limit-setting or structure.
B. The child is expressing a physical need, such as hunger.
C. The mother has nurtured overdependence in the child.
D. The mother is describing her child’s separation anxiety.
20. Mylene Lopez, a 16 year old girl with scoliosis has recently received an
invitation to a pool party. She asks the nurse how she can disguise her
impairment when dressed in a bathing suit. Which nursing diagnosis can be
justified by Mylene’s statement?
A. Anxiety
B. Body image disturbance
C. Ineffective individual coping
D. Social isolation
21. The foul-smelling, frothy characteristic of the stool in cystic fibrosis
results from the presence of large amounts of which of the following:
A. Turner’s syndrome
B. Down’s syndrome
C. Marfan’s syndrome
D. Klinefelter’s syndrome
24. A 4 year old boy most likely perceives death in which way:
A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe depression. Which of
the following nursing approach is important in depression?
A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to leave an order. The senior nurse
had conversation with the other staff. The newly hired nurse answers the
phone so that the senior nurses may continue their conversation. The new
nurse does not knowthe physician or the client to whom the order pertains.
The nurse should:
A. Ask the physician to call back after the nurse has read the hospital
policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the
telephone order.
12. The staff nurse on the labor and delivery unit is assigned to care to a
primigravida in transition complicated by hypertension. A new pregnant
woman in active labor is admitted in the same unit. The nurse manager
assigned the same nurse to the second client. The nurse feels that the client
with hypertension requires one-to-one care. What would be the initial actionof
the nurse?
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The nurse manager
informs the staff nurse in the critical care unit that she has to float to the
emergency department. What should the staff nurse expect under these
conditions?
A. The float staff nurse will be informed of the situation before the shift
begins.
B. The staff nurse will be able to negotiate the assignments in the
emergency department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the pediatrics
unit. The client is receiving digoxin. Which of the following questions will be
asked by the nurse to the parents of the child in order to assess the client’s
risk for digoxin toxicity?
A. Determine who is responsible for the mistake and terminate his or her
employment.
B. Record the event in an incident/variance report and notify the nursing
supervisor.
C. Reassure both mothers, report to the charge nurse, and do not record.
D. Record detailed notes of the event on the mother’s medical record.
19. Before the administration of digoxin, the nurse completes an assessment
to a toddler client for signs and symptoms of digoxin toxicity. Which of the
following is the earliest and most significant sign of digoxin toxicity?
A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate
20. Which of the following treatment modality is appropriate for a client with
paranoid tendency?
A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.
21. The client with rheumatoid arthritis is for discharge. In preparing the client
for discharge on prednisone therapy, the nurse should advise the client to:
A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime.
If you have frequency associated with fever, pain on voiding, or blood in
the urine, call your doctor/nurse-midwife.
B. “Placental progesterone causes irritability of the bladder sphincter. Your
symptoms will go away after the baby comes.”
C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit
fluids to 1L/daily.”
D. “Frequency is due to bladder irritation from concentrate urine and is
normal in pregnancy. Increase your daily fluid intake to 3L.”
23. Which of the following will help the nurse determine that the expression of
hostility is useful?
A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.
27. Which of the following nursing intervention is essential for the client who
had pneumonectomy?
A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.
32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift.
The nurse is responsible for the overall planning, giving and evaluating care
during the entire shift. After the shift, same responsibility will be endorsed to
the next nurse in charge. This describes nursing care delivered via the:
A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.
35. An older adult client wakes up at 2 o’clock in the morning and comes to
the nurse’s station saying, “I am having difficulty in sleeping.” What is the best
nursing response to the client?
A. “I’ll give you a sleeping pill to help you get more sleep now.”
B. “Perhaps you’d like to sit here at the nurse’s station for a while.”
C. “Would you like me to show you where the bathroom is?”
D. “What woke you up?”
36. The nurse is taking care of a multipara who is at 42 weeks of gestation
and in active labor, her membranes ruptured spontaneously 2 hours ago.
While auscultating for the point of maximum intensity of fetal heart tones
before applying an external fetal monitor, the nurse counts 100 beats per
minute. The immediate nursing action is to:
A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.
38. A male client is brought to the emergency department due to motor
vehicle accident. While monitoring the client, the nurse suspects increasing
intracranial pressure when:
A. Client is oriented when aroused from sleep, and goes back to sleep
immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional skipped beat.
39. The nurse is conducting a lecture to a class of nursing students about
advance directives to preoperative clients. Which of the following statement
by the nurse js correct?
A. “The spouse, but not the rest of the family, may override the advance
directive.”
B. “An advance directive is required for a “do not resuscitate” order.”
C. “A durable power of attorney, a form of advance directive, may only be
held by a blood relative.”
D. “The advance directive may be enforced even in the face of opposition
by the spouse.”
40. A client diagnosed with schizophrenia is shouting and banging on the door
leading to the outside, saying, “I need to go to an appointment.” What is the
appropriate nursing intervention?
A. Tell the client that he cannot bang on the door.
B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.
41. Which of the following action is an accurate tracheal suctioning
technique?
A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
43. A mother is in the third stage of labor. Which of the following signs will
help the nurse determine the signs of placental separation?
A. 3+ peripheral pulses.
B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy has a large flank incision. Which
of the following nursing action will facilitate deep breathing and coughing?
A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.
47. A client with ruptured appendix had surgery an hour ago and is transferred
to the nursing care unit. The nurse placed the client in a semi-Fowler’s
position primarily to:
A. Icterus neonatorum
B. Multiple hemangiomas
C. Erythema toxicum
D. Milia
52. The client is brought to the emergency department because of serious
vehicle accident. After an hour, the client has been declared brain dead. The
nurse who has been with the client must now talk to the family about organ
donation. Which of the following consideration is necessary?
A. Stand with legs apart and touch hands to floor three times per day.
B. Ten minutes of walking per day with an emphasis on good posture.
C. Ten minutes of swimming or leg kicking in pool per day.
D. Pelvic rock exercise and squats three times a day.
54. A client with obsessive-compulsive behavior is admitted in the psychiatric
unit. The nurse taking care of the client knows that the primary treatment goal
is to:
A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.
55. After ileostomy, the nurse expects that the drainage appliance will be
applied to the stoma:
A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.
61. Which of the following situations cannot be delegated by the registered
nurse to the nursing assistant?
A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.
65. A tracheostomy cuff is to be deflated, which of the following nursing
intervention should be implemented before starting the procedures?
A. Gloves are worn when handling the client’s tissue, excretions, and linen.
B. Both client and attending nurse must wear masks at all times.
C. Nurse and visitors must wear masks until chemotherapy is begun.
Client is instructed in cough and tissue techniques.
D. Full isolation; that is, caps and gowns are required during the period of
contagion.
67. A client with lung cancer is admitted in the nursing care unit. The husband
wants to know the condition of his wife. How should the nurse respond to the
husband?
A. A telephone call notifying the school nurse that the child’ pediatrician
has informed the mother that the child will need cardiac repair surgery
within the next few weeks.
B. A telephone call notifying the school nurse that the child’s pediatrician
has informed the mother that the child has head lice.
C. A telephone call notifying the school nurse that a child has a
temperature of 102ºF and a rash covering the trunk and upper extremities
of the body.
D. A telephone call notifying the school nurse that a child underwent an
emergency appendectomy during the previous night.
71. Which of the following signs and symptoms that require immediate
attention and may indicate most serious complications during pregnancy?
A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a toddler understands the
instructions regarding the administration of syrup of ipecac. Which of the
following statement will help the nurse to know that the mother needs
additional teaching?
A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.”
B. “I’ll give the medicine if my child gets into some aspirin.”
C. “I’ll give the medicine if my child gets into some plant bulbs.”
D. “I’ll give the medicine if my child gets into some vitamin pills.”
77. To assess if the cranial nerve VII of the client was damaged, which
changes would not be expected?
A. “It provides a way to see if you are passing any protein in your urine.”
B. “It tells how well the kidneys filter wastes from the blood.”
C. “It tells if your renal insufficiency has affected your heart.”
D. “The test measures the number of particles the kidney filters.”
83. The nurse observes the female client in the psychiatric ward that she is
having a hard time sleeping at night. The nurse asks the client about it and the
client says, “I can’t sleep at night because of fear of dying.” What is the best
initial nursing response?
A. “It must be frightening for you to feel that way. Tell me more about it.”
B. “Don’t worry, you won’t die. You are just here for some test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest before tomorrow’s test.”
84. In the hospital lobby, the registered nurse overhears a two staff members
discussing about the health condition of her client. What would be the
appropriate action for the registered nurse to take?
A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units
(IV or IM) must be given to a client after birth fo the fetus. The nurse is correct
to explain that oxytocin:
A. 1 g
B. 500 mg
C. 250 mg
D. 125 mg
90. The nurse is completing an obstetric history of a woman in labor. Which
event in the obstetric history will help the nurse suspects dysfunctional labor
in the current pregnancy?
A. Total time of ruptured membranes was 24 hours with the second birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation.
91. The nurse is planning to talk to the client with an antisocial personality
disorder. What would be the most therapeutic approach?
A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”
96. A pregnant client in late pregnancy is complaining of groin pain that
seems worse on the right side. Which of the following is the most likely cause
of it?
A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a group of volunteer nurses. The
nurse is correct in imparting the idea that the Good Samaritan law protects
the nurse from a suit for malpractice when:
A. The nurse stops to render emergency aid and leaves before the
ambulance arrives.
B. The nurse acts in an emergency at his or her place of employment.
C. The nurse refuses to stop for an emergency outside of the scope of
employment.
D. The nurse is grossly negligent at the scene of an emergency.
98. A woman is hospitalized with mild preeclampsia. The nurse is formulating
a plan of care for this client, which nursing care is least likely to be done?
A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.
Answers and Rationales
1. A. The oxytocic effect of Pitocin increases the intensity and durations of
contractions; prolonged contractions will jeopardize the safetyof the fetus
and necessitate discontinuing the drug.
2. B. It is of paramount importance to prevent the client from hurting
himself or herself or others.
3. B. After tonsillectomy, clear, cool liquids should be given. Citrus,
carbonated, and hot or cold liquids should be avoided because they may
irritate the throat. Red liquids should be avoided because they give the
appearance of blood if the child vomits. Milk and milk products including
pudding are avoided because they coat the throat, cause the child to clear
the throat, and increase the risk of bleeding.
4. A. Phenylephrine, with frequent and continued use, can cause rebound
congestion of mucous membranes.
5. B. The N 95 respirator is a high-particulate filtration mask that meets the
CDC performance criteria for a tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the treatment of
chronic, or open-angle glaucoma is the miotic effects of pilocarpine.
Pupillary constriction impedes normal accommodation, making night
driving difficult and hazardous, reducing the client’s ability to read for
extended periods and making participation in games with fast-moving
objects impossible.
7. B. This stops the sucking of air through the tube and prevents the entry
of contaminants. In addition, clamping near the chest wall provides for
some stability and may prevent the clamp from pulling on the chest tube.
8. D. Because umbilical cord’s insertion site is born before the fetal head,
the cord may be compressed by the after-coming head in a breech birth.
9. B. It is important to externalize the anger away from self.
10. D. Development normally proceeds cephalocaudally; so the first major
developmental milestone that the infant achieves is the ability to hold the
head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s
muscle tone would be poor and the infant would not be able to achieve
this milestone.
11. D. Get a senior nurse who know s the policies, the client, and the doctor.
Generally speaking, a nurse should not accept telephone orders. However,
if it is necessary to take one, follow the hospital’s policy regarding
telephone orders. Failure to followhospital policy could be considered
negligence. In this case, the nurse was new and did not know the
hospital’s policy concerning telephone orders. The nurse was also
unfamiliar with the doctor and the client. Therefore the nurse should not
take the order unless a) no one else is available and b) it is an emergency
situation.
12. C. The nurse is obligated to inform the nurse manager about changes in
the condition of the client, which may change the decision made by the
nurse manager.
13. A. Perinatal risk factors for the development of Down syndrome include
advanced maternal age, especially with the first pregnancy.
14. B. Assignments should be based on scope of practice and expertise.
15. B. The child who is concurrently taking digoxin and diuretics is at
increased risk for digoxin toxicity due to the loss of potassium. The child
and parents should be taught what foods are high in potassium, and the
child should be encouraged to eat a high-potassium diet. In addition, the
child’s serum potassium level should be carefully monitored.
16. A. The responsible for an accurate informed consent is the physician.
An exception to this answer would be a life-threatening emergency, but
there are no data to support another response.
17. D. Asking the client to cough and take a deep breath will help determine
if the chest tube is kinked or if the lungs has reexpanded.
18. B. Every event that exposes a client to harm should be recorded in an
incident report, as well as reported to the appropriate supervisors in order
to resolve the current problems and permit the institution to prevent the
problem from happening again.
19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a
toddler, any heart rate that falls below the norm of about 100-120 bpm
would indicate Bradycardia and would necessitate holding the medication
and notifying the physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving prednisone, the
nurse should caution the client to (a) take oral preparations after meals;
(b) remember that routine checks of vital signs, weight, and lab studies are
critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION
WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant
container.
22. A. Progesterone also reduces smooth muscle motility in the urinary
tract and predisposes the pregnant woman to urinary tract infections.
Women should contact their doctors if they exhibit signs of infection.
Kegel exercise will help strengthen the perineal muscles; limiting fluids at
bedtime reduces the possibility of being awakened by the necessity of
voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but the commonality
is comprehensive coordination of care to better predict needs of high-risk
clients, decrease exacerbations and continually monitor progress
overtime.
25. A. Phenytoin should be infused or injected into larger veins to avoid the
discoloration know as purple glove syndrome; infusing into a smaller vein
is not appropriate.
26. C. Serum radioimmunoassay (RIA) is accurate within 7days of
conception. This test is specific for HCG, and accuracy is not
compromised by confusion with LH.
27. D. Surgery and anesthesia can increase mucus production. Deep
breathing and coughing are essential to prevent atelectasis and
pneumonia in the client’s only remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough,
eosinophilia) and conjunctivitis from Chlamydia.
29. D. The client may perceive this as avoidance, but it is more important to
redirect back to the client, especially in light of the manipulative behavior
of drug abusers and adolescents.
30. C. It describes a democratic process in which all members have input in
the client’s care.
31. A. Contraction of the milk ducts and let-down reflex occur under the
stimulation of oxytocin released by the posterior pituitary gland.
32. B. In case management, the nurse assumes total responsibility for
meeting the needs of the client during the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain viable for about 3
days. If ovulation occurs during this period, conception may result.
35. B. This option shows acceptance (key concept) of this age-typical sleep
pattern (that of waking in the early morning).
36. D. Taking the mother’s pulse while listening to the FHR will differentiate
between the maternal and fetal heart rates and rule out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be avoided with
glaucoma.
38. A. This suggests that the level of consciousness is decreasing.
39. D. An advance directive is a form of informed consent, and only a
competent adult or the holder of a durable power of attorney has the right
to consent or refuse treatment. If the spouse does not hold the power of
attorney, the decisions of the holder, even if opposed by the spouse, are
enforced.
40. C. Gentle but firm guidance and nonverbal direction is needed to
intervene when a client with schizophrenic symptoms is being disruptive.
41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter
is being withdrawn.
42. D. The priority for this client is being able to establish an airway.
43. A. Signs of placental separation include a change in the shape of the
uterus from ovoid to globular.
44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic
enzyme that lyses thrombi and emboli. Bleeding is an adverse effect.
Monitor clotting times and signs of any gastrointestinal or internal
bleeding.
45. D. Because flank incision in nephrectomy is directly below the
diaphragm, deep breathing is painful. Additionally, there is a greater
incisional pull each time the person moves than there is with abdominal
surgery. Incisional pain following nephrectomy generally requires
analgesics administration every 3-4 hours for 24-48 hours after surgery.
Therefore, turning, coughing and deep-breathing exercises should be
planned to maximize the analgesic effects.
46. B. Under high estrogen levels, during the period surrounding ovulation,
the cervical mucus becomes thin, clear, and elastic (spinnbarkeit),
facilitating sperm passage.
47. D. After surgery for a ruptured appendix, the client should be placed in a
semi-Fowler’s position to promote drainage and to prevent possible
complications.
48. C. Directing and evaluation of staff is a major responsibility of a nursing
manager.
49. A. The recommended procedure for administering eyedrops to any
client calls for the drops to be placed in the middle of the lower
conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and hypoxemia.
Internal bleeding is difficult to recognized and evaluate because it is not
apparent.
51. C. Erythema toxicum is the normal, nonpathological macular newborn
rash.
52. D. The family needs to understand what brain death is before talking
about organ donation. They need time to accept the death of their family
member. An environment conducive to discussing an emotional issue is
needed.
53. A. Bending from the waist in pregnancy tends to make backache worse.
54. B. Support and limit setting decrease anxiety and provide external
control.
55. C. The stoma drainage bag is applied in the operating room. Drainage
from the ileostomy contains secretions that are rich in digestive enzymes
and highly irritating to the skin. Protection of the skin from the effects of
these enzymes is begun at once. Skin exposed to these enzymes even for
a short time becomes reddened, painful and excoriated.
56. B. It is the most accurate statement of physiological facts for a 28-day
menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life
span of 72 hours. Fertilization could occur from sperm deposited before
ovulation.
57. C. An advocate role encourage freedom of choice, includes speaking
out for the client, and supports the client’s best interests.
58. A. Abstinence will eliminate any unnecessary pain during intercourse
and will reduce the possibility of transmitting infection to one’s sexual
partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic
behavioral defense of hand washing decreases anxiety by avoiding group
therapy.
60. D. Denial is a very strong defense mechanism used to allay the
emotional effects of discovering a potential threat. Although denial has
been found to be an effective mechanism for survival in some instances,
such as during natural disasters, it may in greater pathology in a woman
with potential breast carcinoma.
61. B. The registered nurse cannot delegate the responsibility for
assessment and evaluation of clients. The status of the client in restraint
requires further assessment to determine if there are additional causes
for the behavior.
62. C. The client with chest pain may be having a myocardial infarction, and
immediate assessment and intervention is a priority.
63. B. Is correct because semen analysis requires that a freshly
masturbated specimen be obtained after a rest (abstinence) period of 48-
72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to
produce surfactant.
65. A. Secretions may have pooled above the tracheostomy cuff. If these
are not suctioned before deflation, the secretions may be aspirated.
66. C. Proper handling of sputum is essential to allay droplet transference
of bacilli in the air. Clients need to be taught to cover their nose and mouth
with tissues when sneezing or coughing. Chemotherapy generally renders
the client noninfectious within days to a few weeks, usually before
cultures for tubercle bacilli are negative. Until chemical isolation is
established, many institutions require the client to wear a mask when
visitors are in the room or when the nurse is in attendance. Client should
be in a well-ventilated room, without air recirculation, to prevent air
contamination.
67. A. It is best to establish baseline information first.
68. B. Listening is probably the most effective response of the four choices.
69. A. Urine flow is continuous. The pouch has an outlet valve for easy
drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or
sooner if the adhesive is loose).
70. C. A high fever accompanied by a body rash could indicate that the child
has a communicable disease and would have exposed other students to
the infection. The school nurse would want to investigate this telephone
call immediately so that plans could be instituted to control the spread of
such infection.
71. A. Severe abdominal pain may indicate complications of pregnancy
such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge
from the vagina may indicate premature rupture of the membrane.
72. D. Gentle aspiration of mucus helps maintain a patent airway, required
for effective gas exchange.
73. A. Somatoform disorders provide a way of coping with conflicts.
74. C. Immunization should never be mixed together in a syringe, thus
necessitating three separate injections in three sites. Note: some
manufacturers make a premixed combination of immunization that is safe
and effective.
75. A. Clients with radioactive implants should be positioned flat in bed to
prevent dislodgement of the vaginal packing. The client may roll to the
side for meals but the upper body should not be raised more than 20
degrees.
76. A. Syrup of ipecac is not administered when the ingested substances is
corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly
corrosive substances. If the ingested substance “burned” the esophagus
going down, it will “burn” the esophagus coming back up when the child
begins to vomit after administration of syrup of ipecac.
77. B. Inability to open eyelids on operative side is seen with cranial nerve III
damage.
78. A. Assessment of physical injuries (like bruises, lacerations, bleeding
and fractures) is the first priority.
79. C. The nurse who is supervising others has a legal obligation to
determine that they are competent to perform the assignment, as well as
legal obligation to provide adequate supervision.
80. D. Increasing hydrostatic pressure in the urinary tract will facilitate
passage of the calculi.
81. A. Infertility is not diagnosed until atleast 12months of unprotected
intercourse has failed to produce a pregnancy. Older couples will
experience a longer time to get pregnant.
82. B. Determining how well the kidneys filter wastes states the purpose of
a Creatinine clearance test.
83. A. Acknowledging a feeling tone is the most therapeutic response and
provides a broad opening for the client to elaborate feelings.
84. C. The behavior should be stopped. The first is to remind the staff that
confidentiality maybe violated.
85. C. With a right-sided cerebrovascular accident the client would have left-
sided hemiplegia or weakness. The client’s good side should be closest to
the bed to facilitate the transfer.
86. D. Legos are small plastic building blocks that could easily slip under
the child’s cast and lead to a break in skin integrity and even infection.
Pencils, backscratchers, and marbles are some other narrow or small
items that could easily slip under the child’s cast and lead to a break in
skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that expose clients to
harm does not remove the obligation to report ongoing behavior as long
as the risk to the client continues.
89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the
child weighs 20kg and the maximum dose is 50mg/kg, this would indicate
a total daily dose of 1000mg of tetracycline. In this case, the child is being
given this medication four times a day. Therefore the maximum single
dose that can be given is 250mg (1000 mg of tetracycline divided by four
doses.)
90. C. An abnormality in the uterine muscle could reduce the effectiveness
of uterine contractions and lengthen the duration of subsequent labors.
91. A. Personality disorders stem from a weak superego, implying a lack of
adequate controls.
92. C. The basal body temperature is the lowest body temperature of a
healthy person that is taken immediately after waking and before getting
out of bed. The BBT usually varies from 36.2 ºC to 36.3ºC during menses
and for about 5-7 days afterward. About the time of ovulation, a slight
drop in temperature may be seen, after ovulation in concert with the
increasing progesterone levels of the early luteal phase, the BBT rises 0.2-
0.4 ºC. This elevation remains until 2-3 days before menstruation, or if
pregnancy has occurred.
93. A. This choice implies concern for client care and self-improvement.
94. C. The first trimester is the period of organogenesis, that is, cell
differentiation into the various organs, tissues, and structures.
95. C. This response does not contradict the client’s perception, is honest,
and shows empathy.
96. D. Tension on round ligament occurs because of the erect human
posture and pressure exerted by the growing fetus.
97. D. The Good Samaritan Law does not impose a duty to stop at the
scene of an emergency outside of the scope of employment, therefore
nurses who do not stop are not liable for suit.
98. C. Although reducing environment stimuli and activity is necessary for a
woman with mild preeclampsia, she will most probably have bathroom
privileges.
99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute.
100. D. The behavior described is likely to be symptoms of delirium tremens,
or alcohol withdrawal (often unsuspected on a surgical unit.)
A. Make believe
B. Hide and seek
C. Peek-a-boo
D. Building blocks
4. Which of the following information indicate that Raphael is normal for his
age?
A. Punishment-obedience
B. “good boy-Nice girl”
C. naïve instrumental orientation
D. social contact
Situation 2 Baby boy Lacson delivered at 36 weeks gestation weighs
3,400 gm and height of 59 cm (6-10)
6. Baby boy Lacson’s height is
A. Long
B. Short
C. Average
D. Too short
7. Growth and development in a child progresses in the following ways
EXCEPT
A. Hypothermia
B. Decreased activity level
C. Shaking
D. Increased RR
Situation 3 Nursing care after delivery has an important aspect in
every stages of delivery
11. After the baby is delivered, the cord was cut between two clamps using a
sterile scissors and blade, then the baby is placed at the:
A. Mother’s breast
B. Mother’s side
C. Give it to the grandmother
D. Baby’s own mat or bed
12. The baby’s mother is RH(-). Which of the following laboratory tests will
probably be ordered for the newborn?
A. Direct Coomb’s
B. Indirect Coomb’s
C. Blood culture
D. Platelet count
13. Hypothermia is common in newborn because of their inability to control
heat. The following would be an appropriate nursing intervention to prevent
heat loss except:
A. Hypoglycemia
B. Increase ICP
C. Metabolic acidosis
D. Cerebral palsy
15. During the feto-placental circulation, the shunt between two atria is called
A. Ductus venosous
B. Foramen Magnum
C. Ductus arteriosus
D. Foramen Ovale
16. What would cause the closure of the Foramen ovale after the baby had
been delivered?
A. Sitting up
B. With low back rest
C. With moderate back rest
D. Lying semi flat
19. A common problem in children is the inflammation of the middle ear. This
is related to the malfunctioning of the:
A. Tympanic membrane
B. Eustachian tube
C. Adenoid
D. Nasopharynx
20. For acute otitis media, the treatment is prompt antibiotic therapy. Delayed
treatment may result in complications of:
A. Tonsillitis
B. Eardrum Problems
C. Brain damage
D. Diabetes mellitus
21. When assessing gross motor development in a 3 year old, which of the
following activities would the nurse expect to finds?
A. Riding a tricycle
B. Hopping on one foot
C. Catching a ball
D. Skipping on alternate foot.
22. When assessing the weight of a 5-month old, which of the following
indicates healthy growth?
A. Push-pull toys
B. Card games
C. Doctor and nurse kits
D. Books and Crafts
24. Which of the following statements would the nurse expects a 5-year old
boy to say whose pet gerbil just died
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
27. Which of the following is not a possible systemic clinical manifestation of
severe burns?
A. Growth retardation
B. Hypermetabolism
C. Sepsis
D. Blisters and edema
28. When assessing a family for potential child abuse risks, the nurse would
observe for which of the following?
A. Prevent infection
B. Promote normal growth and development
C. Decrease hypoxic spells
D. Hydrate adequately
32. The immediate nursing intervention for cyanosis of Agata is:
A. Waterston-Cooley
B. Raskkind Procedure
C. Coronary artery bypass
D. Blalock-Taussig
34. Which of the following is not an indicator that Agata experiences
separation anxiety brought about her hospitalization?
A. Laryngeotracheobronchitis (LTB)
B. Epiglottitis
C. Asthma
D. Cystic Fibrosis
37. Which of the following statements by the family of a child with asthma
indicates a need for additional teaching?
A. Dental health
B. Mouth dryness
C. Height and weight
D. Excessive appetite
Situation 6 Laura is assigned as the Team Leader during the
immunization day at the RHU
39. What program for the DOH is launched at 1976 in cooperation with WHO
and UNICEF to reduce morbidity and mortality among infants caused by
immunizable disease?
A. Patak day
B. Immunization day on Wednesday
C. Expanded program on immunization
D. Bakuna ng kabtaan
40. One important principle of the immunization program is based on?
A. Statistical occurrence
B. Epidemiologic situation
C. Cold chain management
D. Surveillance study
41. The main element of immunization program is one of the following?
A. Interruption of transmission
B. All to be vaccinated
C. Selected group for vaccination
D. Shorter incubation
43. Measles vaccine can be given simultaneously. What is the combined
vaccine to be given to children starting at 15 months?
A. MCG
B. MMR
C. BCG
D. BBR
Situation 7: Braguda brought her 5-month old daughter in the nearest
RHU because her baby sleeps most of the time, with decreased
appetite, has colds and fever for more than a week. The physician
diagnosed pneumonia.
44. Based on this data given by Braguda, you can classify Braguda’s daughter
to have:
A. 60 bpm
B. 40 bpm
C. 70 bpm
D. 50 pbm
46. You asked Braguda if her baby received all vaccines under EPI. What legal
basis is used in implementing the UN’s goal on Universal Child Immunization?
A. PD no. 996
B. PD no. 6
C. PD no. 46
D. RA 9173
47. Braguda asks you about Vitamin A supplementation. You responded that
giving Vitamin A starts when the infant reaches 6 months and the first dose
is”
A. 200,000 “IU”
B. 100,000 “IU”
C. 500,000 “IU”
D. 10,000 “IU”
48. As part of CARI program, assessment of the child is your main
responsibility. You could ask the following question to the mother except:
A. Grapes
B. Apple slices
C. A glass of milk
D. A glass of cola
51. Which of the following immunizations would the nurse expect to
administer to a child who is HIV (+) and severely immunocomromised?
A. Varicella
B. Rotavirus
C. MMR
D. IPV
52. When assessing a newborn for developmental dysplasia of the hip, the
nurse would expect to assess which of the following?
A. Phimosis
B. Hydrocele
C. Epispadias
D. Hypospadias
54. When teaching a group of parents about seat belt use, when would the
nurse state that the child be safely restrained in a regular automobile
seatbelt?
A. 30 lb and 30 in
B. 35 lb and 3 y/o
C. 40 lb and 40 in
D. 60 lb and 6 y/o
55. When assessing a newborn with cleft lip, the nurse would be alert which of
the following will most likely be compromised?
A. Sucking ability
B. Respiratory status
C. Locomotion
D. GI function
56. For a child with recurring nephritic syndrome, which of the following areas
of potential disturbances should be a prime consideration when planning
ongoing nursing care?
A. Muscle coordination
B. Sexual maturation
C. Intellectual development
D. Body image
57. An inborn error of metabolism that causes premature destruction of RBC?
A. G6PD
B. Hemocystinuria
C. Phenylketonuria
D. Celiac Disease
58. Which of the following would be a diagnostic test for Phenylketonuria
which uses fresh urine mixed with ferric chloride?
A. Guthrie Test
B. Phenestix test
C. Beutler’s test
D. Coomb’s test
59. Dietary restriction in a child who has Hemocystenuria will include which of
the following amino acid?
A. Lysine
B. Methionine
C. Isolensine tryptophase
D. Valine
60. A milk formula that you can suggest for a child with Galactosemia:
A. Lofenalac
B. Lactum
C. Neutramigen
D. Sustagen
Answers and Rationales
1. B. a decline in growth rate. During the Preschooler stage growth is very
minimal. Weight gain is only 4.5lbs (2kgs) per year and Height is 3.5in (6-
8cm) per year.
Review:
Most rapid growth and development- Infancy
Slow growth- Toddler hood and Preschooler
Slower growth- School age
Rapid growth- Adolescence
2. D. Rate and pattern of growth can be modified. Growth and development
occurs in cephalo-caudal meaning development occurs through out the
body’s axis. Example: the child must be able to lift the head before he is
able to lift his chest. Proximo-distal is development that progresses from
center of the body to the extremities. Example: a child first develops arm
movement before fine-finger movement. Different parts of the body grows
at different range because some body tissue mature faster than the other
such as the neurologic tissues peaks its growth during the first years of
life while the genital tissue doesn’t till puberty. Also G&D is predictable in
the sequence which a child normally precedes such as motor skills and
behavior. Lastly G&D can never be modified .
3. A. Make believe. Make believe is most appropriate because it enhances
the imitative play and imagination of the preschooler. C and D are for
infants while letter A is B is recommended for schoolers because it
enhances competitive play.
4. C. Has the ability to try new things. Erickson defines the developmental
task of a preschool period is learning Initiative vs. Guilt. Children can
initiate motor activities of various sorts on their own and no longer
responds to or imitate the actions of other children or of their parents.
5. C. naïve instrumental orientation. According to Kohlber, a preschooler is
under Pre-conventional where a child learns about instrumental purpose
and exchange, that is they will something do for another if that that person
does something with the child in return. Letter A is applicable for Toddlers
and letter B is for a School age child.
6. A. Long. The average length of full-term babies at birth is 20 in. (51 cm),
although the normal range is 46 cm (18 in.) to 56 cm (22 in.).
7. A. From cognitive to psychosexual. Growth and development occurs in
cephalo-caudal (head to toe), proximo-distal (trunk to tips of the
extremities and general to specific, but it doesn’t occurs in cognitive to
psychosexual because they can develop at the same time.
8. C. Trust vs. mistrust. According to Erikson, children 0-18 months are
under the developmental task of Trust vs. Mistrust.
9. A. Disappears in about a year. Mongolian spots are stale grey or bluish
patches of discoloration commonly seen across the sacrum or buttocks
due to accumulation of melanocytes and they disappears in 1 year. They
are not linked to steroid use and pathologic conditions.
10. D. Increased RR. Hypothermia is inaccurate cause normally, temperature
of a newborn drop, Also a child under cold stress will kick and cry to
increase the metabolic rate thereby increasing heat so B isn’t a good
choice. A newborn doesn’t have the ability to shiver, so letter B and C is
wrong. A newborn will increase its RR because the NB will need more
oxygen because of too much activity.
11. A. Mother’s breast. Place it at the mother’s breast for latch-on. (Note: for
NSD breast feed ASAP while for CS delivery, breast feed after 4 hours)
12. A. Direct Coomb’s. Coomb’s test is the test to determine if RH antibodies
are present. Indirect Coomb’s is done to the mother and Direct Coomb’s is
the one don’t to the baby. Blood culture and Platelet count doesn’t help
detect RH antibodies.
13. A. Place the crib beside the wall. Placing the crib beside the wall is
inappropriate because it can provide heat loss by radiation. Doing
Kangaroo care or hugging the baby, mechanical pressure or incubators
and drying and wrapping the baby will help conserve heat.
14. B. Increase ICP. Hypoglycemia may occur due to increase metabolic rate,
and because of newborns are born slightly acidic, and they catabolize
brownfat which will produce ketones which is an acid will cause metabolic
acidosis. Also a NB with severe hypothermia is in high risk for kernicterus
(too much bilirubin in the brain) can lead to Cerebral palsy. There is no
connection in the increase of ICP with hypothermia. (NOTE: pathognomonic
sign of Kernicterus in adult- asterexis, or involuntary flapping of the hand.)
15. D. Foramen Ovale. Foramen ovale is opening between two atria, Ductus
venosus is the shunt from liver to the inferior vena cava, and your Ductus
Arteriosus is the shunt from the pulmonary artery to the aorta.
16. B. Shifting of pressures from right side to the left side of the heart. During
feto-placental circulation, the pressure in the heart is much higher in the
right side, but once breathing/crying is established, the pressure will shift
from the R to the L side, and will facilitate the closure of Foramen Ovale.
(Note: that is why you should position the NB in R side lying position to
increase pressure in the L side of the heart.)
Review:
Increase PO2-> closure of ductus arteriosus
Decreased bloodflow -> closure of the ductus venosus
Circulation in the lungs is initiated by -> lung expansion and
pulmonary ventilation
What will sustain 1st breath-> decreased artery pressure
What will complete circulation-> cutting of the cord
17. B. Atrial Septal defect. Foramen ovale is the opening between two Atria
so, if its will not close Atrial Septal defect can occur.
18. A. Sitting up. The correct position is making the child having an upright
sitting position with the head slightly tilted forward. This position will
minimize the amount of blood pressure in nasal vessels and keep blood
moving forward not back into the nasopharynx, which will have the
choking sensation and increase risk of aspiration. Choices b, c, d, are
inappropriate cause they can cause blood to enter the nasopharynx.
19. B. Eustachian tube. This is because children has short, horizontal
Eustachian tubes. The dysfunction in the Eustachian tube enables
bacterial invasion of the middle ear and obstructs drainage of secretions.
20. C. Brain damage. One of the complication of recurring acute otitis media
is risk for having Meningitis, thereby causing possible brain damage. That
is why patient must follow a complete treatment regimen and follow up
care. A,B and D are not complications of AOM.
21. A. Riding a tricycle. Answer is A, riding a tricycle is appropriate for a 3 y/o
child. Hopping on one foot can be done by a 4 y/o child, as well as
catching and throwing a ball over hand. Skipping can be done by a 5 y/o.
22. A. Doubling of birth weight. During the first 6 months of life the weight
from birth will be doubled and as soon as the baby reaches 1 year, its birth
weight is tripled.
23. C. Doctor and nurse kits. Letter C is appropriate because it will enhance
the creativity and imagination of a pre-school child. Letter B and D are
inappropriate because they are too complex for a 4 y/o. Push-pull toys are
recommended for infants.
24. B. “He’s just a bit dead”. A 5 y/o views death in “degrees”, so the child
most likely will say that “he is just a bit dead”. Personification of death like
boogeyman occurs in ages 7 to 9 as well as denying death can if they will
be good. Denying death using jokes and attributing life qualities to death
occurs during age 3-5.
25. D. Infant have greater body surface area than adults. Infants have greater
body surface area than adult, increasing their risk to F&E imbalances. Also
infants cant concentrate a urine at an adult level and their metabolic rate,
also called water turnover, is 2 to 3 times higher than adult. Plus more
fluids of the infants are at the ECF spaces not in the ICF spaces.
26. C. Metabolic acidosis. Remember that Aspirin is acid (Acetylsalicylic
ACID).
27. D. Blisters and edema. The question was asking for a SYSTEMIC clinical
manifestation, Letters A,B and C are systemic manifestations while
Blisters and Edema weren’t.
28. D. Problematic pregnancies. Typical factors that may be risk for Child
abuse are problematic pregnancies, chronic exposure to stress not
periodic, low level of self esteem not high level. Also child abuse can
happen in all socio-economic status not just on low socio-economic
status.
29. C. Unexplained symptoms of diarrhea, vomiting and apnea with no organic
basis. Munchausen syndrome by Proxy is the fabrication or inducement of
an illness by one person to another person, usually mother to child. It is
characterized by symptoms such as apnea and siezures, which may be
due to suffocation, drugs or poisoning, vomiting which can be induced
with poisons and diarrhea with the use of laxatives. Letter A can be seen
in a Physical abuse, Letter B for sexual abuse and Letter C is for Physical
Neglect.
30. B. Offering large amount of fresh fruits and vegetables. A child with HIV is
immunocompromised. Fresh fruits and vegetables, which may be
contaminated with organisms and pesticides can be harmful, if not fatal to
the child, therefore these items should be avoided.
31. C. Decrease hypoxic spells. The correct answer is letter C. Though letter B
would be a good answer too, this goal is too vague and not specific.
Nursing interventions will not solely promote normal G&D unless he will
undergo surgical repair. So decreasing Hypoxic Spells is more SMART.
Letter A and D are inappropriate.
32. B. Place her in knee chest position. The immediate intervention would be to
place her on knee-chest or “squatting” position because it traps blood into
the lower extremities. Though also letter C would be a good choice but the
question is asking for “Immediate” so letter B is more appropriate. Letter A
and D are incorrect because its normal for a child who have ToF to have
hypoxic or “tets” spells so there is no need to transfer her to the NICU or to
alert the Pediatrician.
33. D. Blalock-Taussig. Blalock-Taussig procedure its just a temporary or
palliative surgery which creates a shunt between the aorta and pulmonary
artery so that the blood can leave the aorta and enter the pulmonary artery
and thus oxygenating the lungs and return to the left side of the heart, then
to the aorta then to the body. This procedure also makes use of the
subclavian vein so pulse is not palpable at the right arm. The full repair for
ToF is called the Brock procedure. Raskkind is a palliative surgery for TOGA.
34. A. Friendly with the nurse. Because toddlers views hospitalization is
abandonment, separation anxiety is common. Its has 3 phases: PDD
(parang c puff daddy LOL) 1. Protest 2. despair 3. detachment (or denial).
Choices B, C, D are usually seen in a child with separation anxiety (usually
in the protest stage).
REVIEW:
Separation anxiety begin at: 9 months
Peaks: 18 months
35. D. Anticipatory grieving r/t gravity of child’s physical status. In this item
letter A and be are inappropriate response so remove them. The possible
answers are C and D. Fear defined as the perceived threat (real or
imagined) that is consciously recognized as danger (NANDA) is applicable
in the situation but its defining characteristics are not applicable. Crying
per se can not be a subjective cue to signify fear, and most of the
symptoms of fear in NANDA are physiological. Anticipatory grieving on the
other hand are intellectual and EMOTIONAL responses based on a
potential loss. And remember that procedures like this cannot assure total
recovery. So letter D is a more appropriate Nursing diagnosis.
36. B. Epiglottitis. Acute and sever inflammation of the epiglottis can cause
life threatening airway obstruction, that is why its always treated as a
medical emergency. NSG intervention : Prepare tracheostomy set at bed
side. LTB, can also cause airway obstruction but its not an emergency.
Asthma is also not an emergency. CF is a chronic disease, so its not a
medical emergency.
37. C. “We’ll make sure he avoids exercise to prevent asthma attacks”. Asthmatic
children don’t have to avoid exercise. They can participate on physical
activities as tolerated. Using a bronchodilator before administering
steroids is correct because steroids are just anti-inflammatory and they
don’t have effects on the dilation of the bronchioles. OF course letters A
and B are obviously correct.
38. C. Height and weight. Dental problems are more likely to occur in children
under going TCA therapy. Mouth dryness is a expected side effects of
Ritalin since it activates the SNS. Also loss of appetite is more likely to
happen, not increase in appetite. The correct answer is letter C, because
Ritalin can affect the child’s G&D. Intervention: medication “holidays or
vacation”. (This means during weekends or holidays or school vacations,
where the child wont be in school, the drug can be withheld.)
39. C. Expanded program on immunization
40. B. Epidemiologic situation. Letters A, C and D are not included in the
principles of EPI.
41. D. Target setting
42. A. Interruption of transmission
43. B. MMR. MMR or Measles, Mumps, Rubella is a vaccine furnished in
one vial and is routinely given in one injection (Sub-Q). It can be given at
15 months but can also be given as early as 12th month.
44. B. Severe pneumonia. For a child aging 2months up to 5 years old can be
classified to have sever pneumonia when he have any of the following
danger signs:
Not able to drink
Convulsions
Abnormally sleepy or difficult to wake
Stridor in calm child or
Severe under-nutrition
45. D. 50 pbm. A child can be classified to have Pneumonia (not severe) if:
the young infant is less than 2 months- 60 bpm or more
if the child is 2 months up to less than 12 months- 50 bpm or
more
if the child is 12 months to 4 y/o- 40 bpm or more
46. B. PD no. 6 Presidential Proclamation no. 6 (April 3, 1986) is the
“Implementing a United Nations goal on Universal Child Immunization by
1990”. PD 996 (September 16, 1976) is “providing for compulsory basic
immunization for infants and children below 8 years of age. PD no. 46
(September 16, 1992) is the “Reaffirming the commitment of the
Philippines to the universal Child and Mother goal of the World Health
Assembly. RA 9173 is of course the “Nursing act of 2002”
47. B. 100,000 “IU”. An infant aging 6-11 months will be given Vitamin
supplementation of 100, 000 IU and for Preschoolers ages 12-83 months
200,000 “IU” will be given.
48. C. “Did the child have chest indrawing?”. The CARI program of the DOH
includes the “ASK” and “LOOK, LISTEN” as part of the assessment of the
child who has suspected Pneumonia. Choices A, B and D are included in
the “ASK” assessment while Chest indrawings is included in the “LOOK,
LISTEN” and should not be asked to the mother.
49. A. Aganglionic Mega colon. Failure to pass meconium of Newborn during
the first 24 hours of life may indicate Hirschsprung disease or Congenital
Aganglionic Megacolon, an anomaly resulting in mechanical obstruction
due to inadequate motility in an intestinal segment. B, C, and D are not
associated in the failure to pass meconium of the newborn.
50. B. Apple slices. Grapes is in appropriate because of its “balat” that can
cause choking. A glass of milk is not a good snack because it’s the most
common cause of Iron-deficiency anemia in children (milk contains few
iron), A glass of cola is also not appropriate cause it contains complex
sugar. (walang kinalaman ang asthma dahil ala naman itong diatery
restricted foods na nasa choices.)
51. D. IPV. IPV or Inactivated polio vaccine does not contain live micro
organisms which can be harmful to an immunocompromised child. Unlike
OPV, IPV is administered via IM route.
52. C. Ortolani’s sign. Correct answer is Ortolani’s sign; it is the abnormal
clicking sound when the hips are abducted. The sound is produced when
the femoral head enters the acetabulum. Letter A is wrong because its
should be “asymmetrical gluteal fold”. Letter B and C are not applicable for
newborns because they are seen in older children.
53. D. Hypospadias. Hypospadias is a c condition in which the urethral
opening is located below the glans penis or anywhere along the ventral
surface of the penile shaft. Epispadias, the urethral meatus is located at
the dorsal surface of the penile shaft. (Para di ka malilto, I-alphabetesize
mo Dorsal, (Above) eh mauuna sa Ventral (Below) , Epis mauuna sa
Hypo.)
54. C. 40 lb and 40 in. Basta tandaan ang rule of 4! 4 years old, 40 lbs and 40
in.
55. A. Sucking ability. Because of the defect, the child will be unable to form
the mouth adequately arounf the nipple thereby requiring special devices
to allow feeding and sucking gratification. Respiratory status may be
compromised when the child is fed improperly or during post op period.
56. D. Body image. Because of edema, associated with nephroitic syndrome,
potential self concept and body image disturbance related to changes in
appearance and social isolation should be considered.
57. A. G6PD. G6PD is the premature destruction of RBC when the blood is
exposed to antioxidants, ASA (ano un? Aspirin), legumes and flava beans.
58. B. Phenestix test. Phenestix test is a diagnostic test which uses a fresh
urine sample (diapers) and mixed with ferric chloride. If positive, there will
be a presence of green spots at the diapers. Guthrie test is another test for
PKU and is the one that mostly used. The specimen used is the blood and
it tests if CHON is converted to amino acid.
59. B. Methionine. Hemocystenuria is the elevated excretion of the amino
acid hemocystiene, and there is inability to convert the amino acid
methionine or cystiene. So dietary restriction of this amino acids is
advised. This disease can lead to mental retardation.
60. C. Neutramigen. Neutramien is suggested for a child with Galactosemia.
Lofenalac is suggested for a child with PKU.
A. Community organizing
B. Nursing process
C. Community diagnosis
D. Epidemiologic process
4. R.A. 1054 is also known as the Occupational Health Act. Aside from
number of employees, what other factor must be considered in determining
the occupational health privileges to which the workers will be entitled?
A. 21
B. 101
C. 201
D. 301
6. When the occupational health nurse employs ergonomic principles, she is
performing which of her roles?
A. It involves providing home care to sick people who are not confined in
the hospital.
B. Services are provided free of charge to people within the catchment
area.
C. The public health nurse functions as part of a team providing a public
health nursing services.
D. Public health nursing focuses on preventive, not curative, services.
12. According to Margaret Shetland, the philosophy of public health nursing is
based on which of the following?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
15. Which is true of primary facilities?
A. Requesting for BCG from the RHU for school entrant immunization
B. Conducting random classroom inspection during a measles epidemic
C. Taking remedial action on an accident hazard in the school playground
D. Observing places in the school where pupils spend their free time
17. When the nurse determines whether resources were maximized in
implementing Ligtas Tigdas, she is evaluating
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
18. You are a new B.S.N. graduate. You want to become a Public Health
Nurse. Where will you apply?
A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit
19. R.A. 7160 mandates devolution of basic services from the national
government to local government units. Which of the following is the major
goal of devolution?
A. Mayor
B. Municipal Health Officer
C. Public Health Nurse
D. Any qualified physician
21. Which level of health facility is the usual point of entry of a client into the
health care delivery system?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
22. The public health nurse is the supervisor of rural health midwives. Which
of the following is a supervisory function of the public health nurse?
A. 1
B. 2
C. 3
D. The RHU does not need any more midwife item.
25. If the RHU needs additional midwife items, you will submit the request for
additional midwife items for approval to the
A. Poliomyelitis
B. Measles
C. Rabies
D. Neonatal tetanus
29. The public health nurse is responsible for presenting the municipal health
statistics using graphs and tables. To compare the frequency of the leading
causes of mortality in the municipality, which graph will you prepare?
A. Line
B. Bar
C. Pie
D. Scatter diagram
30. Which step in community organizing involves training of potential leaders
in the community?
A. Integration
B. Community organization
C. Community study
D. Core group formation
Answers and Rationales
1. Answer: (B) To enhance the capacity of individuals, families and communities
to cope with their health needs
2. Answer: (B) The nurse has to conduct community diagnosis to determine
nursing needs and problems.
3. Answer: (C) Community diagnosis. Population-focused nursing care
means providing care based on the greater need of the majority of the
population. The greater need is identified through community diagnosis.
4. Answer: (B) Location of the workplace in relation to health facilities. Based
on R.A. 1054, an occupational nurse must be employed when there are 30
to 100 employees and the workplace is more than 1 km. away from the
nearest health center.
5. Answer: (B) 101. Again, this is based on R.A. 1054.
6. Answer: (D) Environmental manager. Ergonomics is improving efficiency
of workers by improving the worker’s environment through appropriately
designed furniture, for example.
7. Answer: (C) Public health nurse of the RHU of their municipality. You’re
right! This question is based on R.A.1054.
8. Answer: (B) The statement is false; people pay indirectly for public health
services. Community health services, including public health services, are
pre-paid services, though taxation, for example.
9. Answer: (A) For people to attain their birthrights of health and
longevity. According to Winslow, all public health efforts are for people to
realize their birthrights of health and longevity.
10. Answer: (C) Swaroop’s index. Swaroop’s index is the percentage of the
deaths aged 50 years or older. Its inverse represents the percentage of
untimely deaths (those who died younger than 50 years).
11. Answer: (D) Public health nursing focuses on preventive, not curative,
services.The catchment area in PHN consists of a residential community,
many of whom are well individuals who have greater need for preventive
rather than curative services.
12. Answer: (D) The worth and dignity of man. This is a direct quote from Dr.
Margaret Shetland’s statements on Public Health Nursing.
13. Answer: (B) Ensure the accessibility and quality of health care
14. Answer: (D) Tertiary. Regional hospitals are tertiary facilities because
they serve as training hospitals for the region.
15. Answer: (B) Their services are provided on an out-patient basis. Primary
facilities government and non-government facilities that provide basic out-
patient services.
16. Answer: (B) Conducting random classroom inspection during a measles
epidemic. Random classroom inspection is assessment of pupils/students
and teachers for signs of a health problem prevalent in the community.
17. Answer: (B) Efficiency. Efficiency is determining whether the goals were
attained at the least possible cost.
18. Answer: (D) Rural Health Unit. R.A. 7160 devolved basic health services
to local government units (LGU’s ). The public health nurse is an employee
of the LGU.
19. Answer: (C) To empower the people and promote their self-reliance. People
empowerment is the basic motivation behind devolution of basic services
to LGU’s.
20. Answer: (A) Mayor. The local executive serves as the chairman of the
Municipal Health Board.
21. Answer: (A) Primary. The entry of a person into the health care delivery
system is usually through a consultation in out-patient services.
22. Answer: (B) Providing technical guidance to the midwife. The nurse provides
technical guidance to the midwife in the care of clients, particularly in the
implementation of management guidelines, as in Integrated Management
of Childhood Illness.
23. Answer: (C) Municipal Health Officer. A public health nurse and rural
health midwife can provide care during normal childbirth. A physician
should attend to a woman with a complication during labor.
24. Answer: (A) 1. Each rural health midwife is given a population
assignment of about 5,000.
25. Answer: (D) Municipal Health Board. As mandated by R.A. 7160, basic
health services have been devolved from the national government to local
government units.
26. Answer: (A) Act 3573. Act 3573, the Law on Reporting of Communicable
Diseases, enacted in 1929, mandated the reporting of diseases listed in
the law to the nearest health station.
27. Answer: (B) Health education and community organizing are necessary in
providing community health services. The community health nurse develops
the health capability of people through health education and community
organizing activities.
28. Answer: (B) Measles. Presidential Proclamation No. 4 is on the Ligtas
Tigdas Program.
29. Answer: (B) Bar. A bar graph is used to present comparison of values, a
line graph for trends over time or age, a pie graph for population
composition or distribution, and a scatter diagram for correlation of two
variables.
30. Answer: (D) Core group formation. In core group formation, the nurse is
able to transfer the technology of community organizing to the potential or
informal community leaders through a training program.
PNLE: Community Health Nursing
Exam 2
1. In which step are plans formulated for solving community problems?
A. Mobilization
B. Community organization
C. Follow-up/extension
D. Core group formation
2. The public health nurse takes an active role in community participation.
What is the primary goal of community organizing?
A. Pre-pathogenesis
B. Pathogenesis
C. Prodromal
D. Terminal
5. Isolation of a child with measles belongs to what level of prevention?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
6. On the other hand, Operation Timbang is _____ prevention.
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
7. Which type of family-nurse contact will provide you with the best
opportunity to observe family dynamics?
A. Clinic consultation
B. Group conference
C. Home visit
D. Written communication
8. The typology of family nursing problems is used in the statement of nursing
diagnosis in the care of families. The youngest child of the de los Reyes family
has been diagnosed as mentally retarded. This is classified as a:
A. Health threat
B. Health deficit
C. Foreseeable crisis
D. Stress point
9. The de los Reyes couple have a 6-year old child entering school for the first
time. The de los Reyes family has a:
A. Health threat
B. Health deficit
C. Foreseeable crisis
D. Stress point
10. Which of the following is an advantage of a home visit?
A. Wash his/her hands before and after providing nursing care to the
family members.
B. In the care of family members, as much as possible, use only articles
taken from the bag.
C. Put on an apron to protect her uniform and fold it with the right side out
before putting it back into the bag.
D. At the end of the visit, fold the lining on which the bag was placed,
ensuring that the contaminated side is on the outside.
14. The public health nurse conducts a study on the factors contributing to the
high mortality rate due to heart disease in the municipality where she works.
Which branch of epidemiology does the nurse practice in this situation?
A. Descriptive
B. Analytical
C. Therapeutic
D. Evaluation
15. Which of the following is a function of epidemiology?
A. Epidemic occurrence
B. Cyclical variation
C. Sporadic occurrence
D. Secular variation
21. In the year 1980, the World Health Organization declared the Philippines,
together with some other countries in the Western Pacific Region, “free” of
which disease?
A. Pneumonic plague
B. Poliomyelitis
C. Small pox
D. Anthrax
22. In the census of the Philippines in 1995, there were about 35,299,000
males and about 34,968,000 females. What is the sex ratio?
A. 99.06:100
B. 100.94:100
C. 50.23%
D. 49.76%
23. Primary health care is a total approach to community development. Which
of the following is an indicator of success in the use of the primary health care
approach?
A. Effectiveness
B. Efficacy
C. Specificity
D. Sensitivity
25. Use of appropriate technology requires knowledge of indigenous
technology. Which medicinal herb is given for fever, headache and cough?
A. Sambong
B. Tsaang gubat
C. Akapulko
D. Lagundi
26. What law created the Philippine Institute of Traditional and Alternative
Health Care?
A. R.A. 8423
B. R.A. 4823
C. R.A. 2483
D. R.A. 3482
27. In traditional Chinese medicine, the yielding, negative and feminine force is
termed
A. Yin
B. Yang
C. Qi
D. Chai
28. What is the legal basis for Primary Health Care approach in the
Philippines?
A. 1,500
B. 1,800
C. 2,000
D. 2,300
Answers and Rationales
1. Answer: (B) Community organization. Community organization is the step
when community assemblies take place. During the community assembly,
the people may opt to formalize the community organization and make
plans for community action to resolve a community health problem.
2. Answer: (D) To maximize the community’s resources in dealing with health
problems. Community organizing is a developmental service, with the goal
of developing the people’s self-reliance in dealing with community health
problems. A, B and C are objectives of contributory objectives to this goal.
3. Answer: (A) Participate in community activities for the solution of a
community problem. Participation in community activities in resolving a
community problem may be in any of the processes mentioned in the
other choices.
4. Answer: (D) Terminal. Tertiary prevention involves rehabilitation,
prevention of permanent disability and disability limitation appropriate for
convalescents, the disabled, complicated cases and the terminally ill
(those in the terminal stage of a disease)
5. Answer: (A) Primary. The purpose of isolating a client with a
communicable disease is to protect those who are not sick (specific
disease prevention).
6. Answer: (B) Secondary. Operation Timbang is done to identify members
of the susceptible population who are malnourished. Its purpose is early
diagnosis and, subsequently, prompt treatment.
7. Answer: (C) Home visit. Dynamics of family relationships can best be
observed in the family’s natural environment, which is the home.
8. Answer: (B) Health deficit. Failure of a family member to develop
according to what is expected, as in mental retardation, is a health deficit.
9. Answer: (C) Foreseeable crisis. Entry of the 6-year old into school is an
anticipated period of unusual demand on the family.
10. Answer: (B) It provides an opportunity to do first hand appraisal of the home
situation.. Choice A is not correct since a home visit requires that the nurse
spend so much time with the family. Choice C is an advantage of a group
conference, while choice D is true of a clinic consultation.
11. Answer: (C) A home visit should be conducted in the manner prescribed by the
RHU.The home visit plan should be flexible and practical, depending on
factors, such as the family’s needs and the resources available to the
nurse and the family.
12. Answer: (B) Should minimize if not totally prevent the spread of infection. Bag
technique is performed before and after handling a client in the home to
prevent transmission of infection to and from the client.
13. Answer: (A) Wash his/her hands before and after providing nursing care to the
family members. Choice B goes against the idea of utilizing the family’s
resources, which is encouraged in CHN. Choices C and D goes against the
principle of asepsis of confining the contaminated surface of objects.
14. Answer: (B) Analytical. Analytical epidemiology is the study of factors or
determinants affecting the patterns of occurrence and distribution of
disease in a community.
15. Answer: (D) Evaluating the effectiveness of the implementation of the
Integrated Management of Childhood Illness. Epidemiology is used in the
assessment of a community or evaluation of interventions in community
health practice.
16. Answer: (C) Participating in the investigation to determine the source of the
epidemic. Epidemiology is the study of patterns of occurrence and
distribution of disease in the community, as well as the factors that affect
disease patterns. The purpose of an epidemiologic investigation is to
identify the source of an epidemic, i.e., what brought about the epidemic.
17. Answer: (A) Delineate the etiology of the epidemic. Delineating the etiology
of an epidemic is identifying its source.
18. Answer: (D) There is a gradual build up of cases before the epidemic becomes
easily noticeable. A gradual or insidious onset of the epidemic is usually
observable in person-to-person propagated epidemics.
19. Answer: (A) Establishing the epidemic. Establishing the epidemic is
determining whether there is an epidemic or not. This is done by
comparing the present number of cases with the usual number of cases
of the disease at the same time of the year, as well as establishing the
relatedness of the cases of the disease.
20. Answer: (B) Cyclical variation. A cyclical variation is a periodic fluctuation
in the number of cases of a disease in the community.
21. Answer: (C) Small pox. The last documented case of Small pox was in
1977 at Somalia.
22. Answer: (B) 100.94:100. Sex ratio is the number of males for every 100
females in the population.
23. Answer: (D) Health programs are sustained according to the level of
development of the community. Primary health care is essential health care
that can be sustained in all stages of development of the community.
24. Answer: (D) Sensitivity. Sensitivity is the capacity of a diagnostic
examination to detect cases of the disease. If a test is 100% sensitive, all
the cases tested will have a positive result, i.e., there will be no false
negative results.
25. Answer: (D) Lagundi. Sambong is used as a diuretic. Tsaang gubat is
used to relieve diarrhea. Akapulko is used for its antifungal property.
26. Answer: (A) R.A. 8423
27. Answer: (A) Yin. Yang is the male dominating, positive and masculine
force.
28. Answer: (B) Letter of Instruction No. 949. Letter of Instruction 949 was
issued by then President Ferdinand Marcos, directing the formerly called
Ministry of Health, now the Department of Health, to utilize Primary Health
Care approach in planning and implementing health programs.
29. Answer: (D) Cooperation between the PHN and public school
teacher. Intersectoral linkages refer to working relationships between the
health sector and other sectors involved in community development.
30. Answer: (D) 2,300. Based on the Philippine population composition, to
estimate the number of 1-4 year old children, multiply total population by
11.5%.
A. 265
B. 300
C. 375
D. 400
2. To describe the sex composition of the population, which demographic tool
may be used?
A. Sex ratio
B. Sex proportion
C. Population pyramid
D. Any of these may be used.
3. Which of the following is a natality rate?
A. 4.2/1,000
B. 5.2/1,000
C. 6.3/1,000
D. 7.3/1,000
5. Knowing that malnutrition is a frequent community health problem, you
decided to conduct nutritional assessment. What population is particularly
susceptible to protein energy malnutrition (PEM)?
A. 27.8/1,000
B. 43.5/1,000
C. 86.9/1,000
D. 130.4/1,000
8. Which statistic best reflects the nutritional status of a population?
A. Census
B. Survey
C. Record review
D. Review of civil registry
11. In the conduct of a census, the method of population assignment based
on the actual physical location of the people is termed
A. De jure
B. De locus
C. De facto
D. De novo
12. The Field Health Services and Information System (FHSIS) is the recording
and reporting system in public health care in the Philippines. The Monthly
Field Health Service Activity Report is a form used in which of the components
of the FHSIS?
A. Tally report
B. Output report
C. Target/client list
D. Individual health record
13. To monitor clients registered in long-term regimens, such as the Multi-
Drug Therapy, which component will be most useful?
A. Tally report
B. Output report
C. Target/client list
D. Individual health record
14. Civil registries are important sources of data. Which law requires
registration of births within 30 days from the occurrence of the birth?
A. P.D. 651
B. Act 3573
C. R.A. 3753
D. R.A. 3375
15. Which of the following professionals can sign the birth certificate?
A. Tetanus toxoid
B. Retinol 200,000 IU
C. Ferrous sulfate 200 mg
D. Potassium iodate 200 mg. capsule
21. During prenatal consultation, a client asked you if she can have her
delivery at home. After history taking and physical examination, you advised
her against a home delivery. Which of the following findings disqualifies her
for a home delivery?
A. Niacin
B. Riboflavin
C. Folic acid
D. Thiamine
23. You are in a client’s home to attend to a delivery. Which of the following
will you do first?
A. 3 months
B. 6 months
C. 1 year
D. 2 years
28. What is given to a woman within a month after the delivery of a baby?
A. Malunggay capsule
B. Ferrous sulfate 100 mg. OD
C. Retinol 200,000 I.U., 1 capsule
D. Potassium iodate 200 mg, 1 capsule
29. Which biological used in Expanded Program on Immunization (EPI) is
stored in the freezer?
A. DPT
B. Tetanus toxoid
C. Measles vaccine
D. Hepatitis B vaccine
30. Unused BCG should be discarded how many hours after reconstitution?
A. 2
B. 4
C. 6
D. At the end of the day
Answers and Rationales
1. Answer: (A) 265. To estimate the number of pregnant women, multiply
the total population by 3.5%.
2. Answer: (D) Any of these may be used. Sex ratio and sex proportion are
used to determine the sex composition of a population. A population
pyramid is used to present the composition of a population by age and
sex.
3. Answer: (A) Crude birth rate. Natality means birth. A natality rate is a birth
rate.
4. Answer: (B) 5.2/1,000. To compute crude death rate divide total number
of deaths (94) by total population (18,000) and multiply by 1,000.
5. Answer: (C) 1-4 year old children. Preschoolers are the most susceptible
to PEM because they have generally been weaned. Also, this is the
population who, unable to feed themselves, are often the victims of poor
intrafamilial food distribution.
6. Answer: (C) Swaroop’s index. Swaroop’s index is the proportion of deaths
aged 50 years and above. The higher the Swaroop’s index of a population,
the greater the proportion of the deaths who were able to reach the age of
at least 50 years, i.e., more people grew old before they died.
7. Answer: (B) 43.5/1,000. To compute for neonatal mortality rate, divide the
number of babies who died before reaching the age of 28 days by the total
number of live births, then multiply by 1,000.
8. Answer: (A) 1-4 year old age-specific mortality rate. Since preschoolers are
the most susceptible to the effects of malnutrition, a population with poor
nutritional status will most likely have a high 1-4 year old age-specific
mortality rate, also known as child mortality rate.
9. Answer: (B) Number of registered live births. To compute for general or
total fertility rate, divide the number of registered live births by the number
of females of reproductive age (15-45 years), then multiply by 1,000.
10. Answer: (B) Survey. A survey, also called sample survey, is data
gathering about a sample of the population.
11. Answer: (C) De facto. The other method of population assignment, de
jure, is based on the usual place of residence of the people.
12. Answer: (A) Tally report. A tally report is prepared monthly or quarterly by
the RHU personnel and transmitted to the Provincial Health Office.
13. Answer: (C) Target/client list. The MDT Client List is a record of clients
enrolled in MDT and other relevant data, such as dates when clients
collected their monthly supply of drugs.
14. Answer: (A) P.D. 651. P.D. 651 amended R.A. 3753, requiring the registry
of births within 30 days from their occurrence.
15. Answer: (D) Any of these health professionals. D. R.A. 3753 states that any
birth attendant may sign the certificate of live birth.
16. Answer: (C) Magnitude of the health problem. Magnitude of the problem
refers to the percentage of the population affected by a health problem.
The other choices are criteria considered in both family and community
health care.
17. Answer: (D) Its main strategy is certification of health centers able to comply
with standards. Sentrong Sigla Movement is a joint project of the DOH and
local government units. Its main strategy is certification of health centers
that are able to comply with standards set by the DOH.
18. Answer: (D) Those who just had a delivery within the past 15 months. The
ideal birth spacing is at least two years. 15 months plus 9 months of
pregnancy = 2 years.
19. Answer: (C) Adequate information for couples regarding the different
methods. To enable the couple to choose freely among different methods
of family planning, they must be given full information regarding the
different methods that are available to them, considering the availability of
quality services that can support their choice.
20. Answer: (B) Retinol 200,000 IU. Retinol 200,000 IU is a form of megadose
Vitamin A. This may have a teratogenic effect.
21. Answer: (A) Her OB score is G5P3. Only women with less than 5
pregnancies are qualified for a home delivery. It is also advisable for a
primigravida to have delivery at a childbirth facility.
22. Answer: (C) Folic acid. It is estimated that the incidence of neural tube
defects can be reduced drastically if pregnant women have an adequate
intake of folic acid.
23. Answer: (D) Note the interval, duration and intensity of labor
contractions.. Assessment of the woman should be done first to determine
whether she is having true labor and, if so, what stage of labor she is in.
24. Answer: (D) Explain to her that putting the baby to breast will lessen blood loss
after delivery. Suckling of the nipple stimulates the release of oxytocin by
the posterior pituitary gland, which causes uterine contraction. Lactation
begins 1 to 3 days after delivery. Nipple stretching exercises are done
when the nipples are flat or inverted. Frequent washing dries up the
nipples, making them prone to the formation of fissures.
25. Answer: (B) To stimulate milk production by the mammary acini. Suckling of
the nipple stimulates prolactin reflex (the release of prolactin by the
anterior pituitary gland), which initiates lactation.
26. Answer: (B) The mother does not feel nipple pain.. When the baby has
properly latched on to the breast, he takes deep, slow sucks; his mouth is
wide open; and much of the areola is inside his mouth. And, you’re right!
The mother does not feel nipple pain.
27. Answer: (B) 6 months. After 6 months, the baby’s nutrient needs,
especially the baby’s iron requirement, can no longer be provided by
mother’s milk alone.
28. Answer: (C) Retinol 200,000 I.U., 1 capsule. A capsule of Retinol 200,000
IU is given within 1 month after delivery. Potassium iodate is given during
pregnancy; malunggay capsule is not routinely administered after delivery;
and ferrous sulfate is taken for two months after delivery.
29. Answer: (C) Measles vaccine. Among the biologicals used in the Expanded
Program on Immunization, measles vaccine and OPV are highly sensitive
to heat, requiring storage in the freezer.
30. Answer: (B) 4. While the unused portion of other biologicals in EPI may
be given until the end of the day, only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is scheduled only in the
morning.
PNLE: Community Health Nursing
Exam 4
1. In immunizing school entrants with BCG, you are not obliged to secure
parental consent. This is because of which legal document?
A. P.D. 996
B. R.A. 7846
C. Presidential Proclamation No. 6
D. Presidential Proclamation No. 46
2. Which immunization produces a permanent scar?
A. DPT
B. BCG
C. Measles vaccination
D. Hepatitis B vaccination
3. A 4-week old baby was brought to the health center for his first
immunization. Which can be given to him?
A. DPT1
B. OPV1
C. Infant BCG
D. Hepatitis B vaccine 1
4. You will not give DPT 2 if the mother says that the infant had
A. 1 year
B. 3 years
C. 10 years
D. Lifetime
7. A 4-month old infant was brought to the health center because of cough.
Her respiratory rate is 42/minute. Using the Integrated Management of Child
Illness (IMCI) guidelines of assessment, her breathing is considered
A. Fast
B. Slow
C. Normal
D. Insignificant
8. Which of the following signs will indicate that a young child is suffering
from severe pneumonia?
A. Dyspnea
B. Wheezing
C. Fast breathing
D. Chest indrawing
9. Using IMCI guidelines, you classify a child as having severe pneumonia.
What is the best management for the child?
A. Prescribe an antibiotic.
B. Refer him urgently to the hospital.
C. Instruct the mother to increase fluid intake.
D. Instruct the mother to continue breastfeeding.
10. A 5-month old infant was brought by his mother to the health center
because of diarrhea occurring 4 to 5 times a day. His skin goes back slowly
after a skin pinch and his eyes are sunken. Using the IMCI guidelines, you will
classify this infant in which category?
A. No signs of dehydration
B. Some dehydration
C. Severe dehydration
D. The data is insufficient.
11. Based on assessment, you classified a 3-month old infant with the chief
complaint of diarrhea in the category of SOME DEHYDRATION. Based on IMCI
management guidelines, which of the following will you do?
A. Bring the infant to the nearest facility where IV fluids can be given.
B. Supervise the mother in giving 200 to 400 ml. of Oresol in 4 hours.
C. Give the infant’s mother instructions on home management.
D. Keep the infant in your health center for close observation.
12. A mother is using Oresol in the management of diarrhea of her 3-year old
child. She asked you what to do if her child vomits. You will tell her to
A. Voracious appetite
B. Wasting
C. Apathy
D. Edema
14. Assessment of a 2-year old child revealed “baggy pants”. Using the IMCI
guidelines, how will you manage this child?
A. Keratomalacia
B. Corneal opacity
C. Night blindness
D. Conjunctival xerosis
16. To prevent xerophthalmia, young children are given Retinol capsule every 6
months. What is the dose given to preschoolers?
A. 10,000 IU
B. 20,000 IU
C. 100,000 IU
D. 200,000 IU
17. The major sign of iron deficiency anemia is pallor. What part is best
examined for pallor?
A. Palms
B. Nailbeds
C. Around the lips
D. Lower conjunctival sac
18. Food fortification is one of the strategies to prevent micronutrient
deficiency conditions. R.A. 8976 mandates fortification of certain food items.
Which of the following is among these food items?
A. Sugar
B. Bread
C. Margarine
D. Filled milk
19. What is the best course of action when there is a measles epidemic in a
nearby municipality?
A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days
21. Management of a child with measles includes the administration of which
of the following?
A. Do a tourniquet test.
B. Ask where the family resides.
C. Get a specimen for blood smear.
D. Ask if the fever is present everyday.
23. The following are strategies implemented by the Department of Health to
prevent mosquito-borne diseases. Which of these is most effective in the
control of Dengue fever?
A. Ascaris
B. Pinworm
C. Hookworm
D. Schistosoma
26. Which of the following signs indicates the need for sputum examination
for AFB?
A. Hematemesis
B. Fever for 1 week
C. Cough for 3 weeks
D. Chest pain for 1 week
27. Which clients are considered targets for DOTS Category I?
A. Liver cancer
B. Liver cirrhosis
C. Bladder cancer
D. Intestinal perforation
2. What is the most effective way of controlling schistosomiasis in an
endemic area?
A. Use of molluscicides
B. Building of foot bridges
C. Proper use of sanitary toilets
D. Use of protective footwear, such as rubber boots
3. When residents obtain water from an artesian well in the neighborhood, the
level of this approved type of water facility is
A. I
B. II
C. III
D. IV
4. For prevention of hepatitis A, you decided to conduct health education
activities. Which of the following is IRRELEVANT?
A. DPT
B. Oral polio vaccine
C. Measles vaccine
D. MMR
6. You will conduct outreach immunization in a barangay with a population of
about 1500. Estimate the number of infants in the barangay.
A. 45
B. 50
C. 55
D. 60
7. In Integrated Management of Childhood Illness, severe conditions generally
require urgent referral to a hospital. Which of the following severe conditions
DOES NOT always require urgent referral to a hospital?
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease
8. A client was diagnosed as having Dengue fever. You will say that there is
slow capillary refill when the color of the nailbed that you pressed does not
return within how many seconds?
A. 3
B. 5
C. 8
D. 10
9. A 3-year old child was brought by his mother to the health center because
of fever of 4-day duration. The child had a positive tourniquet test result. In the
absence of other signs, which is the most appropriate measure that the PHN
may carry out to prevent Dengue shock syndrome?
A. Nasal mucosa
B. Buccal mucosa
C. Skin on the abdomen
D. Skin on the antecubital surface
11. Among the following diseases, which is airborne?
A. Viral conjunctivitis
B. Acute poliomyelitis
C. Diphtheria
D. Measles
12. Among children aged 2 months to 3 years, the most prevalent form of
meningitis is caused by which microorganism?
A. Hemophilus influenzae
B. Morbillivirus
C. Steptococcus pneumoniae
D. Neisseria meningitidis
13. Human beings are the major reservoir of malaria. Which of the following
strategies in malaria control is based on this fact?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
14. The use of larvivorous fish in malaria control is the basis for which
strategy of malaria control?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
15. Mosquito-borne diseases are prevented mostly with the use of mosquito
control measures. Which of the following is NOT appropriate for malaria
control?
A. Giardiasis
B. Cholera
C. Amebiasis
D. Dysentery
17. In the Philippines, which specie of schistosoma is endemic in certain
regions?
A. S. mansoni
B. S. japonicum
C. S. malayensis
D. S. haematobium
18. A 32-year old client came for consultation at the health center with the
chief complaint of fever for a week. Accompanying symptoms were muscle
pains and body malaise. A week after the start of fever, the client noted
yellowish discoloration of his sclera. History showed that he waded in flood
waters about 2 weeks before the onset of symptoms. Based on his history,
which disease condition will you suspect?
A. Hepatitis A
B. Hepatitis B
C. Tetanus
D. Leptospirosis
19. MWSS provides water to Manila and other cities in Metro Manila. This is
an example of which level of water facility?
A. I
B. II
C. III
D. IV
20. You are the PHN in the city health center. A client underwent screening for
AIDS using ELISA. His result was positive. What is the best course of action
that you may take?
A. Get a thorough history of the client, focusing on the practice of high risk
behaviors.
B. Ask the client to be accompanied by a significant person before
revealing the result.
C. Refer the client to the physician since he is the best person to reveal the
result to the client.
D. Refer the client for a supplementary test, such as Western blot, since the
ELISA result may be false.
21. Which is the BEST control measure for AIDS?
A. Respiratory candidiasis
B. Infectious mononucleosis
C. Cytomegalovirus disease
D. Pneumocystis carinii pneumonia
23. To determine possible sources of sexually transmitted infections, which is
the BEST method that may be undertaken by the public health nurse?
A. Contact tracing
B. Community survey
C. Mass screening tests
D. Interview of suspects
24. Antiretroviral agents, such as AZT, are used in the management of AIDS.
Which of the following is NOT an action expected of these drugs.
A. Pregnant women
B. Elderly clients
C. Young adult males
D. Young infants
Answers and Rationales
1. Answer: (B) Liver cirrhosis. The etiologic agent of schistosomiasis in the
Philippines is Schistosoma japonicum, which affects the small intestine
and the liver. Liver damage is a consequence of fibrotic reactions to
schistosoma eggs in the liver.
2. Answer: (C) Proper use of sanitary toilets. The ova of the parasite get out of
the human body together with feces. Cutting the cycle at this stage is the
most effective way of preventing the spread of the disease to susceptible
hosts.
3. Answer: (B) II. A communal faucet or water standpost is classified as
Level II.
4. Answer: (A) Use of sterile syringes and needles. Hepatitis A is transmitted
through the fecal oral route. Hepatitis B is transmitted through infected
body secretions like blood and semen.
5. Answer: (A) DPT. DPT is sensitive to freezing. The appropriate storage
temperature of DPT is 2 to 8° C only. OPV and measles vaccine are highly
sensitive to heat and require freezing. MMR is not an immunization in the
Expanded Program on Immunization.
6. Answer: (A) 45. To estimate the number of infants, multiply total
population by 3%.
7. Answer: (B) Severe dehydration. The order of priority in the management
of severe dehydration is as follows: intravenous fluid therapy, referral to a
facility where IV fluids can be initiated within 30 minutes,
Oresol/nasogastric tube, Oresol/orem. When the foregoing measures are
not possible or effective, tehn urgent referral to the hospital is done.
8. Answer: (A) 3. Adequate blood supply to the area allows the return of the
color of the nailbed within 3 seconds.
9. Answer: (B) Instruct the mother to give the child Oresol. Since the child does
not manifest any other danger sign, maintenance of fluid balance and
replacement of fluid loss may be done by giving the client Oresol.
10. Answer: (B) Buccal mucosa. Koplik’s spot may be seen on the mucosa of
the mouth or the throat.
11. Answer: (D) Measles. Viral conjunctivitis is transmitted by direct or
indirect contact with discharges from infected eyes. Acute poliomyelitis is
spread through the fecal-oral route and contact with throat secretions,
whereas diphtheria is through direct and indirect contact with respiratory
secretions.
12. Answer: (A) Hemophilus influenzae. Hemophilus meningitis is unusual
over the age of 5 years. In developing countries, the peak incidence is in
children less than 6 months of age. Morbillivirus is the etiology of
measles. Streptococcus pneumoniae and Neisseria meningitidis may
cause meningitis, but age distribution is not specific in young children.
13. Answer: (D) Zooprophylaxis. Zooprophylaxis is done by putting animals
like cattle or dogs close to windows or doorways just before nightfall. The
Anopheles mosquito takes his blood meal from the animal and goes back
to its breeding place, thereby preventing infection of humans.
14. Answer: (A) Stream seeding. Stream seeding is done by putting tilapia fry
in streams or other bodies of water identified as breeding places of the
Anopheles mosquito
15. Answer: (C) Destruction of breeding places of the mosquito vector. Anopheles
mosquitoes breed in slow-moving, clear water, such as mountain streams.
16. Answer: (B) Cholera. Passage of profuse watery stools is the major
symptom of cholera. Both amebic and bacillary dysentery are
characterized by the presence of blood and/or mucus in the stools.
Giardiasis is characterized by fat malabsorption and, therefore,
steatorrhea.
17. Answer: (B) S. japonicum. S. mansoni is found mostly in Africa and South
America; S. haematobium in Africa and the Middle East; and S. malayensis
only in peninsular Malaysia.
18. Answer: (D) Leptospirosis. Leptospirosis is transmitted through contact
with the skin or mucous membrane with water or moist soil contaminated
with urine of infected animals, like rats.
19. Answer: (C) III. Waterworks systems, such as MWSS, are classified as
level III.
20. Answer: (D) Refer the client for a supplementary test, such as Western blot,
since the ELISA result may be false. A client having a reactive ELISA result
must undergo a more specific test, such as Western blot. A negative
supplementary test result means that the ELISA result was false and that,
most probably, the client is not infected.
21. Answer: (A) Being faithful to a single sexual partner. Sexual fidelity rules out
the possibility of getting the disease by sexual contact with another
infected person. Transmission occurs mostly through sexual intercourse
and exposure to blood or tissues.
22. Answer: (B) Infectious mononucleosis. Cytomegalovirus disease is an
acute viral disease characterized by fever, sore throat and
lymphadenopathy.
23. Answer: (A) Contact tracing. Contact tracing is the most practical and
reliable method of finding possible sources of person-to-person
transmitted infections, such as sexually transmitted diseases.
24. Answer: (D) They are able to bring about a cure of the disease
condition. There is no known treatment for AIDS. Antiretroviral agents
reduce the risk of opportunistic infections and prolong life, but does not
cure the underlying immunodeficiency.
25. Answer: (D) Consult a physician who may give them rubella
immunoglobulin. Rubella vaccine is made up of attenuated German
measles viruses. This is contraindicated in pregnancy. Immune globulin, a
specific prophylactic against German measles, may be given to pregnant
women.
26. Answer: (D) Proper handwashing during food preparation is the best way of
preventing the condition. Symptoms of this food poisoning are due to
staphylococcal enterotoxin, not the microorganisms themselves.
Contamination is by food handling by persons with staphylococcal skin or
eye infections.
27. Answer: (A) The older one gets, the more susceptible he becomes to the
complications of chicken pox. Chicken pox is usually more severe in adults
than in children. Complications, such as pneumonia, are higher in
incidence in adults.
28. Answer: (C) Young adult males. Epididymitis and orchitis are possible
complications of mumps. In post-adolescent males, bilateral inflammation
of the testes and epididymis may cause sterility.
PNLE : Medical Surgical Nursing
Exam 1
SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle
while crossing a train railway. The old woman fell at the railway. Arthur rushed at
the scene.
1. As a registered nurse, Arthur knew that the first thing that he will do at the
scene is
A. Stay with the person, Encourage her to remain still and Immobilize the
leg while While waiting for the ambulance.
B. Leave the person for a few moments to call for help.
C. Reduce the fracture manually.
D. Move the person to a safer place.
2. Arthur suspects a hip fracture when he noticed that the old woman’s leg is
A. Infection
B. Thrombophlebitis
C. Inflammation
D. Degenerative disease
4. The old woman told John that she has osteoporosis; Arthur knew that all of
the following factors would contribute to osteoporosis except
A. Hypothyroidism
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin.
5. Martha, The old woman was now Immobilized and brought to the
emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse
would carefully monitor Martha for which of the following sign and
symptoms?
A. PPD
B. PDP
C. PDD
D. DPP
10. The nurse would inject the solution in what route?
A. IM
B. IV
C. ID
D. SC
11. The nurse notes that a positive result for Alfred is
A. 5 mm wheal
B. 5 mm Induration
C. 10 mm Wheal
D. 10 mm Induration
12. The nurse told Alfred to come back after
A. a week
B. 48 hours
C. 1 day
D. 4 days
13. Mang Alfred returns after the Mantoux Test. The test result read
POSITIVE. What should be the nurse’s next action?
A. I
B. II
C. III
D. IV
16. How long is the duration of the maintenance phase of his treatment?
A. 2 months
B. 3 months
C. 4 months
D. 5 months
17. Which of the following drugs is UNLIKELY given to Mang Alfred during the
maintenance phase?
A. Rifampicin
B. Isoniazid
C. Ethambutol
D. Pyridoxine
18. According to the DOH, the most hazardous period for development of
clinical disease is during the first
A. DOTS
B. National Tuberculosis Control Program
C. Short Coursed Chemotherapy
D. Expanded Program for Immunization
20. Susceptibility for the disease [ TB ] is increased markedly in those with the
following condition except
A. Primary
B. Secondary
C. Tertiary
D. Quarterly
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in
colostomy.
22. Michiel shows the BEST adaptation with the new colostomy if he shows
which of the following?
A. 1-2 inches
B. 3-4 inches
C. 6-8 inches
D. 12-18 inches
25. The maximum height of irrigation solution for colostomy is
A. 5 inches
B. 12 inches
C. 18 inches
D. 24 inches
26. Which of the following behavior of the client indicates the best initial step
in learning to care for his colostomy?
A. Eat eggs
B. Eat cucumbers
C. Eat beet greens and parsley
D. Eat broccoli and spinach
30. The nurse will start to teach Michiel about the techniques for colostomy
irrigation. Which of the following should be included in the nurse’s teaching
plan?
A. Brick Red
B. Gray
C. Blue
D. Pale Pink
SITUATION: James, A 27 basketball player sustained inhalation burn that required
him to have tracheostomy due to massive upper airway edema.
32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of
James. Which of the following, if made by Wilma indicates that she is
committing an error?
A. Fr. 5
B. Fr. 10
C. Fr. 12
D. Fr. 18
34. Wilma is using a portable suction unit at home, What is the amount of
suction required by James using this unit?
A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 20-25 mmHg
35. If a Wall unit is used, What should be the suctioning pressure required by
James?
A. 50-95 mmHg
B. 95-110 mmHg
C. 100-120 mmHg
D. 155-175 mmHg
36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the
inner and outer cannulas was removed and left hanging on James’ neck. What
are the 2 equipment’s at james’ bedside that could help Wilma deal with this
situation?
A. 10 seconds
B. 20 seconds
C. 30 seconds
D. 45 seconds
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with
Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
40. What specific manifestation would nurse Jet see in Acute close angle
glaucoma that she would not see in an open angle glaucoma?
A. IRIS
B. PUPIL
C. RODS [RETINA]
D. CONES [RETINA]
44. Nurse Jet knows that Aqueous Humor is produce where?
A. 8-21 mmHg
B. 2-7 mmHg
C. 31-35 mmHg
D. 15-30 mmHg
46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test
would Nurse Jet implement to measure CN II’s Acuity?
A. Slit lamp
B. Snellen’s Chart
C. Wood’s light
D. Gonioscopy
47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug
is to
A. Atropine Sulfate
B. Pindolol [Visken]
C. Naloxone Hydrochloride [Narcan]
D. Mesoridazine Besylate [Serentil]
SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will
help a nurse assess and analyze changes in the adult client’s health.
52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old
university professor who recently went into coma after being mauled by her
disgruntled 3rd year nursing students whom she gave a failing mark. After
instilling a warm water in the ear, Anna noticed a rotary nystagmus towards
the irrigated ear. What does this means?
A. Indicates a CN VIII Dysfunction
B. Abnormal
C. Normal
D. Inconclusive
53. Ear drops are prescribed to an infant, The most appropriate method to
administer the ear drops is
A. Pull the pinna up and back and direct the solution towards the eardrum
B. Pull the pinna down and back and direct the solution onto the wall of the
canal
C. Pull the pinna down and back and direct the solution towards the
eardrum
D. Pull the pinna up and back and direct the solution onto the wall of the
canal
54. Nurse Jenny is developing a plan of care for a patient with Menieres
disease. What is the priority nursing intervention in the plan of care for this
particular patient?
A. Air, Breathing, Circulation
B. Love and Belongingness
C. Food, Diet and Nutrition
D. Safety
55. After mastoidectomy, Nurse John should be aware that the cranial nerve
that is usually damage after this procedure is
A. CN I
B. CN II
C. CN VII
D. CN VI
56. The physician orders the following for the client with Menieres disease.
Which of the following should the nurse question?
A. Dipenhydramine [Benadryl]
B. Atropine sulfate
C. Out of bed activities and ambulation
D. Diazepam [Valium]
57. Nurse Anna is giving dietary instruction to a client with Menieres disease.
Which statement if made by the client indicates that the teaching has been
successful?
A. I will try to eat foods that are low in sodium and limit my fluid intake
B. I must drink atleast 3,000 ml of fluids per day
C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
D. I will not eat turnips, red meat and raddish
58. Peachy was rushed by his father, Steven into the hospital admission.
Peachy is complaining of something buzzing into her ears. Nurse Joemar
assessed peachy and found out It was an insect. What should be the first
thing that Nurse Joemar should try to remove the insect out from peachy’s
ear?
A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml
66. Postural Hypotension is
A. Disturbed vision
B. Forgetfulness
C. Mask like facial expression
D. Muscle atrophy
70. The onset of Parkinson’s disease is between 50-60 years old. This
disorder is caused by
A. Balance
B. Judgment
C. Speech
D. Endurance
75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He
suffers from:
A. Insomnia
B. Aphraxia
C. Agnosia
D. Aphasia
76. The nurse is aware that in communicating with an elderly client, the nurse
will
A. Emergency Numbers
B. Drug Compliance
C. Relaxation technique
D. Dietary prescription
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine]
Is necessary in treatment of various disorders.
79. What is the action of this drug?
A. Caffeine
B. NSAID
C. Acetaminophen
D. Alcohol
82. What should the nurse tell clients when taking Probanthine?
A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
D. Glaucoma
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak
at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
84. Which of the following is the most important assessment during the acute
stage of an unconscious patient like Mr. Franco?
89. Which result of the lab test will be significant to the diagnosis?
A. RBC : 4.5 TO 5 Million / cu. mm.
B. Hgb : 13 to 14 gm/dl.
C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm
90. Stat appendectomy was indicated. Pre op care would include all of the
following except?
A. Spinal
B. General
C. Caudal
D. Hypnosis
93. Post op care for appendectomy include the following except
A. Early ambulation
B. Diet as tolerated after fully conscious
C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise
94. Peritonitis may occur in ruptured appendix and may cause serious
problems which are
A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon
96. NGT was connected to suction. In caring for the patient with NGT, the
nurse must
A. Inorganic Stroke
B. Inorganic Psychoses
C. Organic Stroke
D. Organic Psychoses
99. The main difference between chronic and organic brain syndrome is that
the former
A. Memory deficit
B. Disorientation
C. Impaired Judgement
D. Inappropriate affect
Answers
1. D. Move the person to a safer place.
2. D. Shortened, Adducted and Externally Rotated.
3. C. Inflammation
4. A. Hypothyroidism
5. A. Tachycardia and Hypotension
6. B. On his left hand, because of reciprocal motion.
7. c. 6 Inches at the lateral side of the foot.
8. A. Moves the cane when the right leg is moved.
9. A. PPD
10. C. ID
11. D. 10 mm Induration
12. B. 48 hours
13. A. Call the Physician
14. D. Almost all Filipinos will test positive for Mantoux Test
15. A. I
16. C. 4 months
17. C. Ethambutol
18. A. 6-12 months after
19. B. National Tuberculosis Control Program
20. A. 23 Year old athlete with diabetes insipidus
21. B. Secondary
22. B. Participate with the nurse in his daily ostomy care
23. A. Plain NSS / Normal Saline
24. B. 3-4 inches
25. C. 18 inches
26. C. Agrees to look at the colostomy
27. A. Stop the irrigation by clamping the tube
28. D. Protruding stoma with swollen appearance
29. C. Eat beet greens and parsley
30. B. Suspend the irrigant 45 cm above the stoma
31. A. Brick Red
32. D. Suction the client every hour
33. D. Fr. 18
34. C. 10-15 mmHg
35. C. 100-120 mmHg
36. C. Obturator and Kelly clamp
37. A. Wilma places 2 fingers between the tie and neck
38. A. James’ respiratory rate is 18
39. A. 10 seconds
40. D. Pain
41. A. Sudden blockage of the anterior angle by the base of the iris
42. B. Measures the Intra Ocular Pressure
43. D. CONES [RETINA]
44. D. In the Ciliary Body
45. A. 8-21 mmHg
46. B. Snellen’s Chart
47. A. Contract the Ciliary muscle
48. B. Reduce production of Aquesous Humor
49. B. Bending at the waist
50. A. Reading newsprint
51. A. Atropine Sulfate
52. C. Normal
53. B. Pull the pinna down and back and direct the solution onto the wall of the
canal
54. D. Safety
55. C. CN VII
56. C. Out of bed activities and ambulation
57. A. I will try to eat foods that are low in sodium and limit my fluid intake
58. A. Use a flashlight to coax the insect out of peachy’s ear
59. D. I should avoid air travel for a while
60. D. This indicates an intact and working vestibular branch of CN VIII
61. B. Sensory perceptual alteration R/T Lens extraction and replacement
62. C. He might have a sensory hearing loss in the right hear, and/or a conductive
hearing loss in the left ear.
63. D. low sodium and restricted fluid intake
64. B. Fluid volume deficit R/T uncontrolled vomiting
65. C. 500 ml
66. B. A drop in systolic pressure greater than 10 mmHg when patient changes
position from lying to sitting
67. A. Offer large amount of oral fluid intake to replace fluid lost
68. D. 2,3,4
69. C. Mask like facial expression
70. D. Impairment of dopamine producing cells in the brain
71. A. Increase dopamine availability
72. D. Vitamin B6 rich food
73. A. You will need a cane for support
74. B. Judgment
75. D. Aphasia
76. D. Use a medium-pitched voice
77. B. I told her she is wrong and I explained to her what is right
78. B. Drug Compliance
79. C. Reduces secretion of the glandular organ of the body
80. A. Avoid hazardous activities like driving, operating machineries etc.
81. D. Alcohol
82. A. Avoid hot weathers to prevent heat strokes
83. B. Peptic Ulcer Disease
84. D. Patency of airway and adequacy of respiration
85. D. Suction machine and gloves
86. D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa
dying and cracking.
87. B. Turn frequently every 2 hours
88. A. Expressive aphasia is prominent on clients with right sided weakness
89. D. WBC : 12,000 to 13,000/cu.mm
90. B. Enema STAT
91. A. Allay anxiety and apprehension
92. A. Spinal
93. B. Diet as tolerated after fully conscious
94. D. All of the above
95. B. Paralytic Ileus
96. A. Irrigate the tube with saline as ordered
97. C. Abdomen is soft and flatus has been expelled
98. D. Organic Psychoses
99. C. tends to be progressive and irreversible
100. B. Disorientation