1. Florence Nightingale’s theory focused on environment.

Which of the following did she define and describe in her

theory?
a. Food, air, water, elimination, and shelter
b. Ventilation, warmth, light, diet, cleanliness, and noise
c. Physical, emotional, mental and spiritual
d. Physiologic, safety, love & belongingness, self-esteem, and self-actualization
ANSWER: B In Florence Nightingale’s theory she has focused on ventilation, warmth, light, diet or nutrition, cleanliness
and elimination of noise. Letter A leans more into the physiologic needs of a patient. Letter C is not related to any
nursing theories. Letter D is talking about Maslow’s hierarchy of needs.

2. In Jean Watson’s Theory of Human Caring, she has stated that nursing is concerned with the following EXCEPT
a. Promoting health c. Caring for the sick
b. Preventing illness d. Identifying the basic needs
ANSWER: D Choices A, B, and C is in Jean Watson’s statement that says, “Nursing is concerned with promoting health,
preventing illness, caring for the sick, and restoring health.” Letter D is not included in this statement.

3. According to Jean Watson, which one is central to nursing practice and promotes health better than a simple medical
cure?
a. Caring c. Dedication
b. Compassion d. Empathy
ANSWER: A According to Jean Watson’s theory caring should be central or essential to the nursing practice. She did not
indicate compassion, dedication, and empathy in her theory.
Jean Watson contends that caring regenerates life energies and potentiates our capabilities. The benefits are
immeasurable and promote self-actualization on both a personal and professional level. Caring is a mutually beneficial
experience for both the patient and the nurse, as well as between all health team members.
Watson's caring theory contains three major elements: (1) the carative factors, (2) the transpersonal caring
relationship, and (3) the caring occasion/caring moment

4. In Jean Watson’s theory she has stated to focus on which of the following?
a. Treatment of diseases c. Health promotion
b. Rehabilitation d. Control of environment
ANSWER: C In Jean Watson’s theory, she has focused on health promotion in order for the people to achieve a great
well-being and avoid the occurrence of illnesses.

5. In Patricia Benner’s nursing theory she has described the advanced-beginner nurse as
a. They are taught general rules to help perform tasks, and their rule-governed behavior is limited and inflexible.
b. Shows acceptable performance, and has gained prior experience in actual nursing situations.
c. Generally, has two or three years’ experience on the job in the same field.
d. Perceives and understands situations as whole parts.
ANSWER: B RATIO: Choice A is pertaining to a nurse novice. While Letter C is talking about a competent nurse. Letter D
meanwhile is describing a proficient nurse. Expert nurses no longer rely on principles, rules, or guidelines to connect
situations and determine actions

6. How many levels of nursing experience did Patricia Benner identify?

a. 3 c. 5
b. 4 d. 7
ANSWER: C Patricia Benner has identified 5 levels of nursing experience namely the novice nurse, the competent nurse,
the proficient nurse, and the expert nurse.

7. According to Katie Eriksson’s nursing theory, she said to take which of the following into use when caring for the
human being in health and suffering?
a. Charity c. Comfort
b. Chastity d. Caritas
ANSWER: D In Katie Eriksson’s theory she has used caritas which is Latin for “Love for all” when caring for the human
being in health and suffering.

8. Which of the following is NOT a part of Dorothea Orem’s nursing theory?

a. The theory of self-care c. The 21 nursing problems
b. The self-care deficit theory d. The theory of nursing systems
ANSWER: C A, B, and D is included in Dorothea Orem’s nursing theory. Letter C is identified by another nursing
theorist, Faye Abdellah.
9. This theory from Dorothea Orem focuses on the performance or practice of activities that individuals initiate and
perform on their own behalf to maintain life, health and well-being.
a. Theory of self-care c. The theory of nursing systems
b. The self-care deficit theory d. All of the above
ANSWER: A Letter B (Self-care deficit theory) delineates when nursing is needed. Nursing is required when an adult (or
in the case of a dependent, the parent or guardian) is incapable of or limited in the provision of continuous effective
self- care. Letter C (The theory of nursing systems) This theory is the product of a series of relations between the
persons: legitimate nurse and legitimate client. This system is activated when the client’s therapeutic self-care demand
exceeds available self-care agency, leading to the need for nursing.

10. In Martha E. Roger’s Theory of Human Beings she defined nursing as

a. “The act of assisting others in the provision and management of self-care to maintain or improve human
functioning at home level of effectiveness.”
b. “Unique profession in that is concerned with all of the variables affecting an individual’s response to stress.”
c. “An art and science that is humanistic and humanitarian.”
d. “Health care profession that focuses on human life processes and patterns and emphasizes promotion of health for
individuals, families, groups, and society as a whole.”
ANSWER: C Letter A is from Dorothea Orem’s theory, Letter B is from Betty Neuman’s theory, while Letter D is from
Sister Callista Roy’s theory.

11. Which of the following sentences is NOT a concept related to Florence Nightingale’s theory?
a. "Poor or difficult environments led to poor health and disease"
b. "Environment could be altered to improve conditions so that the natural laws would allow healing to occur"
c. The goal of nursing is “to put the patient in the best condition for nature to act upon him”
d. "Human beings are open systems in constant interaction with the environment"
ANSWER: D Letter D is from Imogene King’s Goal Attainment theory. The rest of the choices are related concepts to
Florence Nightingale’s Theory.

12. In Martha E. Roger’s the Science of Unitary Human Beings contains two dimensions: the science of nursing, which is
the knowledge specific to the field of nursing that comes from scientific research; and
a. Art of nursing c. Behavioral Systems Model
b. Adaptation Model d. Carative caring
ANSWER: A The art of nursing, which involves using the science of nursing creatively to help better the life of the
patient. Letter B is from Sister Callista Roy, Letter C is from Dorothy Johnson, and Letter D is from Katie Eriksson.

13. What are the five variables identified in Betty Neuman’s System model?
a. Oral, Anal, Phallic, Latent, and Genital
b. Physiologic, safety and security, love and belongingness, self-esteem, and self actualization
c. Ventilation, warmth, light, diet, cleanliness, and noise
d. Physiological, psychological, sociocultural, developmental, and spiritual
ANSWER: D Letter A is from Sigmund Freud’s Psychosexual Theory, Letter B is from Maslow’s Heirarchy of Needs, Letter
C is from Florence Nightingale’s nursing theory.

14. In Betty Neuman’s model, the focus is on the client as a system (which may be an individual, family, group, or
community) and on the client’s responses to
a. Illness c. Needs
b. Stressors d. Health promotion
ANSWER: B In Neuman’s System Model, she defined nursing as a “unique profession in that is concerned with all of
the variables affecting an individual’s response to stress.”

15. In Imogene King’s nursing theory, her model focuses on the attainment on which of the following?
a. Goal c. Balanced nutrition
b. Well-being d. Basic needs
ANSWER: A
RATIO: Imogene M. King’s Theory of Goal Attainment focuses on this process to guide and direct nurses in the nurse-
patient relationship, going hand-in-hand with their patients to meet the goals towards good health.

16. Which of the following is the theory associated with Sister Callista Roy?
a. Behavioral System Model c. Adaptation Model of Nursing
b. Theory of Carative Caring d. Theory of Bureaucratic Nursing
ANSWER: C Letter A is from Dorothy Johnson’s theory, Letter B is from Katie Eriksson, while Letter D is from Marilyn
Ann Ray. In Adaptation Model, Roy defined nursing as a “health care profession that focuses on human life processes
and patterns and emphasizes promotion of health for individuals, families, groups, and society as a whole.”
17. In Dorothy Johnson’s Behavioral System Model, she defined which of the following statements?
a. “Nursing is a science and the performing art of nursing is practiced in relationships with persons
(individuals, groups, and communities) in their processes of becoming.” - Parse
b. “participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses,
whereas the CORE and CURE are shared with other members of the health team.” Lydia Hall
c. “People may differ in their concept of nursing, but few would disagree that nursing is nurturing or caring for someone
in a motherly fashion.” Ernestine Wiedenbach
d. “an external regulatory force which acts to preserve the organization and integration of the patients’
behaviors at an optimum level under those conditions in which the behavior constitutes a threat to the
physical or social health, or in which illness is found.”
ANSWER: D Letter A is from Rosemarie Rizzo Parse’s Theory of Human Becoming, Letter B is from Lydia Hall’s Core,
Care and Cure Theory, while Letter C is from Ernestine Wiedenbach’s The Helping Art of Clinical Nursing.

18. According to Myra Levine’s theory, she states that nursing is

a. An art
b. Human interaction
c. Concerned with promoting health, preventing illness, caring for the sick, and restoring health.
d. Science and the performing art of nursing is practiced in relationships with persons (individuals, groups,
and communities) in their processes of becoming.”
ANSWER: B According to the Conservation Model, “Nursing is human interaction.” Logically congruent, is externally
and internally consistent, has breadth as well as depth, and is understood, with few exceptions, by professionals and
consumers of health care.

19. In Hildegard Peplau’s Theory of Interpersonal Relations, she has identified four components which are
a. Digestion, respiration, elimination, and sleep
b. Person, environment, health, and nursing
c. Orientation, identification, exploitation, and resolution
d. Air, food, water, and shelter
ANSWER: B The four components of the theory are: person, which is a developing organism that tries to
reduce anxiety caused by needs; environment, which consists of existing forces outside of the person, and put in the
context of culture; health, which is a word symbol that implies forward movement of personality and nursing, which is a
significant therapeutic interpersonal process that functions cooperatively with other human process that make health
possible for individuals in communities. The nursing model identifies four sequential phases in the interpersonal
relationship: orientation, identification, exploitation, and resolution.

20. Which phase of interpersonal relations in Peplau’s Theory of Interpersonal Relations should the nurse establish
rapport with the client?
a. Orientation c. Exploitation
b. Identification d. Resolution
ANSWER: A Establishment of rapport is done during the orientation phase, in the identification phase the nurse
identifies the major problems of the client, while in the exploitation phase the nurse works with the client with problem
solving, and the last stage which is the resolution phase is where the nurse evaluates and ends her professional
relationship with the client.

21. The nursing theorist who identified the 5 stages of the nursing process is
a. Lydia Hall c. Ida Jean Orlando
b. Madeleine Leininger d. Imogene King
ANSWER: C
RATIO: Lydia Hall’s theory is the Core, Care, Cure model, Madeleine Leininger’s theory is about transcultural nursing, and
Imogene King’s theory is all about Goal Attainment. Ida Jean Orlando identified the 5 stages of the nursing process
namely: (1) Assessment, (2) Diagnosis, (3) Planning, (4) Implementation, and (5) Evaluation.

22. According to Joyce Travelbee’s theory, nursing is accomplished through

a. Human-to-human relationships c. Manipulation of the environment
b. Nurse-patient relationship d. Promoting health
ANSWER: A States in her Human-to-Human Relationship Model that the purpose of nursing was to help and support an
individual, family, or community to prevent or cope with the struggles of illness and suffering and, if necessary, to find
significance in these occurrences, with the ultimate goal being the presence of hope. Nursing was accomplished through
human-to-human relationships.

23. In Lydia Hall’s Core, Care, Cure model, she has identified the core as which of the following?
a. Primary role of a professional nurse such as providing bodily care for the patient
b. The patient receiving nursing care
c. The aspect of nursing which involves the administration of medications and treatments
d. the purpose of nursing was to help and support an individual, family, or community
ANSWER: B The “care” circle defines the primary role of a professional nurse such as providing bodily care for the
patient. The “core” is the patient receiving nursing care. The “cure” is the aspect of nursing which involves the
administration of medications and treatments.

24. Faye Glenn Abdellah’s 21 nursing problems were categorized into which of the following?
a. Physical, sociological, and emotional needs c. Physiological, psychological, and spiritual
b. Prevention, treatment, and rehabilitation d. Food, air, and water
ANSWER: A The 21 nursing problems fall into three categories: physical, sociological, and emotional needs of patients;
types of interpersonal relationships between the patient and nurse; and common elements of patient care. She used
Henderson’s 14 basic human needs and nursing research to establish the classification of nursing problems.

25 Nurse Edberg is about to perform physical assessment of the abdomen. Which order of assessment must Nurse
Edberg do?
a. Inspection, palpation, percussion, and auscultation c. Inspection, auscultation, percussion, and palpation
b. Auscultation, percussion, palpation, and inspection d. Any order that the nurse desires
ANSWER: C Letter C is the correct order that must be done in order to avoid any alterations in the bowel sounds.
Letter A is done for the rest of the body.

26. Nurse Ann is going to assess a newly admitted client who is suspected to have Dengue Hemorrhagic Fever.
Which of the following should she record as subjective data?
a. Body temperature of 38.8 degrees Celsius c. Patient’s complaint about abdominal pain
b. Complete blood count result d. Client’s blood pressure of 110/78
ANSWER: C Subjective data also known as symptoms are things that the patient alone can feel and observe. The other
choices will fall under objective data or also known as signs, these are things that the medical worker can assess from
the patient.

27. Which of the following is the purpose of physical examination?

a. To obtain subjective data from the patient
b. To know about the patient’s chief complaint
c. To determine changes in a patient’s health status and how to respond to a problem as well as promote healthy
lifestyles and wellbeing
d. To evaluate the outcome of the nursing interventions
ANSWER: C Letter A, B, and D will fall into Letter C’s statement. It is the duty of the nurse to do physical examination in
order to assess the patient’s health status and formulate a plan on how to address any changes in the normal bodily
functioning of the patient.

28. A student nurse is instructed to perform an intramuscular injection by using the Z-track method. The student nurse
must know that the purpose of doing the Z-track method is
a. To enhance blood flow to the injection site
b. To allow faster absorption of the drug into the muscle
c. To prevent drug leakage into the subcutaneous tissue, helps seal the drug in the muscle, and minimizes
skin irritation.
d. To allow faster drug clearance.
ANSWER: C The Z-track method is a type of IM injection technique used to prevent tracking (leakage) of the medication
into the subcutaneous tissue (underneath the skin). During the procedure, skin and tissue are pulled and held firmly
while a long needle is inserted into the muscle.

29. Nurse Aladdin Abdulrahman is reviewing the patient’s blood pressure after administering an oral antihypertensive
30 minutes before. The nurse is employing which stage of the nursing process?
a. Nursing diagnosis c. Implementation
b. Planning d. Evaluation
ANSWER: D By reviewing the effects of a drug that was administered prior, the nurse here is employing the final step of
the nursing process which is evaluation.

30. A patient named Jasmine Allamudin is in the bathroom when Nurse Belle enters to give a prescribed medication.
What should the nurse in charge do?
a. Wait for the patient to return to her bed then leave the medication at her bedside.
b. Return shortly to the patient’s room and remain there until the patient takes her medication.
c. Tell the patient to be sure to take the medication and then leave it at her bedside.
d. Leave the medication at her patient’s bedside.
ANSWER: B This ensures that the patient is compliant by taking the medication at the right time. The nurse must see to
it that medications are really taken by the patients.
31. Dr. Rodrigo Robredo orders heparin, 7500 units, to be administered subcutaneously every 6 hours. The vial reads
10000 units per milliliter. Nurse Leni should anticipate giving how much heparin for each dose?
a. 0.25 ml c. 0.75 ml
b. 0.5 ml d. 1.25 ml

ANSWER: C Doctor’s order/Stock Dose x Quantity (in ml)

7500 units/10000 units x 1 ml = 0.75 ml (cancel out the units).

32. A patient named Panfilo dela Rosa is suffering from hypoxia. The physician is most likely to order which of the
following tests?
a. Arterial blood gas analysis c. Chest X-ray
b. Total hemoglobin and hematocrit d. Complete blood count

ANSWER: A In order to totally know the patients O2 and CO2 levels in his blood the most accurate test to do this
would be through ABG analysis. Choices B, C, and D will not measure the oxygen and carbon dioxide saturation in the
blood.

33. Nurse Ishbelle uses a stethoscope to auscultate a female patient’s chest. Which statement about the stethoscope
with the bell and the diaphragm is true?
a. The bell detects thrills best c. The diaphragm detects high-pitched sounds best
b. The bell detects high-pitched sounds best d. The diaphragm detects low-pitched sounds best
ANSWER: C The diaphragm is used when detecting high-pitched sounds while the bell is used for detecting low-pitched
sounds.

34. Nurse Vincent is teaching the community about the importance of exercise to prevent the occurrence of type II
diabetes mellitus.
a. Primary prevention c. Tertiary prevention
b. Secondary prevention d. Passive prevention
ANSWER: A Promoting the community’s well-being in order to prevent the occurrence of diseases would be primary
prevention, secondary prevention is done when a medical worker gives the patient a treatment for a certain disease,
while tertiary prevention involves rehabilitation of patients with chronic illnesses or who has debilitating conditions.
There is no passive prevention.

35. When observing universal precaution, the nurse must always practice which of the following to prevent the
transmission of infection?
a. Having a proper diet c. Taking supplemental vitamins and minerals
b. Maintain adequate exercise d. Practice hand hygiene at all times
ANSWER: D The primary mandate of universal precaution to prevent the transmission of infection would always be
handwashing. By practicing handwashing, people can eliminate the transmission of contagious or communicable
diseases.

36. Nurse Jason is going to feed the patient via the nasogastric tube. Which nursing action is essential in performing
enteral feeding?
a. Elevating the head of the bed c. Warming the formula before administering it
b. Positioning the patient to the left side d. Hanging a full day’s worth of formula at one time
ANSWER: A The nurse must make sure that before feeding the patient via the nasogastric tube, the nurse must
properly position the head of the bed in an elevated position. With this position, the feeding will easily go down the tube
due to gravity.

37. Nurse Joy is going to administer a tablet via the sublingual route. She should instruct her patient to place the
tablet on the:
a. Inside of the cheek c. Roof of the mouth
b. Floor of the mouth d. Top of the tongue
ANSWER: B The sublingual route is under the tongue or also known as the floor of the mouth. Drug administration
inside of the cheek would be the buccal route.

38. Which of the following best describes Kussmaul respirations?

a. Increased rate and depth of breathing over a prolonged period of time. In response to metabolic acidosis,
the body's attempt to blow off CO2 to buffer a fixed acid such as ketones.
b. Gradual increase in volume and frequency, followed by a gradual decrease in volume and frequency, with
apnea periods of 10 - 30 seconds between cycle.
c. Short episodes of rapid, deep inspirations followed by 10 - 30 second apneic period.
d. Only able to breathe comfortable in upright position (such as sitting in chair), unable to breath laying
down.
ANSWER: A Letter A best describes Kussmaul respirations. Letter B is describing Chyne-Stokes Respirations. Letter C is
describing Biot’s respirations, while Letter D describes orthopnea.

39. Doctor Rodrigo Robredo has ordered dextrose 5% in water, 1000 ml to be infused over 8 hours. The I.V. tubing is
delivering 15 drops per milliliter. Nurse Bong should run the infusion rate at:
a. 15 drops per minute
b. 21 drops per minute
c. 31 drops per minute
d. 125 drops per minute
ANSWER: C
volume in ml x drop factor = gtt/min
_______________________
Time in hrs x 60 min

1000 ml x 15 gtt/ml = 15000 gtts = 31.25 gtts/min

8 x 60 480 min

40. Which of the following is true about the working phase of the nurse-patient relationship?
a. Obtain subjective data c. Greet the patient
b. Make the patient comfortable d. Establish rapport

ANSWER: A RATIO: Obtaining data is one of the things done in the working phase of the nurse-patient relationship. The
remaining choices are done during the orientation phase of the relationship.

41. Which of the following interventions is considered as a primary level of prevention?

a. Using physical therapy to help the patient cope with above-the-knee amputation.
b. Obtaining a breast biopsy to detect breast cancer
c. Administering an anti-Hepatitis B immunization to an infant
d. Administering Ceftriaxone (Rocephin) to a patient who has gonorrhea
ANSWER: C
RATIO: Letter A is under tertiary level of prevention. Letter B and D is under secondary level of prevention.

41. Nurse JM is tasked to do a nursing care plan in the ward. The identification of actual or potential health problems
is done during which step of the nursing process?
a. Assessment c. Planning
b. Nursing diagnosis d. Implementation
ANSWER: B In the nursing diagnosis stage of the nursing process this is where the nurse identifies the problems of the
patient and prioritizes them in what the nurse sees fit.

42. A female patient named Mikasa Ackerman has been found to be suffering from deep-vein thrombosis. Which
nursing diagnosis should Nurse Eren prioritize at this time?
a. Altered peripheral tissue perfusion related to venous congestion
b. Risk for injury related to edema
c. Fluid volume excess related to peripheral vascular disease
d. Impaired gas exchange related to decreased blood flow
ANSWER: A Due to the deep-vein thrombosis, there is an alteration in the patient’s tissue perfusion resulting into the
congestion of blood in the leg veins of the patient. Since blood flow is obstructed, pooling of blood in the lower
extremities will occur.

43. Nurse Erina has found out that after giving proper interventions to Soma who has fever brought about by
meningitis, the patient’s fever has not subsided yet. She is revising patient Soma’s nursing care plan. During
which step of the nursing process does revision take place?
a. Nursing diagnosis c. Evaluation
b. Planning d. Assessment
ANSWER: C During the evaluation step of the nursing process, the nurse determines whether the goals established in
the care plan have been achieved and evaluates the success of the plan. If a goal is unmet or partially met, the nurse
reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities,
establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.

44. A client named Kakashi has been prescribed with diphenhydramine (Benadryl) for his allergies. He then contacts
the nurse and complains of drowsiness after taking the medication making it almost impossible for him to do his
work. This is an example of
a. Drug synergism c. First-pass effect
b. Side effect d. Drug resistance
ANSWER: B Side effect is a secondary, typically undesirable effect of a drug or medical treatment. Synergism, Synergy.
An interaction between two or more drugs that causes the total effect of the drugs to be greater than the sum of the
individual effects of each drug. A synergistic effect can be beneficial or harmful. The first pass effect (also known as first-
pass metabolism or presystemic metabolism) is a phenomenon of drug metabolism whereby the concentration of a
drug, specifically when administered orally, is greatly reduced before it reaches the systemic circulation. Antibiotic
resistance happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them.

45. Doctor Eren has ordered Nurse Misaka to administer cefuroxime (Ceftin) 500 mg via IV bolus t.i.d to a patient with
acute glumerulonephritis. The nurse would expect to give the drug to be given
a. Twice a day c. Once a day
b. Thrice a day d. Four times a day
ANSWER: B t.i.d. latin abbreviation for “ter in die” meaning three times a day. b.i.d. – “bis in die” – twice a day, o.d. –
“omne in die” – once a day, q.i.d. – “quater in die” – four times a day

46. A physician orders 250 mg of an antibiotic suspension, the label on the suspension read “500 mg/5 ml” how much
would the nurse administer?
a. 2.5 ml c. 7.5 ml
b. 5 ml d. 10 ml
ANSWER: A
doctor’s order x quantity in ml = amount in ml
Stock dose
250 mg x 5 ml = 2.5 ml
500mg

47. A nurse is to administer 500 mg of a drug intramuscularly. The label on the multidose vial reads 250 mg/ml. how
much of the medication would the nurse prepare on the syringe?
a. 0.5 ml c. 1.5 ml
b. 1 ml d. 2 ml
ANSWER: D
doctor’s order x quantity in ml = amount in ml
Stock dose
500 mg x 1 ml = 2 ml
250 mg

48. When assessing for the liver functioning of a patient who is receiving hepatotoxic drugs the nurse must check
which of the following?
a. Blood urea nitrogen (BUN)
b. Creatinine clearance (CLcr)
c. Complete blood count
d. Alanine aminotransferase and aspartame aminotransferase
ANSWER: D The presence of alanine aminotransferase and aspartame aminotransferase would indicate liver damage.
Choices A and B would indicate kidney problems. Letter C is not related to assessment of the liver in the lab.

49 Which of the following statements by Nurse Stella is a great example of the therapeutic communication technique
known as giving recognition?
a. “I’m glad that you are already taking your medication. They will help you a lot.”
b. “I can see that you have a new dress today and it seems that you have washed your hair.”
c. “I will sit beside you until it is time for your group session.”
d. “I’ve noticed that you did not attend the group session today. Are you willing to talk about that?”
ANSWER: B This is a good example of the therapeutic communication technique of giving recognition. Giving
recognition acknowledges the patient and shows awareness from the nurse. This type of therapeutic communication
technique avoids giving any judgment from the nurse.

50. A client named Rodrigo De Lima tells the nurse, “Whenever I am furious, I always get into a fistfight with my spouse,
sometimes I punch my children as well.” The nurse states, “I have observed you smiling while you talk about domestic
violence.” The therapeutic communication technique employed by the nurse is
a. Making observations
b. Formulating a plan of action
c. Providing general leads
d. Exploring
ANSWER: A The nurse in the situation has made an observation when she has stated that the patient has smiled while
talking about domestic violence. This technique of making observations allows the patient to compare personal
perceptions with those of the nurse.
 NS 2 QUIZ 2 FUNDA & HA
1. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis.
Which of the following nursing measures should the nurse do FIRST?
A. Institute seizure precautions C. Place in respiratory isolation
B. Assess neurologic status D. Assess vital signs
Answer C. The initial therapeutic management of acute bacterial meningitis includes isolation
precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses
should take necessary precautions to protect themselves and others from possible infection.
2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type
of isolation is MOST appropriate for this client?
A. Reverse isolation C. Standard precautions
B. Respiratory isolation D. Contact isolation
Answer D. Contact or Body Substance Isolation (BSI) involves the use of barrier protection
(e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with
any body fluid is expected. When determining the type of isolation to use, one must consider
the mode of transmission. The hands of personnel continues to be the principal mode of
transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is
limited to the sputum in this example, precautions are taken if contact with the patient"s
sputum is expected. A private room and BSI, along with good hand washing techniques, are
the best defense against the spread of MRSA pneumonia
3. Several clients are admitted to an adult medical unit. The nurse would ensure airborne
precautions for a client with which of the following medical conditions?
A. A diagnosis of AIDS and cytomegalovirus
B. A positive x-ray for a suspicious tuberculin lesion
C. A tentative diagnosis of viral pneumonia
D. Advanced carcinoma of the lung
Answer B. The client who must be placed in airborne precautions is the client with a positive
PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.
4. Which of the following is the FIRST priority in preventing infections when providing care for a client?
A. Handwashing
B. Wearing gloves
C. Using a barrier between client's furniture and nurse's bag
D. Wearing gowns and goggles
Answer A. Handwashing remains the most effective way to avoid spreading infection. However,
too often nurses do not practice good handwashing techniques and do not teach families to do
so. Nurses need to wash their hands before and after touching the client and before entering
the nursing bag.
5. An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected
during a pre-employment physical. Although frightened about her diagnosis, she is anxious to
cooperate with the therapeutic regimen. The teaching plan includes information regarding the
most common means of transmitting the tubercle bacillus from one individual to another. Which
contamination is usually responsible?
A. Hands. C. Milk products.
B. Droplet nuclei. D. Eating utensils.
Answer B. Hands are the primary method of transmission of the common cold. The most
frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is
present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected
person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with
contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid,
or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous
microbes can be transmitted via reservoirs such as linens or eating utensils.
6. You are aware that standard precautions apply to the following except:
A. Blood and blood products
B. Bodily fluids, secretions, excretions including sweat
C. Bodily fluids, secretions, excretions excluding sweat
D. Non-intact skin, and mucous membranes
Answer: C. Sweat is included in applying the standard precautions.
7. When wearing a disposable mask, one must know to follow the following except:
A. Keep talking to a minimum while wearing a mask to reduce respiratory airflow.
B. A mask that has become moist does not provide a barrier to microorganisms and is
ineffective and is discarded.
C. A mask that has become moist does not provide a barrier to microorganisms and should be
air dried to reuse.
D. A properly applied mask fits snugly over the mouth and nose so pathogens and body fluids
cannot enter or escape
E. through the sides.
Answer: C. Masks that are moist are ineffective and should be discarded.
8. The nurse in charge is evaluating the infection control procedures on the unit. Which finding
indicates a break in technique and the need for education of staff?
A. The nurse aide is not wearing gloves when feeding an elderly client.
B. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to
another department for testing.
C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client
care.
D. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict
isolation.
Answer C. There is no need to wear gloves when feeding a client. However, universal precautions
(treating all blood and body fluids as if they are infectious) should be observed in all situations. A
client with active tuberculosis should be on respiratory precautions. Having the client wear a mask
when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis
should not give direct client care or handle client-care equipment until the condition resolves.
Strict isolation requires the use of mask, gown, and gloves.
9. The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound.
After carefully washing her hands the nurse dons sterile gloves to remove the old dressing.
After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile
gloves in preparation for cleaning and redressing the wound. The most appropriate action for
the charge nurse is to:
A. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to
remove the old dressing.
B. congratulate the nurse on the use of good technique.
C. discuss dressing change technique with the nurse at a later date.
D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of
the dirty dressing and gloves.
Answer D. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile
gloves does not put the client in danger so discussion of this can wait until later. The staff nurse
is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The
nurse should wash her hands after removing the soiled dressing and before donning sterile gloves
to clean and dress the wound. The nurse should wash her hands after removing the soiled dressing
and before donning the sterile gloves to clean and dress the wound. Not doing this compromises
client safety and should be brought to the immediate attention of the nurse. The staff nurse is
doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However,
the use of sterile gloves does not put the client in danger so discussion of this can wait until later.
However, the nurse should wash her hands after removing the soiled dressing and before donning
sterile gloves to clean and dress the wound. Not doing this compromises client safety and should
be brought to the immediate attention of the nurse.
[Link]. Jones will have to change the dressing on her injured right leg twice a day. The dressing
will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which
statement best indicates that Mrs. Jones understands the importance of maintaining asepsis?
A. "If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled."
B. "If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline."
C. "If I question the sterility of any dressing material, I should not use it."
D. "I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s."
Answer C. Anything dropped on the floor is no longer sterile and should not be used. The statement
indicates lack of understanding. Anything dropped on the floor is no longer sterile and should not
be used. The statement indicates lack of understanding. If there is ever any doubt about the
sterility of an instrument or dressing, it should not be used. The 4 X 4s should be soaked prior to
donning the sterile gloves. Once the sterile gloves touch the bottle of normal saline they are no
longer sterile. This statement indicates a need for further instruction.
11.A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary
personnel in the correct procedures. Which statement by the nursing assistant indicates the
best understanding of the correct protocol for blood and body fluid isolation?
A. Masks should be worn with all client contact.
B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
C. Isolation gowns are not needed.
D. A private room is always indicated.
Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood
or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and
mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should
be worn during procedures that are likely to cause splashes of blood or body fluids. A private room
is only indicated if the client's hygiene is poor.
12.A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary
personnel in the correct procedures. Which statement by the nursing assistant indicates the
best understanding of the correct protocol for blood and body fluid isolation?
A. Masks should be worn with all client contact.
B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
C. Isolation gowns are not needed.
D. A private room is always indicated.
Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood
or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and
mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should
be worn during procedures that are likely to cause splashes of blood or body fluids. A private room
is only indicated if the client's hygiene is poor.
[Link] nurse is evaluating whether nonprofessional staff understand how to prevent transmission
of HIV. Which of the following behaviors indicates correct application of universal precautions?
A. A lab technician rests his hand on the desk to steady it while recapping the needle after
drawing blood.
B. An aide wears gloves to feed a helpless client.
C. An assistant puts on a mask and protective eye wear before assisting the nurse to suction
a tracheostomy.
D. A pregnant worker refuses to care for a client known to have AIDS.
Answer C. Needles that have been used to draw blood should not be recapped. If it is necessary
to recap them, an instrument such as a hemostat should be used to recap. The hand should never
be used. Gloves are not necessary when feeding, since there is no contact with mucus membranes.
Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken
skin. There is no evidence in the question to indicate broken skin. Masks and protective eye wear
are indicated anytime there is great potential for splashing of body fluids that may be contaminated
with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to
generate droplets that may splash the health care worker. Clients who are suctioned frequently or
have had an invasive procedure like a tracheostomy are likely to have blood in the sputum. There
is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize
universal precautions.
[Link], 1 year old child has a staph skin infection. Her brother has also developed the same
infection. Which behavior by the children is most likely to have caused the transmission of the
organism?
A. Bathing together. C. Sharing pacifiers.
B. Coughing on each other. D. Eating off the same plate.
Answer A. Direct contact is the mode of transmission for staphylococcus. Staph is not spread by
coughing. Staph is not spread through oral secretions. Direct contact is required. Staph is not
spread through oral secretions.
[Link], a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is
being discharged from the hospital. The nurse knows that teaching regarding prevention of
AIDS transmission has been effective when the client:
A. verbalizes the role of sexual activity in spread of the disorder.
B. states he will make arrangements to drop his college classes.
C. acknowledges the need to avoid all contact sports.
D. says he will avoid close contact with his three-year-old niece.
Answer A. The AIDS virus is spread through direct contact with body fluids such as blood and
through sexual intercourse. Casual contact with other people does not pose a risk of transmission
of AIDS. Unless the client is feeling very ill, there is no need for him to drop his college classes.
Contact sports are not contraindicated unless there is a significant chance of bleeding and direct
contact with others. Casual contact with other people does not pose a risk of transmission of AIDS.
There is no need to limit casual contact with children.
[Link] an infectious disease can be transmitted directly from one person to another, it is:
A. A susceptible host
B. A communicable disease
C. A portal of entry to a host
D. A portal of exit from the reservoir

B - If an infectious disease is transmitted directly from one person to another, it is a communicable

disease. Portals of entry and exit are the mechanisms of disease transmission. A susceptible host
is a person who can acquire an infection.
17. A client is isolated because the client has pulmonary tuberculosis. The nurse notes that the client
seems angry but knows this is a normal response to isolation. The best intervention is to:

A. Provide a dark, quiet room to calm the client.

B. Explain the isolation procedures and provide meaningful stimulation.
C. Reduce the level of precautions to keep the client from becoming angry.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection.

B - When a client is in isolation, the nurse should take measures to improve the client's stimulation
and make sure to explain the isolation procedures. Darkening the room can increase the sense of
isolation. The nurse should not change the isolation level but should provide plenty of emotional
support and make time for the client to prevent a sense of isolation. As long as family and
caregivers follow infection precautions, there is no reason to limit contact with these individuals.
(BONUS)

[Link] what situation does a nurse needs to wear a gown?

A. The client's hygiene is poor.

B. The client has acquired immunodeficiency syndrome (AIDS) or hepatitis.
C. The nurse is assisting with medication administration.
D. Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.

D - Gowns should be worn when there is a possibility that blood or body fluids could get on the
nurse's clothes or when the client is on contact isolation status. The other options are not
appropriate uses of gowns.

[Link] remove a glove that is contaminated, what should the nurse do first?
A. Rinse the glove before removing it to minimize contamination.
B. Pull the glove off the back of the hand until it slides off the entire hand and discard it.
C. Grasp the outside of the cuff or palm of the glove and pull it away from the hand without
touching the wrist or fingers.
D. Put the thumb inside the wrist to slide the glove over the hand with minimal touching of the
hand by the other gloved hand.

C - When the outside of the cuff is grasped with the contaminated gloved hand, then dirty to dirty
remains intact. Pulling the glove away from the hand entirely without touching the wrist or fingers
further minimizes the contamination by the gloved hand. If the nurse puts the gloved thumb inside
the glove, the nurse has contaminated the bare hand with a contaminated thumb. Pulling the
glove off by holding it at the back sounds good and could minimize contamination, but it is very
difficult to remove a glove this way without the risk of tearing the glove and creating contamination
through the tear. If excessive secretions are present on gloves, then a towel or the drape could
be used to wipe off excessive secretions before an attempt is made to remove the gloves.

[Link] is the single most effective method by which the nurse can break the chain of infection?
A. Give all clients antibiotics.
B. Wear gloves when caring for all clients.
C. Wash hands between procedures and clients.
D. Make sure housekeeping staff are using the right chemicals.
C - Adequate hand washing will remove bacteria and wastes or contaminates to minimize cross
contamination between clients. Use of alcohol-based waterless antiseptics between clients is also
effective if the guidelines for using these cleansers are followed. Giving all clients antibiotics is
impractical and is a source of new superinfections when persons who do not need antibiotics are
given them and then the bacteria mutate to become resistant to older drugs. It would be both
unethical and costly to try to control infections by treating everyone in the facility. Although
wearing gloves to perform procedures that carry the risk of direct contact with contaminated
material is a correct method of bacterial control, wearing gloves at all times is impractical,
expensive, and unrealistic. Housekeeping staff are trained to use the correct agents for
decontamination and disinfection of all surfaces that place clients at risk.

[Link] nurse has just admitted a client to rule out active hepatitis B. The client is confused, spitting
and scratching everyone who enters the room. The nurse should:
A. Wait an hour until the client calms down and then use gloves when touching the client.
B. Use gloves, mask, face shield, and gown when entering the room to perform the initial
assessment.
C. Administer a sedative and then perform the assessment after the client is asleep; no
precautions would be needed.
D. Realize that isolation equipment might further confuse the client and avoid using a face
mask and shield but use gown and gloves.
B - Hepatitis virus is a blood-borne virus, but the client is increasing the risk of cross contamination
by spitting (saliva can be a source of bacterial contamination) and scratching others, which can
break the skin and become a source of risk. All of the barriers listed would minimize cross
contamination from the client to the nurse. Even though gloves may be all that is needed because
of limited contact with the client, after an hour the client will remain confused and may not
understand. The client may become aggressive again and spit or scratch, and other barriers are
needed to stop that source of possible risks. A sedative may be given if needed, but trying to
perform an assessment when the client is asleep is not appropriate and will prevent the nurse
from successfully establishing rapport with the client. Although masks and shields might be
frightening to some confused clients, if the client is spitting and body fluids could be exchanged,
a barrier should still be used.
[Link] which airborne disease(s) would the nurse be required to use gloves, respiratory devices,
and gown when in close contact with the client?
A. Herpes simplex, scabies
B. Viral pneumonia, atelectasis
C. Chickenpox, pulmonary tuberculosis
D. Multidrug-resistant respiratory syncytial virus
C - Airborne precautions are required for chickenpox and tuberculosis, because in these diseases
small particles float in the air and a barrier is required to prevent contamination of the nurse. A
respiratory protection device is form-fitted to the face to prevent the escape of air around the seal.
Gloves and gown are also worn to prevent contamination and transport of infective particles to
other clients. For viral pneumonia a regular mask is used as a barrier because the particles do not
float in the air and are more likely to be found on surfaces unless coughing or spitting is occurring.
Atelectasis is the collapse of alveoli, and airborne precautions are not needed. Herpes and scabies
are spread by contact, and gloves and gown would be necessary; masks would not be needed.
For multidrug-resistant respiratory syncytial virus the protection of the client would be as
important as preventing the spread of these disorders. Therefore, gown, gloves, and mask would
be used as in reverse isolation to prevent cross contamination of the client.
[Link] the nurse washes the hands when leaving an isolation room, what is the last thing that
is removed?
A. Mask C. Goggles
B. Gown D. Head cover
A - Remove goggles by touching only the ear pieces. Next remove the gown and the nurse should
untie the neck ties and allow the gown to fall from shoulders and only touch the inside of the
gown. The mask is removed last by removing the elastic from the ears or untying the bottom mask
string followed by the top mask string. In both cases the nurse's hands only touch the ties of the
mask. Head covers are usually not worn in isolation rooms as a barrier.
[Link] part of a sterile glove is considered contaminated once the glove is applied by the open
gloving method?
A. The inner cuff of each glove
B. The back of the gloved hands
C. Any surface that the powder from the gloves touches
D. The outer part of the glove that touched the inner wrapper
A - The cuff is folded and touched to apply the glove; thus, it becomes contaminated during
application of the glove. Usually the cuff will fall down over the wrist, but if it does not, then it is
considered unsterile and should not be touched during the procedure. All of the outer part of the
glove is sterile unless it has been contaminated. The inner wrapper that held the sterile glove is
not contaminated unless one touches it. Therefore, the outer part of the glove can touch it without
contamination. The powder is sterile and will not contaminate anything it touches.

[Link] nurse has redressed a client's wound and now plans to administer a medication to the
client. It is important to:
A. Leave the gloves on to administer the medication
B. Remove gloves and perform hand hygiene before leaving the room
C. Remove gloves and perform hand hygiene before administering the medication
D. Leave the medication on the bedside table to avoid having to remove gloves before leaving
the client's room
C. Remove gloves and perform hand hygiene before administering the medication

26. A nurse is working with a patient who has a contagious condition. In recalling the chain of
infection, the nurse knows that an environment favorable for the growth and reproduction of
an infectious agent is referred to as ____.
a. a reservoir c. a vector
b. a susceptible host d. a portal of entry
A . a reservoir which is any environment that is favorable for the growth and reproduction of an
infectious agent

27.A nurse is volunteering in an indigent clinic. She is seeing a patient whom she suspects has
active tuberculosis. In this disease process, which of the following body systems serves as both
the reservoir and portal of entry for this infection?
A. the hematologic system C. the respiratory system
B. the gastrointestinal system D. the integumentary system
C . Tuberculosis (TB) is a bacterial infection that mainly infects the respiratory system caused by
the organism Mycobacterium tuberculosis. It is spread via inhalation of droplets that contain the
bacteria that are released during coughing, sneezing, etc. There are two forms of TB: latent and
active. Patients are contagious only during an active TB infection, and they usually feel sick during
this time. Those with latent infection are not infectious and do not feel ill. The respiratory system
is where this organism best grows and reproduces (a reservoir) and how one becomes infected
with the organism via inhalation (portal of entry).

Case Scenario:
A 52-year-old female client comes to the clinic for her routine physical examination. She has a
history of hypertension and hyperlipidemia. She is currently taking medications for both
conditions. The nurse is performing a health assessment on the client.

[Link] the client's health assessment, which of the following should the nurse prioritize first?
A. Collecting a thorough health history.
B. Assessing vital signs and overall appearance.
C. Inspecting the client's skin for abnormalities.
D. Assessing the client's cardiovascular system.
Answer: b. Assessing vital signs and overall appearance.
Rationale: Assessing vital signs and overall appearance are essential components of the initial
assessment because they provide an indication of the client's physiological status and overall
health. Vital signs and overall appearance include assessment of the client's body temperature,
blood pressure, pulse, respiratory rate, and general appearance.

[Link] of the following is an example of subjective data that the nurse can obtain during the
client's health history?
A. Blood pressure. B. Heart rate.
 C. Family medical history. D. Body mass index.
Answer: c. Family medical history.
Rationale: Subjective data are information that the client provides about their symptoms, feelings, and
experiences. Family medical history is an example of subjective data that can provide valuable
information about the client's genetic predisposition to certain health conditions.

[Link] is the purpose of the inspection phase of a health assessment?

A. To measure the client's vital signs.
B. To observe the client's body movements.
C. To assess the client's skin for abnormalities.
D. To palpate the client's abdomen.
Answer: b. To observe the client's body movements.
Rationale: The inspection phase of a health assessment involves observing the client's body for
any visible abnormalities, such as asymmetry, lesions, or deformities. It also involves observing
the client's body movements, gait, and posture.

[Link] of the following is an example of an objective data that the nurse can obtain during the
health assessment?
A. The client's report of feeling dizzy.
B. The client's report of chest pain.
C. The client's blood pressure reading.
D. The client's description of a rash.
Answer: c. The client's blood pressure reading.
Rationale: Objective data are measurable and observable signs or symptoms, such as vital signs
or laboratory values. Blood pressure readings are an example of objective data that can provide
valuable information about the client's cardiovascular health.

[Link] is the purpose of auscultation during a health assessment?

A. To measure the client's vital signs.
B. To assess the client's skin for abnormalities.
C. To listen to the client's heart, lungs, and abdomen.
D. To palpate the client's abdomen.
Answer: c. To listen to the client's heart, lungs, and abdomen.
Rationale: Auscultation involves listening to the sounds produced by the body's internal organs,
such as the heart, lungs, and abdomen. The purpose of auscultation is to detect any abnormal
sounds or rhythms that may indicate underlying health problems.

Case Scenario:
Aljun, a 28-year-old man, comes to the clinic for a routine check-up. During the assessment, the
nurse performs a physical assessment on Aljun using the IPPA method.
[Link] the physical assessment, the nurse inspects Aljun's skin. What is the appropriate
distance to observe skin color and texture?
A. 1 inch C. 3 inches
B. 2 inches D. 4 inches
Answer: b. 2 inches
Rationale: The appropriate distance to observe skin color and texture during inspection is 2 inches.
This distance allows the nurse to accurately assess the skin's color, texture, and any abnormalities.

[Link] the physical assessment, the nurse palpates Aljun's abdomen. What is the appropriate
technique for palpating the abdomen?
A. Light palpation, using one hand C. Light palpation, using two hands
B. Deep palpation, using one hand D. Deep palpation, using two hands
Answer: a. Light palpation, using one hand
Rationale: The appropriate technique for palpating the abdomen is light palpation, using one hand.
This technique allows the nurse to detect any tenderness, masses, or organ enlargement.
[Link] the physical assessment, the nurse performs percussion on Aljun's lungs. Which area
of the chest should the nurse percuss?
A. Over the sternum C. Over the lung fields
B. Over the scapula D. Over the liver
Answer: c. Over the lung fields
Rationale: The appropriate area to percuss on the chest is over the lung fields. This technique
allows the nurse to detect any changes in sound, which may indicate underlying lung problems.
[Link] the physical assessment, the nurse auscultates Aljun's heart sounds. Which area of the
chest should the nurse place the stethoscope to listen to the heart sounds?
A. Over the upper left sternal border C. Over the apex of the heart
B. Over the upper right sternal border D. Over the lower left sternal border
Answer: c. Over the apex of the heart
Rationale: The appropriate area to auscultate for heart sounds is over the apex of the heart, which
is located in the left lower chest. This technique allows the nurse to detect any abnormalities in
heart sounds, such as murmurs or gallops.

[Link] the physical assessment, the nurse inspects Aljun's eyes. Which technique should the
nurse use to inspect the internal structures of the eye?
A. Direct inspection C. Transillumination
B. Indirect inspection D. Palpation
Answer: b. Indirect inspection
Rationale: The appropriate technique for inspecting the internal structures of the eye is indirect
inspection, using an ophthalmoscope. This technique allows the nurse to visualize the retina, optic
disc, and blood vessels.

Cultural and Spiritual Assessment

Case Scenario:
Maria Agwanta a 63-year-old Filipino immigrant, is admitted to the hospital for management of
diabetes and hypertension. During the admission process, the nurse is performing a cultural and
spiritual nursing assessment on Maria.

[Link] is the primary goal of a cultural and spiritual nursing assessment?

A. To identify the client's cultural and spiritual beliefs and practices.
B. To provide spiritual care to the client.
C. To assess the client's physical health status.
D. To ensure that the client's cultural and spiritual needs are met.
Answer: a. To identify the client's cultural and spiritual beliefs and practices.
Rationale: The primary goal of a cultural and spiritual nursing assessment is to identify the client's
cultural and spiritual beliefs and practices, which can have a significant impact on their health
beliefs, behaviors, and decision-making. By understanding the client's cultural and spiritual
background, nurses can provide culturally sensitive care and avoid misunderstandings and
conflicts.

[Link] a cultural and spiritual nursing assessment, which of the following is an example of a
cultural factor that may affect a client's health beliefs?
A. Gender. C. Religion.
B. Age. D. Marital status.
Answer: c. Religion.
Rationale: Cultural factors that may affect a client's health beliefs include their religion, ethnicity,
language, customs, and traditions. Religion, in particular, can influence a client's views on health,
illness, and healthcare practices.

[Link] is the role of the nurse in addressing a client's spiritual needs?

A. To provide religious counseling to the client.
B. To respect the client's spiritual beliefs and practices.
C. To encourage the client to convert to a different religion.
D. To discourage the client from expressing their spiritual beliefs.
Answer: b. To respect the client's spiritual beliefs and practices.
Rationale: The role of the nurse in addressing a client's spiritual needs is to respect the client's
spiritual beliefs and practices, regardless of their own personal beliefs. The nurse should provide
a safe and supportive environment that allows the client to express their spiritual needs and
preferences.

[Link] of the following is an example of a spiritual need that a client may have?
A. The need for pain management. C. The need for forgiveness.
B. The need for social support. D. The need for nutrition.
Answer: c. The need for forgiveness
Rationale: Spiritual needs are related to a client's sense of meaning, purpose, and connection to
something greater than themselves. Examples of spiritual needs include the need for forgiveness,
the need for hope, the need for acceptance, and the need for inner peace.
[Link] of the following is an example of a culturally sensitive nursing intervention?
A. Encouraging the client to adopt Western healthcare practices.
B. Providing educational materials in the client's native language.
C. Disregarding the client's cultural preferences and beliefs.
D. Ignoring the client's family members during care.
Answer: b. Providing educational materials in the client's native language.
Rationale: A culturally sensitive nursing intervention is one that respects and accommodates the client's
cultural preferences and beliefs. Providing educational materials in the client's native language is an
example of a culturally sensitive intervention that can improve the client's understanding and
adherence to healthcare practices. Encouraging the client to adopt Western healthcare practices,
disregarding the client's cultural preferences, and ignoring their family members are not culturally
sensitive interventions and can lead to misunderstandings and conflicts.

Assessment of Integumentary System

Case Scenario:
Minerva, a 35-year-old woman, comes to the clinic complaining of a rash on her arms and legs.
During the assessment, the nurse performs an integumentary system assessment on Minerva.

[Link] is the purpose of an integumentary system assessment?

A. To assess the client's cognitive function.
B. To identify potential skin problems and abnormalities.
C. To evaluate the client's respiratory status.
D. To measure the client's fluid and electrolyte balance.
Answer: b. To identify potential skin problems and abnormalities.
Rationale: The integumentary system assessment is performed to identify potential skin problems and
abnormalities, such as rashes, lesions, bruising, or discoloration. This assessment is important for
detecting skin cancer, infections, or other conditions that may affect the client's overall health.

[Link] the integumentary system assessment, the nurse assesses Minerva's skin turgor. What
does skin turgor assess?
A. The skin's color and texture.
B. The skin's moisture content.
C. The skin's elasticity and hydration.
D. The skin's sensitivity and pain level.
Answer: c. The skin's elasticity and hydration.
Rationale: Skin turgor is the skin's elasticity and hydration, which can be assessed by pinching the
skin and observing how quickly it returns to its normal position. This assessment is useful in
evaluating the client's hydration status, as well as detecting any signs of dehydration or fluid
overload.

[Link] has a raised, red rash on her arms and legs. What type of skin lesion is this?
A. Papule. C. Vesicle.
B. Macule. D. Pustule.
Answer: a. Papule.
Rationale: A papule is a raised, solid lesion that is less than 1 cm in diameter. It is usually red or
pink in color and may be accompanied by itching or inflammation. Papules can be caused by a
variety of skin conditions, including acne, eczema, or insect bites.

[Link] the integumentary system assessment, the nurse notes that Minerva has dry, flaky skin
on her arms and legs. What condition could this indicate?
A. Eczema. C. Seborrheic dermatitis.
B. Psoriasis. D. Contact dermatitis.
Answer: a. Eczema.
Rationale: Dry, flaky skin is a common symptom of eczema, which is a chronic inflammatory skin
condition. Eczema can cause itching, redness, and swelling, and is often triggered by
environmental factors such as dry weather, irritants, or allergens.
[Link] the integumentary system assessment, the nurse notes that Minerva has a mole on her
arm that has changed in color and size since her last visit. What should the nurse do?
A. Document the finding and inform the healthcare provider.
B. Ignore the finding, as moles are a common skin condition.
C. Apply a topical cream to the mole to reduce inflammation.
D. Schedule a follow-up appointment in six months.
Answer: a. Document the finding and inform the healthcare provider.
Rationale: Changes in the color, size, or shape of a mole can indicate a potential skin cancer, such
as melanoma. It is important for the nurse to document the finding and inform the healthcare
provider, who may order further diagnostic tests or refer the client to a dermatologist. Ignoring
the finding or applying a topical cream could delay diagnosis and treatment of a potentially serious
condition. Scheduling a followup

Assessment of Head, Eyes, Ears, Nose and Throat

Case Scenario:
Darcy, a 45-year-old woman, comes to the clinic complaining of a headache and ear pain.
During the assessment, the nurse performs a head, eyes, ears, nose, and throat (HEENT)
assessment on Darcy.

[Link] the HEENT assessment, the nurse inspects Darcy's eyes. What is the purpose of this
assessment?
A. To assess the client's visual acuity.
B. To evaluate the client's cognitive function.
C. To identify potential eye problems and abnormalities.
D. To measure the client's fluid and electrolyte balance.
Answer: c. To identify potential eye problems and abnormalities.
Rationale: The HEENT assessment includes an inspection of the eyes to identify potential eye
problems and abnormalities, such as redness, swelling, or discharge. This assessment is important
for detecting eye conditions, such as conjunctivitis or glaucoma, that may affect the client's vision
and overall health.

[Link] the HEENT assessment, the nurse examines Darcy's ears. What is the purpose of this
assessment?
A. To assess the client's hearing acuity.
B. To evaluate the client's cognitive function.
C. To identify potential ear problems and abnormalities.
D. To measure the client's fluid and electrolyte balance.
Answer: a. To assess the client's hearing acuity.
Rationale: The HEENT assessment includes an examination of the ears to assess the client's
hearing acuity and identify potential ear problems and abnormalities, such as infection or blockage.
This assessment is important for detecting hearing loss or other conditions that may affect the
client's communication and overall health.

[Link] the HEENT assessment, the nurse inspects Darcy's nose. What is the purpose of this
assessment?
A. To assess the client's sense of smell.
B. To evaluate the client's cognitive function.
C. To identify potential nose problems and abnormalities.
D. To measure the client's fluid and electrolyte balance.
Answer: c. To identify potential nose problems and abnormalities.
Rationale: The HEENT assessment includes an inspection of the nose to identify potential nose
problems and abnormalities, such as nasal congestion, discharge, or deviation. This assessment
is important for detecting conditions, such as sinusitis or nasal polyps, that may affect the client's
breathing and overall health.

[Link] the HEENT assessment, the nurse palpates Darcy's sinuses. What is the purpose of this
assessment?
A. To assess the client's cognitive function.
B. To identify potential sinus problems and abnormalities.
C. To evaluate the client's visual acuity.
D. To measure the client's fluid and electrolyte balance.
Answer: b. To identify potential sinus problems and abnormalities.

Rationale: The HEENT assessment includes a palpation of the sinuses to identify potential sinus
problems and abnormalities, such as tenderness, swelling, or blockage. This assessment is
important for detecting conditions, such as sinusitis or allergies, that may affect the client's
breathing and overall health.

[Link] the HEENT assessment, the nurse inspects Darcy's throat. What is the purpose of this
assessment?
A. To assess the client's cognitive function.
B. To evaluate the client's respiratory status.
C. To identify potential throat problems and abnormalities.
 D. To measure the client's fluid and electrolyte balance.
Answer: c. To identify potential throat problems and abnormalities.
Rationale: The HEENT assessment includes an inspection of the throat to identify potential throat
problems and abnormalities, such as redness, swelling,

Assessment of the Respiratory System

Case Scenario:
VR, a 55-year-old man, comes to the clinic complaining of shortness of breath and chest pain.
During the assessment, the nurse performs a respiratory system assessment on VR.

[Link] the respiratory system assessment, the nurse assesses VR's respiratory rate. What is
the normal range for adult respiratory rate?
A. 8-10 breaths per minute C. 22-28 breaths per minute
B. 12-20 breaths per minute D. 30-40 breaths per minute
Answer: b. 12-20 breaths per minute
Rationale: The normal range for adult respiratory rate is 12-20 breaths per minute. This
assessment is important to identify any alterations in respiratory rate, which may indicate
respiratory distress or failure.

[Link] the respiratory system assessment, the nurse auscultates VR's lungs. What is the
purpose of this assessment?
A. To assess for chest wall abnormalities
B. To evaluate the client's cognitive function
C. To identify potential lung problems and abnormalities
D. To measure the client's fluid and electrolyte balance
Answer: c. To identify potential lung problems and abnormalities
Rationale: The respiratory system assessment includes auscultation of the lungs to identify
potential lung problems and abnormalities, such as wheezing, crackles, or decreased breath
sounds. This assessment is important for detecting respiratory conditions, such as asthma,
pneumonia, or pulmonary embolism.

[Link] the respiratory system assessment, the nurse assesses VR's oxygen saturation level.
What is the normal range for oxygen saturation level?
A. 70-80% C. 90-95%
B. 80-90% D. 95-100%
Answer: d. 95-100%
Rationale: The normal range for oxygen saturation level is 95-100%. This assessment is important
to identify any alterations in oxygen saturation level, which may indicate respiratory distress or
hypoxia.

[Link] the respiratory system assessment, the nurse assesses VR's respiratory pattern. What
is the normal respiratory pattern for adults?
A. Apnea C. Cheyne-Stokes breathing
B. Kussmaul breathing D. Eupnea
Answer: d. Eupnea
Rationale: The normal respiratory pattern for adults is eupnea, which is characterized by regular
and even breathing. This assessment is important to identify any alterations in respiratory pattern,
which may indicate respiratory distress or dysfunction

[Link] the respiratory system assessment, the nurse assesses VR's cough. What is the purpose
of this assessment?

A. To assess for chest wall abnormalities

B. To evaluate the client's cognitive function
C. To identify potential respiratory problems and abnormalities
D. To measure the client's fluid and electrolyte balance
Answer: c. To identify potential respiratory problems and abnormalities
Rationale: The respiratory system assessment includes assessment of the cough to identify
potential respiratory problems and abnormalities, such as coughing up blood or sputum. This
assessment is important for detecting respiratory conditions, such as bronchitis or tuberculosis.

Assessment of the Cardiovascular and Peripheral Vascular System

Case Scenario:
Mr. RJ is a 65-year-old male with a history of hypertension, hyperlipidemia, and smoking. He
presents to the clinic complaining of chest pain that radiates to his left arm. The nurse suspects
a cardiac issue and performs a cardiovascular and peripheral vascular assessment.

[Link] assessing Mr. RJ's pulse, the nurse notes a regular rhythm with a rate of 70 beats per
minute. What is the normal range for an adult pulse rate?
A. 40-60 beats per minute C. 100-140 beats per minute
B. 60-100 beats per minute D. 140-180 beats per minute
Answer: B. The normal range for an adult pulse rate is 60-100 beats per minute.
Rationale: The normal pulse rate for an adult is 60-100 beats per minute.

[Link] the assessment, the nurse auscultates a blowing sound over the carotid artery. What is
this sound called?
A. Murmur C. Thrill
B. Bruit D. Rub
Answer: B. The blowing sound heard over the carotid artery is called a bruit.
Rationale: A bruit is a blowing sound heard over an artery due to turbulence caused by narrowed
or irregular vessel walls.

[Link] nurse palpates Mr. RJ’'s radial pulse and notes a weak, thready pulse. What might cause
this finding?
A. Hypertension C. Tachycardia
B. Hypotension D. Bradycardia
Answer: B. A weak, thready pulse may be caused by hypotension.
Rationale: A weak, thready pulse is often seen in hypotension, which is defined as a blood pressure
reading less than 90/60 mmHg.

[Link] the cardiovascular assessment, the nurse assesses Mr. RJ's jugular venous pressure
(JVP). Where is the JVP measured?
A. At the carotid artery C. At the femoral artery
B. At the brachial artery D. At the jugular vein
Answer: D. The jugular venous pressure is measured at the jugular vein.
Rationale: The jugular venous pressure is measured at the jugular vein to assess for fluid overload
or right-sided heart failure.

[Link] palpating Mr. RJ's apical pulse, the nurse notes an irregular rhythm. What might cause
this finding?
A. Atrial fibrillation C. Sinus tachycardia
B. Ventricular fibrillation D. Sinus bradycardia
Answer: A. An irregular apical pulse rhythm may indicate atrial fibrillation.
Rationale: An irregular apical pulse rhythm may indicate atrial fibrillation, which is a common
cardiac arrhythmia.

[Link] the peripheral vascular assessment, the nurse observes Mr. RJ's legs for signs of
peripheral artery disease (PAD). What is a classic symptom of PAD?
A. Pallor of the legs C. Warmth of the legs
B. Redness of the legs D. Swelling of the legs
Answer: A. Pallor of the legs is a classic symptom of PAD.
Rationale: Pallor of the legs is a classic symptom of PAD, which is caused by narrowing or blockage
of the arteries in the legs.

[Link] nurse assesses Mr. RJ's pedal pulses and notes that they are absent bilaterally. What might
this finding indicate?
A. Peripheral artery disease C. Deep vein thrombosis
B. Peripheral venous disease D. Pulmonary embolism
Answer: A. Absent pedal pulses may indicate peripheral artery disease.
Rationale: Absent pedal pulses may indicate peripheral artery disease, which is a condition
characterized by narrowing or blockage of the arteries in the legs.

[Link] the cardiovascular assessment, the nurse performs a point of maximal impulse (PMI)
assessment. Where is the PMI located?
A. At the apex of the heart C. At the left sternal border
B. At the base of the heart D. At the right sternal border
Answer: A. The point of maximal impulse is located at the apex of the heart.
Rationale : The point of maximal impulse is located at the apex of the heart, which is the point
where the heartbeat is felt most strongly.

[Link] auscultating Mr. RJ's heart, the nurse notes a high-pitched, blowing sound during systole.
What might cause this sound?
A. Aortic stenosis C. Pulmonary stenosis
B. Mitral regurgitation D. Tricuspid regurgitation
Answer: B. A high-pitched, blowing sound heard during systole is a classic sign of mitral
regurgitation.
Rationale: A high-pitched, blowing sound heard during systole is a classic sign of mitral
regurgitation, which is caused by a leaky mitral valve.

[Link] the cardiovascular assessment, the nurse assesses Mr. RJ's blood pressure and notes a
reading of 160/100 mmHg. What is the term for this blood pressure reading?
A. Normal blood pressure C. Stage 1 hypertension
B. Prehypertension D. Stage 2 hypertension
Answer: C. A blood pressure reading of 160/100 mmHg is classified as stage 1 hypertension.
Rationale: A blood pressure reading of 160/100 mmHg is classified as stage 1 hypertension, which
requires medical intervention to prevent further complications.

Assessment of the Lymphatic System

Case Scenario:
Mr. Jonas, a 55-year-old male, presents to the clinic complaining of swelling in his left leg. Upon
examination, the nurse notes the presence of pitting edema and tenderness on palpation of the
left leg. The nurse suspects lymphedema and performs an assessment of the lymphatic system.

[Link] of the following is a characteristic finding of lymphedema?

A. Brawny edema C. Non-pitting edema
B. Dependent edema D. Peripheral edema
Answer: A. Brawny edema
Rationale: Lymphedema is a condition characterized by the accumulation of lymphatic fluid,
leading to swelling in the affected area. Brawny edema is a type of edema that is hard, non-pitting,
and may have a brownish appearance, which is a characteristic finding in lymphedema.

[Link] of the following techniques is used to assess the lymphatic system?

A. Blood pressure measurement C. Percussion
B. Palpation D. Auscultation
Answer: B. Palpation
Rationale: Palpation is the technique used to assess the lymphatic system. The nurse may use
their fingers to feel for lymph nodes and check for swelling, tenderness, or hardness.

[Link] lymph nodes are commonly palpated during an assessment of the lower extremities?
A. Axillary lymph nodes C. Popliteal lymph nodes
B. Supraclavicular lymph nodes D. Submandibular lymph nodes
Answer: C. Popliteal lymph nodes
Rationale: Popliteal lymph nodes are commonly palpated during an assessment of the lower
extremities. They are located in the popliteal fossa, behind the knee.

[Link] of the following is a potential complication of lymphedema?

A. Cellulitis C. Hypertension
B. Anemia D. Hyperthyroidism
Answer: A. Cellulitis
Rationale: Cellulitis is a potential complication of lymphedema. The accumulation of lymphatic fluid
can increase the risk of infection, and cellulitis is a bacterial skin infection that can occur in areas
of lymphedema.

[Link] of the following is an appropriate nursing intervention for lymphedema?

A. Elevating the affected limb
B. Applying heat to the affected limb
C. Encouraging the patient to cross their legs
D. Applying tight clothing to the affected limb
Answer: A. Elevating the affected limb
Rationale: Elevating the affected limb is an appropriate nursing intervention for lymphedema. It
can help reduce swelling by promoting lymphatic drainage. Applying heat or tight clothing can
worsen lymphedema, and crossing the legs can impede lymphatic flow.

[Link] of the following is a sign of lymphangitis?

A. Tender, red streaks along the skin C. Cyanosis of the affected limb
B. Pitting edema in the affected area D. Cool skin temperature
Answer: A. Tender, red streaks along the skin
Rationale: Lymphangitis is an inflammation of the lymphatic vessels, and it can present with
tender, red streaks along the skin that may be warm to the touch.

[Link] of the following lymph nodes are commonly palpated during an assessment of the head
and neck?
A. Inguinal lymph nodes C. Epitrochlear lymph nodes
B. Cervical lymph nodes D. Supratrochlear lymph nodes
Answer: B. Cervical lymph nodes
Rationale: Cervical lymph nodes are commonly palpated during an assessment of the head and
neck. They are located in the neck, along the jugular vein

[Link] of the following is a diagnostic test used to evaluate lymphatic function?

A. Magnetic resonance imaging (MRI) C. Lymphoscintigraphy
B. Computed tomography (CT) scan D. Electrocardiogram (ECG)
Answer: C. Lymphoscintigraphy
Rationale: Lymphoscintigraphy is a diagnostic test used to evaluate lymphatic function. It involves
injecting a radioactive tracer into the lymphatic system and using a special camera to monitor the
movement of the tracer.

[Link] of the following is a potential cause of lymphedema?

A. Hypertension C. Cancer treatment
B. Diabetes mellitus D. Osteoarthritis
Answer: C. Cancer treatment
Rationale: Cancer treatment, such as radiation therapy or lymph node removal, is a potential cause of
lymphedema. Other potential causes include infection or injury to the lymphatic system.

[Link] of the following is an appropriate nursing intervention for a patient with lymphedema?
A. Encouraging the patient to avoid physical activity
B. Applying compression bandages to the affected limb
C. Massaging the affected limb vigorously
D. Keeping the affected limb in a dependent position
Answer: B. Applying compression bandages to the affected limb
Rationale: Applying compression bandages to the affected limb is an appropriate nursing
intervention for a patient with lymphedema. Compression can help reduce swelling and promote
lymphatic drainage. Avoiding physical activity, massaging the limb vigorously, or keeping it in a
dependent position can worsen lymphedema.

Assessment of Breast and Axilla

Case Scenario: Ms. Jonabel is a 45-year-old woman who presents to the clinic for her annual
physical exam. During the exam, the nurse performs a breast and axilla assessment.

[Link] of the following techniques should the nurse use to assess Ms. Jonabel’s' breasts?
A. Inspection C. Auscultation
B. Palpation D. Percussion
Answer: b. Palpation
Rationale: Breast assessment involves inspection and palpation. Inspection involves visual
examination of the breasts for size, shape, symmetry, and any abnormalities. Palpation involves
using the fingers to feel for any lumps or masses in the breasts.

[Link] the breast assessment, the nurse palpates a 2cm firm, non-mobile, painless lump in
Ms. Jonabel's right breast. What is the nurse's next step?
A. Document the finding and continue with the exam
B. Refer Ms. Jonabels for a mammogram
C. Tell Ms. Jonabels not to worry about it
D. Ignore the finding and continue with the exam
Answer: b. Refer Ms. Jonabels’s for a mammogram
Rationale: A lump in the breast requires further evaluation to rule out the possibility of breast
cancer. The nurse should refer Ms. Jonabel’s for a mammogram or breast ultrasound.

[Link] the axilla assessment, the nurse notes that Ms. Jonabel has enlarged lymph nodes in
her left axilla. What is the nurse's next step?
A. Document the finding and continue with the exam
B. Palpate the lymph nodes to determine if they are tender
C. Notify the healthcare provider
D. Tell Ms. Jones not to worry about it
Answer: c. Notify the healthcare provider
Rationale: Enlarged lymph nodes in the axilla can be a sign of breast cancer or other conditions
The nurse should notify the healthcare provider and document the finding.

[Link] of the following is not a risk factor for breast cancer?

A. Family history of breast cancer C. Smoking
B. Age over 50 D. Female gender
Answer: c. Smoking
Rationale: Smoking is not a risk factor for breast cancer. However, family history of breast cancer,
age over 50, and female gender are all risk factors for breast cancer.

[Link] of the following is not a symptom of breast cancer?

A. A painless lump in the breast
B. Nipple discharge
C. Breast pain
D. Dimpling or puckering of the skin on the breast
Answer: c. Breast pain
Rationale: Breast pain is not typically a symptom of breast cancer. However, a painless lump in
the breast, nipple discharge, and dimpling or puckering of the skin on the breast can be signs of
breast cancer.

[Link] the breast assessment, the nurse observes asymmetry between Ms. Jonabel’s' breasts.
What is the nurse's next step?
A. Document the finding and continue with the exam
B. Palpate the breasts to determine if there are any lumps or masses
C. Notify the healthcare provider
D. Tell Ms. Jonabel not to worry about it
Answer: b. Palpate the breasts to determine if there are any lumps or masses
Rationale: Asymmetry between the breasts can be a normal variation, but it can also be a sign of
breast cancer or other conditions. The nurse should palpate both breasts to determine if there are
any lumps or masses present.

[Link] of the following statements about breast self-exams (BSE) is true?

A. BSE should be done only once a year
B. BSE is not recommended for women under 50 years of age
C. BSE should be done at the same time every month
D. BSE should only be done by healthcare providers
Answer: c. BSE should be done at the same time every month
Rationale: Breast self-exams should be done once a month, at the same time every month. BSE
is recommended for women starting in their 20s and should continue throughout their lifetime.

[Link] the breast assessment, the nurse palpates a soft, movable lump in Ms. Jonabel’s' left
breast. What is the nurse's next step?

A. Document the finding and continue with the exam

B. Refer Ms. Jonable for a mammogram
C. Tell Ms. Jonabel not to worry about it
D. Palpate the lump again to confirm its characteristics
Answer: a. Document the finding and continue with the exam
Rationale: A soft, movable lump in the breast is likely a benign cyst or fibroadenoma. The nurse
should document the finding and continue with the exam.

[Link] of the following is not a potential complication of breast cancer surgery?

A. Lymphedema C. Hemorrhage
B. Infection D. Blindness
Answer: d. Blindness
Rationale: Blindness is not a potential complication of breast cancer surgery. However,
lymphedema (swelling of the arm), infection, and hemorrhage are all potential complications

87.A client asks the nurse to explain how to perform a proper handwashing procedure. Which of
these responses would be the most appropriate for the nurse to make?
A. "Running water helps to wash away the dirt on your hands."
B. "Be sure to wet your hands thoroughly before using soap."
C. "It is okay to use your washed hands to turn off the faucet."
D. "You should wash your hands for at least 30 seconds before rinsing them."
[Link] of these client statements is the most reliable indicator that a client has an
understanding of infection prevention?
A. "I will use alcohol to wash my hands."
B. "Soiled dressings can be placed in a paper bag."
C. "My fingernails are short and well-trimmed."
D. "The family dog can sleep with me on the bed."
[Link] nurse instructs a client in infection prevention. Which of the following statements, if made
by the client, indicates that the teaching was effective?
A. "I should wash my hands before changing my wound dressing."
B. "The organisms on my skin will not infect my leg wound."
C. "The dressings from my wound can be removed without wearing gloves."
D. "The drainage from my wound can be rinsed down the kitchen sink."
[Link] an infectious disease can be transmitted directly from one person to another, it is a:
A. Susceptible host.
B. Communicable disease.
C. Port of entry to a host.
D. Port of exit from the reservoir.
[Link] of the following is the most effective way to break the chain of infection?
A. Hand hygiene
B. Wearing gloves
C. Placing patients in isolation
D. Providing private rooms for patients
92.A family member is providing care to a loved one who has an infected leg wound. What would
you instruct the family member to do after providing care and handling contaminated
equipment or organic material?
A. Wear gloves before eating or handling food.
B. Place any soiled materials into a bag and double bag it.
C. Have the family member check with the doctor about need for immunization.
D. Perform hand hygiene after care and/or handling contaminated equipment or material.
93.A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be
angry, but he knows that this is a normal response to isolation. Which is the best intervention?
A. Provide a dark, quiet room to calm the patient.
B. Reduce the level of precautions to keep the patient from becoming angry.
C. Explain the reasons for isolation procedures and provide meaningful stimulation.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection.
[Link] nurse has redressed a patient's wound and now plans to administer a medication to the
patient. Which is the correct infection control procedure?
A. Leave the gloves on to administer the medication.
B. Remove gloves and administer the medication.
C. Remove gloves and perform hand hygiene before administering the medication.
D. Leave the medication on the bedside table to avoid having to remove gloves before leaving
the patient's room.
 NS 1 QUIZ 3 OB 1

1. Which nursing assessment indicates that a woman who is in second-stage labor is almost ready
to give birth?
A. The fetal head is felt at 0 station during vaginal examination.
B. Bloody mucus discharge increases.
C. The vulva bulges and encircles the fetal head.
D. The membranes rupture during a contraction.

ANSWER C. During the active pushing (descent) phase, the woman has strong urges to bear down as
the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. The
vulva stretches and begins to bulge encircling the fetal head. Birth of the head occurs when the station is
+4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an
indication of an imminent birth. Rupture of membranes can occur at any time during the labor process
and does not indicate an imminent birth

2. The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the
maternal long axis. The nurse documents this finding as which of the following?
A. Attitude
B. Lie
C. Position
D. Presentation

ANSWER B. The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long
axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to longitudinal.
Presentation is the portion of the fetus that overlies the maternal pelvic inlet. Attitude is the relationship
of the different fetal parts to one another. Position is the relationship of the fetal denominator to the
different sides of the maternal pelvis

3. The nurse should initially implement which intervention when a nulliparous woman telephones
the hospital to report that she is in labor.
A. Emphasize that food and fluid should stop or be light
B. Tell the woman to stay home until her membranes rupture
C. Ask the woman to describe why she believes that she is in labor
D. Arrange for the woman to come to the hospital for labor evaluation

ANSWER C. The nurse needs further information to assist in determining if the woman is in true or
false labor. She will need to ask the patient questions to seek further assessment and triage information.
Having her wait until membranes rupture may be dangerous, as she may give birth before reaching the
hospital. She should continue fluid intake until it is determined whether or not she is in labor. She may
be in false labor, and more information should be obtained before she is brought to the hospital.

4. The nurse is assessing the pH level of the vaginal environment of a 26-year-old client. Which of
the following would be an expected finding for this client?
A. pH level of 3.4
B. pH level of 4.6
 C. pH level of 5.7
D. pH level of 6.9

Answer B. The normal range for vaginal pH levels for a client during the childbearing years is 4.0-5.0. The
environment of the vagina is acidic. Below 4.0 is too low and above 5.0 is too high.

5. Which statement best describes the correct order of the four phases of the menstrual cycle?
A. Menstrual, follicular, secretory, ischemic
B. Luteal, follicular, secretory, menstrual
C. Menstrual, proliferative, secretory, ischemic
D. Luteal, secretory, ischemic, follicular

Answer C. Menstrual, proliferative, secretory, ischemic is the correct order for the four phases of the
menstrual cycle. There is no luteal or follicular phase in the menstrual cycle

6. When going through the transition phase of labor women often feel out of control. What do
women in the transition phase of labor need?
A. Their significant other beside them
B. Intense nursing care
C. Just to be left alone
D. Positive reinforcement

ANSWER D. Any women, even ones who have had natural childbirth classes, have a difficult time
maintaining positive coping strategies during this phase of labor. Many women describe feeling out of
control during this phase of labor. A woman in transition needs support, encouragement, and positive
reinforcement

7. The initial descent of the fetus into the pelvis to zero station is which one of the cardinal
movements of labor?
A. Engagement
B. Felxion
C. Extension
D. Expulsion

ANSWER A. The movement of the fetus into the pelvis from the upper uterus is engagement. This is
the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion
occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension
is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through
the birth canal. Expulsion occurs after delivery of the anterior and posterior shoulders.

8. One of the theories about the onset of labor is the prostaglandin theory. While not being
conclusively proven that the action of prostaglandins initiate labor, it is known that
prostaglandins do play a role in labor. What is an action of prostaglandins?
A. Stimulates uterine muscle to relax
B. Softens cervix
C. Initiates relaxation of perineum
D. Initiates cervical dilation
ANSWER B. The prostaglandin theory is another theory of labor initiation. Prostaglandins influence
labor in several ways, which include softening the cervix and stimulating the uterus to contract. However,
evidence supporting the theory that prostaglandins are the agents that trigger labor to begin is
inconclusive

9. Which of the following would be least effective in promoting a positive birth outcome for a
woman in labor?
A. Promoting the woman's feelings of control
B. Providing clear information about procedures
C. Encouraging the woman to use relaxation techniques
D. Allowing the woman time to be alone

ANSWER D. Positive support, not being alone, promotes a positive birth experience. Being alone can
increase anxiety and fear, decreasing the woman's ability to cope. Feelings of control promote self-
confidence and self-esteem, which in turn help the woman to cope with the challenges of labor.
Information about procedures reduces anxiety about the unknown and fosters cooperation and self-
confidence in her abilities to deal with labor. Catecholamines are secreted in response to anxiety and
fear and can inhibit uterine blood flow and placental perfusion. Relaxation techniques can help to reduce
anxiety and fear, in turn decreasing the secretion of catecholamines and ultimately improving the
woman's ability to cope with labor

10. There are four essential components of labor. The first is the passageway. It is composed of the
bony pelvis and soft tissues. What is one component of the passageway?
A. Uterus
B. False pelvis
C. Cervix
D. Perineum

ANSWER C. The cervix and vagina are soft tissues that form the part of the passageway known as the
birth canal

11. A client in labor is agitated and nervous about the birth of her child. The nurse explains to the
client that fear and anxiety cause the release of certain compounds which can prolong labor.
Which of the following is the nurse referring to in the explanation?
A. Catecholamines
B. Relaxin
C. Prostaglandins
D. Oxytocin

ANSWER A. Fear and anxiety cause the release of catecholamines, such as norepinephrine and
epinephrine which stimulate the adrenergic receptors of the myometrium. This in turn interferes with
effective uterine contractions and results in prolonged labor. Estrogen promotes the release of
prostaglandins and oxytocin. Relaxin is a hormone that is involved in producing backache by acting on
the pelvic joints. Prostaglandins, oxytocin and relaxin are not produced due to fear or anxiety in clients
during labor
 12. A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it
can be determined. The nurse informs the client that she should be able to find out the sex at 12
weeks' gestation because of which factor?
A. The appearance of the fetal external genitalia
B. The beginning of differentiation in the fetal groin
C. The fetal testes are descended into the scrotal sac
D. The internal differences in males and females become apparent

ANSWER A. By the end of the twelfth week, the external genitalia of the fetus have developed to such a
degree that the sex of the fetus can be determined visually. Differentiation of the external genitalia
occurs at the end of the ninth week. Testes descend into the scrotal sac at the end of the thirty-eighth
week. Internal differences in the male and female occur at the end of the seventh week.

13. The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that
the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority
nursing action?
A. Document the finding.
B. Check the mother's heart rate.
C. Notify the health care provider (HCP).
D. Tell the client that the fetal heart rate is normal.

ANSWER C. The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first
trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the
FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may
be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP.
Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse
documents the findings, based on the information in the question, the HCP needs to be notified.

14. Which hormone is necessary for a positive pregnancy test?

A. Progesterone
B. Human chorionic gonadotropin
C. Estrogen
D. Lactogen

ANSWER: B Human chorionic gonadotropin is a hormone produced primarily by syncytiotrophoblastic

cells of the placenta during pregnancy. The hormone stimulates the corpus luteum to produce
progesterone to maintain the pregnancy

15. When teaching Aling Nena about her pregnancy, you should include personal common
discomforts. Which of the following is an indication for prompt professional supervision?
A. Constipation and hemorrhoids
B. Backache
C. Facial edema
D. Frequency of urination
ANSWER: C Choices A, B, and D are common discomforts during pregnancy that can be easily avoided
or attended to by the mother. Choice C however is an indication that the mother may have pregnancy
induced hypertension and needs immediate professional help.

16. Which of the following statements would be appropriate for you to include in Aling Nena’s
prenatal teaching plan?
A. Exercise is very stressful, it is not recommended
B. Limit your food intake to vegetables only
C. Alcohol has no harmful effects on the fetus
D. Avoid unnecessary fatigue, rest periods should be included in your schedule

ANSWER: D Exercises are still needed during pregnancy, especially pelvic muscle exercises in order to
facilitate easy delivery. The mother should never limit her food intake to vegetables only since she needs
other sources of food that is rich in protein and other nutrients. Alcohol can have a harmful effect on the
fetus which can cause fetal alcohol syndrome. Letter D is the correct answer, unnecessary fatigue can
stress the mother especially if the mother is working, this can sometimes have an effect on pregnancy.
Rest periods should always be included.

17. An adolescent boy asks, "Does the scrotum have a function?" The nurse's best response is:
A. "The scrotum maintains a higher temperature than the core body temperature."
B. "The scrotum is an insensitive structure that houses the testicles."
C. "The scrotum is the source of ejaculation."
D. "The scrotum helps to protect the testes and provides an ideal environment to create sperm."

Answer D. The scrotum's main purpose is to protect the testes and maintain a temperature that is lower
than body temperature so spermatogenesis can occur. Because it is sensitive to touch, pain, and
pressure, the scrotum defends against potential harm to the testes. Ejaculation occurs with sexual
stimulation and expulsion of semen by rhythmic contractions of the penile muscles.

18. A nurse is teaching a sex education class about the female reproductive system for 6th-grade
girls in a local middle school. The nurse explains that the primary components of the external
female reproductive system are:
A. The clitoris, vaginal canal, and perineal body.
B. The labia, clitoris, and urethra.
C. The mons, labia, and clitoris.
D. The mons, labia, and vagina.

Answer C. The mons, labia, and the clitoris make up part of the external female reproductive system.
They can be seen directly and inspected. The vaginal canal, urethra, and vagina are all part of the
internal female reproductive system.

19. The couple has finally chosen the intrauterine device as a method of contraception. Nurse Dina
must inform Aling Sion of which of the following?
A. Breast tenderness after insertion of the IUD
B. Vaginal discoloration 1 week after insertion of the IUD
C. Amenorrhea for 6 months after the insertion of the IUD
D. Vaginal spotting and uterine cramping during the first 2 or 3 weeks after IUD insertion.
ANSWER: D The most common discomfort the female can have related to IUD is Letter D. Choices B, C,
and D are not related with IUD usage.

20. The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid.
The student responds correctly by explaining which as characteristics of amniotic fluid? Select all
that apply.
A. Allows for fetal movement
B. Surrounds, cushions, and protects the fetus
C. Maintains the body temperature of the fetus
D. Can be used to measure fetal kidney function
E. All of the above

ANSWER E. Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. It allows the
fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid
contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents
large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and
waste products between the mother and the fetus.

21. The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?
A. "Your type of pelvis has a narrow pubic arch."
B. "Your type of pelvis is the most favorable for labor and birth."
C. "Your type of pelvis is a wide pelvis, but it has a short diameter."
D. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal
delivery."

ANSWER B. A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor
and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the
narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately
narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the
anteroposterior diameter is short, making the outlet inadequate.

22. Which purposes of placental functioning should the nurse include in a prenatal class? Select all
that apply.
A. It cushions and protects the baby.
B. It maintains the temperature of the baby.
C. It is the way the baby gets food and oxygen.
D. It prevents all antibodies and viruses from passing to the baby.

ANSWER C. The placenta provides an exchange of oxygen, nutrients, and waste products between the
mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the
body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the
placenta.

23. The nurse would expect which maternal cardiovascular finding during labor?
A. Increased cardiac output
B. Decreased pulse rate
C. Decreased white blood cell (WBC) count
 D. Decreased blood pressure

ANSWER A. During each contraction, 400 mL of blood is emptied from the uterus into the maternal
vascular system. This increases cardiac output by about 51% above baseline pregnancy values at term.
The heart rate increases slightly during labor. The WBC count can increase during labor. During the first
stage of labor, uterine contractions cause systolic readings to increase by about 10 mm Hg. During the
second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings
to increase by 25 mm Hg.

24. The factors that affect the process of labor and birth, known commonly as the five Ps, include all
except:
A. Passenger.
B. Powers.
C. Passageway.
D. Pressure.

ANSWER D. The five Ps are passenger (fetus and placenta), passageway (birth canal), powers
(contractions), position of the mother, and psychologic response.

25. The slight overlapping of cranial bones or shaping of the fetal head during labor is called:
A. Lightening.
B. Molding.
C. Ferguson reflex.
D. Valsalva maneuver.

ANSWER B. Fetal head formation is called molding. Molding also permits adaptation to various
diameters of the maternal pelvis. Lightening is the mother's sensation of decreased abdominal
distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the
uterus after stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the
second stage of labor

26. Which description of the four stages of labor is correct for both definition and duration?
A. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours
B. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours
C. Third state: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first-timer)
D. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

ANSWER A. Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20
hours. The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes,
although 2 hours is still considered normal. The third stage extends from birth to expulsion of the
placenta and usually takes a few minutes. The fourth stage begins after expulsion of the placenta and
lasts until homeostasis is reestablished (about 2 hours)

27. With regard to factors that affect how the fetus moves through the birth canal, nurses should be
aware that:
A. The fetal attitude describes the angle at which the fetus exits the uterus.
B. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is
parallel to the long axis of the mother.
 C. The normal attitude of the fetus is called general flexion.
D. The transverse lie is preferred for vaginal birth.

ANSWER C. The normal attitude of the fetus is general flexion. The fetal attitude is the relation of fetal
body parts to one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or
vertical) lie the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus
stays in a transverse lie

28. Which statement is the best rationale for assessing maternal vital signs between contractions?
A. During a contraction, assessing fetal heart rates is the priority.
B. Maternal circulating blood volume increases temporarily during contractions.
C. Maternal blood flow to the heart is reduced during contractions.
D. Vital signs taken during contractions are not accurate

ANSWER B. During uterine contractions, blood flow to the placenta temporarily stops, causing a
relative increase in the mother's blood volume, which in turn temporarily increases blood pressure and
slows pulse. It is important to monitor fetal response to contractions; however, this question is
concerned with the maternal vital signs. Maternal blood flow is increased during a contraction. Vital
signs are altered by contractions but are considered accurate for that period of time.

29. While providing care to a patient in active labor, the nurse should instruct the woman that:
A. The supine position commonly used in the United States increases blood flow.
B. The "all fours" position, on her hands and knees, is hard on her back.
C. Frequent changes in position will help relieve her fatigue and increase her comfort.
D. In a sitting or squatting position, her abdominal muscles will have to work harder.

ANSWER C. Frequent position changes relieve fatigue, increase comfort, and improve circulation.
Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The
"all fours" position is used to relieve backache in certain situations. In a sitting or squatting position, the
abdominal muscles work in greater harmony with uterine contractions

30. To teach patients about the process of labor adequately, the nurse knows that which event is the
best indicator of true labor?
A. Bloody show
B. Cervical dilation and effacement
C. Fetal descent into the pelvic inlet
D. Uterine contractions every 7 minutes

ANSWER B. The conclusive distinction between true and false labor is that contractions of true labor
cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur
before true labor. False labor may have contractions that occur this frequently; however, this is usually
inconsistent

31. Which occurrence is associated with cervical dilation and effacement?

A. Bloody show
B. Lightening
C. False labor
D. Bladder distention
ANSWER A. As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that
sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries. Cervical
dilation and effacement do not occur with false labor. Lightening is the descent of the fetus toward the
pelvic inlet before labor. Bladder distention occurs when the bladder is not emptied frequently. It may
slow down the descent of the fetus during labor

32. When teaching Aling Nena about her pregnancy, you should include personal common
discomforts. Which of the following is an indication for prompt professional supervision?
A. Constipation and hemorrhoids
B. Backache
C. Facial edema
D. Frequency of urination

ANSWER: C. Choices A, B, and D are common discomforts during pregnancy that can be easily avoided
or attended to by the mother. Choice C however is an indication that the mother may have pregnancy
induced hypertension and needs immediate professional help.

33. Which of the following statements would be appropriate for you to include in Aling Nena’s
prenatal teaching plan?
A. Exercise is very stressful, it is not recommended
B. Limit your food intake to vegetables only
C. Alcohol has no harmful effects on the fetus
D. Avoid unnecessary fatigue, rest periods should be included in your schedule

ANSWER: D Exercises are still needed during pregnancy, especially pelvic muscle exercises in order to
facilitate easy delivery. The mother should never limit her food intake to vegetables only since she needs
other sources of food that is rich in protein and other nutrients. Alcohol can have a harmful effect on the
fetus which can cause fetal alcohol syndrome. Letter D is the correct answer, unnecessary fatigue can
stress the mother especially if the mother is working, this can sometimes have an effect on pregnancy.
Rest periods should always be included.

SITUATION: Rodrigo a 35-year-old male and Leni a 33-year-old female is visiting a fertility clinic. The
couple has mentioned that they have been married for 7 years and have been trying since then to
conceive a child. They have always been unsuccessful. It was found out that the female has obstructed
fallopian tubes. The physician has recommended the couple to undergo in vitro fertilization (IVF).

34. The nurse must know that the process of in vitro fertilization involves which of the following
procedures?
A. Oophorectomy
B. Laparoscopy
C. Salpingectomy
D. Drug therapy

ANSWER: B Laparoscopy is utilized to obtain one or more oocytes from the woman’s ovary and fertilized
by exposure to sperm in a laboratory.
Case Scenario:

Miss. Julia, a 30-year-old Filipino woman, is admitted to the labor and delivery unit. She is pregnant with
her first child and is currently in the active phase of labor. Her cervix is dilated to 6 centimeters, and
contractions are occurring every 3-4 minutes. The healthcare provider has decided to closely monitor
Julia's progress during this stage.

35. During which stage of labor is Miss. Julia currently in?

A. Latent phase
B. Active phase
C. Transition phase
D. Second stage

Answer B. Active phase The active phase of labor begins when the cervix is dilated around 4-6
centimeters and lasts until the cervix is fully dilated at 10 centimeters. During this stage, contractions
become stronger, longer, and more frequent.

36. Miss. Julia's contractions are occurring every 3-4 minutes. What is the duration of each
contraction during the active phase?
A. 10-20 seconds
B. 30-40 seconds
C. 50-60 seconds
D. 70-80 seconds

Answer C. 50-60 seconds. During the active phase of labor, contractions typically last 50-60 seconds.

37. Which of the following is a characteristic of contractions during the active phase?
A. Occur every 15-20 minutes
B. Mild in intensity
C. Last 30-45 seconds
D. Felt primarily in the lower back

Answer C. Last 30-45 seconds. Contractions during the active phase of labor are typically longer in
duration, lasting approximately 30-45 seconds.

38. Miss. Julia's cervix is dilated to 6 centimeters. What does this indicate?
A. Transition phase of labor
B. Complete cervical dilation
C. Early labor stage
D. Active labor stage

Answer D. Active labor stage. A cervical dilation of 6 centimeters is considered part of the active labor
stage.

39. During the active phase of labor, what position is typically recommended for the mother?
A. Supine position
B. Trendelenburg position
 C. Semi-Fowler's position
D. Side-lying position

Answer D. Side-lying position. The side-lying position is often recommended during the active phase of
labor to enhance maternal comfort and promote optimal fetal oxygenation.

40. Miss. Julia's labor is progressing normally. How frequently should her cervical dilation be
assessed during the active phase?
A. Every hour
B. Every 2 hours
C. Every 4 hours
D. Every 6 hours

Answer: b. Every 2 hours. During the active phase of labor, cervical dilation should be assessed every 2
hours to monitor progress and identify any deviations.

41. Miss. Julia's labor is progressing slowly. What intervention might the healthcare provider
consider?
A. Amniotomy
B. Administration of oxytocin
C. Epidural anesthesia
D. Fundal massage

Answer: b. Administration of oxytocin. If labor progresses slowly during the active phase, the healthcare
provider may consider administering oxytocin (Pitocin) to augment or stimulate contractions.

42. Miss. Julia is experiencing pain during the active phase of labor. Which nursing intervention is
most appropriate?
A. Offer her a warm bath or shower.
B. Administer opioid analgesics.
C. Encourage frequent position changes.
D. Apply a cold pack to her lower abdomen.

Answer: c. Encourage frequent position changes. Encouraging frequent position changes during the
active phase of labor can help alleviate pain by promoting comfort, facilitating optimal fetal descent, and
relieving pressure on specific areas.

43. Miss. Julia's partner asks about the signs of progress during the active phase of labor. Which
response by the nurse is accurate?
A. "The cervix will be fully dilated."
B. "The baby's head will descend into the pelvis."
C. "The contractions will become less frequent."
D. "The mother will feel a strong urge to push."

Answer: b. "The baby's head will descend into the pelvis." During the active phase of labor, a sign of
progress is the descent of the baby's head into the pelvis, indicating that labor is advancing.

44. Miss. Julia requests an epidural for pain relief. What should the nurse inform her about the
potential side effects of an epidural?
 A. Decreased blood pressure
B. Increased fetal heart rate
C. Rapid cervical dilation
D. Prolonged labor duration

Answer: a. Decreased blood pressure. Epidurals can cause a decrease in blood pressure as a side effect
due to the effects of the medication on the sympathetic nervous system.

45. Miss. Julia has an epidural in place. What nursing action is essential to prevent complications
related to the epidural anesthesia?
A. Encourage deep breathing and relaxation techniques.
B. Monitor maternal and fetal vital signs regularly.
C. Administer a bolus of intravenous fluids.
D. Assist with pushing during contractions.

Answer: b. Monitor maternal and fetal vital signs regularly. Regular monitoring of maternal and fetal vital
signs is essential when an epidural anesthesia is in place to detect any potential complications, such as
hypotension or fetal distress.

46. Miss. Julia's labor progresses, and she enters the second stage. What is the primary
characteristic of the second stage of labor?
A. Full cervical dilation
B. Onset of regular contractions
C. Strong urge to push
D. Rupture of membranes

Answer: c. Strong urge to push. The primary characteristic of the second stage of labor is the maternal
urge to bear down and push, indicating full cervical dilation and fetal descent.

47. Miss. Julia is in the second stage of labor. What position is most advantageous for pushing?
A. Supine position with legs elevated
B. Semi-Fowler's position
C. Side-lying position
D. Squatting position

Answer: d. Squatting position. The squatting position is most advantageous for pushing during the
second stage of labor as it increases the pelvic outlet diameter and utilizes gravity to aid in the descent
of the baby.

48. Miss. Julia's contractions become less frequent during the second stage. What should the nurse
do?
A. Administer oxytocin to stimulate contractions.
B. Encourage Miss. Julia to push harder during contractions.
C. Reassure Miss. Julia that this is a normal part of labor.
D. Notify the healthcare provider immediately.

Answer: c. Reassure Miss. Julia that this is a normal part of labor. During the second stage of labor,
contractions may become less frequent but more intense. This is a normal part of labor as the body
prepares for the birth of the baby. Reassuring Miss. Julia that this is a normal occurrence can help
alleviate her concerns.

49. Miss. Julia's baby's head begins to emerge during the second stage of labor. What should the
nurse do to facilitate the birth?
A. Apply gentle pressure to the perineum.
B. Perform an episiotomy.
C. Administer an oxytocic medication.
D. Prepare for immediate resuscitation of the newborn.

Answer: a. Apply gentle pressure to the perineum. Applying gentle pressure to the perineum during the
birth of the baby's head can help prevent rapid stretching and tearing, facilitating a controlled birth.

50. Miss. Julia delivers her baby's head, but the shoulder remains impacted. What maneuver should
the nurse perform?
A. McRoberts maneuver
B. Suprapubic pressure
C. Episiotomy
D. Fundal pressure

Answer: a. McRoberts maneuver. If the baby's shoulder remains impacted after the delivery of the head
(shoulder dystocia), the McRoberts maneuver is performed. This involves flexing the mother's legs
toward her shoulders to increase the pelvic outlet diameter and facilitate the release of the impacted
shoulder.

51. Miss. Julia delivers her baby, and the healthcare provider performs fundal massage. What is the
purpose of this intervention?
A. Promote placental separation and prevent hemorrhage
B. Assess the perineum for tears or lacerations
C. Facilitate expulsion of the umbilical cord
D. Evaluate the baby's Apgar score

Answer: a. Promote placental separation and prevent hemorrhage. Fundal massage is performed after
delivery to promote uterine contractions, aid in placental separation, and prevent postpartum
hemorrhage by compressing the blood vessels at the placental site.

52. Miss. Julia delivers her placenta, but the nurse notes that a portion of the placenta remains in
the uterus. What is the priority nursing intervention?
A. Administer oxytocin to stimulate uterine contractions.
B. Prepare for immediate manual removal of the placenta.
C. Encourage Miss. Julia to breastfeed her baby.
D. Assess vital signs and monitor for signs of infection.

Answer: b. Prepare for immediate manual removal of the placenta. If a portion of the placenta remains
in the uterus after delivery, it can lead to complications such as postpartum hemorrhage or infection.
The priority nursing intervention is to prepare for the immediate manual removal of the placenta under
the guidance of a healthcare provider.
 53. Miss. Julia is in the third stage of labor. What nursing action should be prioritized during this
stage?
A. Monitoring the baby's vital signs
B. Assessing the perineum for lacerations
C. Encouraging breastfeeding initiation
D. Monitoring maternal vital signs and uterine contraction

Answer: d. Monitoring maternal vital signs and uterine contraction. During the third stage of labor, the
nurse should prioritize monitoring the mother's vital signs, including blood pressure and pulse, as well as
assessing uterine contraction to ensure the uterus is firmly contracted to prevent postpartum
hemorrhage.

54. Miss. Julia's baby is born, and the nurse assesses the Apgar score. The baby has a heart rate of
90, slow, irregular respirations, some flexion of extremities, a weak cry, and a pink body with
blue hands and feet. What is the Apgar score for this baby?
A. 5
B. 6
C. 7
D. 8

Answer: c. 7. The Apgar score is a quick assessment of a newborn's physical condition at 1 and 5
minutes after birth. The criteria assessed include heart rate, respiratory effort, muscle tone, reflex
irritability, and color. In this case, the baby scores 1 point for heart rate (90 beats per minute), 1 point for
respiratory effort (slow, irregular respirations), 1 point for muscle tone (some flexion of extremities), 1
point for reflex irritability (weak cry), and 3 points for color (pink body with blue hands and feet). Adding
the points together, the Apgar score is 7.

55. Miss. Julia's baby is experiencing acrocyanosis. What is the nurse's appropriate action?
A. Notify the healthcare provider immediately.
B. Administer oxygen supplementation.
C. Document the finding in the baby's chart.
D. Initiate cardiopulmonary resuscitation (CPR).

Answer: c. Document the finding in the baby's chart. Acrocyanosis, which refers to blue hands and feet,
is a common finding in newborns. It is a normal variation and does not require any immediate
intervention. The nurse should document this finding in the baby's chart for future reference.

56. Miss. Julia is interested in breastfeeding her baby. What should the nurse do to support
successful breastfeeding initiation?
A. Offer the baby a pacifier to soothe sucking reflexes.
B. Position the baby in a semi-upright position.
C. Encourage Miss. Julia to breastfeed within the first hour.
D. Supplement breastfeeding with formula to meet nutritional needs.

Answer: c. Encourage Miss. Julia to breastfeed within the first hour. To support successful breastfeeding
initiation, it is crucial to encourage Miss. Julia to breastfeed within the first hour after birth. This helps
promote bonding, stimulates milk production, and establishes breastfeeding as early as possible.
 57. Miss. Julia's baby is having difficulty latching onto the breast. What should the nurse suggest to
improve latching?
A. Apply lanolin cream to the nipples.
B. Use a nipple shield during breastfeeding.
C. Massage the breasts to stimulate milk flow.
D. Ensure proper positioning and latch technique.

Answer: d. Ensure proper positioning and latch technique. When a baby has difficulty latching onto the
breast, the nurse should suggest ensuring proper positioning and latch technique. This includes aligning
the baby's nose to the nipple, aiming the nipple toward the baby's upper lip, and ensuring a wide mouth
opening for effective latch.

58. Miss. Julia asks about the benefits of rooming-in with her baby. What should the nurse explain?
A. Rooming-in promotes better sleep for the baby.
B. Rooming-in increases the risk of infection transmission.
C. Rooming-in enhances bonding and breastfeeding.
D. Rooming-in allows more rest for the mother.

Answer: c. Rooming-in enhances bonding and breastfeeding. Rooming-in, where the mother and baby
stay together in the same room, promotes bonding between the mother and baby and facilitates
breastfeeding initiation and establishment. It allows for close proximity, facilitates frequent
breastfeeding, and promotes the development of a strong mother-infant relationship.

59. Miss. Julia asks about the signs that her baby is getting enough breast milk. What should the
nurse include in the response?
A. Frequent urination and yellow, seedy stools
B. Sleeping for longer durations between feedings
C. Rapid weight loss during the first week
D. Decreased frequency of breastfeeding

Answer: a. Frequent urination and yellow, seedy stools. Signs that indicate a baby is receiving enough
breast milk include frequent urination (at least 6-8 wet diapers per day) and the passage of yellow, seedy
stools. These signs indicate that the baby is adequately hydrated and receiving appropriate nutrition.

60. Miss. Julia expresses concern about postpartum blues. What should the nurse explain about this
condition?
A. Postpartum blues is a severe form of depression that requires immediate treatment.
B. Postpartum blues is a normal, self-limiting condition that resolves on its own.
C. Postpartum blues only occurs in women who have a history of mental illness.
D. Postpartum blues typically persists for several months after delivery.

Answer: b. Postpartum blues is a normal, self-limiting condition that resolves on its own. Postpartum
blues, characterized by mood swings, tearfulness, and mild depression, is a common condition
experienced by many women after childbirth. It is a self-limiting condition that typically resolves without
specific treatment within a few weeks.

61. Miss. Julia asks when she can expect her menstrual cycle to return after childbirth. What is the
nurse's best response?
 A. "Your menstrual cycle will return within a week after delivery."
B. "Your menstrual cycle will return within a month after weaning."
C. "Your menstrual cycle will return within 3-6 months after delivery."
D. "Your menstrual cycle will return after your first postpartum check-up."

Answer: c. "Your menstrual cycle will return within 3-6 months after delivery." The return of the
menstrual cycle varies among women. Typically, it takes 3-6 months for the menstrual cycle to resume
after childbirth. However, this can be influenced by factors such as breastfeeding and individual
variations.

62. Miss. Julia asks about contraception options while breastfeeding. What should the nurse
recommend?
A. Combined hormonal contraceptives (pill, patch, ring)
B. Intrauterine device (IUD)
C. Barrier methods (condoms, diaphragm)
D. Progestin-only contraceptives (mini-pill, implant)

Answer: d. Progestin-only contraceptives (mini-pill, implant). Progestin-only contraceptives, such as the

mini-pill or implant, are generally considered safe and effective options for breastfeeding mothers.

63. Miss. Julia's cervix is fully dilated and effaced. What is the nurse's priority action during this
stage of labor?
A. Prepare for immediate delivery.
B. Assist with pushing efforts during contractions.
C. Monitor fetal heart rate continuously.
D. Administer pain relief medications.

Answer: c. Monitor fetal heart rate continuously. When the cervix is fully dilated and effaced, it signifies
the beginning of the second stage of labor. Continuous monitoring of the fetal heart rate is essential
during this stage to assess the baby's well-being and ensure a safe delivery.

64. Miss. Julia's contractions have slowed down, and she is feeling exhausted. What nursing
intervention can help facilitate labor progress?
A. Encourage Miss. Julia to rest and conserve energy.
B. Administer an oxytocin infusion to strengthen contractions.
C. Prepare for an immediate cesarean section.
D. Assist Miss. Julia with breathing exercises.

Answer: a. Encourage Miss. Julia to rest and conserve energy. Slowed contractions and exhaustion can
occur during labor. Encouraging Miss. Julia to rest, change positions, or engage in relaxation techniques
can help conserve energy and promote labor progress. Intervention such as oxytocin infusion or
cesarean section may be considered based on the healthcare provider's assessment.

65. Why is progesterone or luteinizing hormone prescribed to a woman after undergoing IVF?

A. Due to the blockage of the fallopian tubes

B. Hormonal imbalances brought about by the procedure
C. The corpus luteum can be injured by the aspiration of the follicle
 D. Due to cysts growing on the mother’s ovaries

ANSWER: C One of the common occurrences in aspirating ova from the female’s ovaries is that the
needle tends to rupture the corpus luteum which is responsible for producing progesterone.
NS 1 QUIZ 4 OB 2

1. In planning for home care of a woman with preterm labor, which concern must the nurse address?

a. Nursing assessments will be different from those done in the hospital setting.
b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor.
c. Prolonged bed rest may cause negative physiologic effects.
d. Home health care providers will be necessary.

ANSWER C

Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone
demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance,
and prolonged postpartum recovery. Nursing assessments will differ somewhat from those performed in the acute care
setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm
labor, but not in all women. In addition, the plan of care is individualized to meet the needs of each woman. Many
women will receive home health nurse visits, but care is individualized for each woman.

2. In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the
nurse to possible side effects?

a. Urine output of 160 mL in 4 hours

b. Deep tendon reflexes 2+ and no clonus
c. Respiratory rate of 16 breaths/min
d. Serum magnesium level of 10 mg/Dl

ANSWER D

The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could
lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in
4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings.

3. A 22-year old woman has been brought into the delivery room and was diagnosed to have tachysystole labor.

What would be the characteristic of tachysystole labor?

a. Infrequent and brief contractions

b. More than 5 contractions per 10 minute intervals in 2 consecutive intervals
c. Prolonged active phase
d. Uterus can be easily indented by the fingertip

ANSWER: B

RATIO: Uterine tachysystole is a condition of excessively frequent uterine contractions during pregnancy. Uterine
tachysystole is defined as more than 5 contractions in 10 minutes, averaged over a 30-minute window.

4. A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The
purpose of this pharmacologic treatment is to:

a. Stimulate fetal surfactant production.

b. Reduce maternal and fetal tachycardia associated with ritodrine administration.
c. Suppress uterine contractions.
d. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.

ANSWER A

Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would
be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium
gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.

5. A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What
finding indicates that preterm labor is occurring?

a. Estriol is not found in maternal saliva.

b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes.
c. Fetal fibronectin is present in vaginal secretions.
d. The cervix is effacing and dilated to 2 cm.

ANSWER D

Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm
labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of
estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been
shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not
considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could
predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic
clues of preterm labor such as cervical changes.

6. In evaluating the effectiveness of oxytocin induction, the nurse would expect:

a. Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.

b. The intensity of contractions to be at least 110 to 130 mm Hg.
c. Labor to progress at least 2 cm/hr dilation.
d. At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.

ANSWER A

The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90
seconds. The intensity of the contractions should be 40 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation
of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2
mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a
maximum of 20 to 40 mU/min.

7. A pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would
be the top priority?

a. Placing the woman in the knee-chest position

b. Covering the cord in sterile gauze soaked in saline
c. Preparing the woman for a cesarean birth
d. Starting oxygen by face mask

ANSWER A

The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position)
in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze
soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing
interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to
relieve cord compression.

8. Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes
that this medication will be administered to:

a. Enhance uteroplacental perfusion in an aging placenta.

b. Increase amniotic fluid volume.
c. Ripen the cervix in preparation for labor induction.
d. Stimulate the amniotic membranes to rupture.

ANSWER C

It is accurate to state that Prepidil will be administered to ripen the cervix in preparation for labor induction. a hormone-
like substance, used in a pregnant woman to relax the muscles of the cervix (opening of the uterus) in preparation for
inducing labor at the end of a pregnancy. It is not administered to enhance uteroplacental perfusion in an aging
placenta, increase amniotic fluid volume, or stimulate the amniotic membranes to rupture.

9. The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin
should be discontinued immediately if there is evidence of:

a. Uterine contractions occurring every 8 to 10 minutes.

b. A fetal heart rate (FHR) of 180 with absence of variability.
c. The client's needing to void.
d. Rupture of the client's amniotic membranes.

ANSWER B

This FHR is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified. The
oxytocin should be discontinued if uterine hyperstimulation occurs. Stopping oxytocin after the active phase of labour
has started may reduce the number of women with contractions that become too long or too strong resulting in changes
to the baby's heart rate, and the risk of having a caesarean . Uterine contractions that are occurring every 8 to 10
minutes do not qualify as hyperstimulation. The client's needing to void is not an indication to discontinue the oxytocin
induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is non reassuring or the
client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be
notified that the client's membranes have ruptured.

10. With regard to the care management of preterm labor, nurses should be aware that:
 a. Because all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching
pregnant women the symptoms probably causes more harm through false alarms.
b. Braxton Hicks contractions often signal the onset of preterm labor.
c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several
hours before contacting the primary caregiver.
d. The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

ANSWER D

Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates
preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton
Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health
care provider could result in not administering essential medications. Preterm labor is not necessarily long-term labor.

11. A 25-year old woman in the delivery room has been diagnosed to have hypotonic labor. The nurse would confirm the
diagnosis with the presence of which of the following characteristics?

a. Contractions has more than 90 seconds duration

b. Frequency of contractions are less than 2 minutes
c. The number of contractions is usually infrequent which is not more than 2 or 3 occurring in a 10-mute period
d. Strong and frequent contractions

ANSWER: C

RATIO: A mother who has hypotonic labor has the following signs and symptoms: the number of uterine contractions in
hypotonic contractions is unusually slow or infrequent; there are only two or three contractions occurring within a 10-
minute period; the strength of contractions does not rise above 10 mmHg, and they occur mostly during the active
phase of labor.

12, Which of the following cases would strongly contribute to the hypotonic labor of the mother?

a. Nulliparity
b. Polyhydramnios
c. Small for gestational age fetus
d. Grand multiparity

ANSWER: D

RATIO: The uterus of a mother who has given birth four or more times (grand multiparity) becomes lax leading to the
occurrence of hypotonic labor. Other predisposing factors of hypotonic labor would be multiple gestations, macrosomia,
and hydramnios.

13, During hypotonic labor the fetus may be in distress. When the obstetrician has performed amniotomy, which of the
following is the nurse going to do?

a. Observe for the odor of the amniotic fluid

b. Determine the amount of amniotic fluid present
c. Observe for the color of the amniotic fluid
d. Check for the presence of blood in the amniotic fluid

ANSWER: C

RATIO: The first thing that the nurse should do once amniotomy is done during a hypotonic labor is to assess for the
color of the amniotic fluid and check for the presence of meconium. If the amniotic fluid is green, this must be reported
immediately since the fetus is already in distress.

14. When assessing the mother who is undergoing hypotonic labor the nurse must assess signs of infection if the is
already prolonged. Which of the following would indicate that the mother has an infection?

a. Fetal bradycardia
b. Presence of meconium in the amniotic fluid
c. Fever and chills
d. Distended bladder

ANSWER: C

RATIO: The presence of fever alone would indicate that the mother is currently experiencing an infection. Fever is a
defense mechanism of the body in order to decrease the proliferation of microorganisms in the body.
15. During an ultrasonography the physician has noticed that the baby’s hips and knees are flexed so that the baby is

sitting cross-legged, with feet beside the bottom. What is being presented in this situation?

a. Frank breech
b. Incomplete breech
c. Complete breech
d. Footling breech

ANSWER: C

RATIO: Complete breech is when both of the baby's knees are bent and his feet and bottom are closest to the birth
canal. Incomplete breech is when one of the baby's knees is bent and his foot and bottom are closest to the birth canal.
Frank breech is when the baby's legs are folded flat up against his head and his bottom is closest to the birth canal.
There is also footling breech where one or both feet are presenting.

16. Which of the following conditions must the nurse alert to the obstetrician when performing a delivery?

a. Cord prolapse
b. Rupture of membranes
c. Crowning of head
d. External rotation of the head

ANSWER: A

RATIO: Cord prolapse must be placed in priority since this will cause fetal distress due to the cord compression due to
the prolapse. This can lead to oxygen flow obstruction to the fetus. 4 of 6

17. When the fetus is in a breech presentation, the nurse must perform which of the following procedures early in

labor?

a. Ritgen’s maneuver
b. Episiotomy
c. External cephalic version
d. Fundal push

ANSWER: A

RATIO: In order to facilitate easy delivery in a breech presentation, the nurse must perform Ritgen’s Maneuver in order
to protect the perineum during delivery. Since it is difficult for the mother to deliver the malpresented fetus during
delivery, the perineum is prone to develop tears or worse the tears can extend to the anus causing large lacerations.

18. This type of presentation is caused by hyper-extension of the fetal head so that neither the occiput nor the

sinciput is palpable on vaginal examination

a. Sinciput
b. Occiput
c. Transverse
d. Face

ANSWER: D

RATIO: Face presentation occurs when baby's spine extended until the head is shifted back so baby's face comes

through the pelvis first. Baby may settle in a face presentation before labor. A baby who is in a face-first position often

started as an extended (chin up) occiput posterior or occiput transverse position.

19. Anna Carla the mother who is already prolonged in labor says to the nurse, “This is hopeless; I really can’t do it

anymore. I’m so much frustrated.” Which of the following nursing responses is most therapeutic?

a. “The doctor is doing everything she can in order to help you get past this labor.”
b. “Would you opt to be placed in a caesarean section instead?”
c. “It must be hard for you to be experiencing this. But let’s think positive and be patient, you can still do
this.”
d. “We’ll see other options that we can do in order to augment this labor that you are experiencing.”

ANSWER: C

RATIO: The nurse acknowledges the difficulties of the mother during labor and encourages the mother to push through
with it. The rest of the other options are non-therapeutic.

20. The nurse providing care to a woman in labor should understand that cesarean birth:
 a. Is declining in frequency in the twenty-first century in the United States.
b. Is more likely to be performed for poor women in public hospitals who do not receive the nurse counseling as do
wealthier clients.
c. Is performed primarily for the benefit of the fetus.
d. Can be either elected or refused by women as their absolute legal right.

ANSWER C

The most common indications for cesarean birth are danger to the fetus related to labor and birth complications.
Cesarean births are increasing in the United States in this century. Wealthier women who have health insurance and
who give birth in a private hospital are more likely to experience cesarean birth. A woman's right to elect cesarean
surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely
clear.

21. Which drug is used for treating a client with severe postpartum bleeding?

a. Nifedipine (Adalat)
b. Oxytocin (Pitocin)
c. Propranolol (Inderal)
d. Metronidazole (Flagyl)

ANSWER B

(Oxytocin (Pitocin) is a synthetic hormone used to induce labor and to control severe postpartum bleeding by making
the uterus contract. Nifedipine (Adalat) is a calcium channel blocker that is used intocolytic therapy for preterm labor.
Propranolol (Inderal) is used to reverse intolerable cardiovascular effects of terbutaline (Brethine). Metronidazole
(Flagyl) is a broad-spectrum antibiotic that is used to treat chorioamnionitis after cesarean birth.)

22. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by
evaporation?

a. Warming the crib pad

b. Closing the doors to the room
c. Drying the infant with a warm blanket
d. Turning on the overhead radiant warmer

ANSWER C

Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying
the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the
newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the
colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs
as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat
from the newborn radiates to a colder surface (indirect contact).

23. The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord
was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

a. Bring the infant to the clinic.

b. This is a normal occurrence.
c. Increase the number of times that the cord is cleaned per day.
d. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

ANSWER A

Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If
symptoms of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms
occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given
in the question.

24. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which
assessment findings would alert the nurse to the possibility of this syndrome?

a. Tachypnea and retractions

b. Acrocyanosis and grunting
c. Hypotension and bradycardia
d. Presence of a barrel chest and acrocyanosis

ANSWER A

A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea,
nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis, a bluish discoloration of the hands and feet, is
associated with immature peripheral circulation, and is common in the first few hours of life. Options 2, 3, and 4 do not
indicate clinical signs of respiratory distress syndrome

25. Ms Melissa a mother of a term newborn has curiously asked about the thick, white, cheesy coating on her son’s skin.
The nurse must correctly describe this as

a. lanugo
b. milia
c. café-au-lait spots
d. vernix caseosa

ANSWER: D

RATIO: Lanugo is a type of fine hair that grows on the bodies of human fetuses while they are developing in the womb.

Milia are small, bump-like cysts found under the skin. They are usually 1 to 2 millimeters (mm) in size. Café-au-lait

spots or macules (CALS or CALM) are flat, pigmented spots on the skin. They are commonly referred to as “birthmarks”,

but are often not present at birth.

26. When Nurse Lovely is assessing the newborn, she has noted that the newborn has caput succedaneum. Which of the
following statements about this condition is correct?

a. It usually resolves within 3 to 6 weeks

b. It involves swelling of tissue over the presenting part of the presenting head
c. It doesn’t cross the cranial suture lines
d. It’s a collection of blood between the skull and the periosteum

ANSWER: B

RATIO: Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure;
it resolves within the next 4 days.

27. Nurse Sierra is attending a newborn. To help her limit the development of hyperbilirubinemia in the newborn, her
plan of care for her patient should include

a. Monitoring for the passage of meconium each shift

b. Instituting phototherapy for 30 minutes every 6 hours
c. Substituting breastfeeding for formula during the 2nd day after birth
d. Supplementing breastfeeding with glucose water during the first 24 hours

ANSWER: A

RATIO: Bilirubin is excreted via the digestive tract through bile; if meconium is retained, that means that the newborn’s

bilirubin was reabsorbed.

28. Nurse V is preparing to administer a vitamin K shot to a newborn. Aling Julia is asking the nurse why her newborn
infant needs the injection. The best nursing response would be

a. “Your infant needs vitamin K to develop immunity passive artificial immunity.”

b. “Vitamin K will protect your infant from having jaundice.”
c. “Newborn infants are deficient in vitamin K, and this shot will prevent your infant from any abnormal bleeding.”
d. “Newborns have sterile bowels, and vitamin K will help promote the growth of good bacteria in the digestive
tract.”

ANSWER: C

RATIO: Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn
infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the
bacteria necessary for synthesizing fat-soluble vitamin K. The infant’s bowel does not have support the production of
vitamin K until bacteria adequately colonizes it by food ingestion.

29. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding
would the nurse expect to note during the assessment of this newborn?

a. Lethargy
b. Sleepiness
c. Constant crying
d. Cuddles when being held

ANSWE C
A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry
incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.

30. A full-term newborn was just born. Nurse Sasha must know that the most important nursing intervention to perform
first would be

a. Assessing the APGAR score

b. Remove the wet blankets
c. Apply eye prophylaxis
d. Elicit the Moro reflex

ANSWER: B

RATIO: When newborns are wet, they can become hypothermic from heat loss resulting from evaporation. They may
then develop cold stress syndrome. The first Apgar score is not done until 60 seconds after delivery. The wet blankets
should have been removed from the baby well before that time. Eye prophylaxis can be delayed until after the parents
have begun bonding with their baby. Although the baby’s central nervous system must be carefully assessed, reflex
assessment should be postponed until after the baby is dried and is breathing on his or her own.

31. Nurse Angel notes that a 6-hour-old newborn has cyanotic hands and feet. Which of the following nursing
interventions would be appropriate?

a. Assess oxygen saturation with the pulse oximeter

b. Swaddle the newborn in a blanket
c. Place the child under the UV light
d. Administer oxygen

ANSWER: B

RATIO: The baby’s extremities are cyanotic as a result of the baby’s immature circulatory system. Swaddling helps to
warm the baby’s hands and feet.

32. The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why
this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

a. Protects the newborn's eyes from possible infections acquired while hospitalized.
b. Prevents cataracts in the newborn born to a woman who is susceptible to rubella.
c. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor.
d. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a
woman with an untreated gonococcal infection.

ANSWER D

Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is
caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and
3 are not the purposes for administering this medication to a newborn infant.

33. The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant
needs the injection. What best response should the nurse provide?

a. "Your newborn needs vitamin K to develop immunity."

b. "The vitamin K will protect your newborn from being jaundiced."
c. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
d. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

ANSWER D

Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn to
prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are
vitamin K-deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The
normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of
vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K
does not promote the development of immunity or prevent the infant from becoming jaundiced

34. The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse
notes that the ears are low-set. Which nursing action is most appropriate?

a. Document the findings.

b. Arrange for hearing testing.
c. Notify the health care provider.
d. Cover the ears with gauze pads.

ANSWER C
Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although
the findings should be documented, the most appropriate action would be to notify the health care provider. Options 2
and 4 are inaccurate and inappropriate nursing actions.

35. The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which
action?

a. Make a loud, abrupt noise to startle the newborn.

b. Stimulate the ball of the foot of the newborn by firm pressure.
c. Stimulate the perioral cavity of the newborn infant with a finger.
d. Stimulate the pads of the newborn infant's hands by firm pressure.

ANSWER A

The Moro reflex is elicited by placing the newborn on a flat surface and striking the surface or making a loud, abrupt
noise to startle the newborn. The newborn assumes sharp extension and abduction of the arms with the thumbs and
forefingers in a C position; this is followed by flexion and adduction to an "embrace" position (legs follow a similar
pattern). The Moro reflex is present at birth and is absent by 6 months of age if neurological maturation is not delayed.
A persistent response lasting more than 6 months may indicate a neurological abnormality. The rooting reflex is elicited
by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by
firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.

36. The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is
less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces
when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should
most appropriately document which Apgar score for the newborn?

a. 3
b. 5
c. 7
d. 10

ANSWER B

One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five
criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2.
Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0;
some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no
response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of
extremities = 1; pink = 2. Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores
of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more
vigorous resuscitation.

37. The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the
umbilical cord, the nurse should expect to observe which finding?

a. One artery
b. Two veins
c. Two arteries
d. One artery and one vein

ANSWER C

The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that
returns blood to the embryo. There should be no odor noted from the umbilical cord. Options 1, 2, and 4 are incorrect

38. The nursing history for a newborn suspected of having pyloric stenosis would most likely reveal which of the

following?

a. Frequent vomiting of bile-stained fluid

b. Cyanosis and vomiting immediately after feedings
c. Mild emesis progressing to projectile vomiting
d. Absence of gastrointestinal peristalsis

ANSWER: C

RATIO: Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with
pyloric stenosis.

39. Nurse Madeline is assessing the reflexes of a newborn. The nurse assesses which of the following reflexes by placing
a finger in the newborn’s mouth?
 a. Sucking reflex
b. Landau reflex
c. Babinski reflex
d. Moro reflex

ANSWER: A The sucking reflex is tested by placing something, such as a finger, in the infant’s mouth and seeing if the
infant begins to suck on the object.

40. Nurse Hope is assessing a newborn on admission to the NICU. Which of the following findings should the nurse
report to the attending physician?

a. Intercostal retractions
b. Caput succedaneum
c. Epstein’s pearls
d. Harlequin sign

ANSWER: A Intercostal retractions are a sign of respiratory distress. Caput succedaneum is a normal finding in a
neonate. Epstein’s pearls are often seen in the mouths of neonates. Harlequin sign, although odd-appearing, is a normal
finding in a neonate

41. A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the newborn
infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to

a. Allow the newborn infant to signal a need

b. Anticipate all of the needs of the newborn infant
c. Avoid the newborn infant during the first 10 minutes of crying
d. Attend to the newborn infant immediately when crying

ANSWER A

Allow the newborn infant to signal a need. Trust vs Mistrust stage-This will allow the infant opportunity to gain trust.

42. A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. The
nurse most appropriately tells the mother to:

a. Punish the child every time the child says "no", to change the behavior
b. Allow the behavior because this is normal at this age period
c. Set limits on the child's behavior
d. Ignore the child when this behavior occurs

ANSWER C

Set limits on the child's behavior-According to Erikson, the child focuses on independence between ages 1 and 3 years.
Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or
"mine" and having temper tantrums are common during this period of development. Being consistent and setting limits
on the child's behavior are the necessary elements.

43. A nurse is evaluating the developmental level of a 2-year-old. Which of the following does the nurse expect to
observe in this child?

a. Uses a fork to eat

b. Uses a cup to drink
c. Uses a knife for cutting food
d. Pours own milk into a cup

ANSWER B. By age 2 years, the child can use a cup and can use a spoon correctly but with some spilling. By ages 3 to 4,
the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and
begin to use a knife for cutting.

44. A clinic nurse assesses the communication patterns of a 5-month-old infant. The nurse determines that the infant is
demonstrating the highest level of developmental achievement expected if the infant:

a. Uses simple words such as "mama"

b. Uses monosyllabic babbling
c. Links syllables together
d. Coos when comforted

ANSWER B. Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as "mama"
occurs between 9 and 12 months. Linking syllables together when communicating occurs between 6 and 9 months.
Cooing begins at birth and continues until 2 months.

45. A nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The
nurse plans care, knowing that which of the following is the most appropriate activity for this child?
 a. Large picture books
b. A radio
c. Crayons and coloring book
d. A sports video

ANSWER C. In the preschooler, play is simple and imaginative and includes activities such as crayons and coloring
books, puppets, felt and magnetic boards, and Play-Doh. Large picture books are most appropriate for the infant. A radio
and a sports video are most appropriate for the adolescent.

46. A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of the
following nursing interventions is most appropriate to facilitate normal growth and development?

a. Allow the family to bring in the child's favorite computer games

b. Encourage the parents to room-in with the child
c. Encourage the child to rest and read
d. Allow the child to participate in activities with other individuals in the same age group when the condition
permits

ANSWER D. Adolescents often are not sure whether they want their parents with them when they are hospitalized.
Because of the importance of the peer group, separation from friends is a source of anxiety. Ideally, the members of the
peer group will support their ill friend. Options a, b, and c isolate the child from the peer group

47. The nurse teaches parents how to help their children learn impulse control and cooperative behaviors. This would
occur during which of the stages of development defined by Erikson?

a. [Link] versus mistrust

b. [Link] versus guilt
c. [Link] versus inferiority
d. [Link] vs. Shame and doubt

ANSWER B Initiative vs Guilt. The stage of initiative versus guilt occurs from ages 3 to 6 years, during which children
develop direction and purpose. Teaching impulse control and cooperative behaviors during this stage help the child to
avoid risks of altered growth and development. In the autonomy versus sense of shame and doubt stage, toddlers learn
to achieve self-control and willpower. Trust versus mistrust is the first stage, during which children develop faith and
optimism. During the industry versus inferiority stage, children develop a sense of competency.

48. The abnormal finding in an evaluation of growth and development for a 6-month-old infant would be:

a. weight gain of 4 to 7 ounces per week.

b. length increase of 1 inch in 2 months.
c. head lag present.
d. can sit alone for a few seconds.

ANSWER: C The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the
child should undergo further evaluation. development is cephalocaudal lifting the head and shoulders is the one that the
infant learns to do first at 4 months. The infant can usually sit with support at about 5 months of age and can sit alone at
about 8 months.

49. A mother of a child tells the nurse, “I constantly see my five-year-old son fondling with his genitals.” She appears
tensed because according to him this may seem deviant for a preschooler. The nurse should tell the father that

a. “This behavior is abnormal. You should scold your child when you see him next time.”
b. “Just ignore the behavior of the child.”
c. “This act is to deviant. He probably will develop sexual disorders later on.”
d. “Tell the child to do it privately in his room. And make no issue out of it.”

ANSWER: D According to Freud’s Psychosexual Theory the child’s sexual energy at this stage is located at the genitals.
One of the common behavior of children at this stage is fondling of the genitals which is normal. The parent should
advise the child to do it privately instead.

50. A mother tells the nurse, “My 4-year-old daughter tells me that she hates me. What should I do?” As a nurse you are
going to tell her

a. “You may be mistreating your daughter. That’s why she hates you.”
b. “You should take your daughter out for a play sometimes for her to like you.”
c. “You should tell your daughter that you love her very much.”
d. “You should be patient about your daughter. She is undergoing a stage which is normal for her. Just be
supportive.”
ANSWER: D The daughter, according to Freud, is undergoing a phase during her age known as Elektra Complex, where
the girl will be more attached to the father than the mother. Oedipal Complex is the opposite for the male child.

51. How many hours after fertilization will the laboratory-grown zygotes be inserted into the woman’s uterus?

A. 12 hours
B. 24 hours
C. 48 hours
D. 40 hours
ANSWER: D By 40 hours after fertilization, the fertilized ovum will have undergone their first cell division. This is the
perfect time to insert the zygotes into the mother’s uterus.

52. Based from the information above, how many fertilized eggs will be inserted in the woman’s uterus?

A. 1 only
B. 1-2 fertilized ova
C. 3-4 fertilized ova
D. Up to 5 fertilized ova may be transferred
ANSWER B. For women who is under 35 years of age, only one or two fertilized ova are chosen and transferred back to
her uterine cavity through the cervix by means of a thin catheter. If the woman is more than 40 years of age up to five
embryos may be transferred.

53. Why is progesterone or luteinizing hormone prescribed to a woman after undergoing IVF?
A. Due to the blockage of the fallopian tubes
B. Hormonal imbalances brought about by the procedure
C. The corpus luteum can be injured by the aspiration of the follicle
D. Due to cysts growing on the mother’s ovaries
ANSWER: C One of the common occurrences in aspirating ova from the female’s ovaries is that the needle tends to
rupture the corpus luteum which is responsible for producing progesterone.
 NS 1 QUIZ 5 OB3 & PEDIA

Case Scenario: Nurse Anthony is caring for a 5-year-old boy named Alex, who has been admitted
to the pediatric unit for a routine check-up. Nurse Anthony is responsible for assessing Alex's
growth and development milestones during this visit.

1. Which of the following statements by Nurse Anthony indicates a correct understanding of

age-appropriate growth and development for a 5-year-old child?
A. "At this age, Alex should be able to ride a tricycle independently."
B. "Alex should already have all of his permanent teeth by now."
C. "It's normal for Alex to still have difficulty holding a crayon properly."
D. "At 5 years old, Alex may not be able to understand the concept of time yet."

Answer: a) "At this age, Alex should be able to ride a tricycle independently."

Rationale: At the age of 5, children usually develop the physical coordination and balance
required to ride a tricycle independently. They may still be working on refining their fine motor
skills, such as holding a crayon properly. Understanding the concept of time usually begins to
develop around 7 years of age.

2. Nurse Anthony observes that Alex engages in parallel play while interacting with other
children in the playroom. Which of the following statements best describes parallel play?
A. "Alex prefers to play with toys that do not require the involvement of other
children."
B. "Alex enjoys playing games that involve cooperation and teamwork with other
children."
C. "Alex is playing alongside other children but not actively engaging with them."
D. "Alex only plays with children of the same age group."

Answer: c) "Alex is playing alongside other children but not actively engaging with them."

Rationale: Parallel play is a normal developmental stage in which children play alongside each
other without direct interaction. They may be interested in the same activity or toy but do not
actively engage or cooperate with one another. This is common among toddlers and young
children as they begin to socialize and develop their social skills.

3. Nurse Anthony is conducting a physical examination of Alex to assess his growth. Which of
the following parameters is most appropriate for Nurse Anthony to use in plotting Alex's
growth on a growth chart?
A. Birth weight
B. Birth length
C. Current weight and height
D. Head circumference at 1 year old

Answer: c) Current weight and height

Rationale: To plot Alex's growth on a growth chart accurately, Nurse Anthony should use his
current weight and height. Growth charts are used to monitor a child's growth over time, and
plotting current measurements will help assess his growth trajectory and identify any potential
growth issues or deviations from the expected patterns.

4. Nurse Anthony is providing health education to Alex's parents about age-appropriate

nutrition. Which food item should Nurse Anthony recommend as the best source of iron
for a 5-year-old child?
A. Whole milk
1
 B. Apple juice
C. Peanut butter
D. Spinach

Answer: d) Spinach

Rationale: Spinach is an excellent source of iron, which is an essential nutrient for a child's growth
and development. Whole milk, although nutritious, does not contain as much iron as spinach.
Apple juice and peanut butter are not significant sources of iron.

5. Nurse Anthony is conducting a developmental assessment on Alex to evaluate his

language and communication skills. Which of the following behaviors would be a normal
finding for a 5-year-old child?
A. Alex speaks in full, grammatically correct sentences.
B. Alex is still using mostly single words to communicate.
C. Alex can count from 1 to 20 but struggles with the alphabet.
D. Alex is hesitant to speak in front of unfamiliar people.

Answer: c) Alex can count from 1 to 20 but struggles with the alphabet.

Rationale: At 5 years old, children should have developed basic language and communication
skills. They can typically speak in full sentences, engage in conversation, and have a vocabulary of
several thousand words. While counting from 1 to 20 is an age-appropriate skill, struggling with
the alphabet at this age is also within the normal range of development.

6. Nurse Anthony is assessing Alex's cognitive development. Which of the following

behaviors indicates that Alex is at the preoperational stage of cognitive development, as
described by Piaget?
A. Alex understands basic cause-and-effect relationships.
B. Alex can conserve quantity, such as understanding that two glasses of water are
the same, even if poured into different-shaped containers.
C. Alex engages in pretend play and can imagine himself as a superhero.
D. Alex can solve complex mathematical problems involving addition and subtraction.

Answer: c) Alex engages in pretend play and can imagine himself as a superhero.

Rationale: The preoperational stage, according to Piaget's theory, occurs between ages 2 and 7.
During this stage, children engage in symbolic play, pretend play, and can imagine themselves in
different roles, such as superheroes or animals. Understanding cause-and-effect relationships and
conservation of quantity are characteristic of the concrete operational stage, which typically
begins around age 7.

7. Nurse Anthony is discussing appropriate discipline strategies with Alex's parents. Which
approach to discipline is most effective for a 5-year-old child?
A. Time-out as a consequence for misbehavior.
B. Grounding from using electronic devices for a week.
C. Spanking as a deterrent for undesirable behavior.
D. Rewarding good behavior with extra playtime.

Answer: a) Time-out as a consequence for misbehavior.

Rationale: Time-out is considered an effective and age-appropriate discipline strategy for a 5-

year-old child. It provides a brief period of isolation during which the child can reflect on their
behavior without resorting to physical punishment or severe restrictions. Positive reinforcement,

2
such as rewarding good behavior, is also effective in promoting positive behaviors and self-
regulation in young children.

8. Nurse Anthony is assessing Alex's fine motor skills. Which activity would be most
appropriate to evaluate his fine motor development?
A. Throwing a ball
B. Riding a tricycle
C. Building a tower with blocks
D. Jumping on one foot

Answer: c) Building a tower with blocks

Rationale: Building a tower with blocks requires precise hand-eye coordination and fine motor
control, making it an appropriate activity to assess Alex's fine motor development. Throwing a
ball, riding a tricycle, and jumping on one foot involve gross motor skills rather than fine motor
skills.

9. Nurse Anthony is assessing Alex's gross motor skills. Which activity would be most
appropriate to evaluate his gross motor development?
A. Tying shoelaces
B. Putting together a jigsaw puzzle
C. Skipping with a skipping rope
D. Holding a pencil and writing his name

Answer: c) Skipping with a skipping rope

Rationale: Skipping with a skipping rope involves complex coordination of the arms and legs and is
a good indicator of a child's gross motor development. Tying shoelaces, putting together a jigsaw
puzzle, and holding a pencil and writing his name are more related to fine motor skills.

10. Nurse Anthony is educating Alex's parents about safety measures. Which safety
precaution should be emphasized the most for a 5-year-old child?
A. Properly installing a rear-facing car seat in the vehicle.
B. Teaching Alex how to swim and be water-safe.
C. Keeping small objects and toys out of Alex's reach to prevent choking.
D. Encouraging Alex to explore the neighborhood independently.

Answer: b) Teaching Alex how to swim and be water-safe.

Rationale: Drowning is a significant cause of injury and death in young children, so teaching a 5-
year-old child how to swim and be water-safe is a crucial safety precaution. While all the options
are important safety measures, water safety is particularly critical, especially if Alex spends time
near pools, lakes, or other bodies of water.

11. Nurse Anthony is discussing Erik Erikson's Psychosocial Theory of Development with Alex's
parents. According to Erikson, what is the primary developmental task for a 5-year-old
child?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority

Answer: c) Initiative vs. Guilt

3
Rationale: According to Erikson's Psychosocial Theory, the primary developmental task during the
preschool years (around 3 to 6 years old) is the stage of Initiative vs. Guilt. During this stage,
children develop a sense of purpose and engage in activities that they initiate themselves. Success
in this stage leads to a sense of accomplishment, while failure may lead to feelings of guilt.

12. Nurse Anthony observes that Alex frequently takes the initiative in various activities, such
as organizing games with other children in the playroom. What is the most appropriate
way for Nurse Anthony to support Alex's psychosocial development during this stage?
A. Discourage Alex from taking the lead in activities to avoid overwhelming him.
B. Praise Alex for his efforts and encourage his exploration and creativity.
C. Assign Alex tasks that are beyond his capabilities to foster a sense of challenge.
D. Advise Alex to seek constant approval from adults to boost his self-esteem.

Answer: b) Praise Alex for his efforts and encourage his exploration and creativity.

Rationale: During the Initiative vs. Guilt stage, children are eager to take on new challenges and
demonstrate initiative in their activities. It is essential for caregivers to support and encourage
their efforts. Praising Alex for his initiatives and encouraging his exploration and creativity will
promote a positive self-image and foster a sense of accomplishment.

13. Nurse Anthony is caring for a 6-year-old child who is consistently disruptive and aggressive
towards others. According to Erikson's theory, what might be the underlying psychosocial
issue this child is experiencing?
A. Trust issues due to early life experiences
B. Feelings of inadequacy and low self-esteem
C. Conflict between autonomy and self-doubt
D. A sense of identity crisis during adolescence

Answer: b) Feelings of inadequacy and low self-esteem

Rationale: The behaviors described are characteristic of the psychosocial crisis of Industry vs.
Inferiority, which occurs during middle childhood (around 6 to 12 years old). Children who
experience repeated feelings of failure and inadequacy during this stage may develop a sense of
inferiority. They may become disruptive or aggressive as a way to compensate for their perceived
lack of competence.

14. Nurse Anthony is caring for a toddler who becomes anxious and upset when separated
from their primary caregiver. According to Erikson's theory, which stage of psychosocial
development is the child likely experiencing?
A. Autonomy vs. Shame and Doubt
B. Trust vs. Mistrust
C. Initiative vs. Guilt
D. Identity vs. Role Confusion

Answer: b) Trust vs. Mistrust

Rationale: The behaviors described are characteristic of the psychosocial crisis of Trust vs.
Mistrust, which occurs during infancy (0 to 1 year old). During this stage, infants

15. Nurse Anthony is caring for a 2-year-old boy named Liam. According to Jean Piaget's
Cognitive Development theory, which stage of cognitive development is Liam most likely
experiencing?
A. Sensorimotor
B. Preoperational
C. Concrete operational
4
 D. Formal operational

Answer: a) Sensorimotor

Rationale: Piaget's first stage of cognitive development is the sensorimotor stage, which occurs
during infancy (birth to 2 years). During this stage, children like Liam explore the world through
their senses and motor actions. They develop object permanence and begin to understand cause-
and-effect relationships. Symbolic thinking is not yet present at this stage.

16. Nurse Anthony is caring for a newborn baby named Liam. According to the traditional
stages of development, which stage of life does Liam belong to?
A. Early childhood
B. Infancy
C. Adolescence
D. Late adulthood

Answer: b) Infancy

Rationale: Infancy is the stage of life that covers the period from birth to about 2 years of age.
During this stage, infants experience rapid growth and development, forming attachments with
caregivers and developing basic motor and sensory abilities.

17. Nurse Anthony is conducting a health promotion workshop for parents of preschool-age
children. According to Jean Piaget's theory of cognitive development, which stage of
cognitive development do preschool-age children fall into?
A. Sensorimotor stage
B. Preoperational stage
C. Concrete operational stage
D. Formal operational stage

Answer: b) Preoperational stage

Rationale: According to Piaget's theory, the preoperational stage occurs between ages 2 and 7.
During this stage, children develop language and symbolic thinking but have difficulty with logical
reasoning and understanding others' perspectives.

18. Nurse Anthony is assisting with the delivery of a newborn baby. After the baby is born,
what is the appropriate time frame for performing the APGAR scoring?
A. Immediately after birth
B. 5 minutes after birth
C. 10 minutes after birth
D. 15 minutes after birth

Answer: b) 5 minutes after birth

Rationale: The APGAR scoring is typically performed 1 minute and 5 minutes after birth. The first
score is obtained at 1 minute to assess the baby's initial response to birth, and the second score
at 5 minutes evaluates the baby's overall condition and adaptation to the extrauterine life. In
some cases, an additional score may be obtained at 10 minutes if the 5-minute score is low.

19. Nurse Anthony is assessing a newborn baby's heart rate for the APGAR scoring. The baby's
heart rate is above 100 beats per minute. What score should Nurse Anthony assign for this
parameter?
A. 0
B. 1
C. 2
5
 D. 3

Answer: c) 2

Rationale: In the APGAR scoring, a heart rate above 100 beats per minute is considered normal,
and the baby should be assigned a score of 2 for this parameter. A score of 0 is given for absent
heart rate, and a score of 1 is given for a heart rate below 100 beats per minute.

20. Nurse Anthony observes that a newborn baby has acrocyanosis (bluish discoloration of the
hands and feet) but the rest of the body appears pink. What score should Nurse Anthony
assign for the baby's color during the APGAR scoring?
A. 0
B. 1
C. 2
D. 3

Answer: b) 1

Rationale: In the APGAR scoring, a baby with acrocyanosis (bluish discoloration of the hands and
feet) but a pink body is assigned a score of 1 for color. A score of 0 is given for a completely blue
or pale body, and a score of 2 is given for a completely pink body.

21. Nurse Anthony observes that a newborn baby has weak muscle tone and is demonstrating
minimal movement of the arms and legs. What score should Nurse Anthony assign for this
parameter during the APGAR scoring?
A. 0
B. 1
C. 2
D. 3

Answer: b) 1

Rationale: In the APGAR scoring, a baby with weak muscle tone and minimal movement of the
arms and legs is assigned a score of 1 for muscle tone. A score of 0 is given for flaccid (limp)
muscle tone, and a score of 2 is given for active movement and flexion of the arms and legs.

22. Nurse Anthony observes that a newborn baby is crying vigorously and has a strong cry.
What score should Nurse Anthony assign for the baby's cry during the APGAR scoring?
A. 0
B. 1
C. 2
D. 3

Answer: c) 2

Rationale: In the APGAR scoring, a baby with a strong and vigorous cry is assigned a score of 2 for
cry. A score of 0 is given for no cry or a weak, feeble cry, and a score of 1 is given for a weak cry
with some grimacing.

23. Nurse Anthony is performing a physical examination on a newborn baby. He shines a

bright light into the baby's eyes and observes that the pupils constrict in response to the
light. Which reflex is Nurse Anthony assessing?
A. Moro reflex
B. Rooting reflex
C. Blink reflex
6
 D. Pupillary reflex

Answer: d) Pupillary reflex

Rationale: The pupillary reflex is tested by shining a light into the newborn's eyes. The normal
response is for the pupils to constrict (get smaller) in response to the bright light. This reflex helps
protect the newborn's eyes from excessive light exposure.

24. Nurse Anthony is assessing the presence of a red reflex in a newborn's eyes. He uses an
ophthalmoscope to look into the baby's eyes and observes a reddish-orange glow. What
does the presence of a red reflex indicate?
A. Normal eye development
B. Cataracts
C. Strabismus (crossed eyes)
D. Nystagmus (involuntary eye movement)

Answer: a) Normal eye development

Rationale: The red reflex is an important screening test used to assess the presence of
abnormalities in the eyes, particularly cataracts. A normal red reflex indicates that light is
reflecting off the retina properly, suggesting normal eye development. An absent or abnormal red
reflex could be indicative of conditions like cataracts or other eye abnormalities.

25. Nurse Anthony is observing a newborn baby's eyes as he moves a finger toward the baby's
cheek. The baby turns his head and opens his mouth, rooting in the direction of the
stimulus. Which reflex is Nurse Anthony assessing?
A. Moro reflex
B. Rooting reflex
C. Blink reflex
D. Sucking reflex

Answer: b) Rooting reflex

Rationale: The rooting reflex is tested by lightly touching or stroking the baby's cheek or corner of
the mouth. In response, the baby turns his head and opens his mouth, as if searching for
something to suck. This reflex helps the newborn locate the mother's breast or a feeding source.

26. Nurse Anthony is examining a newborn baby's eyes and observes that the baby's eyes
cross or turn inward occasionally. What term is used to describe this condition, and when
is it considered normal in newborns?
A. Amblyopia, persists up to 6 months old
B. Nystagmus, persists up to 1 year old
C. Strabismus, persists up to 3 months old
D. Retinopathy of prematurity, persists up to 2 years old

Answer: c) Strabismus, persists up to 3 months old

Rationale: Strabismus, also known as crossed eyes, is a condition where the eyes do not align
properly. In newborns, slight misalignment or crossing of the eyes is relatively common and
considered normal up to around 3 months of age. However, if the condition persists beyond this
age or is significantly pronounced, it should be further evaluated by a healthcare professional.

27. Nurse Anthony is providing education to new parents about the primary factors that
influence a child's growth and development. Which of the following factors is considered a
genetic factor affecting growth?
7
 A. Nutrition
B. Environmental stimuli
C. Socioeconomic status
D. Family history

Answer: d) Family history

Rationale: Family history and genetics play a significant role in a child's growth and development.
Genes inherited from parents influence various aspects of growth, such as height, weight, and
certain physical characteristics. However, it's essential to note that genetic factors interact with
environmental factors in shaping a child's growth and development.

28. Nurse Anthony is discussing the impact of nutrition on a child's growth and development
with parents. Which of the following nutrients is most crucial for supporting brain
development during infancy and early childhood?
A. Vitamin C
B. Iron
C. Vitamin D
D. Calcium

Answer: b) Iron

Rationale: Iron is a crucial nutrient for supporting brain development and cognitive function
during infancy and early childhood. Iron is necessary for the production of neurotransmitters and
myelin, which are essential for proper brain function and communication. Iron deficiency during
this critical period can lead to cognitive impairments and developmental delays.

29. Nurse Anthony is counseling parents on promoting optimal growth and development in
their child. Which of the following environmental factors is considered important for
fostering positive social development?
A. Exposure to lead-based paints
B. Low-quality childcare
C. Frequent exposure to violent media
D. Secure and nurturing family environment

Answer: d) Secure and nurturing family environment

Rationale: A secure and nurturing family environment is essential for fostering positive social
development in children. The family provides the primary socialization and emotional support for
a child, laying the foundation for healthy relationships and social interactions later in life.
Exposure to lead-based paints, low-quality childcare, and violent media can have negative effects
on a child's development.

30. Nurse Anthony is discussing the importance of early childhood education with parents.
Which of the following aspects of development is significantly influenced by high-quality
early childhood education programs?
A. Physical growth
B. Cognitive development
C. Genetic factors
D. Socioeconomic status

Answer: b) Cognitive development

8
Rationale: High-quality early childhood education programs can have a significant positive impact
on a child's cognitive development. These programs provide stimulating and age-appropriate
activities that promote language development, problem-solving skills, and social interactions, all
of which contribute to enhanced cognitive abilities in children.

31. The nurse is aware that the age at which the posterior fontanelle closes is _____ months.

A. 2 to 3
B. 3 to 6
C. 6 to 9
D. 9 to 12

Rationale: A) The posterior fontanelle closes between 2 and 3 months of age.

32. A nurse is evaluating the developmental level of a 2-year-old. Which of the following does the
nurse expect to observe in this child?
A. Uses a fork to eat
B. Uses a cup to drink
C. Uses a knife for cutting food
D. Pours own milk into a cup

Rationale: B.) By age 2 years, the child can use a cup and can use a spoon correctly but with
some spilling. By ages 3 to 4, the child begins to use a fork. By the end of the preschool period,
the child should be able to pour milk into a cup and begin to use a knife for cutting.
33. A nurse, who is performing the preliminary physical examination of a female patient, notes the
physical changes shown in the figures above. The nurse should interview the child about which of
the following information at this time? The young woman’s:
A. Readiness for menstruation to begin.
B. Sexual activity
C. Menstrual cycle
D. Feelings about her bodily changes.

Rationale: D. It would be appropriate for the nurse to interview the child about her feelings
about her bodily changes.
34. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath
and is unable to sleep unless she places three pillows under her head. After listening to the client's
concerns, the nurse should take which action?
A. Make an appointment because the dent needs to be evaluated.
B. Explain that these are expected problems for the latter stages of pregnancy.
C. Arrange for the dent to be admitted to the birth center and prepare for birth.
D. Tell the client to go to the hospital; she may be experiencing signs of heart failure.
RATIONALE: The nurse must distinguish between normal physiologic complaints of the latter stages of
pregnancy and those that need referral to the health care provider. In this case, the client indicates
normal physiologic changes caused by the growing uterus and pressure on the diaphragm. These signs
don't indicate heart failure. The client doesn't need to be seen or admitted to the birth center.
Reference: Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 230.

35. During the first trimester, a nurse evaluates a pregnant client for factors that suggest she might abuse a
child. Which parental characteristic is of most concern to the nurse?
A. The client didn’t graduate high school.
B. The client states she is stupid and ugly.
C. The client is carrying twins.
D. None of the above
The client eats fast food every day.
RATIONALE: Typically, the abusive parent has low self-esteem, which may be evident by self-deprecating
statements, and many unmet needs. Lack of nurturing experience and inadequate knowledge of
childhood growth and development may also contribute to the potential for child abuse. A low
educational level, multiple gestations, and poor diet aren't direct risk factors for committing child abuse.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
9
 Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1743.

36. A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for
the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client?
A. Deficient knowledge of pregnancy
B. Deficient fluid volume
C. Anticipatory grieving
D. Acute pain
RATIONALE: If bleeding and clots are excessive, this client may become hypovolemic , leading to a
nursing diagnosis of Deficient fluid volume. Although Deficient knowledge (pregnancy), Anticipatory
grieving, and Acute pain are applicable to this client, they aren't the primary diagnosis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 400.

37. A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether
the client is at risk for a TORCH infection , the nurse should ask:
A. “Have you ever had osteomyelitis?”
B. “Do you have any cats at home?
C. “Do you have any birds at home?’
D. “Have you recently had a rubeola vaccination?”
RATIONALE: Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus and agents
that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to
humans through contact with the feces of infected cats (which may occur when emptying a litter box),
through ingesting raw meat, or through contact with raw meat followed by improper hand washing.
Osteomyelitis , a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola
aren't TORCH infections
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.

38. A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help
confirm that she's in true labor, the nurse should assess for:
A. irregular contractions.
B. increased fetal movement.
C. changes in cervical effacement and dilation atter 1 to 2 hours.
D. contractions that feel like pressure in the abdomen and qroin.
E. Both C & D

RATIONALE: True labor is characterized by progressive cervical effacement and dilation after 1 to 2
hours, regular contractions, discomfort that moves from the back to the front of the abdomen and,
possibly, bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and
groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical
effacement or dilation even after 1 or 2 hours.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 227.

39. A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain
from her episiotomy . What should the nurse instruct the woman to do?
A. Apply an ice pack to her perineum.
B. Take a sitz bath.
C. Perform perineal care after voiding or a bowel movement.
D. Drink plenty of fluids.
RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after chidbirth may reduce
edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may
reduce discomfort by promoting circulation and healing. Although perineal care should be performed
after each voiding and bowel movement, its purpose is to prevent infection — not reduce
discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it
doesn't relieve perineal discomfort.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 637.
40. A client who's 24 weeks pregnant has sickle cell anemia . When preparing the care plan, the nurse should
identify which factor as a potential trigger for a sickle cell crisis during pregnancy?
A. Sedative use
B. Dehydration
C. Hypertension

10
 D. Tachycardia
RATIONALE: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration ,
infection , stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and
tachycardia aren't known to precipitate a sickle cell crisis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 363.
41. A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-
making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called?
A. Taking-in phase
B. Taking-hold phase
C. Letting-go phase
D. Taking-over phase
RATIONALE: The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by
the responsibilities of caring for the neonate while still fatigued from childbirth. Taking hold is the next
phase, when the mother has rested and she can think and learn mothering skills with confidence. During
the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the
neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate.
Depression may occur during this stage.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 624.

42. Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision?
A. Assessing vital signs
B. Providing for dietary needs
C. Managing pain
D. Providing emotional support
RATIONALE: Providing for the client's dietary needs isn't appropriate because the client shouldn't eat or
drink anything pending surgery. Assessing vital signs for indicators of potential shock , managing pain,
and providing emotional support are essential nursing interventions in caring for a client with an ectopic
pregnancy.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 409.

43. A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the
client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit?
A. Edema
B. Pelvic adequacy
C. Rh factor changes
D. Hemoglobin alterations
RATIONALE: At each prenatal visit, the nurse should assess the client for edema because edema,
increased blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic
measurements and Rh typing are determined at the first visit only because they don't change. The nurse
should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36
weeks' gestation.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 257.

44. A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this
client, the nurse's highest priority is to evaluate:
A. cervical effacement and dation.
B. maternal vital signs and fetal heart rate (FHR).
C. frequency and duration of contractions.
D. white blood cell (WBC) count.
RATIONALE: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR
takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection
caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis
caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this
client because it requires a pelvic examination, which may introduce pathogens into the birth canal.
Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC
count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and
FHR can and therefore provides less current information
REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 531.

45. A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of

11
 monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds.
What should the nurse do next ?
A. Continue to monitor the baby for fetal distress.
B. Notify the physician and transfer the mother to labor and delivery for imminent delivery.
C. Inform the physician and prepare for discharge: this client has a reassuring strip.
D. Ask the mother to eat something and return for a repeat test; the results are inconclusive.
RATIONALE: Fetal well-being is determined during a nonstress test by two accelerations occurring
within20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully
demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal
distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids
hasn't been shown to influence the outcome of a nonstress test. REFERENCE: Pillitteri, A. Maternal &
Child
Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams
& Wilkins, 2007, p. 203.

46. A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for
complications?
A. Gravida 2 para 2002, cesarean bith, incision site intact, hemoglobin level 9.8 g/dl
B. Gravida 2 para 1011, cesarean birth, incision site intact, pulse 84 beats/minute
C. Gravida 1 para 1001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7C)
D. Gravida 1 para 1001, vaginal delivery, membranes ruptured 10 hours before birth
RATIONALE: Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may
experience more complications such as poor wound healing and inability to tolerate activity. An intact
incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8F after a
vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly
elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth
are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 362.

47. Which measure included in the care plan for a client in the fourth stage of labor requires revision?
A. Check vital signs and fundal checks every 15 minutes.
B. Have the client spend time with the neonate to initiate breast-feeding.
C. Obtain an order for catheterization to protect the bladder from trauma.
D. Perform perineal assessments for swelling and bleeding.
RATIONALE: Catheterization isn't routinely done to protect the bladder from trauma. It's done, however,
for a postpartum complication of urinary retention. The other options are appropriate measures to
include in the care plan during the fourth stage of labor. CLIENT NEEDS CATEGORY: Physiological integrity
Basic care and comfort
REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 370.

48. A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health
history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe
level of alcohol intake for this client?
A. “The clent consumes no more than 2 oz of alcohol dady.”
B. “The client consumes no more than 4 oz of alcohol dady.”
C. “The client consumes 2 to 6 oz of alcohol daily, dependlng on body weight."
D. “The client consumes no alcohol.”
RATIONALE: A safe level of alcohol intake during pregnancy hasn't been established. Therefore,
authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has
serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected
neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth retardation, short
palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may
predispose her to complications in early pregnancy. REFERENCE: Pillitteri, A. Maternal & Child Health
Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 291.

49. A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pillsin
a row, the nurse should instruct the client to:
A. take all the missed doses as soon as she discovers the oversight.
B. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle.
C. take three pills for the next 3 days and use an alternative contraceptive method until the next cycle.
D. discard the pack, use an atternative contraceptive method untii her period begins, and start a new
pack on the regular schedule.

12
 RATIONALE: A client who misses three or more pills in a row should discard the pack, use an alternative
contraceptive method until her period begins, and start a new pack on the regular schedule. Taking all the
missed doses, taking two pills for the next 2 days, or taking three pills for the next 3 days doesn't ensure
effectiveness and can increase the risk of adverse reactions. REFERENCE: Pillitteri, A. Maternal & Child
Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams
& Wilkins, 2007, p. 112.

50. A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in
fetal heart rate. What should the nurse do first ?
A. Change the client's position.
B. Prepare for emergency cesarean birth.
C. Check for placenta previa.
D. Administer oxygen.
RATIONALE: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the
umbilical cord. Changing the client's position may immediately correct the problem. An emergency
cesarean birth is necessary only if other measures, such as changing position and amnioinfusion with
sterile saline, prove unsuccessful. Placenta previa doesn't cause variable decelerations. Administering
oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 526.

13
51. Immediately after an amniotomy has been performed, the nurse should first assess:
a) For bladder distention
b) For cervical dilation
c) The maternal blood pressure
d) The fetal heart rate (FHR) pattern
RATIONALE: The FHR is assessed immediately after amniotomy to detect any changes that may indicate
cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things
to check after an amniotomy. Once the membranes are ruptured, minimal vaginal examinations will be
done because of the risk of infection.
REFERENCES: Lowdermilk, D., & Perry, S. (2004).

Maternity and women’s health care

(8th ed., p. 1009). St. Louis: Mosby.

52. A nurse in the labor room is caring for a client in the active stage of labor. The nurse is assessing the fetal
patterns and notes a late deceleration on the monitor strip. The appropriate nursing action is to:
a) Administer oxygen via face mask.
b) Place the mother in a supine position.
c) Increase the rate of the oxytocin (Pitocin) IV infusion.
d) Document the findings and continue to monitor the fetal patterns.
RATIONALE: Late decelerations are the result of uteroplacental insufficiency as the result of decreased
blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore,
oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus.
The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena
cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin
would cause further hypoxemia because of increased uteroplacental insufficiency resulting from
stimulation of contractions by this medication. Option 4 would delay necessary treatment.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nursing (7th ed., p. 386). St. Louis: Mosby.

53. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which
assessment finding would indicate a need to contact the physician?
a) Hemoglobin of 11.0 g/dL
b) Fetal heart rate of 180 beats/min
c) Maternal pulse rate of 85 beats/min
d) White blood cell count of 12,000/mm3
RATIONALE: A normal fetal heart rate is 120 to 160 beats/min. A count of 180 beats/min could indicate
fetal distress and would warrant physician notification. White blood cell counts in a normal pregnancy
begin to rise in the second trimester and peak in the third trimester, with a normal range of 11,000 to
15,000/mm3
, up to 18,000/mm3. During the immediate postpartum period, the count may be as high as 25,000 to
30,000/mm3 as a result of increased leukocytosis during delivery. By full term, a normal maternal
hemoglobin range is 11 to 13 g/dL as a result of the hemodilution caused by an increase in plasma volume
during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/min over
prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.
REFERENCES: Lowdermilk, D., & Perry, S. (2004). Maternity and women’s health care (8th ed., pp. 356,
358, 518). St. Louis: Mosby.

54. A nurse has provided discharge instructions to a client who delivered a healthy newborn infant by
cesarean delivery. Which statement, if made by the client, indicates a need for further instructions?
a) “I will begin abdominal exercises immediately.”
b) “I will notify the physician if I develop a fever.”
c) “I will turn on my side and push up with my arms to get out of bed.”
d) “I will lift nothing heavier than the newborn infant for at least 2 weeks.”
RATIONALE: Abdominal exercises should not start immediately following abdominal surgery, and the
client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3,
and 4 are appropriate instructions for the client following a cesarean delivery.
REFERENCES: Lowdermilk, D., & Perry, S. (2006). Maternity nursing (7th ed., p. 804). St. Louis: Mosby.

14
55. A nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to
stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion
needs to be discontinued?
a) Increased urinary output
b) A fetal heart rate of 90 beats/min
c) Three contractions occurring within a 10-minute period
d) Adequate resting tone of the uterus palpated between contractions
RATIONALE: A normal fetal heart rate is 120 to 160 beats/min. Bradycardia or late or variable
decelerations indicate fetal distress and the need to discontinue the oxytocin. The goal of labor
augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-
minute period. The uterus should return to resting tone between contractions, and there should be no
evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.
REFERENCES: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005).
Maternal-child nursing
(2nd ed., p. 448). St. Louis: W.B. Saunders.

56. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the
following is noted on the external monitor tracing during a contraction?
a) Late decelerations
b) Early decelerations
c) Short-term variability
d) Variable decelerations
RATIONALE: Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood
flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head
during a contraction. Late decelerations are an ominous pattern in labor because they suggest
uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in
the fetal heart rate.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).

Maternity nursing
(7th ed., p. 378). St. Louis: Mosby.

57. A labor and delivery room nurse has just received report on four clients. The nurse should assess which
client first?
a) A primiparous client in the active stage of labor
b) A multiparous client who was admitted for induction of labor
c) A client who is not contracting, but has suspected premature rupture of the membranes
d) A client who has just received an IV loading dose of magnesium sulfate to stop preterm
labor RATIONALE: Magnesium sulfate is a central nervous system (CNS) depressant and the
client could experience adverse effects that includes depressed respiratory rate (below 12
breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). This client should
be seen before the clients inoptions 1, 2, and 3 because these clients conditions represent
stable ones.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).

Maternity nurs
ing (7th ed., p. 778). St. Louis: Mosby.

58. A nurse is reviewing the physician’s orders for a client admitted for premature rupture of the membranes.
Gestational age of the fetus is determined to be 37 weeks. Which physician’s order should the nurse
question?
a) Perform a vaginal examination every shift.
b) Monitor maternal vital signs every 4 hours.
c) Monitor fetal heart rate (FHR) continuously.
d) Administer ampicillin 1 gm as an intravenous piggyback (IVPB) every 6 hours.
RATIONALE: Vaginal examinations should not be done routinely on a client with premature rupture of the
membranes because of the risk of infection. The nurse would expect to administer an antibiotic, monitor
maternal vital signs, and monitor the FHR.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).

Maternity nurs
ing (7th ed., p. 782). St. Louis: Mosby.

59. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what
other intervention should be done?
a) Slow the intravenous (IV) flow rate.
15
b) Place the client in a high-Fowler’s position.

16
 c) Continue the oxytocin (Pitocin) drip if infusing.
d) Administer oxygen at 8 to 10 L/min via face mask.
RATIONALE: Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood.
Option 1 is incorrect because the IV infusion should be increased to increase the maternal blood volume. Option 2 is
incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and
improve fetal perfusion. Option 3 is incorrect becausethe oxytocin stimulation of the uterus is discontinued if fetal
heart rate patterns change for any reason. REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nursing
(7th ed., p. 386). St. Louis: Mosby.

60. A nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of
the umbilical cord protruding from the vagina. Which of the following is the initial nursing action?
a) Gently push the cord into the vagina.
b) Place the client in Trendelenburg’s position.
c) Find the closest telephone and page the physician stat.
d) Call the delivery room to notify the staff that the client will be transported immediately.
RATIONALE: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal
oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward
the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician
and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because
to do so could traumatize it and further reduce blood flow. The examiner, however, may place a gloved hand into the
vagina and hold the presenting part off the umbilical cord. Oxygen at 8 to 10 L/min by face mask is administered to the
client to increase fetal oxygenation.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).Maternity nursing (7th ed., p. 811). St. Louis: Mosby.
 NS 1 QUIZ 6 PEDIA
1. The finding the nurse would expect when measuring blood pressure on all four extremities of a child with
coarctation of the aorta is blood pressure that is:
a. higher on the right side.
b. higher on the left side.
c. lower in the arms than in the legs.
d. lower in the legs than in the arms.

Rationale: d. The characteristic symptoms of coarctation of the aorta are a marked difference in blood
pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect
and decreased distal to the coarctation.

2. A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums.
The nurse most appropriately tells the mother to:
a. Punish the child every time the child says "no", to change the behavior
b. Allow the behavior because this is normal at this age period
c. Set limits on the child's behavior
d. Ignore the child when this behavior occurs

Rationale: C) Set limits on the child's behavior-According to Erikson, the child focuses on independence
between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the
parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this
period of development. Being consistent and setting limits on the child's behavior are the necessary
elements.

3. The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases
the response on the understanding that clubbing is due to which of the following?
a. Anemia.
b. Peripheral hypoxia.
c. Delayed physical growth.
d. Destruction of bone marrow.

Rationale: B.) Clubbing of the fingers is one common finding in the child with persistent hypoxia leading to
tissue changes in the body because of the low oxygen content of the blood (hypoxemia). It apparently
results from tissue fibrosis and hypertrophy from the hypoxemia and from an increase in capillaries in the
area, which occur as the body attempts to improve blood supply. Clubbing of the fingers is associated with
polycythemia, not anemia. Polycythemia results from the body's attempt to increase oxygen levels in the
tissues. The child may be small for his or her chronological age, but clubbing does not result from slow
physical growth. Destruction of the bone marrow is not related to this congenital heart malformation.
Instead, bone marrow is actively producing erythrocytes to compensate for the chronic hypoxia.

4. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would
explain that squatting:
a. increases the return of venous blood back to the heart.
b. decreases arterial blood flow away from the heart.
c. is a common resting position when a child is tachycardic.
d. increases the workload of the heart.
 Rationale: A. The squatting position allows the child to breathe more easily because systemic venous return
is increased.

5. The nurse is aware that the age at which the posterior fontanelle closes is _____ months.
a. 2 to 3
b. 3 to 6
c. 6 to 9
d. 9 to 12

Rationale: A) The posterior fontanelle closes between 2 and 3 months of age.

6. A chest x-ray examination is ordered for a child with suspected cardiac problems. The child's parent asks the
nurse, "What will the x-ray show about the heart?" The nurse's response should be based on knowledge that the
x-ray film will do which of the following?
a. Show bones of chest but not the heart
b. Evaluate the vascular anatomy outside of the heart
c. Show a graphic measure of electrical activity of the heart
d. Provide information on heart size and pulmonary blood flow patterns

Rationale: D.) Chest x-ray films provide information on the size of the heart and pulmonary blood flow
patterns. The bones of the chest are visible on the chest x-ray film, but the heart and blood vessels are also
seen. Magnetic resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy
outside of the heart. A graphic measure of electrical activity of the heart is provided by electrocardiography.

7. Asthma is now classified into four categories: mild intermittent, mild persistent, moderate persistent, and
severe persistent. Clinical features used to determine these categories include all of the following except
a. Lung function.
b. Associated allergies.
c. Frequency of symptoms.
d. Frequency and severity of exacerbations.

Rationale: b. Associated allergies are not part of the classification system used in the Guidelines for the
Diagnosis and Management of Asthma. The clinical features that are assessed in the classification system are
frequency of daytime and nighttime symptoms, frequency and severity of exacerbations, and lung function.
8. Which of the following is a clinical manifestation of increased intracranial pressure (ICP) in infants?
a. Irritability
b. Photophobia
c. Vomiting and diarrhea
d. Pulsating anterior fontanel

Rationale: a. Irritability is one of the changes that may indicate increased ICP. Photophobia is not indicative
of increased ICP in infants. A pulsing anterior fontanel is normal. Vomiting is one of the signs of increased
ICP in children, but when present with diarrhea, it is indicative of a gastrointestinal disturbance.

9. The nurse is admitting a young child to the hospital because bacterial meningitis is suspected. Which of the
following is a priority of nursing care?
a. Initiate isolation precautions as soon as diagnosis is confirmed.
b. Provide environmental stimulation to keep the child awake.
c. Administer antibiotic therapy as soon as it is available.
 d. Administer sedatives and analgesics on a preventive schedule to manage pain.

Rationale: c. Administering antibiotic therapy is the priority action. Antibiotics are begun as soon as possible
to avoid resultant disabilities and to prevent death. Isolation should be instituted as soon as diagnosis is
anticipated. It is important to decrease the external stimuli. The nurse should keep the room as quiet as
possible. Antibiotics are the priority function; pain should be managed if it occurs.

10. An appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant would be:
a. counting the apical rate for 30 seconds before administering the medication.
b. withholding a dose if the apical heart rate is less than 100 beats/min.
c. repeating a dose if the child vomits within 30 minutes of the previous dose.
d. checking respiratory rate and blood pressure before each dose.

Rationale: B. As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and
the physician is notified.

11. A nurse is evaluating the developmental level of a 2-year-old. Which of the following does the nurse expect to
observe in this child?
a. Uses a fork to eat
b. Uses a cup to drink
c. Uses a knife for cutting food
d. Pours own milk into a cup

Rationale: B.) By age 2 years, the child can use a cup and can use a spoon correctly but with some spilling. By
ages 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to
pour milk into a cup and begin to use a knife for cutting.

12. A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis
are the:
a. coronary arteries.
b. heart muscle and the mitral valve.
c. aortic and pulmonic valves.
d. contractility of the ventricles.

Rationale: B. The tissues that cover the heart and heart valves are affected. The heart muscle may be
involved and the mitral valve is frequently involved.

13. A clinic nurse assesses the communication patterns of a 5-month-old infant. The nurse determines that the
infant is demonstrating the highest level of developmental achievement expected if the infant:
a. Uses simple words such as "mama"
b. Uses monosyllabic babbling
c. Links syllables together
d. Coos when comforted

Rationale: B.) Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such
as "mama" occurs between 9 and 12 months. Linking syllables together when communicating occurs
between 6 and 9 months. Cooing begins at birth and continues until 2 months.
14. What is an appropriate nursing intervention when caring for an infant with an upper respiratory tract infection
and elevated temperature?
a. Give tepid water baths to reduce fever.
b. Encourage fluid intake to maintain caloric needs.
c. Have the child wear heavy clothing to prevent chilling.
d. Give small amounts of favorite fluids frequently to prevent dehydration.

Rationale: d. Preventing dehydration by small, frequent feedings is an important intervention in a febrile

child. Tepid water baths may induce shivering, which raises temperature. Food should not be forced; it may
result in the child vomiting. A febrile child should be dressed in light, loose clothing.

15. The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital
heart defect is:
a. "He is always hungry."
b. "He tires out during feedings."
c. "He is fussy for several hours every day."
d. "He sleeps all the time."

Rationale: B.) Fatigue during feeding or activity is common to most infants with congenital cardiac
problems.

16. John is a 6-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be which of the
following?
a. Directed at his parents because he is too young to understand
b. Adapted to his level of development so that he can understand
c. Done several days before the procedure so he will be prepared
d. Provide details about the actual procedures so he will know what to expect

Rationale: B.) Preoperative teaching should always be directed to the child's stage of development. The
caregivers also benefit from these explanations. The parents may ask additional questions, which should be
answered, but the child needs to receive the information based on developmental level. This age-group will
not understand in-depth descriptions. School-age children should be prepared close to the time of the
cardiac catheterization.

17. Which statement accurately expresses the genetic implications of cystic fibrosis (CF)?
a. It is inherited as an autosomal dominant trait.
b. It is a genetic defect found primarily in nonwhite population groups.
c. If it is present in a child, both parents are carriers of the defective gene.
d. There is a 50% chance that siblings of an affected child will also be affected.

Rationale: c. CF is an autosomal recessive gene inherited from both parents. CF is inherited as an autosomal
recessive, not autosomal dominant, trait. CF is found primarily in white populations. An autosomal recessive
inheritance patterns means that there is an 25% chance a sibling will be infected but a 50% chance a sibling
will be a carrier.

18. The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, "How does
Kawasaki disease affect my child's heart and blood vessels?" The nurse's response is based on the understanding
that:
a. inflammation weakens blood vessels, leading to aneurysm.
 b. increased lipid levels lead to the development of atherosclerosis.
c. untreated disease causes mitral valve stenosis.
d. altered blood flow increases cardiac workload with resulting heart failure.

Rationale: A. Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.

19. A nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur.
The nurse plans care, knowing that which of the following is the most appropriate activity for this child?
a. Large picture books
b. A radio
c. Crayons and coloring book
d. A sports video

Rationale: C.) In the preschooler, play is simple and imaginative and includes activities such as crayons and
coloring books, puppets, felt and magnetic boards, and Play-Doh. Large picture books are most appropriate
for the infant. A radio and a sports video are most appropriate for the adolescent.

20. The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic.
The nurse can determine the father understood the instructions when he states "If the baby turns blue, I will:
a. hold him against my shoulder with his knees bent up toward his chest."
b. lay him down on a firm surface with his head lower than the rest of his body."
c. immediately put the baby upright in an infant seat."
d. put the baby in supine position with his head elevated."

Rationale: A. In the event of a paroxysmal hypercyanotic or "tet" spell, the infant should be placed in a knee-
chest position.

21. A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of
the following nursing interventions is most appropriate to facilitate normal growth and development?
a. Allow the family to bring in the child's favorite computer games
b. Encourage the parents to room-in with the child
c. Encourage the child to rest and read
d. Allow the child to participate in activities with other individuals in the same age group when the condition
permits

Rationale: D.) Adolescents often are not sure whether they want their parents with them when they are
hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety.
Ideally, the members of the peer group will support their ill friend. Options a, b, and c isolate the child from
the peer group.

22. A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On
assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the disease?
a. cracked lips
b. a normal appearance
c. conjunctival hyperemia
d. desquamation of the skin

Rationale: C.) In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands,
rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures,
 desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and
thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may
be present.

23. A 10-year-old has undergone a cardiac catheterization. At the end of the procedure, the nurse should first
assess:
a. Pain.
b. Pulses.
c. Hemoglobin and hematocrit levels.
d. Catheterization report.

Rationale: b. Checking for pulses, especially in the canulated extremity, would assure perfusion to that
extremity and is the priority post procedure.

24. A 16-year-old being treated for hypertension has laboratory values of hemoglobin B 16 g/dL, hematocrit level
43%, sodium 139 mEq/L, potassium 4.4 mEq/L, and total cholesterol of 220 mg/dL. Which drug does the nurse
suspect the patient takes based on the total cholesterol?
a. Beta blockers.
b. Calcium channel blockers.
c. ACE inhibitors.
d. Diuretics.

Rationale: a. Beta blockers are used with caution in patients with hyperlipidemia, hyperglycemia, and
impotence.

25. A child diagnosed with congestive heart failure (CHF) is receiving maintenance doses of digoxin and furosemide.
She is rubbing her eyes when she is looking at the lights in the room, and her HR is 70 beats per minute. The
nurse expects which laboratory finding?
a. Hypokalemia.
b. Hypomagnesemia.
c. Hypocalcemia.
d. Hypophosphatemia.

Rationale: a. The rubbing of the child's eyes may mean that she is seeing halos around the lights, indicating
digoxin toxicity. The HR is slow for her age and also indicates digoxin toxicity. A decrease in serum potassium
because of the furosemide can increase the risk for digoxin toxicity

26. A child has a Glasgow Coma Scale of 3, HR of 88 beats per minute and regular, respiratory rate of 22, BP of
78/52, and blood sugar of 35 mg/dL. The nurse asks the caregiver about accidental ingestion of which drug?
a. Calcium channel blocker.
b. Beta blocker.
c. ACE inhibiter.
d. ARB.

Rationale: b. The beta blocker not only affects the heart and lungs but also blocks the beta sites in the liver,
reducing the amount of glycogen available for use, causing hypoglycemia. The lower HR and BP also suggest
ingestion of a cardiac medication.
27. A child has been diagnosed with valvular disease following rheumatic fever (RF). During patient teaching, the
nurse discusses the child's long-term prophylactic therapy with antibiotics for dental procedures, surgery, and
childbirth. The parents indicate they understand when they say:
a. "She will need to take the antibiotics until she is 18 years old."
b. "She will need to take the antibiotics for 5 years after the last attack."
c. "She will need to take the antibiotics for 10 years after the last attack."
d. "She will need to take the antibiotics for the rest of her life."

Rationale: d. Valvular involvement indicates significant damage, so antibiotics would be taken for the rest of
her life.

28. A 3-month-old has been diagnosed with a ventricular septal defect (VSD). The flow of blood through the heart is
_____________________.
a. Left to right
b. Right to left
c. Up to down
d. Down to up

Rationale: A. The pressures in the left side of the heart are greater, causing the flow of blood to be from an
area of higher pressure to lower pressure, or left to right, increasing the pulmonary blood flow with the
extra blood

29. An infant with CHF is receiving digoxin to enhance myocardial function. What should the nurse assess prior to
administering the medication?
a. Yellow sclera.
b. Apical pulse rate.
c. Cough.
d. Liver function test.

Rationale: b. The apical pulse rate is ordered because digoxin decreases the HR, and if the HR is <60 digoxin
should not be administered.

30. One of the goals for children with asthma is to prevent respiratory tract infection. This is because respiratory
tract infection does which of the following?
a. Increases sensitivity to allergens.
b. Causes exercise-induced asthma.
c. Lessens effectiveness of medications.
d. Can trigger an episode or aggravate asthmatic state.

Rationale: d. Viral respiratory tract infections can exacerbate asthma, especially in young children, whose
airways are mechanically smaller and more reactive than those of older children. Respiratory tract infections
do not affect sensitivity to allergens. Exercise precipitates exercise-induced asthma. The respiratory tract
infection does not lessen the effectiveness of the medications.

31. The mother of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. The
best nursing response is which of the following?
a. When the toddler weighs 20 lbs
b. The seat should not be placed in a face-forward position unless there are safety locks in the car
 c. The seat should never be place in a face-forward position because the risk of the child unbuckling the
harness
d. When the weight of the toddler is greater than 40 lbs

Rationale: A.) The transition point for switching to the forward facing position is defined by the
manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg or 20 lb and 1 year
of age. Convertible car safety seats are used until the child weighs at least 40 lb. Options b, c, and d are
incorrect

32. A mother calls the pediatrician's office because her infant is "colicky." The helpful measure the nurse would
suggest to the parent is to:
a. sing songs to the infant in a soft voice.
b. place the infant in a well-lit room.
c. walk around and massage the infant's back.
d. rock the fussy infant slowly and gently.

Rationale: D.) One technique the nurse can offer parents of a fussy infant is to rock the infant gently and
slowly while being careful to avoid sudden movements.

33. After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion
site is weaker. The nurse should do which of the following?
a. Elevate affected extremity.
b. Notify practitioner of the observation.
c. Record data on assessment flow record.
d. Apply warm compresses to insertion site.

Rationale: C.) The pulse distal to the catheterization site may be weaker for the first few hours after
catheterization, but should gradually increase in strength. Documentation of the finding provides a baseline.
The extremity is maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If
there are neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm
compresses are not indicated.

34. A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is
obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following
actions would the nurse do first?
a. obtain an order for sedation for the child
b. assess for an irregular heart rate and rhythm
c. explain to the child that it will only hurt for a short time
d. place the child in knee-to-chest position

Rationale: D. The child is experiencing a "tet spell" or hypoxic episode. Therefore, the nurse should place the
child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from lower extremities and
reduces the volume of blood being shunted through the interventricular septal defect and the overriding
aorta in the child with tetralogy of fallot. As a result, the blood then entering the systemic circulation has
higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and
pressure in the left ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea. If this
position is ineffective, then the child may need sedative. Once the child is in this position, the nurse may
assess for an irregular heart rate and rhythm. Explaining tho the child that it will only hurt for a short time
does nothing to alleviate hypoxia.
35. When administering a liquid medication to an uncooperative toddler, the nurse should implement which
strategy?
a. Restrain the child in a high chair.
b. Allow the parents to remain in the room.
c. Restrain the child in a papoose-type device.
d. Remove the child to another room away from the parents.

Rationale: b. Allowing the parents to remain in the room will promote positive parent-child relationships as
well as decrease the irrational fears that are so common in this age group.

36. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her
bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial
nursing action is which of the following?
a. Notify the physician.
b. Place child in Trendelenburg position.
c. Apply a new bandage with more pressure.
d. Apply direct pressure above catheterization site.

Rationale: D.) When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the
percutaneous skin site to localize pressure on the vessel puncture. The physician can be notified and a new
bandage with more pressure can be applied after pressure is applied. The nurse can have someone else
notify the physician while the pressure is being maintained. Trendelenburg position would not be a helpful
intervention. It would increase the drainage from the lower extremities.

37. A 4-year-old child who was recently hospitalized is brought to the clinic by his mother for a follow-up visit. The
mother tells the nurse that the child has begun to wet the bed ever since he was brought home from the
hospital. The mother is concerned and asks the nurse what to do. Which is the appropriate nursing response?
a. "You need to discipline the child."
b. "This is a normal occurrence after hospitalization."
c. "The child probably has developed a urinary tract infection."
d. "We will need to discuss this behavior with the pediatrician."

Rationale: b. Regression can occur in a preschooler, and it is most often a result of the stress of the
hospitalization.

38. A nurse, who is performing the preliminary physical examination of a female patient, notes the physical changes
shown in the figures above. The nurse should interview the child about which of the following information at
this time? The young woman’s:
a. Readiness for menstruation to begin.
b. Sexual activity
c. Menstrual cycle
d. Feelings about her bodily changes.

Rationale: D. It would be appropriate for the nurse to interview the child about her feelings about her bodily
changes.

39. The nurse should recognize that congestive heart failure (CHF) is which of the following?
a. Disease related to cardiac defects
 b. Consequence of an underlying cardiac defect
c. Inherited disorder associated with a variety of defects
d. Result of diminished workload imposed on an abnormal myocardium

Rationale: B. CHF is the inability of the heart to pump an adequate amount of blood to the systemic
circulation at normal filling pressures to meet the body's metabolic demands. CHF is not a disease but rather
a result of the inability of the heart to pump efficiently. CHF is not inherited. CHF occurs most frequently
secondary to congenital heart defects in which structural abnormalities result in increased volume load or
increased pressures on the ventricles.

40. The nurse is caring for a hospitalized adolescent who is on respiratory isolation precautions. The nurse is
preparing a plan of care and provides the adolescent with which appropriate age-related activity?
a. A puzzle
b. Finger paints
c. A computer iPad
d. Drawing materials

Rationale: c. Age-related activities for adolescents include sports, videos, movies, reading, parties, hobbies, a
computer iPad, and experimenting with makeup and hairstyles. The remaining options are most appropriate
for the preschooler.

41. When planning care for a 4-month-old child admitted with respiratory distress caused by respiratory syncytial
virus (RSV) and bronchiolitis, it is essential to include which of the following?
a. Give antibiotics.
b. Ensure adequate hydration.
c. Administer cough syrup.
d. Feed 4 oz of formula every 4 hours.

Rational: b. When respiratory distress is present, hydration is an essential consideration. Usually infants
cannot take fluids by the oral route because of the difficulty breathing. Intravenous fluid administration may
be necessary. RSV is a virus, so antibiotics are not beneficial. Cough syrup is not routinely used in RSV.
Although fluid and calories are important, an infant with respiratory distress is usually unable to drink this
amount of fluid.

42. A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because it
a. Liquefies secretions.
b. Improves oxygenation.
c. Promotes less labored ventilation.
d. Soothes inflamed mucous membranes.

Rationale: d. Warm or cold mist is useful to soothe the inflamed mucous membranes. Humidification is most
useful when hoarseness of laryngeal involvement occurs. Normal saline nose drops should be used to liquefy
secretions. The mist particles do not penetrate in sufficient amounts to accomplish this. There is no
additional oxygen in the mist therapy commonly used for respiratory tract infections. The primary effect of
mist is to soothe the inflamed membranes. A reduction in swelling might ease ventilatory effect, but it is not
the primary purpose of the therapy.

43. An appropriate nursing intervention when caring for a child with pneumonia is which of the following?
a. Avoiding placing child on the affected side.
 b. Monitor the respiratory status frequently.
c. Place in a Trendelenburg position.
d. Administer antitussive agents around the clock.

Rationale: b. The child's respiratory rate, status, oxygenation, general disposition, and level of activity are
frequently monitored. Lying on the affected side may promote comfort by splinting the chest and reducing
pleural rubbing. The child should be positioned on the unaffected side up to promote maximum expansion.
Children should be placed in a semi-erect position or position of comfort. Antitussives are usually not
indicated.

44. The nurse is interviewing the parents of a 4-month-old infant brought to the hospital emergency department.
The infant is dead on arrival, and no attempt at resuscitation is made. The parents state that the baby was found
in the crib with a blanket over the head, lying face down in bloody fluid from the nose and mouth. The parents
indicate no problems when the infant was placed in the crib asleep. Which of the following causes of death does
the nurse suspect?
a. Suffocation
b. Child abuse
c. Infantile apnea
d. Sudden infant death syndrome (SIDS)

Rationale: d. Death is consistent with the appearance of SIDS. The infant is usually found in a disheveled
bed; with blankets over the head; huddled into a corner and clutching the sheets; with frothy, blood-tinged
fluid in the mouth and nose; and lying face down. The diaper is also usually full of stool, indicating a
cataclysmic type of death. Although the child was found under the blanket, the other findings are consistent
with SIDS. The findings as reported are consistent with SIDS, not child abuse. The history and physical
findings are consistent with SIDS, not infantile apnea.

45. The nurse explains that a ventricular septal defect will allow:
a. blood to shunt left to right, causing increased pulmonary flow and no cyanosis.
b. blood to shunt right to left, causing decreased pulmonary flow and cyanosis.
c. no shunting because of high pressure in the left ventricle.
d. increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume.

Rationale: A. Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts
from left to right because of the higher pressure in the left ventricle. This particular shift does not cause
cyanosis.

46. The nurse is developing a plan of care for a school-age child who needs teaching related to the use of inhalers
and peak flow meters. What is the best expected outcome to be included in the plan of care for this child?
a. The child denies shortness of breath or difficulty breathing.
b. The child has regular respirations at a rate of 18 to 22 breaths per minute.
c. The child watches the educational video and reads printed information provided.
d. The child expresses feelings of mastery and competence with the breathing devices.

Rationale: d. School-age children strive for mastery and competence to achieve the developmental task of
industry and accomplishment. Assessment data do not relate to the child needing teaching. Although
reading and watching may be components of the teaching-learning process, they are passive processes.
Expressing feelings of mastery and competence with the breathing devices indicates that learning took
place.
47. What clinical manifestation would the nurse expect when a pneumothorax occurs in a neonate who is
undergoing mechanical ventilation?
a. Barrel chest
b. Wheezing
c. Thermal instability
d. Nasal flaring and retractions

Rationale: d. Nasal flaring, retractions, and grunting are signs of respiratory distress in a neonate. Barrel
chest develops with chronic obstructive pulmonary disease, not with acute pneumothorax. Wheezing has a
greater association with bronchopulmonary dysplasia or an obstruction in the airways than with an acute
pneumothorax. An acute pneumothorax would not affect the neonate's thermal stability.

48. In providing nourishment for a child with cystic fibrosis (CF), which of the following factors should the nurse
keep in mind?
a. Fats and proteins must be greatly curtailed.
b. The diet should be high in calories and protein.
c. Most fruits and vegetables are not well tolerated.
d. The diet should be high in easily digested carbohydrates and fats.

Rationale: b. Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired
intestinal absorption. Fats and proteins are a necessary part of a well-balanced diet. A well-balanced diet
containing fruits and vegetables is important. Enzyme supplementation helps digest foods; other
modifications are not necessary.

49. Which age group has the greatest potential to demonstrate regression when they are sick?
a. Infant
b. Toddler
c. Adolescent
d. Young Adult

Rationale: b. Regression is most seen among toddlers and it can be caused by stressful situations such as
hospitalization, the arrival of a new sibling, or starting a new school. When a child regresses, he or she
appears to be going backward in an earlier stage of development where he or she feels comfortable (e.g.
toilet trained toddlers suddenly start wetting their pants when they become sick, thumbsucking).

50. A child has been seen by the school nurse for dizziness since the start of the school term. It happens when
standing in line for recess and homeroom. The child now reports that she would rather sit and watch her friends
play hopscotch because she cannot count out loud and jump at the same time. When the nurse asks her if her
chest ever hurts, she says yes. Based on this history, the nurse suspects that she has:
a. Ventricular septal defect (VSD).
b. Aortic stenosis (AS).
c. Mitral valve prolapse.
d. Tricuspid atresia.

Rationale: b. AS can progress, and the child can develop exercise intolerance that can be better when resting

51. The nurse is performing an admission assessment on a 9-year-old who has just been diagnosed with systemic
lupus erythematosus. Which assessment findings should the nurse expect?
 a. Headaches and nausea.
b. Fever, malaise, and weight loss.
c. A papular rash covering the trunk and face.
d. Abdominal pain and dysuria.

Rationale: b. Fever, malaise, and weight loss are common presenting signs.

52. Several blood tests are ordered for a preschool child with severe anemia. The child is crying and upset because
of memories of the venipuncture done at the clinic 2 days ago. The nurse should explain:
a. venipuncture discomfort is very brief.
b. only one venipuncture will be needed.
c. topical application of local anesthetic can eliminate venipuncture pain.
d. most blood tests on children require only a finger puncture because a small amount of blood is needed.

Rationale: C. Preschool children are concerned with both pain and the loss of blood. When preparing the
child for venipuncture, the nurse will use a topical anesthetic to eliminate any pain. This is a traumatic
experience for preschool children. They are concerned about their bodily integrity. A local anesthetic should
be used, and a bandage should be applied to maintain bodily integrity. The nurse should not promise one
attempt in case multiple attempts are required. Both finger punctures and venipunctures are traumatic for
children. Both require preparation.

53. The parents of a preschooler diagnosed with muscular dystrophy are asking questions about the course of their
child's disease. Which should the nurse tell them?
a. "Muscular dystrophies usually result in progressive weakness."
b. "The weakness that your child is having will probably not increase.
c. "Your child will be able to function normally and not need any special accommodations."
d. "The extent of weakness depends on doing daily physical therapy."

Rationale: a. Muscular dystrophies are progressive degenerative disorders. The most common is Duchenne
muscular dystrophy, which is an X-linked recessive disorder.

54. The nurse is planning activity for a 4-year-old child with anemia. Which activity should the nurse plan for this
child?
a. Game of "hide and seek" in the children's outdoor play area
b. Participation in dance activities in the playroom
c. Puppet play in the child's room
d. A walk down to the hospital lobby

Rationale: C. Because the basic pathologic process in anemia is a decrease in oxygen-carrying capacity, an
important nursing responsibility is to assess the child's energy level and minimize excess demands. The
child's level of tolerance for activities of daily living and play is assessed, and adjustments are made to allow
as much self-care as possible without undue exertion. Puppet play in the child's room would not be overly
tiring. Hide and seek, dancing, and walking to the lobby would not conserve the anemic child's energy.

55. The nurse should tell the parents of a child with Duchenne (pseudohypertrophic) muscular dystrophy that some
of the progressive complications include:
a. Dry skin and hair, hirsutism, protruding tongue, and mental retardation.
b. Anorexia, gingival hyperplasia, and dry skin and hair.
c. Contractures, obesity, and pulmonary infections.
 d. Trembling, frequent loss of consciousness, and slurred speech.

Rationale: c. The major complications of muscular dystrophy include contractures, disuse atrophy,
infections, obesity, respiratory complications, and cardiopulmonary problems.

56. The nurse is teaching parents about the importance of iron in a toddler's diet. Which explains why iron
deficiency anemia is common during toddlerhood?
a. Milk is a poor source of iron.
b. Iron cannot be stored during fetal development.
c. Fetal iron stores are depleted by age 1 month.
d. Dietary iron cannot be started until age 12 months.

Rationale: A. Children between the ages of 12 and 36 months are at risk for anemia because cow's milk is a
major component of their diet and it is a poor source of iron. Iron is stored during fetal development, but
the amount stored depends on maternal iron stores. Fetal iron stores are usually depleted by age 5 to 6
months. Dietary iron can be introduced by breastfeeding, iron-fortified formula, and cereals during the first
12 months of life.

57. Which can elicit the Gower sign? Have the patient:
a. Close the eyes and touch the nose with alternating index fingers.
b. Hop on one foot and then the other.
c. Bend from the waist to touch the toes.
d. Walk like a duck and rise from a squatting position.

Rationale: d. Children with muscular dystrophy display the Gower sign, which is great difficulty rising and
standing from a squatting position due to the lack of muscle strength.

58. The nurse is teaching parents of an infant about the causes of iron deficiency anemia. Which statement best
describes iron deficiency anemia in infants?
a. It is caused by depression of the hematopoietic system.
b. It is easily diagnosed because of an infant's emaciated appearance.
c. Clinical manifestations are similar regardless of the cause of the anemia.
d. Clinical manifestations result from a decreased intake of milk and the premature addition of solid foods.

Rationale: C. In iron deficiency anemia, the child's clinical appearance is a result of the anemia, not the
underlying cause. Usually the hematopoietic system is not depressed in iron deficiency anemia. The bone
marrow produces red cells that are smaller and contain less hemoglobin than normal red cells. Children who
are iron deficient from drinking excessive quantities of milk are usually pale and overweight. They are
receiving sufficient calories, but are deficient in essential nutrients. The clinical manifestations result from
decreased intake of iron-fortified solid foods and an excessive intake of milk.

59. Which foods would be best for a child with Duchenne muscular dystrophy?
a. High-carbohydrate, high-protein foods.
b. No special food combinations.
c. Extra protein to help strengthen muscles.
d. Low-calorie foods to prevent weight gain.

Rationale: d. As the child becomes less ambulatory, moving the child will become more of a problem. It is
not good for the child to become overweight for several health reasons in addition to decreased ambulation.
60. Which should the nurse include when teaching the mother of a 9-month-old infant about administering liquid
iron preparations?
a. They should be given with meals.
b. They should be stopped immediately if nausea and vomiting occur.
c. Adequate dosage will turn the stools a tarry green color.
d. Allow preparation to mix with saliva and bathe the teeth before swallowing.

Rationale: C. The nurse should prepare the mother for the anticipated change in the child's stools. If the iron
dose is adequate, the stools will become a tarry green color. The lack of the color change may indicate
insufficient iron. The iron should be given in two divided doses between meals when the presence of free
hydrochloric acid is greatest. Iron is absorbed best in an acidic environment. Vomiting and diarrhea may
occur with iron administration. If these occur, the iron should be given with meals, and the dosage reduced,
then gradually increased as the child develops tolerance. Liquid preparations of iron stain the teeth. They
should be administered through a straw and the mouth rinsed after administration.

61. Which will help a school-aged child with muscular dystrophy stay active longer?
a. Normal activities, such as swimming.
b. Using a treadmill every day.
c. Several periods of rest every day.
d. Using a wheelchair upon getting tired.

Rationale: a. Children who are active are usually able to postpone use of a wheelchair. Itis important to keep
using muscles for as long as possible, and aerobic activity is good for a child.

62. Iron dextran is ordered for a young child with severe iron deficiency anemia. Nursing considerations include to:
a. administer with meals.
b. administer between meals.
c. inject deeply into a large muscle.
d. massage injection site for 5 minutes after administration of drug.

Rationale: C. Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be
injected into a large muscle. Iron dextran is for intramuscular or intravenous (IV) administration. The site
should not be massaged to prevent leakage, potential irritation, and staining of the skin.

63. The nurse knows that teaching was successful when a parent states which of the following are early signs of
muscular dystrophy?
a. Increased muscle strength.
b. Difficulty climbing stairs.
c. High fevers and tiredness.
d. Respiratory infections and obesity.

Rationale: b. Difficulty climbing stairs, running, and riding a bicycle are frequently the first symptoms of
Duchenne muscular dystrophy.

64. The nurse is recommending how to prevent iron deficiency anemia in a healthy, term, breast-fed infant. Which
should be suggested?
a. Iron (ferrous sulfate) drops after age 1 month
b. Iron-fortified commercial formula by age 4 to 6 months
 c. Iron-fortified infant cereal by age 2 months
d. Iron-fortified infant cereal by age 4 to 6 months

Rationale: D. Breast milk supplies inadequate iron for growth and development after age 5 months.
Supplementation is necessary at this time. The mother can supplement the breastfeeding with iron-fortified
infant cereal. Iron supplementation or the introduction of solid foods in a breast-fed baby is not indicated.
Providing iron-fortified commercial formula by age 4 to 6 months should be done only if the mother is
choosing to discontinue breastfeeding.

65. The nurse is caring for a school-aged child with Duchenne muscular dystrophy in the elementary school. Which
would be an appropriate nursing diagnosis?
a. Anticipatory grieving.
b. Anxiety reduction.
c. Increased pain.
d. Activity intolerance.

Rationale: d. The child would not be able to keep up with peers because of weakness, progressive loss of
muscle fibers, and loss of muscle strength.

66. Parents of a child with sickle cell anemia ask the nurse, "What happens to the hemoglobin in sickle cell anemia?"
Which statement by the nurse explains the disease process?"
a. Normal adult hemoglobin is replaced by abnormal hemoglobin.
b. There is a lack of cellular hemoglobin being produced.
c. There is a deficiency in the production of globulin chains.
d. The size and depth of the hemoglobin are affected.

Rationale: A. Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which
normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements
being produced. Thalassemia major refers to a variety of inherited disorders characterized by deficiencies in
production of certain globulin chains. Iron deficiency anemia affects the size and depth of the color.

67. The nurse knows that teaching has been successful when the parent of a child with muscle weakness states that
the diagnostic test for muscular dystrophy is which of the following?
a. Electromyelogram.
b. Nerve conduction velocity.
c. Muscle biopsy.
d. Creatine kinase level.

Rationale: c. Muscle biopsy confirms the type of myopathy that the patient has.

68. Which should a nurse in the ED be prepared for in a child with a possible spinal cord injury?
a. Severe pain.
b. Elevated temperature.
c. Respiratory depression.
d. Increased intracranial pressure

Rationale: c. A spinal cord injury can occur at any level. The higher the level of the injury, the more likely the
child is to have respiratory insufficiency or failure. The nurse should be prepared to support the child's
respiratory system.
69. The nurse evaluates the teaching as successful when a parent states that which of the following can cause
autonomic dysreflexia?
a. Exposure to cold temperatures.
b. Distended bowel or bladder.
c. Bradycardia.
d. Headache.

Rationale: b. Autonomic dysreflexia results from an uncontrolled, paroxysmal, continuous lower motor
neuron reflex arc due to stimulation of the sympathetic nervous system. It is a response that typically results
from stimulation of sensory receptors such as a full bladder or bowel.

70. The nurse is conducting a staff in-service on sickle cell anemia. Which describes the pathologic changes of sickle
cell anemia?
a. Sickle-shaped cells carry excess oxygen.
b. Sickle-shaped cells decrease blood viscosity.
c. Increased red blood cell destruction occurs.
d. Decreased adhesion of sickle-shaped cells occurs.

ANS: C. The clinical features of sickle cell anemia are primarily the result of increased red blood cell
destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells have decreased
oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension. When the
sickle cells change shape, they increase the
NS 1 QUIZ 7
COMMUNITY HEALTH NURSING

1. Which of the following are the herbal plants approved by the DOH?

a. Sambong
b. Akapulko
c. Niyog-niyogan
d. Tsaang gubat
e. All of the above

ANSWER E.

Sambong, Akapulko, Niyog-niyogan, Tsaang gubat, Ampalaya, Lagundi, Ulasimang bato, Bawang, Bayabas, Yerba Buena
(SANTA LUBBY)

2. A herbal medicine taken as tea used for skin allergies, diarrhea and stomach ache.

a. Niyog-niyogan
b. Tsaang gubat
c. Lagundi
d. Bayabas

ANSWER B. Scientific name Carmona Retusa English name : Wild tea.

For Diarrhea : boil chopped leaves 2 glasses for 15 mins until 1 glass remains, cool and strain

For Stomach ache: Wash leaves and chop leaves+ boil 1 glass of water 15 mins, Cool, strain, drink

3. According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following
best illustrates this statement?

a. The community health nurse continuously develops himself personally and professionally.
b. Health education and community organizing are necessary in providing community health services.
c. Community health nursing is intended primarily for health promotion and prevention and treatment of disease.
d. The goal of community health nursing is to provide nursing services to people in their own places of residence.

ANSWER: B The community health nurse develops the health capability of people through health education and
community organizing activities.

Community Development as a process is about change within communities and it initiates and supports community
action and outcomes

4. 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

ANSWER: B 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.

5. 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

ANSWER: D 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.

6. In which step are plans formulated for solving community problems?

a. Mobilization
b. Community organization
c. Follow-up/extension
d. Core group formation

ANSWER: B 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.
7. The public health nurse takes an active role in community participation. What is the primary goal of community
organizing?

a. To educate the people regarding community health problems

b. To mobilize the people to resolve community health problems
c. To maximize the community’s resources in dealing with health problems
d. None of the above

ANSWER: C 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.

8. Isolation of a child with measles belongs to what level of prevention?

a. Primary
b. Secondary
c. Intermediate
d. Tertiary

ANSWER: A The purpose of isolating a client with a communicable disease is to protect those who are not sick (specific
disease prevention).

9. On the other hand, Operation Timbang is _____ prevention.

a. Primary
b. Secondary
c. Intermediate
d. Tertiary

ANSWER: B Operation Timbang is done to identify members of the susceptible population who are malnourished. Its
purpose is early diagnosis and, subsequently, prompt treatment.

10. 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

ANSWER: C Dynamics of family relationships can best be observed in the family’s natural environment, which is the
home.

11. 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

ANSWER: B Failure of a family member to develop according to what is expected, as in mental retardation, is a health
deficit.

12. CHN (Community Health Nursing) is a community-based practice. Which best explains this statement?

a. The service is provided in the natural environment of people

b. The nurse has to conduct community diagnosis to determine nursing needs and problems
c. The service are based on the available resources within the community
d. Priority setting is based on the magnitude of the health problems identified

ANSWER: B Community-based practice means providing care to people in their own natural environments: the home,
school and workplace, for example.

13. Population- focused nursing practice requires which of the following processes?

a. Community organizing .
b. Nursing, process
c. Community diagnosis
d. Epidemiologic process

ANSWER: C 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.

14. "Public health services are given free of charge". Is this statement true or false?
 a. The statement is true; it is the responsibility of government to provide haste services
b. The statement is false; people pay indirectly for public health services
c. The statement may be true or false; depending on the Specific service required
d. The statement may be true or false; depending on policies of the government concerned.

ANSWER: B Community health services, including public health services, are prepaid paid services, through
taxation, for example.

15. Which of the following is the most prominent feature of public health nursing?

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 service
d. Public health nursing focuses on preventive, not curative services

ANSWER D 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.

16. Which of the following is a function of epidemiology?

a. Identifying the disease condition based on manifestations presented by a client

b. Determining factors that contributed to the occurrence of pneumonia in a 3 year old
c. Determining the efficacy of the antibiotic used in the treatment of the 3 year old client with pneumonia
d. Evaluating the effectiveness of the implementation of the Integrated Management of Childhood Illness

ANSWER D. Epidemiology is used in the assessment of a community or evaluation of interventions in community health
practice. Epidemiology is the method used to find the causes of health outcomes and diseases in populations

17. Which of the following is an epidemiologic function of the nurse during an epidemic?

a. Conducting assessment of suspected cases to detect the communicable diseases

b. Monitoring the condition of the cases affected by the communicable disease
c. Participating in the investigation to determine the source of epidemic
d. Teaching the community on preventive measures against the disease

ANSWER C. 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.

18. Which immunization produces a permanent scar?

a. DPT (Diphtheria, Pertussis, Tetanus)

b. BCG (Bacillus Calmette-Guérin)
c. Measles vaccination
d. Hepatitis B vaccination

ANSWER B. BCG (Bacillus Calmette-Guérin) causes the formation of a superficial abscess, which begins 2 weeks after
immunization. The abscess heals without treatment, with the formation of a permanent scar. BCG Immunity or
protection against tuberculosis (TB). The vaccine may be given to persons at high risk of developing TB

19. What is the best course of action when there is a measles epidemic in a nearby municipality?

a. Give measles vaccine to babies aged 6 to 8 months

b. Give babies aged 6 to 11 months one dose of 100,000 IU of Retinol
c. Instruct mother to keep their babies at home to prevent disease transmission
d. Instruct mothers to feed their babies adequately to enhance their babies resistance

ANSWER A. Ordinarily, measles vaccine is given at 9 months of age. During an impending epidemic, however, one dose
may be given to babies aged 6 to 8 months. The mother is instructed that the baby needs another dose when the baby is
9 months old.

Can measles vaccine be given to adults?

Adults should also be up to date on MMR vaccinations with either 1 or 2 doses (depending on risk factors) unless they
have other presumptive evidence of immunity to measles, mumps, and rubella. One dose of MMR vaccine, or other
presumptive evidence of immunity, is sufficient for most adults.

20. A mother brought her 10 month old infant for consultation because of fever which started 4 days prior to
consultation. To determine malaria risk, what will you do?

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

ANSWER B. Because malaria is endemic, the first question to determine malaria risk is where the client's family resides.
If the area of residence is not a known endemic area, ask if the child had traveled within the past 6 months, where
he/she was brought and whether he/she stayed overnight in that area.

Malaria risk exists throughout the year in 9 remaining endemic provinces (Palawan (90%), Sultan Kudarat, Davao del
norte, Maguindanao, Sulu, Mindoro occidental, Tawi-tawi, Cagayan Valley, and Davao City).

21. Which of the following signs indicates the need for sputum examination for AFB (Acid Fast Bacillus)?

a. Hematemesis
b. Fever for 1 week
c. Cough for 3 weeks
d. Chest pain for 1 week

ANSWER C. A client is considered a PTB (Pulmonary Tuberculosis) suspect when he has cough for 2 weeks or more,
plus one or more of the following signs: fever for 1 month or more; chest pain lasting for 2 weeks or more not attributed
to other conditions; progressive, unexplained weight loss; night sweats; and hemoptysis

What is an AFB?

Acid-fast bacillus (AFB) is a type of bacteria that causes tuberculosis and certain other infections. Tuberculosis,
commonly known as TB, is a serious bacterial infection that mainly affects the lungs. It can also affect other parts of the
body, including the brain, spine, and kidneys.

What is a AFB test?

Acid- Fast Bacilli (AFB) smear and culture are two separate tests always performed together at the MSPHL, Tuberculosis
(TB) Unit. AFB smear refers to the microscopic examination of a fluorochrome stain of a clinical specimen.

22. Which clients are considered targets for DOTS (Directly Observed Treatment Short-course) category?

a. Sputum negative cavitary cases

b. Clients returning after default
c. Relapses and failures of previous PTB treatment regimens
d. Clients diagnosed for the first time through a positive sputum exam

ANSWER D. Category I is for new clients diagnosed by sputum examination and clients diagnosed to have a serious
form of extrapulmonary tuberculosis, such as TB osteomyelitis.

23. To improve compliance to treatment, what innovation is being implemented in DOTS (Directly Observed Treatment
Short-Course)?

a. Having the health worker follow up the client at home

b. Having the health worker or a responsible family member monitor drug intake
c. Having the patient come to the health center every month to get his medications
d. Having a target list to check on whether the patient has collected his monthly supply of drugs

ANSWER B. Directly Observed Treatment Short Course is so-called because a treatment partner, preferably a health
worker accessible to the client, monitors the client's compliance to the treatment.

24. 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 this history/ which disease condition will you suspect?

a. Hepatitis A
b. Hepatitis B
 c. Tetanus
d. Leptospirosis

ANSWER D. A bacterial disease spread through the urine of infected animals. Leptospirosis is transmitted through
contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals, like
rats

25. Which is the BEST control measure for AIDS?

a. Being faithful to a single sexual partner

b. Using a condom during each sexual contact
c. Avoiding sexual contact with commercial sex workers
d. Making sure that one's sexual partner does not have signs of AIDS

ANSWER A. 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.

26. A nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant
women. At the first session the nurse will be meeting with each client individually. The nurse prepares a list of items to
be included in the session and lists which item as the first priority?

a. Review the MyPyramid food guide.

b. Weigh each client and ask the client to document the weight on a progress chart.
c. Discuss the costs of food items.
d. Identify the food preferences and methods of food preparation for each client.

ANSWER D. In order to determine each client's nutritional status and needs, the first priority of the nurse is to
identify each client's food preferences. Cultural background and knowledge about nutrition are important factors
influencing food choices and nutritional status. Although options 1,2 and 3 may be a component of the sessions, option
4 is the first priority.

27. A nurse in community health contacts three individuals who have had sexual encounters with an individual recently
diagnosed with syphilis. The concept basic to community-oriented nursing practice that is best described by this
intervention is:

a. community.
b. community as client.
c. individual as client.
d. partnership.
ANSWER B. When the community is the client, the results of nursing interventions should produce changes that affect
the community as a whole, such as reducing the spread of sexually transmitted diseases (STDs). Although the nurse may
work with individuals, families or other interacting groups, aggregates, institutions, or communities, or within a
population, the resulting changes are intended to affect the whole community. The community health nurse is not
providing care to an individual in this circumstance. It would be ideal if there were some form of partnership in this
intervention.

28. The nurse in community health uses information about family structure, household composition, marriage, divorce,
birth, death, adoption, and other family life events to forecast and predict stresses and developmental changes
experienced by families and identify possible solutions to family challenges. This best describes the study of:

a. family demographics.
b. family functions.
c. family health.
d. family resilience.

ANSWSER A. Family demographics is the study of the structure of families and households and the family-related
events, such as marriage and divorce, that alter the structure through their number, timing, and sequencing. Nurses
must be knowledgeable about family structures, functions, processes, and roles. In addition, nurses must be aware of
and understand their own values and attitudes pertaining to their own families, as well as being open to different family
structures and cultures.

29. When applying the nursing process to environmental health, the community health nurse would:

a. conduct a focused assessment on the presenting problem.

b. coordinate interventions with the physician only.
c. examine criteria that include only the client's immediate response.
d. include outcome measures that mitigate and eliminate the environmental factors.

ANSWER D. If the community health nurse suspects that a client's health problem is being influenced by environmental
factors, the nurse should follow the nursing process and note the environmental aspects of the problem in every step of
the nursing process. For instance, in goal setting, the nurse would include outcome measures that mitigate and
eliminate the environmental factors.

30. A nurse in community health is conducting an assessment on a family of four. During the course of the assessment,
the nurse collects information about previous generations of the family and siblings. The results are used to create a
diagram for the family that displays the family unit across generations. Further discussions occur regarding the patterns
of health and illness that relate to biological health risks. The diagram is called:

a. an ecomap.
b. a family plan.
c. a genogram.
d. a risk plot.

ANSWER C. A genogram is a drawing that shows the family unit of immediate interest and includes several
generations, using a series of circles, squares, and connecting lines. Basic information about the family, relationships in
the family, and patterns of health and illness can be obtained by completing the genogram with the family.

31. A nurse in community health who teaches a client with asthma to recognize and avoid exposure to asthma triggers
and assists the family in implementing specific protection strategies such as removing carpets and avoiding pets is
intervening at the level of:

a. assessment.
b. primary prevention.
c. secondary prevention.
d. tertiary prevention.

ANSWER C. Primary prevention refers to interventions that promote health and prevent the occurrence of disease,
injury, or disability. Interventions at this level are aimed at individuals and groups who are susceptible to disease but
have no discernable pathology (state of prepathogenesis). In this case, the client has already has asthma, so the nurse
teaches the client to recognize and avoid exposure to asthma triggers. This is an example of secondary prevention.
Health screenings are at the core of secondary prevention. Tertiary prevention includes interventions aimed at limiting
disability and interventions that enhance rehabilitation from disease, injury, or disability. Assessment is a component of
epidemiology.

32. The Martinez couple have a 6-year old child entering school for the first time. The Martinez family has a:

a. Health threat
b. Health deficit
c. Foreseeable crisis
 d. Stress point

ANSWER C. Entry of the 6-year old into school is an anticipated period of unusual demand on the family.

33. Which of the following is an advantage of a home visit?

a. It allows the nurse to provide nursing care to a greater number of people.

b. It provides an opportunity to do first hand appraisal of the home situation.
c. It allows sharing of experiences among people with similar health problems.
d. It develops the family’s initiative in providing for health needs of its members.

ANSWER B. 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.

34. The PHN bag is an important tool in providing nursing care during a home visit. The most important principle of bag
technique states that it

a. Should save time and effort.

b. Should minimize if not totally prevent the spread of infection.
c. Should not overshadow concern for the patient and his family.
d. May be done in a variety of ways depending on the home situation, etc.

ANSWER B. Bag technique is performed before and after handling a client in the home to prevent transmission of
infection to and from the client.

The bag technique is a tool by which the nurse, during her visit will enable her to perform a nursing procedure with ease
to save time and effort with the end view of rendering effective nursing care to clients

35. 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

ANSWER B. Analytical epidemiology is the study of factors or determinants affecting the patterns of occurrence and
distribution of disease in a community.

36. Estimate the number of pregnant women who will be given tetanus toxoid during an immunization outreach activity
in a barangay with a population of about 1,500.

a. 265
b. 300
c. 375
d. 400

ANSWER A. To estimate the number of pregnant women, multiply the total population by 3.5%. BONUS

37. 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.

ANSWER: D. 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.

38. The nurse in community health uses information about family structure, household composition, marriage, divorce,
birth, death, adoption, and other family life events to forecast and predict stresses and developmental changes
experienced by families and identify possible solutions to family challenges. This best describes the study of:

A. family demographics.
B. family functions.
C. family health.
D. family resilience.

ANSWER: A. family demographic. Family demographics is the study of the structure of families and households and the
family-related events, such as marriage and divorce, that alter the structure through their number, timing, and
sequencing. Nurses must be knowledgeable about family structures, functions, processes, and roles. In addition, nurses
must be aware of and understand their own values and attitudes pertaining to their own families, as well as being open
to different family structures and cultures.

39. You are computing the crude death rate of your municipality, with a total population of about 18,000, for last year.
There were 94 deaths. Among those who died, 20 died because of diseases of the heart and 32 were aged 50 years or
older. What is the crude death rate?

a. 4.2/1,000
b. 5.2/1,000
c. 6.3/1,000
d. 7.3/1,000

ANSWER B. To compute crude death rate divide total number of deaths (94) by total population (18,000) and multiply
by 1,000.

40. 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

ANSWER A. P.D. 651 amended R.A. 3753, requiring the registry of births within 30 days from their occurrence.

41. Integrated Management of Childhood Illness (IMCI) is promulgated by the UNICEF together with DOH in order to
properly treat common childhood diseases usually in the

a. Hospital
b. Community
c. Clinic
d. School

ANSWER B. IMCI is community-based and usually attended by community health nurses at the rural health units.

42. A 2-year old boy was brought by his mother to the health center for a regular yearly check-up. As a nurse in the
health center you are going to observe first for the general danger signs. All but one is the danger sign.

a. Lethargic or unconscious
b. The child has had convulsions
c. There is bulging fontanel
d. The child vomits everything he eats

ANSWER C. Bulging fontanel is not a danger sign. The general danger signs under IMCI are the following: lethargic or
unconscious; the child has had convulsions; the child is not able to drink or breastfeed; and the child vomits everything
he eats

43. If the child presents with no symptoms of the general danger signs the next thing to do is assess for

a. fever.
b. cough or difficulty of breathing.
c. anemia or malnutrition.
d. ear infection.

ANSWER B. The next step in the IMCI chart booklet for the nurse to look at after assessing for the general danger signs
is for problems related to cough or difficulty of breathing.

44. When observing the 2-year old child for signs of pneumonia you documented that the child is having 45 breaths/min,
there is chest indrawing and stridor. You are going to classify this as

a. cough or colds.
b. pneumonia.
c. no pneumonia.
d. severe pneumonia or very severe disease.

ANSWER D. The presence of stridor alone will make the nurse classify the child as having severe pneumonia or very
severe disease which is in the pink row.

45. This is one way of diagnosing dengue hemorrhagic fever wherein you are going to use a sphygmomanometer on the
arm of the patient and count the number of rashes upon its inflation. This is known as

a. Rumpel Leede’s test

b. ELISA test
 c. Blood smear
d. BP test

ANSWER A. A tourniquet test (also known as a Rumpel-Leede capillary-fragility test or simply a capillary fragility test)
determines capillary fragility. It is a clinical diagnostic method to determine a patient's hemorrhagic tendency. It
assesses fragility of capillary walls and is used to identify thrombocytopenia.

46. When assessing the child who is having diarrhea you observed that the child is restless, has sunken eyes, and is
thirsty and drinking eagerly while the skin pinch goes back slowly. You are going to classify this as

a. Some dehydration
b. Severe dehydration
c. Moderate dehydration
d. No dehydration

ANSWER A. Most of the signs presented in the situation can be found in the yellow row of the dehydration problem.

47. If you are going to check for the skin pinch of the child or the skin turgor, where is the best area to check for this?

a. Forearm
b. Thigh
c. Cheek
d. Abdomen

ANSWER D. Based on the IMCI, the abdomen is the best location to assess for skin turgor because of its large surface
area.

48. When asking the mother for the history of the child’s diarrhea the mother tells you that her child defecates with
blood in the stool. You will suspect for what type of infection?

a. Typhoid fever
b. Dysentery
c. Cholera
d. Acute gastroenteritis

ANSWER B. Once the nurse observes for blood in the stool, the IMCI chart booklet states that the classification of the
child’s condition is dysentery which is in the yellow row.

49. A herbal plant medicine also named Blumea camphora. A diuretic that helps in the excretion of urinary stones. It can
also be used as an edema.
a. Bawang
b. Lagundi
c. Sambong
d. Tsaang Gubat

Correct answer : C.) Sambong

Rationale : Sambong (Blumea balsamifera)
English name: Blumea camphora. A diuretic that helps in the excretion of urinary stones. It can also be used as an
edema.

50. A herbal plant medicine that is used as an analgesic to relive body aches and pain. It can be taken internally as a
decoction or externally by pounding the leaves and applied directly on the afflicted area.

a. Yerba Buena
b. Sambong
c. Pansit-Pansitan
d. Ulasimang Bato

Correct answer :B. Yerba Buena

Rationale : Yerba Buena (Clinopodium douglasii) commonly known as Peppermint, this vine is used as an analgesic to
relive body aches and pain. It can be taken internally as a decoction or externally by pounding the leaves and applied
directly on the afflicted area.
 NS1 QUIZ 8 IMCI 9. According to the IMCI guidelines, which of
1. Which of the following is not included the following main symptoms should
among the main causes of mortality in always be assessed in every sick child age
under-five children in the country? 2 months up to 5 years?
A. Diarrheal diseases A. Cough
B. Pneumonia B. Abdominal pain
C. Road traffic injuries C. Fever
D. Malnutrition D. Skin infection
E. Diarrhea
2. For which of the following settings are the
IMCI guidelines suitable for use? 10. Which of the following signs are "general
A. Inpatient ward of a district hospital danger signs" to be checked in any child 2
B. Outpatient department of a months up to 5 years brought to the
hospital health facility?
C. Outpatient health facility A. Irritability
D. Inpatient ward of a specialized B. Axillary temperature ≥ 39.0°C
hospital C. Severe wheezing
D. Not able to drink or breastfeed
3. Which of the following age groups do the
IMCI clinical guidelines address? 11. What is needed to be able to count the
A. Birth up to 5 years respiratory rate correctly in an 11-month-
B. 2 months up to 2 years old child with cough?
C. 1 week up to 5 years A. Child should be calm
D. 2 months up to 6 years B. Child should be alert
C. A special timer is indispensable
4. Which of the following actions does a D. The count should always be
pink-coded classification require? repeated
A. Give pre-referral treatment
B. Give medicines for home care 12. To classify a child with some dehydration,
C. Advise mother when to return the nurse must correctly identify which of
immediately the following signs and symptoms?
D. Refer urgently to hospital A. Sunken eyes, restless and irritable
B. Sunken eyes and difficult to
5. Which of the following actions does a awaken
green-coded classification require? C. Sunken eyes and blood in the stool
A. Give pre-referral treatment D. Sunken eyes and not able to drink
B. Advise mother when to return
immediately 13. What is the cut-off rate for "fast
C. Advise mother on antibiotic breathing" in a child who is exactly 12
treatment months old?
D. Refer urgently to hospital A. 60 breaths per minute
B. 50 breaths per minute
C. 40 breaths per minute
6. Which of the following color-coded D. 30 breaths per minute
classification rows for fever of the IMCI
chart booklet would apply to a 5-month- 14. What is "fast breathing" in a 3-month-old
old child with fever and stiff neck? child?
A. Pink color-coded row A. 20 breaths per minute or more
B. Yellow color-coded row B. 30 breaths per minute or more
C. Green color-coded row C. 40 breaths per minute or more
D. Orange color-coded row D. 50 breaths per minute or more
7. Which of the following color-coded rows of
the IMCI chart booklet applies to a 42- 15. When the nurse correctly identifies some
month-old child with diarrhea who has dehydration, she plans to intervene
sunken eyes, is thirsty and has no other immediately which of the following
problems? actions?
A. Pink color-coded row A. Give ORS, zinc supplements and
B. Yellow color-coded row food for some dehydration to the
C. Green color-coded row child
D. Orange color-coded row B. Give fluid and food to treat
8. Which of the following are effective diarrhea of the child at home
preventive interventions in children under- C. Give Vitamin A and Zinc
5? supplements
A. Antibiotics for pneumonia D. Advise the mother to resume
B. Immunization breast feeding
C. Prompt treatment of malaria
D. Exclusive breastfeeding

1
 23. Which of the following signs in a 12-
16. If a mother complains of diarrhea of her month-old child with cough are an
child for 14 days and more, the nurse indication for urgent referral?
should classify as which of the following? A. Severe palmar pallor
A. Persistent Diarrhea B. Respiratory rate of 65 per minute
B. Severe Persistent Diarrhea C. Axillary temperature ≥ 39.0°C
C. Dysentery D. Visible severe wasting
D. Dehydration
24. How do you classify a 3-year-old child
17. Which of the following movements of the with cough who has a respiratory rate of
lower chest describes chest indrawing? 55 breaths/ minute and chest indrawing?
A. Inward movement during A. SEVERE PEUMONIA OR VERY
inspiration SEVERE DISEASE
B. Inward movement during B. PNEUMONIA
expiration C. NO PNEUMONIA: COUGH OR COLD
C. Outward movement during D. None of the above
inspiration
D. Outward movement during 25. How do you classify a 1-year-old child
expiration who has been coughing for 2 days, has a
respiratory rate of 60 breaths/ minute and
18. Which of the following statements best whose mother says he had convulsions
describes chest indrawing? last night?
A. Inward movement of the lower A. SEVERE PNEUMONIA OR VERY
chest wall during inspiration SEVERE DISEASE
B. Inward movement of the lower B. PNEUMONIA
chest wall during expiration C. NO PNEUMONIA: COUGH OR COLD
C. Any intercostal retractions during D. None of the above
inspiration
D. Upper intercostal retractions during 26. How do you classify a 10-month-old child
expiration who has had cough for 4 days, has a
respiratory rate of 52 breaths per minute,
19. Which of the following statements best has fever and has no stridor?
describes wheezing? A. SEVERE PNEUMONIA OR VERY
A. It is a harsh sound during SEVERE DISEASE
inspiration B. PNEUMONIA
B. It is a soft musical sound during C. NO PNEUMONIA: COUGH OR COLD
expiration D. None of the above
C. It is accompanied by prolonged
expiration 27. How do you classify a 5-month-old child
D. It is a soft musical sound during who has had cough for 1 day, has a
inspiration respiratory rate of 40 breaths per minute,
has no stridor and has no chest
20. If a mother complains of diarrhea of her indrawing?
child with blood in the stool, the nurse A. SEVERE PNEUMONIA OR VERY
should classify as which of the following? SEVERE DISEASE
A. Persistent Diarrhea B. PNEUMONIA
B. Severe Persistent Diarrhea C. NO PNEUMONIA: COUGH OR COLD
C. Dysentery D. None of the above
D. Dehydration
21. Which of the following signs would make 28. Which among the following situations
you classify any child age 2 months up to classifies a child 2 months up to 5 years
5 years presenting with cough as SEVERE old as PNEUMONIA?
PNEUMONIA OR VERY SEVERE DISEASE? A. Fast breathing, one general danger
A. Stridor when agitated sign, no chest indrawing, no stridor
B. Respiratory rate of 65 breaths per B. Fast breathing, no general danger
minute sign, chest indrawing, no stridor
C. Difficult breathing C. Fast breathing, no general danger
D. Vomiting everything sign, no chest indrawing, stridor
22. Which of the following signs in a 5-month- D. Fast breathing, no general danger
old child with cough are an indication for sign, no chest indrawing, no stridor
urgent referral?
A. Respiratory rate of 60 breaths per
minute
B. Stridor when agitated
C. Chest indrawing
D. Axillary temperature ≥ 39.0°C

2
 36. According to the IMCI guidelines, which of
29. If confirmed that the child has malaria risk the following key questions should be
and a positive blood smear which of the asked to the mother of every child with
following actions would the nurse take diarrhea?
first to treat the child with malaria? A. For how long has the child had
A. Treat child with oral anti malarial diarrhea?
B. Give one dose of paracetamol for B. Does the child have mucous in the
fever of 38 degrees Celsius stools?
C. Treat other causes of malaria aside C. What did the child eat before the
from fever diarrhea started?
D. Treat the child to prevent low blood D. Does the child have fever?
sugar
37. Which of the following signs should you
30. What is the earliest time that a mother of LOOK and FEEL for in an 8-month-old
a 3-month-old child with PNEUMONIA and child with diarrhea to classify his/her
LOW WEIGHT FOR AGE should come for a dehydration status?
follow-up visit? A. Lethargic or unconscious
A. 2 days B. Skin turgor (skin pinch)
B. 5 days C. Unable to drink
C. 7 days D. Restless, irritable
D. 14 days
38. A "skin pinch goes back very slowly" if it
31. What is the earliest time that a mother of returns:
a 13-month-old child with ACUTE EAR A. Immediately
INFECTION and LOW WEIGHT should B. In less than 1 seconds
come for a follow-up visit? C. In less than 2 seconds
A. 2 days D. In more than 2 seconds
B. 5 days
C. 7 days 39. What is the recommended procedure to
D. 14 days take a skin pinch?
A. Pinching the abdomen skin halfway
32. How do you classify a 12-month-old child between the umbilicus and
who has severe palmar pallor? the side of the abdomen
A. SEVERE ANEMIA B. Holding the skin firmly between the
B. ANEMIA thumb and the tip of the 1st
C. NO ANEMIA finger
D. None of the above C. Holding the skin across the child’s
body
33. How do you classify a 4-month-old child D. Holding the skin in line up and
who has some palmar pallor? down the child’s body
A. SEVERE ANEMIA
B. ANEMIA 40. How do you classify a 6-month-old child
C. NO ANEMIA living in a low malaria risk area who has a
D. None of the above history of fever for 2 days, is hot to the
touch, has no general danger signs, no
34. In a 12-month-old child with cough and stiff neck, no generalized rash, no cough,
diarrhea, which of the following signs is no runny nose, no red eyes and no other
an indication for urgent referral? cause of fever?
A. Restless, irritable A. VERY SEVERE FEBRILE DISEASE
B. Respiratory rate of 65 per minute B. MALARIA
C. Axillary temperature ≥ 39.0°C C. FEVER – MALARIA UNLIKELY
D. Child unable to breastfeed D. FEVER NO MALARIA

35. How do you classify a 36-month-old child 41. Which of the following signs are used to
who has had cough for 3 days, has no classify an ear problem in a 3-year-old
general danger signs, has a respiratory child with ear pain?
rate of 29 breaths per minute, has no A. Swelling behind the ear
stridor and has no chest indrawing? B. Tender swelling in front of the ear
A. SEVERE PNEUMONIA OR VERY C. Redness of ear pinna (auricle)
SEVERE DISEASE D. Tender swelling behind the ear
B. PNEUMONIA
C. NO PNEUMONIA: COUGH OR COLD
D. None of the above

3
42. How do you classify a 16-month-old child 48. In home management of a child with
who has ear pain, no pus draining from pneumonia, caretaker is counseled on how
the ear and has a tender swelling behind not to:
the ear? A. Give oral drugs
A. MASTOIDITIS B. Treat local infection at home
B. ACUTE EAR INFECTION C. Inform mother when to return
C. CHRONIC EAR INFECTION D. Discontinue feeding
D. NO EAR INFECTION
49. A child aged 18 months complaining of
43. How do you classify a two-year-old child being very ill with cough, high fever (39.7
with an axillary temperature of 37.5°C, C) and sore throat since 2 days. On
pus seen coming from the ear and no examination, we observed that the child is
tender swelling behind the ear whose very quite, with his eyes opened but no
mother says that pus has been coming for eye contact (lethargy). On examination of
5 days? throat, it was red and congested with
A. MASTOIDITIS enlarged non tender lymph nodes in front
B. ACUTE EAR INFECTION of the neck and his respiratory rate was
C. CHRONIC EAR INFECTION 45 breath/minute. No other abnormality.
D. NO EAR INFECTION According to IMCI:
A. He is classified as having
pneumonia.
44. How do you classify a 5-month-old child B. He has the classification of
who has been having diarrhea for 15 streptococcal sore throat.
days, has no general danger signs, is C. His fever is classified as fever
irritable, has sunken eyes, drinks eagerly possible bacterial infection.
and in whom the skin pinch goes back D. He needs urgent referral to
immediately? hospital.
A. SEVERE DEHYDRATION, SEVERE 50. A 3 years old child complaining of fever 39
PERSISTENT DIARRHEA C in the last 2 days associated with severe
B. SEVERE DEHYDRATION sore throat which makes himunable to
C. SOME DEHYDRATION, SEVERE drink anything , on examination, his
PERSISTENT DIARRHEA throat was red and severely
D. SOME DEHYDRATION congested. Exudates is seen on the throat,
45. Which of the following is consistent with a some cervical lymph nodes are enlarged
classification of PERSISTENT DIARRHEA? and tender. According to IMCI
A. Diarrhea lasting for 7 days or more A. There is no indication to refer him
B. Diarrhea lasting for more than 7 to hospital
days B. Home treatment with antipyretic
C. Diarrhea lasting for more than 10 after initial long acting penicillin in
days outpatient clinic is the only needed
D. Diarrhea lasting for 14 days or therapy
more C. He is classified as having fever
46. What is required to classify the illness of a possible bacterial infection
child age 2 months up to 5 years as D. He is classified as having very
PERSISTENT DIARRHEA AND DYSENTERY? severe disease
A. Blood in the stools for 14 days or
more
B. Diarrhea lasting for 14 days or
more
C. Diarrhea lasting for 14 days or
more
D. Diarrhea lasting for more than 14
days

47. How do you classify a 7-month-old child

living in a high malaria risk area who has
an axillary temperature of 38.0°C and is
lethargic?
A. VERY SEVERE FEBRILE
DISEASE/MALARIA
B. MALARIA
C. FEVER – MALARIA UNLIKELY
D. NO MALARIA UNLIKELY

4
NS 1 QUIZ 9
MANAGEMENT OF COMMUNICABLE DISEASES
1. If an infectious disease can be transmitted directly from one person to another, it is:
A. A susceptible host
B. A communicable disease
C. A portal of entry to a host
D. A portal of exit from the reservoir

ANSWER B - If an infectious disease is transmitted directly from one person to another, it is a communicable disease.
Portals of entry and exit are the mechanisms of disease transmission. A susceptible host is a person who can acquire an
infection.

2, A nurse is assigned to care for a client with a deep wound infection. Which of the following actions would result in the
contamination of sterile gloves?
A. The nurse grasps a sterile cotton-tipped swab to clean wound edges.
B. The nurse takes a gauze pad in hand and places it in the wound.
C. The nurse picks up a gauze pad soaked in sterile saline to cleanse the wound.
D. The nurse pulls up the sheet over the client's perineum for better draping.
ANSWER D - If the nurse touches a sheet (nonsterile) with sterile gloves, the gloves are contaminated. The other actions
do not contaminate sterile gloves.

3. A client is isolated because the client has pulmonary tuberculosis. The nurse notes that the client seems angry but
knows this is a normal response to isolation. The best intervention is to:
A. Provide a dark, quiet room to calm the client.
B. Explain the isolation procedures and provide meaningful stimulation.
C. Reduce the level of precautions to keep the client from becoming angry.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection.

ANSWER B - When a client is in isolation, the nurse should take measures to improve the client's stimulation and make
sure to explain the isolation procedures. Darkening the room can increase the sense of isolation. The nurse should not
change the isolation level but should provide plenty of emotional support and make time for the client to prevent a
sense of isolation. As long as family and caregivers follow infection precautions, there is no reason to limit contact with
these individuals.

4. To remove a glove that is contaminated, what should the nurse do first?

A. Rinse the glove before removing it to minimize contamination.
B. Pull the glove off the back of the hand until it slides off the entire hand and discard it.
C. Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching the wrist or
fingers.
D. Put the thumb inside the wrist to slide the glove over the hand with minimal touching of the hand by the other
gloved hand.

ANSWER C - When the outside of the cuff is grasped with the contaminated gloved hand, then dirty to dirty remains
intact. Pulling the glove away from the hand entirely without touching the wrist or fingers further minimizes the
contamination by the gloved hand. If the nurse puts the gloved thumb inside the glove, the nurse has contaminated the
bare hand with a contaminated thumb. Pulling the glove off by holding it at the back sounds good and could minimize
contamination, but it is very difficulty to remove a glove this way without the risk of tearing the glove and creating
contamination through the tear. If excessive secretions are present on gloves, then a towel or the drape could be used
to wipe off excessive secretions before an attempt is made to remove the gloves.

5. A nurse is teaching a client with genital herpes. Education for this client should include an explanation of:
A. why the disease is transmittable only when visible lesions are present.
B. the need for the use of petroleum products.
C. the option of disregarding safer-sex practices now that he's already infected.
D. the importance of informing his partners of the disease.

ANSWER D ~ Importance of informing his partners of the disease.

Clients with genital herpes should inform their partners of the disease to help prevent transmission. Petroleum products
should be avoided because they can cause the virus to spread. The notion that genital herpes is only transmittable when
visible lesions are present is false. Anyone not in a long-term, monogamous relationship, regardless of current health
status, should follow safer-sex practices.

6. A 22-year-old patient has presented to her primary care provider for her scheduled Pap smear. Abnormal results of
this diagnostic test may imply infection with:
A. human papillomavirus (HPV).
B. Chlamydia trachomatis.
C. Candida albicans.
D. Trichomonas vaginalis.
ANSWER A ~ human papillomavirus (HPV)
Although a Pap smear does not test directly for HPV, dysplasia of cervical cells is strongly associated with HPV infection.
An abnormal Pap smear is not indicative of chlamydial infection, trichomoniasis, or candidiasis.

7. A female college student is distressed at the recent appearance of genital warts, an assessment finding that her care
provider has confirmed as attributable to human papillomavirus (HPV) infection. Which of the following information
should the nurse give the patient?
A. "It's important to start treatment soon, so you will be prescribed pills today."
B. "I'd like to give you an HPV vaccination if that's okay with you."
C. "There is a chance that these will clear up on their own without any treatment."
D. "Unfortunately, this is going to greatly increase your chance of developing pelvic inflammatory disease."

ANSWER C ~ There is a chance that these will clear up on their own without any tx
Genital warts may resolve spontaneously, although this does not preclude recurrence. Pharmacologic treatments are
topical and vaccination is ineffective after infection has occurred. HPV infection is not correlated with pelvic
inflammatory disease (PID).

8. The physical assessment and history of a 29-year-old female patient are indicative of human papillomavirus (HPV)
infection. You would perform patient teaching related to
A. Gardasil.
B. Antibiotic therapy.
C. Wart removal options.
D. Treatment with antiviral drugs.

ANSWER C ~ Wart removal options

The HPV vaccine (Gardasil) is ineffective in cases of existing HPV, whereas neither antiviral nor antibiotic drugs are
effective treatments. Patient teaching should focus on the various options for physically removing the warts.

9. A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection. Physical
assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese appearance. These
findings are consistent with:
A. candidiasis
B. trichomoniasis
C. bacterial vaginosis
D. Chlamydia

ANSWER A ~ The signs and symptoms of candidiasis include inflammation of the vagina and vulva and a cottage cheese
appearance to the vaginal discharge

10. In establishing screening programs for populations at high risk for STIs, the nurse recognizes that which
microorganism causes nongonococcal urethritis in men and cervicitis in women?
A. Herpes simplex virus
B. Treponema pallidum
C. Chlamydia trachomatis
D. Neisseria gonorrhoeae

ANSWER c. Chlamydia trachomatis can cause nongonococcal urethritis in men and cervicitis in women. Herpes simplex
virus causes genital herpes. Treponema pallidum causes syphilis. Neisseria gonorrhoeae causes gonorrhea.

11. The laboratory result of a specimen from a 20-year-old female patient shows human papillomavirus (HPV). What
would the nurse suspect the patient's diagnosis to be?
A. Syphilis
B. Gonorrhea
C. Genital warts
D. Genital herpes

ANSWER C. Genital warts are caused by human papillomavirus (HPV). Syphilis is caused by T. pallidum. Gonorrhea is
caused by N. gonorrhoeae. Genital herpes are caused by herpes simplex virus.

12. A female patient with a purulent vaginal discharge is seen at an outpatient clinic. The nurse suspects a diagnosis of
gonorrhea. How would this STI be treated?
A. Oral acyclovir (Zovirax)
B. Benzathine penicillin G given IM
C. Ceftriaxone (Rocephin) IM or oral cefixime (Suprax)
D. Would need a second confirmatory test result before treatment

ANSWER C. An established diagnosis of gonorrhea is treated with cefixime (Suprax) orally or with a single dose of IM
ceftriaxone (Rocephin). If chlamydia is also present, azithromycin (Zithromax) or doxycycline (Vibramycin) may also be
used. Gram stain smears are not useful in diagnosing gonorrhea in women because the female genitourinary tract
normally harbors a large number of organisms that resemble N. gonorrhoeae and cultures must be performed to
confirm the diagnosis in women.
Penicillin was used to treat gonorrhea but gonorrhea is now resistant to penicillin. Penicillin G is used to treat syphilis.
Although gonorrhea may lead to pelvic inflammatory disease (PID), its diagnosis would not necessarily indicate that the
patient has PID.

13. A 22-year-old woman with multiple sexual partners seeks care after several weeks of experiencing painful and
frequent urination and vaginal discharge. Although the results of a culture of cervical secretions are not yet available,
the nurse explains to the patient that she will be treated as if she has gonorrhea and chlamydia to prevent
A. obstruction of the fallopian tubes.
B. endocarditis and aortic aneurysms.
C. disseminated gonococcal infection.
D. polyarthritis and generalized adenopathy.
ANSWER A. Upward extension of gonorrhea or chlamydia commonly causes PID, which can cause adhesions and fibrous
scarring, leading to tubal pregnancies and infertility. Disseminated gonococcal infection is rare and endocarditis and
aneurysms are associated with syphilis. Polyarthritis and adenopathy are not seen in gonorrhea or chlamydia.

14. Priority Decision: During evaluation and treatment of gonorrhea in a young man at the health clinic, what is most
important for the nurse to question the patient about?
A. A prior history of STIs
B. When the symptoms began
C. The date of his last sexual activity
D. The names of his recent sexual partners

ANSWER D. All sexual contacts of patients with gonorrhea must be notified, evaluated, and treated for STIs. The other
information may be helpful in diagnosis and treatment but the nurse must try to identify the patient's sexual partners.

15. Which manifestations are characteristic of the late or tertiary stage of syphilis?
A. Heart failure
B. Tabes dorsalis
C. Saccular aneurysms
D. Mental deterioration
E. All of the above

ANSWER E. In the tertiary (or late) stage of syphilis there can be gummas (chronic destructive lesions), cardiovascular
problems (heart failure, aneurysms, valve insufficiency), and neurosyphilis manifestations (mental deterioration, tabes
dorsalis, and speech disturbances). Generalized cutaneous rash occurs in the secondary stage of syphilis, a few weeks
after the chancre appears.

16. Which stage of syphilis is identified by the absence of clinical manifestations and a positive fluorescent treponemal
antibody absorption (FTA-Abs) test?
A. Latent
B. Primary
C. Secondary
D. Late (tertiary)

ANSWER A. Lack of clinical manifestations but a positivetreponemal antibody test with normal cerebrospinal fluid
(CSF) occurs in the latent stage. The primary stage is characterized by a chancre, regional lymphadenopathy,
and genital ulcers. The secondary stage has flu-like symptoms and cutaneous lesions. The late or tertiary stage is
characterized by gummas, cardiovascular changes, and neurosyphilis.

17. A premarital blood test for syphilis reveals that a woman has a positive Venereal Disease Research Laboratory (VDRL)
test. How should the nurse advise the patient?
A. A single dose of penicillin will cure the syphilis.
B. She should question her fiancé about prior sexual contacts.
C. Additional testing to detect specific antitreponemal antibodies is necessary.
D. A lumbar puncture to evaluate cerebrospinal fluid (CSF) is necessary to rule out active syphilis.

ANSWER C. Many other diseases or conditions may cause false positive test results on nontreponemal Venereal Disease
Research Laboratory (VDRL) or rapid plasma reagent (RPR) tests and additional testing is needed before a
diagnosis is confirmed or treatment is administered. The diagnosis is confirmed by specific treponemal tests, such as the
fluorescent antibody absorption (FTA-Abs) test or the TP-PA test. Analysis of CSF is used to diagnose asymptomatic
neurosyphilis.

18. Why should the nurse encourage serologic testing for human immunodeficiency virus (HIV) in the patient with
syphilis?
A. Syphilis is more difficult to treat in patients with HIV infection.
B. The presence of HIV infection increases the risk of contracting syphilis.
C. The incidence of syphilis is increased in those with high rates of sexual promiscuity and drug abuse.
 D. Central nervous system (CNS) involvement is more common in patients with HIV infection and syphilis.

ANSWER C. The risk factors of drug abuse and sexual promiscuity are found in patients with both syphilis and human
immunodeficiency virus (HIV) infection and persons at
highest risk for acquiring syphilis are also at high risk for acquiring HIV. Syphilitic lesions on the genitals
enhance HIV transmission. Also, HIV-infected patients with syphilis appear to be at greatest risk for central nervous
system (CNS) involvement and may require more intensive treatment with penicillin to prevent this complication of HIV.

19. A male patient returns to the clinic with a recurrent urethral discharge after being treated for a chlamydial infection
2 weeks ago. Which statement by the patient indicates the most likely cause of the recurrence of his infection?
A. "I took the Vibramycin twice a day for a week."
B. "I haven't told my girlfriend about my infection yet."
C. "I had a couple of beers while I was taking the medication."
D. "I've only had sexual intercourse once since my medication was finished."

ANSWER B. Notification and treatment of sexual partners are necessary to prevent recurrence and the "ping-pong
effect" of passing STIs between partners. Vibramycin is prescribed
twice a day for 7 days and although alcohol may cause more urinary irritation in the patient with chlamydia, it will not
interfere with treatment.

20. What is the most common way to determine a diagnosis of chlamydial infection in a male patient?
A. Cultures for chlamydial organisms are positive.
B. The nucleic acid amplification test (NAAT) is positive.
C. Gram stain smears and cultures are negative for gonorrhea.
D. Signs and symptoms of epididymitis or proctitis are also present.

ANSWER B. The nucleic acid amplification test (NAAT) is more sensitive than other diagnostic tests, can be done with a
urine sample, and has results within 24 hours. A cell culture can be used to detect chlamydia organisms but it requires
specific handling and is not as easy or as fast to perform as the NAAT. Gonorrhea and chlamydia have very similar
symptoms in men and frequently occur together. Gram stain smears and cultures for N. gonorrhoeae do not definitively
diagnose Chlamydia. Manifestations of epididymitis or proctitis may be present, as with other STIs, but are not
diagnostic.

21. During the physical assessment of a female patient with HPV infection, what should the nurse expect to find?
A. Purulent vaginal discharge
B. A painless, indurated lesion on the vulva
C. Painful perineal vesicles and ulcerations
D. Multiple coalescing gray warts in the perineal area

ANSWER D. HPV is responsible for causing genital warts, which manifest as discrete single or multiple white to gray
warts that may coalesce to form large cauliflower-like masses on the vulva, vagina, cervix, and perianal area. Purulent
vaginal discharge is associated with gonorrhea or chlamydia. Painful perineal vesicles and ulcerations are
characteristic of genital herpes and a chancre of syphilis is a painless indurated lesion on the vulva, vagina, lips, or
mouth.

22. Priority Decision: What is most important for the nurse to teach the female patient with genital warts?
A. Have an annual Papanicolaou (Pap) test.
B. Apply topical acyclovir faithfully as directed.
C. Have her sexual partner treated for the condition.
D. Use a contraceptive to prevent pregnancy, which might exacerbate the disease.

ANSWER A. There is a strong association of genital warts with the development of dysplasia and neoplasia of the genital
tract, especially when lesions involve the cervix, introitus, and
perianal and intraanal mucosa of women or the penis and perianal and anal mucosa of men. Regular Papanicolaou (Pap)
tests in women are critical in detecting early
malignancies of the cervix. Oral acyclovir is used to treat HSV-2 but topical use has no value in treating viral STIs. Sexual
partners of patients with HPV should be examined and treated but because treatment does not destroy the
virus, condoms should always be used during sexual activity. Genital warts often grow more rapidly during pregnancy
but pregnancy is not contraindicated.

23. Which STI actively occurring at the time of delivery would indicate the need for a cesarean section delivery of the
woman's baby?
A. Syphilis
B. Chlamydia
C. Gonorrhea
D. Genital herpes

ANSWER D. Women with an active herpes simplex virus (HSV) genital lesion at the time of delivery have the highest
riskof transmitting genital herpes to the neonate, so delivery will be done with a cesarean section (C-section). Syphilis is
spread to the fetus in utero and has a high risk of stillbirth but C-sections are not required. Treatment with parenteral
penicillin will cure both the mother and the
fetus. Chlamydia spread to the fetus can be prevented by treating the pregnant woman, so a C-section is not required.
Prevention of the spread of gonorrhea to the neonate's eyes
is done with erythromycin ophthalmic ointment or silver nitrate aqueous solution.

23. Although an 18-year-old girl knows that abstinence is one way to prevent STIs, she does not consider that as an
alternative. She asks the nurse at the clinic if there are other measures for preventing STIs. What should the nurse teach
her?
A. Abstinence is the only way to prevent STIs.
B. Voiding immediately after intercourse will decrease the risk for infection.
C. A vaccine can prevent genital warts and cervical cancer caused by some strains of HPV.
D. Thorough hand washing after contact with genitals can prevent oral-genital spread of STIs.

ANSWER C. A vaccine is available for HPV types 6, 11, 16, and 18 that protects against genital warts and cervical cancer.
Although sexual abstinence is the most certain method of
avoiding all STIs, it is not usually a feasible alternative. Undamaged condoms also serve to protect against infection.
Conscientious hand washing and voiding after intercourse are positive hygienic measures that will help to prevent
secondary infections but will not prevent STIs.

24. Patients with which STI are most likely to avoid obtaining and following treatment measures for their infection?
A. Syphilis
B. Gonorrhea
C. HPV infection
D. Genital herpes

ANSWER A. STIs, such as syphilis, that can be treated with a single dose or short course of antibiotic therapy often lead
to a casual attitude about the outcome of the disease, which leads to nonadherence with instructions and delays in
treatment. This is particularly true of diseases that initially show few distressing or uncomfortable symptoms, such as
syphilis.

25. An infant receives a a DTaP immuinization at a well baby clinic. The parent returns home and calls the clinic and
reports swelling & redness at the injection site. Which is an appropriate action?
A. Monitor the infant for a fever
B. Bring the infant back to clinic
C. Apply hot pack
D. Apply cold pack

ANSWER D. On occasion tenderness, swelling and redness appear at the site of a DTaP injection. Cold packs for the first
24 hrs, followed by cold or warm compresses if inflammation persist.

26. A nurse prepares to give a MMR to a 5 yr old. What route should this be given?
A. Sub Q in the gluteal muscle
B. IM in the deltoid
C. Sub Q in the outer aspect of the upper arm
D. IM in the anterolateral aspect of the thigh

ANSWER C. MMR is given subq in the outer aspect of the upper arm

27. A kid with rubeola (measles) is being admitted to hosp. The nurse should plan for which precaution
A. enteric
B. airborne
C. protective
D. neutropenic

ANSWER B. rubeola is transmitted via airborne particles and dirsct contact with the infectious drops. People involved
with the kid should wear a mask, private room, door remains closed,

28. The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the
convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further
instruction?
A. "We need to encourage our child to drink fluids."
B. "Coughing spells may be triggered by dust or smoke."
C. "Vomiting may occur when our child has coughing episodes."
D. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

ANSWER D. Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period
occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase.
Options 1, 2, and 3 are accurate components of home care instructions.
29. A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose.
Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which
substance?
A. Eggs
B. Penicillin
C. Sulfonamides
D. A previous dose of hepatitis B vaccine or component
ANSWER D. A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose
of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs,
penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

30. The most effective way to break the chain of infection is by:
A. Practicing good hand hygiene
B. Wearing gloves
C. Placing clients in isolation
D. Providing private rooms for clients

ANSWER A. Good hand hygiene is the most effective way to break the chain of infection. Wearing gloves can help in
decreasing disease transmission, but clean hands are required for it to be truly effective. Placing clients in isolation is
costly and often unnecessary, and clients can be psychologically harmed by isolation. Even providing private rooms for
clients will not be effective if health care workers do not follow good hand hygiene practices.

SITUATION: Freddie a 38-year-old male working as a banker has tested positive for HIV. Upon interview, he has
disclosed that he has had unprotected sex with multiple male and female sexual partners. He also has told the nurse
about his sexuality and considers himself as a bisexual. Based on the findings of his signs and symptoms, his condition
has already progressed to having acquired immunodeficiency syndrome (AIDS).

31. In the diagnosis of HIV, which of the following tests would confirm that Freddie is positive for the virus?
A. Enzyme-linked immunosorbent assay (ELISA) test
B. Western-blot test
C. Viral load test
D. Home access express test

ANSWER: B. The primary tests for diagnosing HIV and AIDs include: ELISA Test ELISA, which stands for enzyme-linked
immunosorbent assay, is used to detect HIV infection. If an ELISA test is positive, the Western blot test is usually
administered to confirm the diagnosis.

32. Freddie is asking Nurse Freda on how the virus is transmitted. The nurse must know that Freddie must have gotten
the virus through unprotected sexual intercourse. Which of the following sexual acts would least likely transmit HIV?
A. Anal sex
B. Vaginal sex
C. Oral sex
D. None of the above

ANSWER: C
RATIONALE: According to the CDC, unless the person has open lesions in the oral mucosa, the person at the receiving
end of oral sex is least likely to have the disease.

33. Nurse Freda is planning for the confinement of Freddie at the infectious disease ward. Which of the following types
of isolation precautions will Nurse Freda implement with regard to Freddie’s diagnosis?
A. Contact precautions
B. Airborne precautions
C. Reverse isolation precautions
D. Droplet precautions

ANSWER: C Since the patient is immunocompromised, reverse isolation is a procedure designed to protect a patient
from infectious organisms carried by staff, patients or other patients. The organisms are typically spread by droplets in
the air or on equipment. All staff should wash their hands prior to entering the room.

34. Freddie has stated to the nurse, “I think my friends have abandoned me when they learned about my condition. I
feel so hopeless.” The nurse’s most appropriate nursing intervention for his statement would be
A. Powerlessness
B. Deficient knowledge
C. Social isolation
D. Disturbed thought processes
ANSWER: C Since the patient feels that his friends may have abandoned him, the most appropriate nursing diagnosis for
him would be social isolation.

35. When doing the discharge planning for Freddie, the nurse must advise the patient to avoid which of the following
types of food?
A. Lean meats such as beef sirloin and chicken breast
B. Raw fresh food such as sushi
C. Soft fruits such as bananas or pears
D. Peanut butter on toast and crackers

ANSWER: B Avoid foods that are raw since they can cause GI infection brought about by the patient’s immunodeficiency.

SITUATION: A 45-year-old male banker named Arturito presents to the health department with complaints of a sore on
his penis. The patient says that it is painless and started out as a “small red bump” and “turned into this”. You note the
area is ulcerated, red, has sharp borders and is approximately 2.5 cm. The patient reports to having multiple sexual
partners the past 3 months. A blood sample was collected from and results show that he is positive for syphilis.

36. Nurse Monica, who is currently assigned to Arturito, must know that syphilis is caused by which of the of following
microorganisms?
A. Clostridium perfringens
B. Treponema pallidum
C. Chlamydia trachomatis
D. Serratia marcescens

ANSWER: B The causative agent for syphilis is treponema pallidum.

37. Rapid point-of-care test has determined his diagnosis of syphilis. Along with syphilis, this method of testing also
detects the presence of
A. Hepatitis A
B. Neisseria gonorheae
C. Human immunodeficiency virus (HIV)
D. Human papilloma virus (HPV)

ANSWER: C The introduction of rapid point-of-care tests (RDTs) that can detect both HIV and syphilis, using one single
blood specimen, would be a promising tool to integrate the detection of syphilis into HIV programs and so improve the
accessibility of syphilis testing and treatment.

38. Arturito asks Nurse Monica about the complications of syphilis if it is left untreated. Nurse Monica must state that
its complication is
A. Epididymitis
B. Epididymo-orchitis
C. Meningitis
D. Immunosuppression

ANSWER: C Meningitis is the late stage complication of syphilis. Epididymitis and orchitis is present in chlamydial and
gonorrheal infections. Immunosuppression is seen in the late stages of HIV infection.

39. Nurse Monica must expect the physician to prescribe which of the following drugs for the treatment of syphilis?
A. Penicillin-G
B. Cotrimoxazole
C. Ceftriaxone
D. Amikacin

ANSWER: A Key principles for the treatment of syphilis include the following: Penicillin is the drug of choice to treat
syphilis. Doxycycline is the best alternative for treating early and late latent syphilis.

40. Nurse Monica is doing patient education prior to patient discharge. Which of the following statements from Arturito
would require further education?
A. “I must abstain from sexual contact with anyone until the skin lesion is healed.”
B. “I will be immune from the disease once I am cured from it.”
C. “When I resume sexual activities, I must wear condoms at all times.”
D. “It is better if I limit my sexual partners to one.”

ANSWER: C The treatment of choice for measles with eye complications would be the application of tetracycline
ointment on the eyes of the child. Advise the mother to apply it 4 times a day by applying it on the inside of the lower
lid of the child.

SITUATION: A 7-year-old child named Berto is brought to the hospital with clinical manifestations of fever 38.5 degrees
Celsius, neck and facial rigidity, board-like abdomen, and a grinning expression. The parents of Berto has stated that
their son has an infected foot injury. The patient was diagnosed to have tetanus.

41. Nurse Carol has noticed that Berto is constantly arching his back. Nurse Carol knows that this in one of the
characteristic signs of tetanus. She must place this on the chart as
A. Nuchal rigidity
B. Opisthotonos
C. Trismus
D. Risus sardonicus

ANSWER: B Opisthotonos is a specific abnormal posture associated with conditions and injuries that impair brain and
muscle function. The characteristic symptoms of opisthotonos are a severely arched or curved spine and head and heels
that tilt backward. Though relatively rare, the condition is usually a symptom of severe neurological conditions that are
life threatening and require medical care.

42. Which of the following tetanus toxins is responsible for muscle spasms?
A. Tetanolysin
B. Tetanospasmin
C. Neurotoxin
D. Hematoxin

ANSWER: B The toxin responsible for muscle spasms is tetanospasmin. Tetanolysin is responsible for the destruction of
the RBCs.

43. One of the equipment that Nurse Carol has to prepare at the patient’s bedside with regard to tetanus is
A. Oxygen tank and mask
B. Tracheostomy set
C. Endotracheal tube and laryngoscope
D. Blood urea-nitrogen and creatinine tests

ANSWER: D The patient who is experiencing oliguria may be experiencing renal failure. In order to check for the kidney
functioning, the doctor will order for BUN and creatinine tests.

44. Which of the following status should Nurse Carol ask from the parents of Carlo?
A. Nutritional status
B. Vitamin A status
C. Deworming status
D. Immunization status

ANSWER: D Tetanus can be easily avoided if the parents are educated about the immunization against it. That within 72
hours of a punctured wound, the patient should receive ATS, especially if the patient has no previous immunization
against it.

45. The parents told Nurse Carol that they are not aware of immunizations of any kind that is why they have not availed
it for their children since they were still infants. Which of the following nursing diagnosis would be most applicable
for them?
A. Anticipatory grieving
B. Knowledge deficit
C. High risk for infection
D. Social isolation

ANSWER: B The parents are not educated about the importance of immunization and the diseases that they can
prevent. It is a good opportunity for the nurse to educate them about vaccines.

SITUATION: A 62-year-old female patient named Dolores is exhibiting the signs and symptoms of chills with rising fever,
stabbing pain whenever she coughs or breathes, has a sputum that is rusty in color, and has body malaise. Sputum
analysis shows that the patient is suffering from community acquired pneumonia.

46. Which the following bacterial microorganisms is most common in this type of pneumonia?
A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Haemophilus influenzae
D. Klebsiella pneumoniae

ANSWER: D The most common causative agent is Streptococcus pneumoniae, which is responsible for almost 50% of
cases, other common causes are respiratory viruses (mainly influenza A) and the atypical bacteria Chlamydophila
pneumoniae and Mycoplasma pneumoniae.

47. Nurse Mitzi is assigned to Dolores and has observed that she has developed dyspnea with a respiratory rate of 32
breaths/minute and is having difficulty in expectorating her secretions. Nurse Mitzi has heard bronchial sounds in
the left lower lobe upon auscultation. The nurse determines that the client requires which of the following initial
treatments?
A. Antibiotics
B. Bed rest
C. Oxygen
D. Nutritional intake

ANSWER: C The client is having difficulty breathing and is probably becoming hypoxic. As an emergency measure, the
nurse can provide oxygen without waiting for a physician’s order. Antibiotics may be warranted, but this isn’t a nursing
decision. The client should be maintained on bedrest if he is dyspneic to minimize his oxygen demands, but providing
additional will deal more immediately with his problem. The client will need nutritional support, but while dyspneic, he
may be unable to spare the energy needed to eat and at the same time maintain adequate oxygenation.

48. Currently Dolores has developed fever with a temperature of 39.4 degrees Celsius, has profuse sweating, and a
productive cough. Nurse Mitzi must include which of the following measures in the plan of care for Dolores?
A. Frequent offering of a bedpan
B. Frequent linen changes
C. Nasotracheal suctioning to clear secretions
D. Position changes every 4 hours

ANSWER: B Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general
discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours.
Nasotracheal
suctioning is not indicated with the client’s productive cough. Frequent offering of a bedpan is not indicated by the data
provided in this scenario.

49. Dolores then is observed to have cyanosis. The cyanosis that accompanies bacterial pneumonia is mainly caused
by which of the following
A. Decreased oxygenation of the blood
B. Inadequate peripheral circulation
C. Pleural effusion
D. Decreased cardiac output

ANSWER: A A client with pneumonia has less lung surface available for the diffusion of gases because of the
inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client
becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation.

50. Continuous positive airway pressure (CPAP) can be provided through an oxygen mask to improve oxygenation in
hypoxic patients by which of the following methods?
A. The mask provides pressurized at the end of expiration to open collapsed alveoli.
B. The mask provides pressurized oxygen so the client can breathe more easily.
C. The mask provides continuous air that the client can breathe.
D. The mask provides 100% oxygen to the client.

ANSWER: B The mask provides pressurized oxygen continuously through both inspiration and expiration. The mask can
be set to deliver any amount of oxygen needed. By providing the client with pressurized oxygen, the client has less
resistance to overcome in taking his next breath, making it easier to breathe. Pressurized oxygen delivered at the end of
expiration is positive end-expiratory pressure (PEEP), not continuous positive airway pressure.
NS 1 QUIZ 10 CARDIO
Scenario: Mara's Cardiovascular Health
Mara, a 58-year-old female, arrives at the emergency department with complaints of chest pain and shortness
of breath. She has a medical history that includes hypertension, hyperlipidemia, and a family history of
cardiovascular disease. She also smokes a pack of cigarettes daily and leads a sedentary lifestyle. The triage
nurse quickly assesses her vital signs, which include a blood pressure of 160/90 mmHg, heart rate of 100 beats
per minute, respiratory rate of 22 breaths per minute, and oxygen saturation of 94% on room air. She appears
anxious and diaphoretic.

1. What is the priority nursing action when caring for Mara?

A. Administer pain medication
B. Perform a complete physical assessment
C. Obtain a detailed health history
D. Draw blood for laboratory tests
Answer: b) Perform a complete physical assessment
Rationale: Assessing Mara's current condition is the priority to determine the cause of her symptoms and
initiate appropriate interventions.
2. Based on Mara's vital signs and symptoms, which condition should the nurse suspect?
A. Pneumonia
B. Gastroesophageal reflux disease (GERD)
C. Myocardial infarction (MI)
D. Anxiety disorder
Answer: c) Myocardial infarction (MI)
Rationale: The combination of chest pain, shortness of breath, diaphoresis, and elevated blood pressure and
heart rate suggests a cardiac event like MI.
3. What is the primary goal of initial treatment for Mara?
A. Decrease blood pressure
B. Relieve chest pain
C. Reduce anxiety
D. Improve oxygen saturation
Answer: b) Relieve chest pain
Rationale: In suspected MI, the priority is to relieve chest pain and minimize myocardial damage.
4. What diagnostic test is essential to confirm the diagnosis of MI?
A. Electrocardiogram (ECG)
B. Chest X-ray
C. Complete blood count (CBC)
D. Urinalysis
Answer: a) Electrocardiogram (ECG)
Rationale: An ECG can show characteristic changes in the presence of an MI, such as ST-segment elevation
or depression.
5. Which medication should the nurse expect to administer to Mara to alleviate chest pain and improve
blood flow to the heart?
A. Morphine sulfate
B. Nitroglycerin
C. Aspirin
D. Heparin
Answer: b) Nitroglycerin
Rationale: Nitroglycerin is commonly used to relieve chest pain (angina) and improve coronary blood flow.
6. Mara's physician orders aspirin for her. What is the purpose of aspirin in the management of MI?
A. To reduce inflammation
B. To lower blood pressure
C. To inhibit platelet aggregation
D. To provide analgesia
Answer: c) To inhibit platelet aggregation
Rationale: Aspirin is used to prevent further clot formation by inhibiting platelet aggregation.
7. While administering nitroglycerin to Mara, the nurse should instruct her to:
A. Swallow the tablet whole with water.
B. Chew the tablet for faster relief.
 C. Apply the ointment to her chest.
D. Place the tablet under her tongue.
Answer: d) Place the tablet under her tongue.
Rationale: Nitroglycerin tablets are typically administered sublingually for rapid absorption.
8. Mara's elevated blood pressure may be due to her anxiety. What non-pharmacological intervention
can help reduce her anxiety?
A. Encourage deep breathing exercises
B. Administer an anxiolytic medication
C. Apply cold packs to the forehead
D. Increase her fluid intake
Answer: a) Encourage deep breathing exercises
Rationale: Deep breathing exercises can help reduce anxiety and promote relaxation.
9. After initial stabilization, what is the next nursing action for Mara?
A. Administer intravenous (IV) antibiotics
B. Arrange for a stress test
C. Provide education on smoking cessation
D. Prepare for immediate surgery
Answer: b) Arrange for a stress test
Rationale: A stress test can help assess the extent of myocardial damage and guide further treatment.
10. What teaching should the nurse provide to Mara regarding her risk factors for cardiovascular disease?
A. "You can continue smoking in moderation."
B. "Exercise is not recommended for you."
C. "Consider a diet rich in saturated fats."
D. "You should aim to quit smoking and adopt a heart-healthy lifestyle."
Answer: d) "You should aim to quit smoking and adopt a heart-healthy lifestyle."
Rationale: Quitting smoking and adopting a heart-healthy lifestyle are crucial in reducing cardiovascular risk
factors.

11. In addition to smoking cessation, which lifestyle modification should the nurse emphasize to Mara to
reduce her risk of cardiovascular disease?
A. Decrease fluid intake to reduce blood pressure
B. Engage in regular physical activity
C. Consume a high-sodium diet
D. Limit emotional expression to prevent stress
Answer: b) Engage in regular physical activity
Rationale: Regular physical activity helps improve cardiovascular health by reducing hypertension and
improving overall fitness.

12. Mara asks why she needs to control her hypertension. The nurse's response should include:
A. "Hypertension can lead to kidney stones."
B. "High blood pressure increases your risk of stroke and heart disease."
C. "Hypertension only affects your blood vessels."
D. "You don't need to worry about hypertension at your age."
Answer: b) "High blood pressure increases your risk of stroke and heart disease."
Rationale: Hypertension is a major risk factor for stroke and heart disease.
13. Mara's physician prescribes a beta-blocker to manage her hypertension. The nurse should monitor her
for which potential side effect?
A. Bradycardia
B. Elevated blood pressure
C. Increased anxiety
D. Respiratory depression
Answer: a) Bradycardia
Rationale: Beta-blockers can slow the heart rate, potentially causing bradycardia.
14. To assess for complications of hypertension, the nurse should prioritize monitoring which organ
system?
A. Respiratory
B. Musculoskeletal
C. Renal
 D. Gastrointestinal
Answer: c) Renal
Rationale: Hypertension can lead to renal complications, including kidney damage.
15. Mara's blood work shows elevated low-density lipoprotein (LDL) cholesterol levels. Which dietary
recommendation should the nurse make to help lower her LDL cholesterol?
A. Increase intake of saturated fats
B. Limit dietary fiber intake
C. Consume more fruits and vegetables
D. Avoid all dietary fats
Answer: c) Consume more fruits and vegetables
Rationale: Fruits and vegetables are low in saturated fats and high in fiber, which can help lower LDL
cholesterol levels.
16. Mara is prescribed a statin medication to manage her hyperlipidemia. The nurse should instruct her to:
A. Take the medication with grapefruit juice for better absorption.
B. Take the medication on an empty stomach.
C. Avoid alcohol while taking the medication.
D. Discontinue the medication if muscle pain occurs.
Answer: c) Avoid alcohol while taking the medication.
Rationale: Alcohol can interact with statin medications and increase the risk of liver damage.
17. Mara's family history of cardiovascular disease is significant. What action should she take to address
this risk factor?
A. Ignore the family history as it doesn't affect her risk.
B. Seek genetic testing to determine her risk.
C. Avoid all physical activity to reduce stress.
D. Continue her current lifestyle with no changes.
Answer: b) Seek genetic testing to determine her risk.
Rationale: Genetic testing can help identify specific cardiovascular risk factors associated with family
history.
18. What is the most common cause of coronary artery disease (CAD)?
A. Smoking
B. Hyperlipidemia
C. Genetic factors
D. Physical inactivity
Answer: b) Hyperlipidemia
Rationale: Hyperlipidemia is a major risk factor for CAD.
19. Mara's chest pain has resolved with treatment, but she still needs ongoing care. What healthcare
provider should she be referred to for long-term management?
A. Dermatologist
B. Cardiologist
C. Ophthalmologist
D. Gastroenterologist
Answer: b) Cardiologist
Rationale: A cardiologist specializes in the diagnosis and treatment of heart conditions.
20. The nurse is teaching Mara about her prescribed medications. What information should be included?
A. "You can stop taking your medications once your symptoms improve."
B. "Medications can cure your heart condition."
C. "Take your medications as prescribed, even if you feel better."
D. "It's safe to skip doses if you experience side effects."
Answer: c) "Take your medications as prescribed, even if you feel better."
Rationale: Medications for cardiovascular conditions often need to be taken long-term to manage the
condition effectively.

21. Mara's chest pain has resolved, and her vital signs are stable. The nurse should continue monitoring
her ECG for:
A. Any changes in rhythm or ST-segment elevation
B. Blood pressure fluctuations
C. Oxygen saturation levels
D. Urine output
Answer: a) Any changes in rhythm or ST-segment elevation
Rationale: Continuous ECG monitoring is essential to detect any cardiac rhythm abnormalities or ST-
segment changes that may indicate ongoing myocardial ischemia.
22. Mara is anxious about her diagnosis and upcoming treatments. What nursing intervention can help
alleviate her anxiety?
A. Administering a sedative immediately
B. Providing emotional support and reassurance
C. Encouraging her to avoid discussing her condition
D. Recommending caffeine intake to stay alert
Answer: b) Providing emotional support and reassurance
Rationale: Emotional support and reassurance are essential for patients experiencing anxiety. Sedatives
should be used cautiously and under medical guidance.
23. Mara asks the nurse about the purpose of heparin, which has been prescribed. The nurse explains that
heparin is given to:
A. Dissolve existing blood clots
B. Reduce blood pressure
C. Prevent the formation of new blood clots
D. Manage chest pain
Answer: c) Prevent the formation of new blood clots
Rationale: Heparin is an anticoagulant used to prevent the formation of new blood clots and to manage
conditions like deep vein thrombosis and pulmonary embolism.
24. To assess the effectiveness of nitroglycerin in relieving chest pain, the nurse should:
A. Monitor oxygen saturation
B. Assess for adverse effects such as headache
C. Count the respiratory rate
D. Ask about the patient's last meal
Answer: b) Assess for adverse effects such as headache
Rationale: Nitroglycerin may cause side effects, such as headache, which should be monitored. Relief of
chest pain is an expected outcome.
25. Mara is scheduled for a cardiac catheterization. The nurse should inform her that this procedure is
done to:
A. Remove plaque from her arteries
B. Measure her cholesterol levels
C. Assess the extent of coronary artery blockages
D. Diagnose lung disease
Answer: c) Assess the extent of coronary artery blockages
Rationale: Cardiac catheterization is a procedure used to visualize the coronary arteries and assess
blockages or other abnormalities.
26. During cardiac catheterization, the nurse should closely monitor for signs of a potential complication
known as contrast-induced nephropathy (CIN). Which assessment finding is most indicative of CIN?
A. Elevated blood pressure
B. Decreased urine output and increased serum creatinine levels
C. Bradycardia
D. Nausea and vomiting
Answer: b) Decreased urine output and increased serum creatinine levels
Rationale: Contrast-induced nephropathy can lead to decreased urine output and increased serum
creatinine levels, indicating renal dysfunction.
27. Mara is prescribed clopidogrel (Plavix). The nurse should educate her about this medication's purpose,
which is to:
A. Reduce cholesterol levels
B. Prevent blood clot formation in her arteries
C. Lower blood pressure
D. Alleviate chest pain
Answer: b) Prevent blood clot formation in her arteries
Rationale: Clopidogrel is an antiplatelet medication used to prevent blood clot formation in the arteries.
28. To promote smoking cessation in Mara, the nurse should:
A. Advise her to switch to smokeless tobacco products
B. Encourage her to smoke only a few cigarettes a day
 C. Provide information on smoking cessation programs and resources
D. Tell her that smoking is not a significant risk factor for cardiovascular disease
Answer: c) Provide information on smoking cessation programs and resources
Rationale: Providing information and resources for smoking cessation is an effective way to support
patients in quitting smoking.
29. What dietary recommendation should the nurse provide to Mara to help lower her blood pressure?
A. Increase sodium intake
B. Consume a high-caffeine diet
C. Reduce potassium-rich foods
D. Maintain a low-sodium diet
Answer: d) Maintain a low-sodium diet
Rationale: Reducing sodium intake is recommended to lower blood pressure.
30. Mara's ECG shows ST-segment elevation. The nurse recognizes this as a sign of:
A. Hypoxia
B. Ventricular fibrillation
C. Myocardial ischemia
D. Bradycardia
Answer: c) Myocardial ischemia
Rationale: ST-segment elevation on the ECG can indicate myocardial ischemia or infarction.

31. Mara is prescribed metoprolol, a beta-blocker. The nurse should educate her about potential side
effects, including:
A. Increased heart rate
B. Decreased blood pressure
C. Weight gain
D. Elevated cholesterol levels
Answer: b) Decreased blood pressure
Rationale: Beta-blockers like metoprolol can cause a decrease in blood pressure, which is a potential side
effect.
32. As part of Mara's ongoing care, which laboratory test should be monitored to assess her response to
statin therapy?
A. Hemoglobin level
B. Blood glucose level
C. Liver function tests
D. Serum sodium level
Answer: c) Liver function tests
Rationale: Statin medications can affect liver function, so monitoring liver function tests is important during
therapy.
33. Mara is scheduled for a stress test. The nurse explains that this test is used to:
A. Measure lung function
B. Assess blood glucose levels
C. Evaluate her response to stress
D. Monitor electrolyte balance
Answer: c) Evaluate her response to stress
Rationale: A stress test is used to evaluate the heart's response to stress or exercise, assessing for
cardiovascular abnormalities.
34. Mara expresses concerns about her ability to exercise regularly due to her busy lifestyle. What nursing
intervention should the nurse recommend to promote physical activity?
A. Suggest a rigorous daily exercise routine
B. Encourage Mara to find short periods for physical activity throughout the day
C. Advise her to prioritize work over exercise
D. Recommend complete rest during leisure time
Answer: b) Encourage Mara to find short periods for physical activity throughout the day
Rationale: Finding short bursts of physical activity throughout the day can help individuals with busy
lifestyles incorporate exercise into their routines.
35. Mara is prescribed sublingual nitroglycerin. What instructions should the nurse provide regarding its
storage?
A. Keep it in the refrigerator to prolong shelf life
 B. Store it in the original container, away from light and moisture
C. Keep it in a warm place to prevent crystallization
D. Store it in a pill organizer for easy access
Answer: b) Store it in the original container, away from light and moisture
Rationale: Nitroglycerin should be stored in its original container to protect it from light and moisture,
which can reduce its effectiveness.
36. Mara's physician prescribes an angiotensin-converting enzyme (ACE) inhibitor. The nurse should
monitor her for which common side effect of ACE inhibitors?
A. Hyperkalemia
B. Hypoglycemia
C. Hypertension
D. Fluid retention
Answer: a) Hyperkalemia
Rationale: ACE inhibitors can lead to hyperkalemia (elevated potassium levels) as a side effect.
37. To assess for peripheral vascular disease (PVD) in Mara, the nurse should:
A. Measure blood pressure in the lower extremities
B. Assess her lung sounds
C. Perform a visual examination of the skin
D. Check for hearing loss
Answer: a) Measure blood pressure in the lower extremities
Rationale: Measuring blood pressure in the lower extremities can help identify PVD by comparing it to arm
blood pressure.
38. Mara is concerned about her family history of cardiovascular disease. What risk factors can be
influenced by genetic factors?
A. Smoking and physical inactivity
B. Diet and obesity
C. Age and gender
D. Hypertension and hyperlipidemia
Answer: c) Age and gender
Rationale: Age and gender are influenced by genetic factors but cannot be changed. Other risk factors like
smoking, diet, hypertension, and hyperlipidemia can be influenced by lifestyle changes.
39. During her hospital stay, Mara experiences an episode of chest pain that is not relieved by
nitroglycerin. What action should the nurse take?
A. Document the pain and reassure Mara that it will pass
B. Administer another dose of nitroglycerin and monitor her closely
C. Notify the healthcare provider immediately
D. Offer a heating pad to relieve the pain
Answer: c) Notify the healthcare provider immediately
Rationale: Persistent chest pain that is not relieved by nitroglycerin may indicate ongoing myocardial
ischemia and requires prompt medical attention.
40. To promote a heart-healthy diet for Mara, the nurse should recommend:
A. High intake of saturated fats and cholesterol-rich foods
B. Limiting fruit and vegetable consumption
C. Reducing salt intake
D. Increasing processed food consumption
Answer: c) Reducing salt intake
Rationale: Reducing salt intake is important for a heart-healthy diet as it helps control blood pressure.

41. A client is admitted to an emergency department with chest pain that is being ruled out for myocardial
infarction. Vital signs are as follows: at 11 AM, pulse (P), 92 beats/min, respiratory rate (RR), 24
breaths/min, blood pressure (BP), 140/88 mm Hg; 11:15 AM, P, 96 beats/min, RR, 26 breaths/min, BP,
128/82 mm Hg; 11:30 AM, P, 104 beats/min, RR, 28 breaths/min, BP, 104/68 mm Hg; 11:45 AM, P, 118
beats/min, RR, 32 breaths/min, BP, 88/58 mm Hg. The nurse should alert the physician because these
changes are most consistent with which of the following complications?
A. Cardiogenic shock
B. Cardiac tamponade
C. Pulmonary embolism
D. Dissecting thoracic aortic aneurysm
Answer A Cardiogenic shock
Rationale: Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs
include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin.
Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is
accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents
suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are
accompanied by back pain.

42. A client admitted to the hospital with chest pain and history of type 2 diabetes mellitus is scheduled for
cardiac catheterization. Which of the following medications would need to be withheld for 48 hours
before and after the procedure?

A. Regular insulin
B. Glipizide (Glucotrol)
C. Repaglinide (Prandin)
D. Metformin (Glucophage)

Answer D. Metformin
Rationale: Metformin (Glucophage) needs to be withheld 48 hours before and after cardiac catheterization
because of the injection of contrast medium during the procedure. If the contrast medium affects kidney
function, with metformin in the system, the client would be at increased risk for lactic acidosis. The
medications in options 1, 2, and 3 do not need to be withheld 48 hours before or after cardiac
catheterization.

43. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and
begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when
auscultating the client's breath sounds?
A. Stridor
B. Crackles
C. Scattered rhonchi
D. Diminished breath sounds

Answer B Crackles
Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the
production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and
diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated
with laryngospasm or edema of the upper airway.

44. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no
electrocardiographic complexes on the screen. Which of the following should be the priority action of
the nurse?
A. Call a code blue.
B. Call the physician.
C. Check the client status and lead placement.
D. Press the recorder button on the electrocardiogram console.
Answer C. Check the client status and lead placement
Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly
electrode displacement. Accurate assessment of the client and equipment is necessary to determine the
cause and identify the appropriate intervention. Options 1, 2, and 4 are unnecessary.

45. A client has developed atrial fibrillation, with a ventricular rate of 150 beats/min. The nurse should
assess the client for which associated signs or symptoms?
A. Flat neck veins
B. Nausea and vomiting
C. Hypotension and dizziness
D. Hypertension and headache
Answer C. Hypotension and dizziness
Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is
at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations,
chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of
breath, and distended neck veins.

46. A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4
hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes
redness and edema. The pedal pulse is palpable and unchanged from admission. How would the nurse
correctly interpret the client's neurovascular status?

A. The neurovascular status is normal because of increased blood flow through the leg.
B. The neurovascular status is moderately impaired, and the surgeon should be called.
C. The neurovascular status is slightly deteriorating and should be monitored for another hour.
D. The neurovascular status is adequate from an arterial approach, but venous complications are
arising.

Answer A. The neurovascular status is normal because of increased blood flow through the leg Rationale: An
expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical
extremity because of increased blood flow. Therefore options 2, 3, and 4 are incorrect interpretations.

47. A client with angina complains that the anginal pain is prolonged and severe and occurs at the same
time each day, most often at rest in the absence of precipitating factors. How would the nurse best
describe this type of anginal pain?
A. Stable angina
B. Variant angina
C. Unstable angina
D. Nonanginal pain

Answer B Variant Angina

Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each
day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets.
Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a
precursor of myocardial infarction.
48. A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse
would determine that the client is receiving the therapeutic effect based on which of the following
results?
A. Prothrombin time of 12.5 seconds
B. Activated partial thromboplastin time of 60 seconds
C. Activated partial thromboplastin time of 28 seconds
D. Activated partial thromboplastin time longer than 120 seconds

Answer B.
Rationale: Common laboratory ranges for activated partial thromboplastin time are 20 to 36 seconds.
Because the activated partial thromboplastin time should be 1.5 to 2.5 times the normal value, the client's
activated partial thromboplastin time would be considered therapeutic if it was 60 seconds.

49. A nurse provides discharge instructions to a postoperative client who is taking warfarin sodium
(Coumadin). Which statement, if made by the client, reflects the need for further teaching?
A. "I will take my pills every day at the same time."
B. "I will avoid alcohol consumption."
C. "I have already called my family to pick up a Medic-Alert bracelet."
D. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."

Answer D.
Rationale: Ecotrin is an aspirin-containing product and should be avoided. Alcohol consumption should be
avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day
increases client compliance. The Medic-Alert bracelet provides health care personnel emergency
information.

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The
client suddenly complains of chest pain. Which of the following questions would best help a nurse discriminate
pain caused by a non cardiac problem?
A. "Can you describe the pain to me?"
B. "Have you ever had this pain before?"
C. "Does the pain get worse when you breathe in?"
D. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

Answer C
Rationale: Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics,
location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Options 1, 2,
and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens
on inspiration.
NS 1 QUIZ 11 HEMA

Case Scenario:

Marga is a 45-year-old female who presents to the emergency department with complaints of
fatigue, shortness of breath, and pallor. She reports that she has been feeling weak for the past
few weeks and has experienced nosebleeds and easy bruising. Marga's vital signs are stable,
but a physical examination reveals pale conjunctiva and generalized weakness. Laboratory tests
are ordered, and further evaluation of her hematologic system is necessary.

1. What common symptom is Marga experiencing that is indicative of a potential

hematologic disorder?
A. Fever
B. Cough
C. Fatigue
D. Headache

Answer: C) Fatigue
Rationale: Fatigue is a common symptom of hematologic disorders, often due to anemia or
other blood-related issues.

2. Which physical examination finding is consistent with Marga's potential hematologic

condition?
A. Reddened throat
B. Yellowing of the skin and eyes
C. Swollen lymph nodes
D. Pallor of the conjunctiva

Answer: D) Pallor of the conjunctiva

Rationale: Pallor of the conjunctiva, or paleness of the mucous membranes, is a common
finding in individuals with anemia or other hematologic disorders.

3. Which laboratory test is typically used to confirm the presence of anemia?

A. Serum calcium levels
B. Serum creatinine levels
C. Complete blood count (CBC)
D. Urine specific gravity

Answer: C) Complete blood count (CBC)

Rationale: A CBC is a standard test used to assess various blood components, including
hemoglobin and hematocrit levels, which are indicative of anemia.

4. Marga's CBC results reveal a low hemoglobin level. What type of anemia is most likely
indicated by this finding?
 A. Iron-deficiency anemia
B. Sickle cell anemia
C. Hemolytic anemia
D. Aplastic anemia

Answer: A) Iron-deficiency anemia

Rationale: Low hemoglobin levels are characteristic of iron-deficiency anemia, which is the
most common type of anemia worldwide.

5. Which dietary component is essential for the production of hemoglobin and should be
considered in the management of iron-deficiency anemia?
A. Vitamin C
B. Vitamin D
C. Calcium
D. Vitamin K

Answer: A) Vitamin C
Rationale: Vitamin C enhances the absorption of dietary iron, making it an essential component
of iron-deficiency anemia management.

6. Marga's iron-deficiency anemia is suspected to be due to chronic gastrointestinal

bleeding. What diagnostic test can help identify the source of the bleeding?
A. Echocardiogram
B. Upper gastrointestinal endoscopy
C. Electrocardiogram (ECG)
D. Lumbar puncture

Answer: B) Upper gastrointestinal endoscopy

Rationale: An upper gastrointestinal endoscopy can visualize the upper digestive tract and help
identify the source of gastrointestinal bleeding.

7. Marga is diagnosed with iron-deficiency anemia, and treatment is initiated. What is the
primary treatment for this type of anemia?
A. Blood transfusion
B. Erythropoietin injection
C. Iron supplementation
D. Platelet transfusion

Answer: C) Iron supplementation

Rationale: The primary treatment for iron-deficiency anemia is the supplementation of iron to
replenish depleted iron stores.

8. Marga's iron supplementation has been initiated. Which adverse effect should the nurse
educate her about and monitor for?
 A. Elevated blood pressure
B. Constipation
C. Increased energy levels
D. Improved appetite

Answer: B) Constipation
Rationale: Iron supplementation can cause constipation as a common adverse effect. Patients
should be educated on this and advised to increase their dietary fiber intake.

9. Marga's symptoms do not improve after iron supplementation. Further evaluation

reveals an underlying autoimmune disorder, leading to the destruction of her red blood
cells. Which type of anemia is she likely experiencing?
A. Iron-deficiency anemia
B. Hemolytic anemia
C. Aplastic anemia
D. Sickle cell anemia

Answer: B) Hemolytic anemia

Rationale: Hemolytic anemia results from the destruction of red blood cells, which can occur in
autoimmune disorders among other causes.

10. In hemolytic anemia, what laboratory finding would be elevated due to the breakdown
of red blood cells?
A. Serum iron levels
B. Bilirubin levels
C. Platelet count
D. Erythropoietin levels

Answer: B) Bilirubin levels

Rationale: In hemolytic anemia, the destruction of red blood cells releases hemoglobin, which is
metabolized to bilirubin, leading to elevated bilirubin levels in the blood.

11. Marga is diagnosed with autoimmune hemolytic anemia (AIHA). What is the primary
goal of treatment for AIHA?
A. Suppress the immune system
B. Increase iron intake
C. Administer blood transfusions
D. Encourage fluid intake

Answer: A) Suppress the immune system

Rationale: The primary goal of treating AIHA is to suppress the immune system's abnormal
response to red blood cells, often achieved through immunosuppressive medications.
 12. Which medication is commonly used as an immunosuppressant in the treatment of
autoimmune hemolytic anemia?
A. Iron supplements
B. Prednisone
C. Folic acid
D. Vitamin K

Answer: B) Prednisone
Rationale: Prednisone is a corticosteroid that is often used to suppress the immune response in
autoimmune hemolytic anemia.

13. Marga's condition improves with prednisone therapy, but she develops an opportunistic
infection. What nursing intervention is crucial when caring for Marga during this time?
A. Administering more prednisone
B. Monitoring blood pressure
C. Implementing strict isolation precautions
D. Encouraging a high-protein diet

Answer: C) Implementing strict isolation precautions

Rationale: Immunosuppressed patients are at increased risk of infections, and strict isolation
precautions are necessary to prevent exposure to pathogens.

14. Marga's AIHA relapses despite prednisone therapy. What additional treatment option
may be considered in refractory cases?
A. Blood transfusion
B. Plasmapheresis
C. Erythropoietin injection
D. High-dose vitamin C supplements

Answer: B) Plasmapheresis
Rationale: Plasmapheresis may be considered in refractory cases of AIHA to remove
autoantibodies and other factors contributing to hemolysis.

15. Marga develops a sudden and severe pain crisis in her joints and extremities. This pain is
due to the vaso-occlusion of small blood vessels by misshapen red blood cells. What
type of anemia is she most likely experiencing?
A. Iron-deficiency anemia
B. Hemolytic anemia
C. Aplastic anemia
D. Sickle cell anemia

Answer: D) Sickle cell anemia

Rationale: Sickle cell anemia is characterized by the presence of misshapen red blood cells
(sickled cells) that can lead to vaso-occlusive crises and severe pain.
 16. Which population group is most commonly affected by sickle cell anemia?
A. Caucasian individuals
B. Hispanic individuals
C. African Americans
D. Asian individuals

Answer: C) African Americans

Rationale: Sickle cell anemia is most commonly seen in individuals of African descent.

17. In sickle cell anemia, what is the underlying genetic mutation responsible for the
production of abnormal hemoglobin?
A. Hemoglobin A
B. Hemoglobin S
C. Hemoglobin C
D. Hemoglobin F

Answer: B) Hemoglobin S
Rationale: Sickle cell anemia results from a genetic mutation that leads to the production of
abnormal hemoglobin known as hemoglobin S.

18. What is the primary goal of treatment during a sickle cell crisis?
A. Promote oxygen delivery to tissues
B. Administer antibiotics
C. Perform blood transfusions
D. Initiate chemotherapy

Answer: A) Promote oxygen delivery to tissues

Rationale: During a sickle cell crisis, the primary goal is to promote oxygen delivery to tissues by
providing adequate pain relief and oxygen therapy.

19. Marga experiences recurrent sickle cell crises, and her healthcare provider recommends
hydroxyurea. What is the mechanism of action of hydroxyurea in sickle cell anemia?
A. Promoting red blood cell sickling
B. Increasing clot formation
C. Stimulating white blood cell production
D. Increasing fetal hemoglobin production

Answer: D) Increasing fetal hemoglobin production

Rationale: Hydroxyurea increases the production of fetal hemoglobin, which can help reduce
the severity and frequency of sickle cell crises.
 20. Marga is scheduled for a routine check-up, and her healthcare provider orders a
transcranial Doppler ultrasound. What is the purpose of this test in individuals with
sickle cell anemia?
A. To assess kidney function
B. To evaluate liver function
C. To screen for stroke risk
D. To monitor lung function

Answer: C) To screen for stroke risk

Rationale: Transcranial Doppler ultrasound is used to assess blood flow in the brain and screen
for the risk of stroke in individuals with sickle cell anemia.

21. Marga is admitted to the hospital with a sickle cell crisis. What is the priority nursing
intervention for Marga during a crisis?
A. Administering pain medications
B. Administering antibiotics
C. Initiating a blood transfusion
D. Administering oxygen therapy

Answer: A) Administering pain medications

Rationale: The priority during a sickle cell crisis is to relieve severe pain. Pain medications
should be administered promptly.

22. Marga's condition deteriorates, and she develops acute chest syndrome. What is acute
chest syndrome, and how should it be managed?
A. Acute chest syndrome is a painful joint crisis treated with heat packs.
B. Acute chest syndrome is a lung-related complication treated with oxygen therapy and
antibiotics.
C. Acute chest syndrome is a neurological complication treated with anticoagulants.
D. Acute chest syndrome is a skin-related complication treated with topical medications.

Answer: B) Acute chest syndrome is a lung-related complication treated with oxygen therapy
and antibiotics.
Rationale: Acute chest syndrome in sickle cell anemia is characterized by lung-related
symptoms and should be managed with oxygen therapy and antibiotics to treat underlying
infections.

23. Marga develops priapism during a sickle cell crisis. What is priapism, and how should it
be managed?
A. Priapism is a heart-related complication treated with beta-blockers.
B. Priapism is a gastrointestinal complication treated with antacids.
C. Priapism is a painful, prolonged erection treated with hydration and analgesics.
D. Priapism is a neurological complication treated with antiepileptic drugs.
Answer: C) Priapism is a painful, prolonged erection treated with hydration and analgesics.
Rationale: Priapism is a medical emergency characterized by a painful, prolonged erection and
should be managed with hydration and analgesics.

24. Marga develops leg ulcers related to sickle cell anemia. What is the most appropriate
nursing intervention for managing these ulcers?
A. Applying cold compresses
B. Elevating the affected leg
C. Applying heat packs
D. Applying topical antibiotics

Answer: B) Elevating the affected leg

Rationale: Elevating the affected leg can help improve blood flow and promote healing of leg
ulcers in individuals with sickle cell anemia.

25. Marga's sickle cell anemia leads to chronic organ damage. Which organ is particularly at
risk for damage in individuals with this condition?
A. Liver
B. Kidneys
C. Lungs
D. Spleen

Answer: D) Spleen
Rationale: The spleen is particularly at risk for damage in individuals with sickle cell anemia due
to vaso-occlusion and infarction, which can lead to splenic dysfunction.

26. Marga's healthcare provider recommends regular blood transfusions to manage her
sickle cell anemia. What is the primary goal of these transfusions?
A. To increase red blood cell destruction
B. To stimulate the immune system
C. To reduce the number of sickled cells
D. To lower platelet counts

Answer: C) To reduce the number of sickled cells

Rationale: Regular blood transfusions in sickle cell anemia aim to reduce the number of sickled
red blood cells in circulation and improve oxygen delivery.

27. Marga experiences a sudden drop in hemoglobin levels after a blood transfusion. What
complication should the nurse monitor for in this situation?
A. Hematuria
B. Hypotension
C. Hyperglycemia
D. Hypoxia
Answer: A) Hematuria
Rationale: A sudden drop in hemoglobin levels after a blood transfusion can indicate a
transfusion reaction, which may manifest as hematuria (blood in the urine) among other
symptoms.

28. Marga's condition deteriorates, and she develops sepsis. What nursing intervention is
crucial when caring for a patient with sickle cell anemia who has sepsis?
A. Administering pain medications
B. Initiating oxygen therapy
C. Administering antibiotics promptly
D. Administering anticoagulants

Answer: C) Administering antibiotics promptly

Rationale: In patients with sickle cell anemia who develop sepsis, prompt administration of
antibiotics is crucial to treat the underlying infection.

29. Marga's healthcare provider recommends a bone marrow transplant as a potential cure
for her sickle cell anemia. What is the goal of a bone marrow transplant in this context?
A. To provide pain relief
B. To replace damaged organs
C. To cure the underlying genetic defect
D. To improve lung function

Answer: C) To cure the underlying genetic defect

Rationale: A bone marrow transplant in sickle cell anemia aims to replace the patient's bone
marrow with healthy donor marrow to cure the underlying genetic defect and provide a
potential cure.

30. Marga's treatment includes regular monitoring of her reticulocyte count. What does an
elevated reticulocyte count indicate in individuals with sickle cell anemia?
A. Increased oxygen levels
B. Increased red blood cell production
C. Decreased iron levels
D. Decreased platelet counts

Answer: B) Increased red blood cell production

Rationale: An elevated reticulocyte count in individuals with sickle cell anemia indicates an
increased production of red blood cells, which is a response to anemia or hemolysis.

31. Marga is diagnosed with aplastic anemia. Which of the following best describes aplastic
anemia?
A. A deficiency of clotting factors in the blood
B. An autoimmune condition causing red blood cell destruction
C. A disorder characterized by inadequate production of blood cells
 D. An overproduction of white blood cells

Answer: C) A disorder characterized by inadequate production of blood cells

Rationale: Aplastic anemia is a condition in which the bone marrow fails to produce an
adequate number of blood cells, including red blood cells, white blood cells, and platelets.

32. What is the most common cause of aplastic anemia?

A. Chemotherapy and radiation therapy
B. Autoimmune disorders
C. Viral infections
D. Genetic mutations

Answer: A) Chemotherapy and radiation therapy

Rationale: Exposure to chemotherapy and radiation therapy is a common cause of aplastic
anemia, as these treatments can damage the bone marrow.

33. Marga's healthcare provider recommends a bone marrow biopsy to confirm the
diagnosis of aplastic anemia. What is the primary purpose of a bone marrow biopsy in
this context?
A. To assess the presence of cancer cells
B. To determine the patient's blood type
C. To evaluate the density of bone tissue
D. To examine the cellular composition of the bone marrow

Answer: D) To examine the cellular composition of the bone marrow

Rationale: A bone marrow biopsy is performed to assess the cellular composition of the bone
marrow, including the number and function of blood-forming cells.

34. Marga's aplastic anemia is severe, and her healthcare provider recommends a bone
marrow transplant as a treatment option. What is the goal of a bone marrow transplant
in this context?
A. To relieve pain
B. To cure the underlying bone disorder
C. To provide temporary relief of symptoms
D. To increase the number of platelets

Answer: B) To cure the underlying bone disorder

Rationale: A bone marrow transplant in severe aplastic anemia aims to replace the damaged
bone marrow with healthy donor marrow, which can cure the underlying bone marrow
disorder.

35. Marga's healthcare provider prescribes immunosuppressive therapy as a treatment for

aplastic anemia. What is the mechanism of action of immunosuppressive therapy in this
condition?
 A. Stimulating the immune system
B. Suppressing the immune system's attack on the bone marrow
C. Increasing the production of red blood cells
D. Promoting the growth of platelets

Answer: B) Suppressing the immune system's attack on the bone marrow

Rationale: Immunosuppressive therapy is used to suppress the immune system's abnormal
attack on the bone marrow in aplastic anemia.

36. Which laboratory finding is commonly seen in patients with aplastic anemia?
A. Elevated red blood cell count
B. Elevated white blood cell count
C. Elevated platelet count
D. Pancytopenia (decreased levels of all blood cell types)

Answer: D) Pancytopenia (decreased levels of all blood cell types)

Rationale: Aplastic anemia is characterized by pancytopenia, which refers to decreased levels of
red blood cells, white blood cells, and platelets in the blood.

37. Marga's aplastic anemia is managed with platelet transfusions. What is the primary goal
of platelet transfusions in this context?
A. To increase hemoglobin levels
B. To stimulate red blood cell production
C. To prevent bleeding or manage bleeding episodes
D. To treat infection

Answer: C) To prevent bleeding or manage bleeding episodes

Rationale: Platelet transfusions are given in aplastic anemia to prevent bleeding or manage
bleeding episodes due to low platelet counts.

38. Marga's aplastic anemia is refractory to treatment, and she experiences recurrent
infections. What nursing intervention is crucial in managing infections in a patient with
aplastic anemia?
A. Administering pain medications
B. Monitoring blood pressure
C. Initiating contact precautions
D. Administering anticoagulants

Answer: C) Initiating contact precautions

Rationale: In patients with aplastic anemia who are immunosuppressed and prone to infections,
initiating contact precautions is crucial to prevent the spread of infections from healthcare
workers and visitors.
 39. Marga's aplastic anemia leads to severe anemia, and she requires red blood cell
transfusions. What is the primary goal of red blood cell transfusions in this context?
A. To stimulate the immune system
B. To reduce platelet counts
C. To increase hemoglobin levels and oxygen-carrying capacity
D. To promote wound healing

Answer: C) To increase hemoglobin levels and oxygen-carrying capacity

Rationale: Red blood cell transfusions in aplastic anemia aim to increase hemoglobin levels and
improve the oxygen-carrying capacity of the blood.

40. Marga's healthcare provider recommends a hematopoietic stem cell transplant (HSCT)
as a potential cure for her aplastic anemia. What is the goal of an HSCT in this context?
A. To relieve pain
B. To provide temporary relief of symptoms
C. To improve lung function
D. To replace the damaged bone marrow with healthy donor stem cells

Answer: D) To replace the damaged bone marrow with healthy donor stem cells
Rationale: A hematopoietic stem cell transplant (HSCT) in aplastic anemia aims to replace the
damaged bone marrow with healthy donor stem cells, providing a potential cure.

41. Marga develops thrombocytopenia, which is characterized by a low platelet count.

What is the primary nursing intervention to manage thrombocytopenia?
A. Administering pain medications
B. Initiating contact precautions
C. Monitoring for signs of bleeding
D. Administering anticoagulants

Answer: C) Monitoring for signs of bleeding

Rationale: Thrombocytopenia increases the risk of bleeding, so the primary nursing intervention
is to monitor for signs of bleeding, such as petechiae, ecchymosis, or mucosal bleeding.

42. What laboratory test is used to assess the platelet count in individuals with
thrombocytopenia?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. Complete blood count (CBC)
D. Serum creatinine

Answer: C) Complete blood count (CBC)

Rationale: A complete blood count (CBC) includes the platelet count and is used to assess the
platelet levels in individuals with thrombocytopenia.
 43. Marga's thrombocytopenia is severe, and she is at risk of bleeding. What intervention
can be considered to temporarily raise her platelet count?
A. Administration of vitamin K
B. Platelet transfusion
C. Initiation of oxygen therapy
D. Administration of antipyretic medications

Answer: B) Platelet transfusion

Rationale: Platelet transfusion is a common intervention to temporarily raise the platelet count
in individuals with severe thrombocytopenia to prevent or manage bleeding.

44. Marga's thrombocytopenia is due to chemotherapy treatment for leukemia. What type
of thrombocytopenia is she likely experiencing?
A. Immune thrombocytopenic purpura (ITP)
B. Drug-induced thrombocytopenia
C. Genetic thrombocytopenia
D. Thrombotic thrombocytopenic purpura (TTP)

Answer: B) Drug-induced thrombocytopenia

Rationale: Thrombocytopenia induced by chemotherapy or medications is referred to as drug-
induced thrombocytopenia.

45. Marga is diagnosed with immune thrombocytopenic purpura (ITP). What is the
underlying pathophysiology of ITP?
A. Increased platelet production in the bone marrow
B. Destruction of platelets by the immune system
C. Impaired clotting factor synthesis
D. Infection of platelets by a virus

Answer: B) Destruction of platelets by the immune system

Rationale: ITP is characterized by the destruction of platelets by the immune system, leading to
a low platelet count.

46. What is the primary nursing intervention for a patient with immune thrombocytopenic
purpura (ITP) experiencing a bleeding episode?
A. Administering pain medications
B. Initiating contact precautions
C. Administering platelet transfusions
D. Monitoring vital signs

Answer: C) Administering platelet transfusions

Rationale: In ITP, platelet transfusions may be administered during bleeding episodes to raise
the platelet count and control bleeding.
 47. Marga's ITP is refractory to treatment, and her healthcare provider recommends a
splenectomy. What is the purpose of a splenectomy in ITP?
A. To remove a cancerous tumor
B. To improve lung function
C. To remove the organ responsible for platelet destruction
D. To stimulate platelet production in the bone marrow

Answer: C) To remove the organ responsible for platelet destruction

Rationale: In some cases of refractory ITP, a splenectomy (removal of the spleen) is performed
to eliminate the organ responsible for platelet destruction.

48. Marga's healthcare provider prescribes corticosteroids as a treatment for ITP. What is
the mechanism of action of corticosteroids in this condition?
A. Stimulating platelet production in the bone marrow
B. Suppressing the immune system's attack on platelets
C. Promoting clot formation
D. Increasing red blood cell count

Answer: B) Suppressing the immune system's attack on platelets

Rationale: Corticosteroids are used in ITP to suppress the immune system's attack on platelets,
helping to prevent platelet destruction.

49. Marga develops complications related to her chronic anemia, including fatigue and
pallor. What is the primary nursing intervention to address these symptoms?
A. Administering platelet transfusions
B. Initiating contact precautions
C. Administering antipyretic medications
D. Administering blood transfusions

Answer: D) Administering blood transfusions

Rationale: Blood transfusions are administered to address chronic anemia and its associated
symptoms such as fatigue and pallor.

50. Marga's healthcare provider recommends a bone marrow biopsy to assess the cause of
her chronic anemia. What is the primary purpose of a bone marrow biopsy in this
context?
A. To determine the patient's blood type
B. To evaluate the density of bone tissue
C. To assess the presence of cancer cells
D. To examine the cellular composition of the bone marrow

Answer: D) To examine the cellular composition of the bone marrow

Rationale: A bone marrow biopsy is performed to assess the cellular composition of the bone
marrow, which can provide information about the cause of chronic anemia.
NS 1 QUIZ 12 GASTROINTESTINAL

Multiple Choice.

1. The nurse explains to the patient with gastroesophageal reflux disease that
this disorder:
A. Results in acid erosion and ulceration of the esophagus caused by
frequent vomiting,
B. Will require surgical wrapping or repair of the pyloric sphincter to control
the symptoms,
C. Is the protrusion of a portion of the stomach into to esophagus through
an opening in the diaphragm,
D. Often involves relaxation of the lower esophageal sphincter, allowing
stomach contents to back up into the espophagus.

RATIONALE: D. The acidic contents of the stomach touching the inside of

the esophagus are responsible for the physical sensation known as "heart-
burn" that is a cardinal symptom of GERD.

2. A patient is admitted with ulcerative colitis. In the physician's notes, it is

stated that the patient's barium enema results showed the patient has colitis
that starts in the rectum and extends into the sigmoid and descending colon.
As the nurse, you know that this is what type of ulcerative colitis?
A. Right-sided colitis
B. Proctosigmoiditis
C. Ulcerative procotitis
D. Left-sided colitis

RATIONALE: D. Left-sided colitis (distal colitis) starts in the rectum and

goes to the sigmoid and descending colon. Ulcerative proctitis affects the
rectum only. Proctosigmoiditis affects the rectum and sigmoid colon.
Right-sided colitis is NOT a type of ulcerative colitis.

3. The client is experiencing bleeding related to peptic ulcer disease (PUD).

Which nursing intervention is the highest priority
A. Starting a large-bore intravenous (IV)
B. Administering intravenous (IV) pain medication
C. Preparing equipment for intubation
D. Monitoring the client's anxiety level

RATIONALE: A. A large-bore IV should be placed as requested, so that

blood products can be administered.

4. Wich of the following types of gastritis is associated with Helicobacter pylori

and duodenal ulcers?
 A. Erosive (hemorrhagic) gastritis
B. Fundic gland gastritis (type A)
C. Antral gland gastritis (type B)
D. Aspiring-induced gastric ulcer

RATIONALE: C. Erosive (hemorrhagic) gastritis can be caused by

ingestion of substances that irritate the gastric mucosa. Fundic gland
gastritis (type A) is associated with diffuse severe mucosal atrophy and
the presence of pernicious anemia. Antral gland gastritis (type B) is the
most common form of gastritis, and is associated with Helicobacter pylori
and duodenal ulcers

5. A patient diagnosed with pancolitis is experiencing extreme abdominal

distension, pain 10 on 1-10 scale in the abdomen, temperature of 103.6 'F,
HR 120, and profuse diarrhea. What complication due you suspect the pain is
experiencing?
A. Fistulae
B. Stricture
C. Bowel obstruction
D. Toxic megacolon

RATIONALE: D. Pancolitis affects all the colon and is a very severe form of
ulcerative colon. The patient is at risk for toxic megacolon. In toxic
megacolon, the large intestine dilates due to the overwhelming
inflammation. The large intestine is unable to function properly and
becomes paralyzed. Typical signs and symptoms of toxic megacolon
include: abdominal distention, fever, diarrhea, abdominal pain,
dehydration, and tachycardia.

6. Gastroesophageal reflux disease (GERD) weakens the lower esophageal

sphincter, predisposing older persons to risk for impaired swallowing. In
managing the symptoms associated with GERD, the nurse should assign the
highest priority to which of the following interventions?
A. Decrease daily intake of vegetables and water, and ambulate frequently
B. Drink coffee diluted with milk at each meal, and remain in an upright
position for 30 minutes.
C. Eat small, frequent meals, and remain in an upright position for at least
30 minutes after eating
D. Avoid over-the-counter drugs that have antacids in them
RATIONALE: C. Eating small and frequent meals requires less release of
hydrochloric acid. Remaining in an upright position for 30 minutes after
meals prevents reflux into the esophagus which is often exacerbated
when lying down, expecially after a large meal which makes the patient
tired.
7. A patient is newly diagnosed with mild ulcerative colitis. What type of anti-
inflammatory medication is typically prescribed as first-line treatment for this
condition?
A. 5-Aminosalicylates (Sulfasalazine)
B. Immunomodulators (Adalimumab)
C. Corticosteroids (Prednisone)
D. Immunosupressors (Azathioprine)

RATIONALE: A. 5-Aminosalicylates (Sulfasalazine) are usually prescribed

for mild to moderate cases of ulcerative colitis as first-line treatment. If
Aminosalicylates are not working (or the patient is allergic to sulfa)
corticosteriods are prescribed. Corticosteriods may be used in
combination with immunosupressors. Immunosupressors and
immunomodulators are used in severe cases of ulcerative colitis when
other medications have not worked.

8. The nurse is reviewing the laboratory results of a client with Crohn's disease.
Which of the following would the nurse most likely find?
A. Decreased white blood cell count
B. Increased albumin levels
C. Stool cultures negative for microorganisms or parasite
D. Decrease erythrocyte sedimentation rate

RATIONALE: C. Stool cultures fail to reveal an etiologic microorganism or

parasite, but occult blood and occult blood and white blood cells (WBCs
often are found in the stool. Results of blood studies indicate anemia from
chronic blood loss and nutritional deficiencies. The WBC count and
erythrocyte sedimentation rate may be elevated, confirming an
inflammatory disorder. Serum protein and albumin levels may be low
because of malnutrition.

9. The client with peptic ulcer disease (PUD) asks the nurse whether licorice and
slippery elm might be useful in managing the disease. What is the nurse's
best response?
A. "No, they probably won't be useful. You should use only prescription
medications in your treatment plan."
B. "These herbs could be helpful. However, you should talk with your
physician before adding them to your treatment regimen."
C. "Yes, these are known to be effective in managing this disease, but make
sure you research the herbs thoroughly before taking them."
D. "No, herbs are not useful for managing this disease. You can use any type
of over-the-counter drugs though. They have been shown to be safe."
 RATIONALE: B. Although these herbs may be helpful in managing PUD,
the client should consult his or her physician before making a change in
the treatment regimen.

10.A patient is receiving treatment for ulcerative colitis by taking Azathioprine.

Which physician's order would the nurse question if received?
A. Ambulate the patient twice day
B. Low-fiber and high-protein diet
C. Administer varicella vaccine intramuscularly
D. Administer calcium carbonate by mouth daily

RATIONALE: C. Azathioprine is an immunosuppression medication that

decreases the immune system. Therefore, the patient should never
receive a live vaccine, such as Varicella. Other vaccinations that are live
include: MMR, Shingles, Nasal influenza mist etc.

[Link]'s disease is a condition of malabsorption caused by which

pathophysiological process?
A. Inflammation of all layers of intestinal mucosa
B. Infectious disease
C. Disaccharidase deficiency
D. Gastric resection

RATIONALE: A. Crohn's disease is also known as regional enteritis and

can occur anywhere along the gastrointestinal tract, but most commonly
at the distal ileum and in the colon. Infectious disease causes problems
such as small-bowel bacterial overgrowth, leading to malabsorption.
Disaccharidase deficiency leads to lactose intolerance. Postoperative
malabsorption occurs after gastric or intestinal resection.

[Link] client with a hiatal hernia chronically experiences heartburn following

meals. The nurse plans to teach the client to avoid which action because it is
contraindicated with hiatal hernia?
A. Lying recumbent following meals
B. Taking in small, frequent, bland meals
C. Raising the head of the bed on 6-inch blocks
D. Taking H2-receptor antagonist medication

RATIONALE: A. Laying recumbant following meals or at night will cause

reflux and pain. Relief is usually achieved with the intake of small, bland
meals, use of H2 receptor antagonists and antacids, and elevation of the
thorax after meals and during sleep.
[Link] response should a nurse offer to a client who asks why he's having a
vagotomy to treat his ulcer?
A. To repair a hole in the stomach
B. To reduce the ability of the stomach to produce acid
C. To prevent the stomach from sliding into the chest
D. To remove a potentially malignant lesion in the stomach

RATIONALE: B. A vagotomy is performed to eliminate the acid-secreting

stimulus to gastric cells. a perforation would be repaired with a gastric
resection. Repair of hiatal hernia (fundoplication) prevents the stomach
from sliding through the diaphragm. Removal of a potentially malignant
tumor wouldn't reduce the entire acid-producing mechanism.

14.A nurse is completing discharge teaching with a client who has Crohn's
disease. Which of the following instructions should the nurse include in the
teaching?
A. Decrease intake of calorie-dense foods
B. Drink canned protein supplements
C. Increase intake of high fiber foods
D. Take a bulk-forming laxative daily

RATIONALE: B. A high-protein diet is recommended for the client who has

Crohn's disease. Canned protein supplements are encouraged

[Link] of the following factors is believed to cause ulcerative colitis?

A. Acidic diet
B. Altered immunity
C. Chronic constipation
D. Emotional stress

RATIONALE: B. Several theories exist regarding the cause of ulcerative

colitis. One suggests altered immunity as the cause based on the extra
intestinal characteristics of the disease, such as peripheral arthritis and
cholangitis. Diet and constipation have no effect on the development of
ulcerative colitis. Emotional stress can exacerbate the attacks but isn't
believed to be the primary cause.

[Link] are most common with which of the following bowel disorders?
A. Crohn's disease
B. Diverticulitis
C. Diverticulosis
D. Ulcerative colitis
 RATIONALE: A. The lesions of Crohn's disease are transmural; that is,
they involve all thickness of the bowel. These lesions may perforate the
bowel wall, forming fistulas with adjacent structures. Fistulas don't
develop in diverticulitis or diverticulosis. The ulcers that occur in the
submucosal and mucosal layers of the intestine in ulcerative colitis usually
don't progress to fistula formation as in Crohn's disease.

[Link] assessment data support the client's diagnosis of gastric ulcer?

A. Presence of blood in the client's stool for the past month.
B. Complaints of a burning sensation that moves like a wave.
C. Sharp pain in the upper abdomen after eating a heavy meal.
D. Comparison of complaints of pain with ingestion of food and sleep

RATIONALE: A. The presence of blood does not specifically indicate

diagnosis of an ulcer. The client could have hemorrhoids or cancer that
would result in the presence of blood. B. A wavelike burning sensation is a
symptom of gastroesophageal reflux. C. Sharp pain in the upper abdomen
after eating a heavy meal is a symptom of gallbladder disease. D.
(CORRECT) In a client diagnosed with a gastric ulcer, pain usually occurs
30-60 minutes after eating, but not at night. In contrast, a client with
duodenal ulcer has pain during the night that is often relieved by eating
food. Pain occurs 1-3 hours after meals.

[Link] of the following associated disorders may a client with ulcerative colitis
exhibit?
A. Gallstones
B. Hydronephrosis
C. Nephrolithiasis
D. Toxic megacolon

RATIONALE: D. Toxic megacolon is extreme dilation of a segment of the

diseased colon caused by paralysis of the colon, resulting in complete
obstruction. This disorder is associated with both Crohn's disease and
ulcerative colitis. The other disorders are more commonly associated with
Crohn's disease.

[Link] nurse is teaching the client with peptic ulcer disease (PUD) about the
prescribed drug regimen. Which statement made by the client indicates a
need for further teaching before discharge?
A. "Nizatidine (Axid) needs to be taken three times a day to be effective."
B. "Taking ranitidine (Zantac) at bedtime should decrease acid production at
night."
C. "Sucralfate (Carafate) should be taken 1 hour before and 2 hours after
meals."
 D. "Omeprazole (Prilosec) should be swallowed whole and not crushed."

RATIONALE: A. Nizatidine (Axid) is most effective if administered twice

daily.

[Link] of the following symptoms is associated with ulcerative colitis?

A. Dumping syndrome
B. Rectal bleeding
C. Soft stools
D. Fistulas

RATIONALE: B. In ulcerative colitis, rectal bleeding is the predominant

symptom. Soft stools are more commonly associated with Crohn's
disease, in which malabsorption is more of a problem. Dumping syndrome
occurs after gastric surgeries. Fistulas are associated with Crohn's
disease.

[Link] nurse is caring for an older adult male client who reports stomach pain
and heartburn. Which syndrome is most significant in determining whether
the client's ulceration is gastric or duodenal in origin?
A. Pain occurs 1 1/2 to 3 hours after a meal, usually at night.
B. Pain is worsened by the ingestion of food.
C. The client has a malnourished appearance.
D. The client is a man older than 50 years.

RATIONALE: A. A key symptom characteristic of duodenal ulcers is that

pain usually awakens the client between 1 AM and 2 AM, occurring 1 1/2
to 3 hours after a meal.

[Link] a client had irritable bowel syndrome, which of the following diagnostic
tests would determine if the diagnosis is Crohn's disease or ulcerative colitis?
A. Abdominal computed tomography (CT) scan
B. Abdominal x-ray
C. Barium swallow
D. Colonoscopy with biopsy

RATIONALE: D. A colonoscopy with biopsy can be performed to determine

the state of the colon's mucosal layers, presence of ulcerations, and level
of cytologic development. An abdominal x-ray or CT scan wouldn't provide
the cytologic information necessary to diagnose which disease it is. A
barium swallow doesn't involve the intestine.
[Link] planning the care for the patient with Crohn's disease, the nurse
recognizes that a major difference between ulcerative colitis and Crohn's
disease is that Crohn's disease:
A. Frequently results in toxic megacolon
B. Causes fewer nutritional deficiencies than does ulcerative colitis.
C. Often recurs after surgery, whereas ulcerative colitis is curable with a
colectomy.
D. Is manifested by rectal bleeding and anemia more frequently than is
ulcerative colitis.

RATIONALE: C. Because there is a high recurrence rate after surgical

treatment of Crohn's disease, medications are the preferred treatment.

[Link] assessing the client with the diagnosis of peptic ulcer disease, which
physical examination should the nurse implement first?
A. Auscultate the client's bowel sounds in all four quadrants.
B. Palpate the abdominal area for tenderness.
C. Percuss the abdominal borders to identify organs.
D. Assess the tender area progressing to nontender

RATIONALE: A. Auscultation should be used prior to palpa-tion or

percussion when assessing the abdomen. If the nurse manipulates the
abdomen, the bowel sounds can be altered and give false information.

[Link] nurse is monitoring a client with a diagnosis of peptic ulcer. Which

assessment finding would most likely indicate perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, board-like abdomen

RATIONALE: D. Perforation of an ulcer is a surgical emergency and is

characterized by sudden, sharp, intolerable severe pain beginning in the
midepigastric area and spreading over the abdomen, which become rigid
and board-like. Nausea and vomiting may occur. Tachycardia may occur
as hypovolemic shock develops. Numbness in the legs is not an
associated finding.

[Link] nurse is monitoring the client with gastric cancer for signs and symptoms
of upper GI bleeding. Which change in vital signs is most indicative of
bleeding related to cancer?
A. Respiratory rate from 24 to 20 breaths/min
B. Apical pulse from 80 to 72 beats/min
C. Temperature from 98.9° F to 97.9° F
 D. Blood pressure from 140/90 to 110/70 mm Hg

RATIONALE: D. A decrease in blood pressure is the most indicative sign of

bleeding.

[Link] management of ulcerative colitis may be performed to treat which of

the following complications?
A. Gastritis
B. Bowel herniation
C. Bowel outpouching
D. Bowel perforation

RATIONALE: D. Perforation, obstruction, hemorrhage, and toxic

megacolon are common complications of ulcerative colitis that may
require surgery. Herniation and gastritis aren't associated with irritable
bowel diseases, and outpouching of the bowel is diverticulosis.

[Link] of the following nursing interventions should the nurse perform for a
female client receiving enteral feedings through a gastrostomy tube?
A. Change the tube feeding solutions and tubing at least every 24 hours
B. Maintain the head of the bed at a 15-degree elevation continuously.
C. Check the gastrostomy tube for position every 2 days.
D. Maintain the client on bed rest during the feedings

RATIONALE: A. Tube feeding solutions and tubing should be changed

every 24 hours, or more frequently if the feeding requires it. Doing so
prevents contamination and bacterial growth. The head of the bed should
be elevated 30 to 45 degrees continuously to prevent aspiration. Checking
for gastrostomy tube placement is performed before initiating the
feedings and every 4 hours during continuous feedings. Clients may
ambulate during feedings.

[Link] planning care for the patient with Crohn's disease, the nurse recognizes
that a major difference between ulcerative colitis and Crohn's disease is that
Crohn's disease:
A. Frequently results in toxic megacolon,
B. Causes fewer nutritional deficiencies than does ulcerative colitis,
C. Often recurs after surgery, whereas ulcerative colitis is curable with a
colectomy,
D. Is manifested by rectal bleeding and anemia more frequently than is
ulcerative colitis.

RATIONALE: C. Because there is a high recurrence rate after surgical

treatment of Crohn's disease, medications are the preferred treatment.
[Link] cancer is most closely associated with which of the following
conditions?
A. Appendicitis
B. Hemorrhoids
C. Hiatal hernia
D. Ulcerative colitis

RATIONALE: D. Chronic ulcerative colitis, granulomas, and familial

polyposis seem to increase a person's chance of developing colon cancer.
The other conditions listed have no known effect on colon cancer risk.

[Link] client is diagnosed with Crohn's disease, also known as regional enteritis.
Which statement by the client would support this diagnosis?
A. "My pain goes away when I have a bowel movement"
B. "I have bright red blood in my stool all the time"
C. "I have episodes of diarrhea and constipation"
D. "My abdomen is hard and rigid and I have a fever".

RATIONALE: A. The terminal ileum is the most common site for regional
enteritis and causes right lower quadrant pain that is relieved by
defecation 2. Stools are liquid or semi-formed and usually do not contain
blood 3. Episodes of diarrhea and constipation may be a sign/symptom of
colon cancer, not Crohn'sdisease 4. A fever and hard rigid abdomen are
signs/symptoms of peritonitis, a complication of Crohn's disease

[Link] nurse is teaching the patient a client with a peptic ulcer discharge
instructions. The client asks the nurse which type of analgesic he may take.
Which of the following responses by the nurse would be most accurate?
A. Aspirin
B. Acetaminophen
C. Naproxen
D. Ibuprofen

RATIONALE: B. Acetaminophen is recommended for pain relief because it

does no promote irritation of the mucosa. Aspirin, and nonsteroidal anti-
inflammatory drugs such as naproxen and ibuprofen, may cause irritation
of the mucosa and subsequent bleeding.

[Link] associated disorder might a client with Crohn's disease exhibit most
often?
A. Ankylosing spondylitis
B. Colon cancer
C. Malabsorption
 D. Lactase deficiency

RATIONALE: C. Malabsorption Because of the transmural nature of

Crohn's disease lesions, malabsorption may occur with Crohn's disease.
Although ankylosing spondylitis and colon cancer are more commonly
associated with ulcerative colitis, they may be seen in clients with Crohn's
disease, Lactase deficiency is caused by a congenital defect in which an
enzyme isn't present.

[Link] nurse finds a client vomiting coffee ground-type material. On

assessment, the client has blood pressure of 100/74 mm Hg, is acutely
confused, and has a weak and thready pulse. Which intervention will be the
nurse's first priority?
A. Administering an H2 antagonist
B. Initiating enteral nutrition
C. Administering intravenous (IV) fluids
D. Administering antianxiety medication

RATIONALE: C. Administration of IV fluids is necessary to treat the

hypovolemia caused by acute GI bleeding.

[Link] of the following instructions should the nurse include in the teaching
plan for a client who is experiencing gastroesophageal reflux disease
(GERD)?
A. Limit caffeine intake to two cups of coffee per day
B. Do not lie down for 2 hours after eating
C. Follow a low-protein diet
D. Take medications with milk to decrease irritation

RATIONALE: B. The nurse should instruct the client to not lie down for
about 2 hours after eating to prevent reflux.

[Link] nurse is caring for a client diagnosed with rule out peptic ulcer disease.
Which test confirms this diagnosis?
A. Esophagogastroduodenoscopy
B. Magnetic resonance imaging
C. Occult blood test
D. Gastric acid stimulation.

RATIONALE: A. The esophagogastroduodenoscopy (EGD) is an invasive

diagnostic test which visualizes the esophagus, stomach, and duodenum
to accurately diagnose an ulcer and evaluate the effectiveness of the
clients treatment.
[Link] client is scheduled to have an upper GI tract series of x-rays. Following
the x-rays, the nurse should instruct the client to:
A. Take a laxative
B. Follow a clear liquid diet
C. Administer an enema
D. Take an antiemetic

RATIONALE: A. The client should take a laxative after an upper GI series

to stimulate a bowel movement. This examination involves the
administration of barium, which must be promptly eliminated from the
body because it may harden and cause an obstruction.

38.A client who has been diagnosed with GERD has heartburn. To decrease the
heartburn, the nurse should instruct the client to eliminate which of the
following items from the diet?
A. Lean beef
B. Air-popped popcorn
C. Hot chocolate
D. Raw vegetables

RATIONALE: C. With GERD, eating substances that decrease lower

esophageal sphincter pressure causes heartburn. A decrease in the lower
esophageal sphincter pressure allows gastric contents to reflux into the
lower end of the esophagus. Foods that can cause a decrease in
esophageal sphincter pressure include fatty foods, chocolate, caffeinated
beverages, peppermint, and alcohol.

[Link] physical examination should the nurse implement first when assessing
the client diagnosed with peptic ulcer disease?
A. Auscultate the clients bowel sounds in all four quadrants
B. Palpate the abdominal area for tenderness
C. Percuss the abdominal borders to identify organs
D. Assess the tender area progressing to nontender

RATIONALE: A. Auscultation should be used prior to palpitation or

percussion when assessing the abdomen. Manipulation of the abdomen
can alter bowel sounds and give false information

[Link] client with GERD has a chronic cough. This symptom may be indicative
of which of the following?
A. Development of laryngeal cancer
B. Irritation of the esophagus
C. Esophageal scar tissue formation
D. Aspiration of gastric contents
 RATIONALE: D. Clients with GERD can develop pulmonary symptoms such
as coughing, wheezing, and dyspnea, that are caused by the aspiration of
gastric contents.

[Link] planning the care for the patient with Crohn's disease, the nurse
recognizes that a major difference between ulcerative colitis and Crohn's
disease is that Crohn's disease:
A. Frequently results in toxic megacolon.
B. Causes fewer nutritional deficiencies than does ulcerative colitis.
C. Often recurs after surgery, whereas ulcerative colitis is curable with a
colectomy.
D. Is manifested by rectal bleeding and anemia more frequently than is
ulcerative colitis.

RATIONALE: C. Because there is a high recurrence rate after surgical

treatment of Crohn's disease, medications are the preferred treatment.

[Link] nurse has been assigned to care for a client diagnosed with peptic ulcer
disease. Which assessment data require further intervention?
A. Bowel sour s auscultated 15 times in 1 minute
B. Belching after eating a heavy and fatty meal late at night
C. A decrease in systolic BP of 20 mm Hg from lying to sitting
D. A decreased frequency of distress located in the epigastric region

RATIONALE: C. A decrease of 20 mm Hg in blood pressure after changing

position from lying, to sitting, to standing is orthostatic hypotension. This
could indicate client is bleeding.

[Link] (Urecholine) has been prescribed for a client with GERD. The
nurse should assess the client for which of the following adverse effects?
A. Constipation
B. Urinary urgency
C. Hypertension
D. Dry oral mucosa

RATIONALE: B. This is a cholinergic drug that may be used in GERD to

increase lower esophageal sphincter pressure and facilitate gastric
emptying. Cholinergic adverse effects may include urinary urgency,
diarrhea, abdominal cramping, hypotension, and increased salivation.

[Link] client attends two sessions with the dietitian to learn about diet
modifications to minimize GERD. The teaching would be considered
successful if the client decreases the intake of which of the following foods?
 A. fats
B. high-sodium foods
C. Carbohydrates
D. high calcium foods

RATIONALE: A. Fats are associated with decreased esophageal sphincter

tone.

[Link] oral medication should the nurse question before administering to the
client with peptic ulcer disease?
A. E-mycin, an antibiotic
B. Prilosec, a proton pump inhibitor
C. Flagyl, an anti microbial agent
D. Tylenol, a nonnarcotic analgesic

RATIONALE: A. E-mycinis irritating to stomach, and it's use in a client

with peptic ulcer disease should be questioned

[Link] nurse is reviewing the record of a female client with Crohn's disease.
Which stool characteristics should the nurse expect to note documented in
the client's record
A. Diarrhea
B. Chronic constipation
C. Constipation alternating with diarrhea
D. Stools constantly oozing form the rectum

RATIONALE: A. Diarrhea, Crohn's disease is characterized by nonbloody

diarrhea and around 4-5 stools per day. Over time, episodes of diarrhea
increase in frequency, duration, and severity.

[Link] is caring for a patient with a diagnosis of ulcerative colitis. Which

finding, if noted on assessment of the client, would the nurse report to the
Dr?
A. Hypotension
B. Bloody diarrhea
C. Rebound tenderness
D. Hemoglobin of 12 mg/ dl

RATIONALE: C. Rebound tenderness because this could indicate peritonitis.

[Link] of the following dietary measures would be useful in preventing

Esophageal reflux?
A. Eating small, frequent meals
B. Increasing fluid intake
 C. Avoiding air swallowing with meals
D. Adding a bedtime snack to the dietary plan

RATIONALE: A. Esophageal reflux worsens when the stomach is over-

distended with food. Therefore, an important measure is to eat small
frequent meals.

[Link] client has a long-term history of Crohn's disease and has recently
developed acute gastritis. The client asks the nurse whether Crohn's disease
was a direct cause of the gastritis. What is the nurse's best response?
A. Yes, Crohn's disease is known to be a direct cause of the development of
chronic gastritis."
B. "We know that there can be an association between Crohn's disease and
chronic gastritis, but Crohn's does not directly cause acute gastritis to
develop."
C. "What has your doctor told you about how your gastritis developed?"
D. "Yes, a familial tendency to inherit Crohn's disease as well as gastritis has
been reported. Have your other family members been tested for Crohn's
disease?"

RATIONALE: B. This is the only accurate statement. Crohn's disease may

be an underlying disease process when chronic gastritis develops, but not
when acute gastritis occurs.

[Link] client is diagnosed with an acute exacerbation of ulcerative colitis. Which

intervention should the nurse implement?
A. Provide a low-residue diet.
B. Monitor intravenous fluids.
C. Assess vital signs daily.
D. Administer antacids orally.

RATIONALE: B. The client requires fluids to help prevent dehydration from

diarrhea and to replace fluid lost through normal body functioning.

Prepared by: Dr. Jhonnifer A. Abarao,

DHCM, MAN, USRN, RN, LPT, CHA,

“Not all angels have wings … some have scrubs.” —Unknown

 1. The nurse is teaching a group of older adults about risk factors related to hip fractures. Which
information should the nurse include in the presentation?
a. Lack of physical activity
b. Osteoporosis
c. Tobacco use
d. Calcium deficiency
e. All of the above

Rationale: E. Risk factors for hip fractures include lack of physical activity; deficiency in calcium or
vitamin D; tobacco and alcohol use; and osteoporosis. Arthritis is not considered a risk factor for hip
fractures.

2. Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching
the patient to care for the injury, the nurse tells the patient to
a. apply a heating pad to reduce muscle spasms.
b. wear an elastic compression bandage continuously.
c. use pillows to keep the arm elevated above the heart.
d. gently exercise the joint to prevent muscle shortening.

Rationale: C. Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48
hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The
wrist should be rested and kept immobile to prevent further swelling or injury.

3. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the
nurse should include information about which major complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump

Rationale: A. Bone fracture is a major complication of osteoporosis that results when loss of calcium and
phosphate increased the fragility of bones. Estrogen deficiencies results from menopause-not
osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism. But
a negative calcium balance isn’t a complication of osteoporosis. Dowager’s hump results from bone
fractures. It develops when repeated vertebral fractures increase spinal curvature.

4. The nurse is assessing a client's risk for sustaining a hip fracture. Which information should the
nurse obtain when obtaining the health history?
a. History of osteoporosis
b. Age
c. History of falls
d. All of the above
Rationale: D. The health history of a client with a hip fracture should include age, history of falls, and
history of osteoporosis. Vital signs and skin integrity are obtained when performing a physical
examination.

5. What is a late sign of compartment syndrome?

a. Paralysis
b. Pain
c. Parethesia
d. Pulselessness

Rationale: D. Pulselessness is a late sign of compartment syndrome.

6. The nurse is assigned to care for a client who experienced a recent fall. Which manifestation
indicates that the client's hip is fractured?
a. Complaints of stiffness when transferring to chair
b. The affected leg is shorter than the other and turned outward
c. Bruising noted to the injured hip and leg
d. Discomfort when performing range of motion exercises

Rationale: B. The leg of the injured hip is shorter than the uninjured leg and is sometimes turned
outward in clients with hip fracture. These clients complain of severe pain, not discomfort, when flexing
and rotating the hip. Bruising noted to the hip and leg may or may not be related to the fall. Complaints
of stiffness may be related to the fall or from lying in bed.

7. A patient arrives in the emergency department with ankle swelling and severe pain after
twisting the ankle playing soccer. All of the following orders are written by the health care
provider. Which one will the nurse act on first?
a. Administer naproxen (Naprosyn) 500 mg PO.
b. Wrap the ankle and apply an ice pack.
c. Give acetaminophen with codeine (Tylenol #3).
d. Take the patient to the radiology department for x-rays.

Rationale: B. Immediate care after a sprain or strain injury includes the application of cold and
compression to the injury to minimize swelling. The other actions should be taken after the ankle is
wrapped with a compression bandage and ice is applied.

8. An 85 year old patient has an accidental fall while going to the bathroom without assistance. It
appears the patient has sustained a bone fracture to the left leg. The leg’s shape is deformed
and the patient is unable to move it. The patient is alert and oriented but in pain. What will you
do FIRST after confirming the patient is safe and stable?
a. Apply an ice pack covered with a towel to the site.
b. Immobilize the fracture with a splint.
c. Administer pain medication.
d. Elevate the extremity above heart level.
Rationale: B. After confirming the patient is safe and stable, the nurse would immobilize the fracture
with a splinting device. This will prevent the accidental movement of the extremity by the patient.
Immobilization is important because it prevents further pain or bleeding along with more damage that
can occur to the surrounding tissues. In addition, if a bone is not immobilized but moved after it has
been fractured this can affect the healing process.

9. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?
a. Basilar
b. Temporal
c. Occipital
d. Parietal

Rationale: A. Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the dura
commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and
nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done.

10. Which statement by a patient, who just received a cast on the right arm for a fracture, requires
you to notify the physician immediately?
a. “It is really itchy inside my cast!”
b. “My pain is so severe that it hurts to stretch or elevate my arm.”
c. “I can feel my fingers and move them.”
d. “I’ve been using ice packs to reduce swelling.””

Rationale: B. This statement is very concerning and may represent a condition called compartment
syndrome. Compartment syndrome is where the nerves and blood vessels are becoming compromised
due to increasing pressure in the compartments within the fascia (remember fascia doesn’t expand, so if
there is building pressure within the compartments of muscle from bleeding etc. it will compromise
circulation and nerve function). Remember to monitor the 6 P’s. (pain, pallor, paralysis, paresthesia,
pulselessness (late sign), poikilothermia)

11. A patient has a short-arm plaster cast applied at the outpatient center for a wrist fracture. An
understanding of discharge teaching is apparent when the patient says,
a. "I can get the cast wet as long as I dry it right away with a hair dryer."
b. "I should avoid moving my fingers and elbow until the cast is removed."
c. "I will apply an ice pack to the cast over the fracture site for the next 24 hours."
d. "I can rub lotion on any itching areas under the cast with a cotton-tipped applicator."

Rationale: C. Ice application for the first 24 hours after a fracture will help to reduce swelling and can be
placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the
joints above and below the cast. Patients should not insert objects inside the cast.

12. A 49-year-old client was admitted for surgical repair of a Colles’ fracture. An external fixator was
placed during surgery. The surgeon explains that this method of repair:
 a. Has very low complication rate
b. Maintains reduction and overall hand function
c. Is less bothersome than a cast
d. Is best for older people

Rationale: B. Complex intra-articular fractures are repaired with external fixators because they have a
better long-term outcome than those treated with casting. This is especially true in a young client. The
incidence of complications, such as pin tract infections and neuritis, is 20% to 60%. Clients must be
taught how to do pin care and assess for development of neurovascular complications.

13. The nurse is caring for four clients. Which client should the nurse identify as having the highest
risk for sustaining a hip fracture if they sustain a fall?
a. 60-year-old man admitted for treatment of pneumonia
b. 80-year-old man admitted for benign prostatic hypertrophy
c. 50-year-old woman with a history of osteoarthritis
d. 70-year-old woman who consumes 800 mg calcium/day

Rationale: D. Women who are postmenopausal and not taking estrogen should consume a minimum of
1500 mg of calcium per day to maintain bone health. The 70-year-old woman who only consumes 800
mg of calcium per day is at the highest risk for a hip fracture if she falls. The 50-year-old woman may not
be postmenopausal and is at a lower risk, and the men are at a lower risk.

14. A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed,
causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as
related to
a. muscle spasms.
b. meniscus injury.
c. repetitive strain injury.
d. carpal tunnel syndrome.

Rationale: C. The patient's occupation and the inflammation, pain, and weakness in the elbow and hand
suggest a repetitive strain injury. Muscle spasms would be characterized by a palpable, firm muscle mass
during the spasm. Meniscus injury would affect the knee. Carpal tunnel syndrome is characterized by
weakness and numbness of the hand.

15. The parish health nurse notices a higher incidence of hip fractures in the church community.
Which intervention should the nurse implement to help decrease the clients' risk of a hip
fracture?
a. Obtain assistive devices
b. A walking program
c. Periodic home care visits
d. Use of medical alert systems
Rationale: B. Weight-bearing exercise can decrease an individual's risk for hip fractures. Therefore,
establishing a walking program would benefit the parishioners. Assistive devices would help with gait
stability, but are not required by every individual. Periodic home care visits can check medication
compliance and blood pressures, but will not prevent hip fractures. Medical alert systems can signal for
help after a fall and fracture have occurred, but does not prevent it.

16. A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the
patient that the cast can be removed only after the bone
a. is strong enough to stand mild stress.
b. union is complete on the x-ray.
c. fragments are fully fused.
d. healing has started.

Rationale: A. The cast may be removed when callus ossification has occurred. It is not necessary to wait
until radiologic union or complete bone fusion occurs. Bone healing starts immediately after the injury,
but the cast will need to be worn at least 3 weeks.

17. The nurse is teaching an older adult client about preventing hip fractures. Which information
should the nurse include?
a. Obtaining a screening to test for osteoporosis
b. Maintaining adequate intake of calcium and vitamin D
c. Drinking one glass of red wine every night
d. All of the above

Rationale: D. Teaching the client about avoiding falls can be helpful in preventing hip fractures. Weight-
bearing exercises increase strength and adequate intake of calcium and vitamin D helps bone health.
Screening for osteoporosis can lead to early treatment to help diminish the risk of bone fractures. Throw
rugs are not recommended because the client can trip or slip on them. There is no recommendation to
drink red wine; in fact, alcohol should be consumed with caution as it can impair balance and increase
the risk for a fall.

18. The nurse assesses an older adult woman and determines the client is at high risk for
osteoporosis and hip fractures. Based on these findings, which test should the nurse request
from the healthcare provider?
a. Computerized tomography (CT) scan
b. Bone density testing
c. Magnetic resonance imaging (MRI) scan
d. X-rays

Rationale: b. Postmenopausal women with low calcium intake are at a very high risk of osteoporosis and
hip fractures. Therefore, the healthcare provider will prescribe bone density testing to determine
further treatment. X-rays, CT scans, and MRIs are used to diagnose hip fractures.
 19. A visiting nurse is performing home assessment for a 59-year-old man recently discharged after
hip replacement surgery. Which home assessment finding warrants health promotion teaching
from the nurse?
a. A bathroom with grab bars for the tub and toilet
b. Items stored in the kitchen so that reaching up and bending down aren’t necessary
c. Many small, unsecured area rugs
d. Sufficient stairwell lighting, with switches to the top and bottom of the stairs

Rationale: c. The presence of unsecured area rugs poses a hazard in all homes, particularly in one with a
resident at high risk for falls.

20. The nurse is caring for a client with a fractures hip. The client combative, confused, and trying to
get out of bed. The nurse should:
a. Leave the client and get help
b. Obtain a physician’s order to restrain the client
c. Read the facility’s policy on restraints
d. Order soft restraints from the storeroom

Rationale: B. It’s mandatory in most settings to have a physician’s order before restraining a client. A
client should never be left alone while the nurse summons assistance. All staff members require annual
instruction on the use of restraints, and the nurse should be familiar with the facility’s policy.

21. A patient hospitalized with multiple fractures has a long-arm plaster cast applied for
immobilization of a fractured left radius. Until the cast has completely dried, the nurse should
a. keep the left arm in a dependent position.
b. handle the cast with the palms of the hands.
c. place gauze around the cast edge to pad any roughness.
d. cover the cast with a small blanket to absorb the dampness.

Rationale: B. Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent
creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to
prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges
before that may cause the cast to be misshapen. The cast should not be covered until it is dry because
heat builds up during drying.

22. Emergency medical technicians transport a 28-year-old iron worker to the emergency
department. They tell the nurse, “He fell from a two-story building. He has a large contusion on
his left chest and a hematoma in the left parietal area. He has compound fracture of his femur
and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92%
by pulse oximeter with a manual-resuscitation bag.” Which intervention by the nurse has the
highest priority.
a. Assessing the left leg
b. Assessing the pupils
c. Placing theclient in Trendelenburg’s position
 d. Assessing the level of consciousness

Rationale: A. In the scenario, airway and breathing are established so the nurse’s next priority should be
circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore,
the nurse should assess the site. Neurologic assessment is a secondary concern to airway, breathing and
circulation. The nurse doesn’t have enough data to warrant putting the client in Trendelenburg’s
position.

23. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency
response team assess for signs of circulatory impairment by:
a. Turning the client to side lying position
b. Asking the client to cough and deep breathe
c. Taking the client’s pedal pulse in the affected limb
d. Instructing the client to wiggle the toes of the right foot.

Rationale: c. Taking the client’s pedal pulse in the affected limb. Monitoring a pedal pulse will assess
circulation to the foot.

24. A patient had surgery to repair a fractured left hip. The nurse obtains items from the unit
storage area, knowing that which of the following will be the most important to use when
repositioning the patient from side to side in bed?
a. Abductor splint
b. Abductor splint
c. Bed pillow
d. Overhead trapeze

Rationale: A. After surgery to repair a fractured hip, and abductor splint is used to maintain the affected
extremity in good alignment when the client is turned from side to side.

25. A nurse in the emergency department is performing an assessment on an elderly client with a
suspected fractured hip from a fall at home. The nurse would suspect that a fracture hip is
present if the injured leg is:
a. Shortened and abducted
b. Abducted and internally rotated
c. Shortened and externally rotated
d. Shortened and internally rotated

Rationale: C. Signs of a hip fracture include shortening and deformity. The affected leg externally rotates
as a result of discontinuation of the femur and loss of alignment and muscle control.

26. Select all the signs and symptoms that will present in compartment syndrome?
a. Capillary refill less than 2 seconds
b. Pallor
c. Pain relief with medication
 d. Feeling of tingling in the extremity
e. Affected extremity feels cooler to the touch than the unaffected extremity

Rationale: B, D, and E. These symptoms may present with compartment syndrome. Option A and C are
normal findings. Remember in compartment syndrome nerve and blood vessel function is being
compromised, so expect signs and symptoms that occur when these structures are affected.

27. A patient in the emergency department is diagnosed with a patellar dislocation. The initial
patient teaching by the nurse will focus on the need for
a. conscious sedation.
b. a knee immobilizer.
c. gentle knee flexion.
d. cast application.

Rationale: A. The first goal of collaborative management is realignment of the knee to its original
anatomic position, which will require anesthesia or conscious sedation. Immobilization of the joint will
be done after realignment. Later, gentle ROM exercises may be started if the joint is stable. Casting is
not usually required for dislocations.

28. Your patient is 2 hours’ post-op from a cast placement on the right leg. The patient has family in
the room. Which action by the significant other requires you to re-educate the patient and
family about cast care?
a. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying.
b. Positioning the cast at heart level with pillows.
c. Checking the color and temperature of the right foot.
d. Using a hair dryer on the cool setting to help with drying.

Rationale: A. The cast should always be moved with the palms of the hands (NOT finger tips) during the
drying period to prevent dent formation because this can cause the development of ulcers under the
skin where the dents develop.

29. In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an
open, displaced fracture of the tibia, the priority nursing diagnosis is
a. risk for constipation related to prolonged bed rest.
b. activity intolerance related to deconditioning.
c. risk for infection related to disruption of skin integrity.
d. risk for impaired skin integrity related to immobility.

Rationale: C. A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis.
After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused
by immobility are not as likely.
 30. A patient sustained a fracture to the femur. The patient has suddenly become confused,
restless, and has a respiratory rate of 30 breaths per minute. Based on the location of fracture
and the presenting symptoms, this patient may be experiencing what type of complication?
a. Compartment Syndrome
b. Osteomyelitis
c. Fat embolism
d. Hypovolemia

Rationale: C. Patients who experience a fracture of the long bones (such as the femur) are at risk for a
fat embolism. The patient will become confused and restless along with an abnormal respiratory status.

31. A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be
most important for the nurse to determine
a. Whether there is bruising at the shoulder area.
b. Whether the right arm is shorter than the left.
c. The amount of pain the patient is experiencing.
d. How much range of motion (ROM) is present?

Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency.
The nurse will expect bruising and pain at the area, even without an injury that requires surgery. The
shoulder should be immobilized until it is evaluated by the health care provider.

32. When counseling an older patient about ways to prevent fractures, which information will the
nurse include?
a. Tacking down scatter rugs in the home is recommended.
b. Occasional weight-bearing exercise will improve muscle and bone strength.
c. Most falls happen outside the home.
d. Buying shoes that provide good support and are comfortable to wear is recommended.

Rationale: Comfortable shoes with good support will help to decrease the risk for falls. Scatter rugs
should be eliminated, not just tacked down. Regular weight-bearing exercise will improve strength, but
occasional exercise is not helpful in improving strength. Falls inside the home are responsible for many
injuries.

33. When working with a patient whose job involves many hours of word processing, the nurse will
teach the patient about the need to
a. Do stretching and warm-up exercises before starting work.
b. Wrap the wrists with a compression bandage every morning.
c. Use acetaminophen (Tylenol) instead of NSAIDs for wrist pain.
d. Obtain a keyboard pad to support the wrist while word processing.

Rationale: Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented
using a pad that will keep the wrists in a straight position. Stretching exercises during the day may be
helpful, but these would not be needed before starting. Use of a compression bandage is not needed,
although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease
swelling.
 34. A patient arrives in the emergency department with ankle swelling and severe pain after
twisting the ankle playing soccer. All the following orders are written by the health care
provider. Which one will the nurse act on first?
a. Administer naproxen (Naprosyn) 500 mg PO.
b. Wrap the ankle and apply an ice pack.
c. Give acetaminophen with codeine (Tylenol #3).
d. Take the patient to the radiology department for x-rays.

Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression
to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a
compression bandage and ice is applied.

35. A 22-year-old patient started an exercise regimen 2 months ago that includes running 3 to 4
miles a day. The patient tells the nurse, "I enjoy my daily runs, but now I have shin splints."
Which response by the nurse is appropriate?
a. "You may be increasing your running time too quickly and need to cut back a little bit."
b. "You need to have x-rays of your lower legs to be sure you do not have stress fractures."
c. "You should expect some leg pain while running."
d. "You should try speed-walking rather than running."

Rationale: The patient's information about running 3 to 4 miles daily after starting an exercise program
only 2 months previously suggests that the shin splints are caused by overuse. Radiographs are not
indicated for the type of injury described by the patient. Shin splints are not a normal or expected
response to running. Because the patient expresses enjoyment of running, it would not be appropriate
for the nurse to suggest a different sport.

36. A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the
patient that the cast can be removed only after the bone.
a. is strong enough to stand mild stress.
b. Union is complete on the x-ray.
c. Fragments are fully fused.
d. Healing has started.

Rationale: The cast may be removed when callus ossification has occurred. It is not necessary to wait
until radiologic union or complete bone fusion occurs. Bone healing starts immediately after the injury,
but the cast will need to be worn at least 3 weeks.

37. Following a motor-vehicle accident, a patient arrives in the emergency department with massive
right lower-leg swelling. Which action will the nurse take first?
a. Elevate the leg on pillows.
b. Apply a compression bandage.
c. Place ice packs on the lower leg.
d. Check leg pulses and sensation.

Rationale: The initial action by the nurse will be to assess the circulation to the leg and to observe for
any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions
may be appropriate based on what is observed during the assessment.
 38. In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an
open, displaced fracture of the tibia, the priority nursing diagnosis is
a. Risk for constipation related to prolonged bed rest.
b. Activity intolerance related to deconditioning.
c. Risk for infection related to disruption of skin integrity.
d. Risk for impaired skin integrity related to immobility.

Rationale: A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis.
After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused
by immobility are not as likely.

39. A patient with lower-leg fractures has an external fixation device in place and is scheduled for
discharge. Which information will the nurse include in the discharge teaching?
a. "You will need to remain on bed rest until bone healing is complete."
b. "The external fixator can be removed during the bath or shower."
c. "Prophylactic antibiotics are needed until the external fixator is removed."
d. "You will need to assess and clean the pin insertion sites daily."

Rationale: Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An
external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The
device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not
routinely given when an external fixator is used.

40. A patient who has severe peripheral arterial disease and ischemic foot ulcers is upset with the
health care provider's recommendation to have an above-the-knee amputation. The patient tells
the nurse, "If they want to cut off my leg, they should just shoot me instead." The most
appropriate response to the patient's statement is,
a. "Let's talk about how you feel this surgery will affect you."
b. "If you do not want the surgery, you do not have to have it."
c. "I understand why you are upset, but there really is no choice because your leg is so badly
diseased."
d. "Many people are able to function normally with a prosthesis after amputation, and you can
too."

Rationale: The initial nursing action should be to assess how the patient feels about the amputation and
what the patient knows about the procedure and rehabilitation process. Discussion about the patient's
option to not have the procedure, the reason the procedure is needed, or rehabilitation after the
procedure may be appropriate after the nurse knows more about the patient's current level of
knowledge and emotional state.

41. A client with osteoporosis asks the nurse why it is important to take vitamin D. Which response
by the nurse is correct?
a. Vitamin D improves the absorption of calcium.
b. Vitamin D reduces excretion of calcium in the kidneys.
c. Vitamin D helps prevent constipation from increased calcium intake.
d. Vitamin D minimizes the risk of kidney stones.

Rationale: Taken with calcium, vitamin D aids with calcium absorption which is essential for bone
building and slowing the progression of osteoporosis. It is taken to enhance calcium absorption and does
not influence how much is excreted by the kidneys. Increased calcium intake can lead to constipation,
but vitamin D will not improve this condition. Renal calculi are common in clients with hypercalcemia,
and hypercalcemia is common in clients with osteoporosis. However, vitamin D does not influence the
occurrence of renal calculi.
42. Which nursing action is contraindicated when caring for a client with a newly applied long leg
cast?
a. Elevating the cast on a pillow.
b. Drying the cast by using a fan.
c. Leaving the cast exposed to air.
d. Handling the cast with fingertips.

Rationale: Handling the cast with fingertips before it is dried may create indentations that can cause
pressure. Elevating the casted extremity on a pillow will help reduce edema. b, and c this will increase air
flow that facilitates drying of the cast.

43. A nurse is caring for a client who has suffered a fracture to the humerus after falling on their
outstretched arm. The ends of the bone were driven into each other during the fall. This type of
fracture is best described as which of the following?
a. Impacted fracture.
b. Greenstick fracture.
c. Comminuted fracture.
d. Oblique fracture.

Rationale: An impacted fracture is one in which the ends of the bone in a fracture are driven into
each other. This type of fracture is most likely the result of a fall, such as onto an outstretched arm.
It may also occur when the bone breaks from collapse of the structure, which is known as a buckle
fracture.

44. Which foods should the nurse teach a client with gout to avoid to limit painful attacks? Select all
that apply. Gout is a common form of inflammatory arthritis that is very painful
a. Eggs
b. Liver
c. Cheese
d. Salmon

Rationale: Eggs have insignificant amounts of purine and are unrestricted. Like other organ meats, liver
is ahigh-purine food (range of 150 to 1000 mg/100 g) and should be avoided. Cheese has insignificant
amounts of purine and is unrestricted. Foods that contain a moderate amount of purine (50 to 150
mg/dL), such as salmon, may be eaten four times a week. Shellfish (e.g., shrimp, lobster) are high-purine
foods and should be avoided.

45. A nurse suspects the development of compartment syndrome for a client who has sustained
blunt trauma to the forearm. For which early sign of compartment syndrome should the nurse
assess the client?
a. Warm skin at site of injury
b. Escalating pain in the fingers
c. Rapid capillary refill in affected hand
 d. Bounding radial pulse in the injured arm

Rationale: Elevated tissue pressure restricts blood flow, causing increasing ischemia and increasing
pain; it is the cardinal early symptom of compartment syndrome.
The arm will feel cool, not warm, because of a decrease in circulation. Sluggish, not rapid, capillary
refill is a sign of compartment syndrome. The pulse will be diminished, not bounding, increasing
edema impairs circulation.

46. A client has an amputation of a lower limb. What instructions should the nurse give the client to
prevent a hip flexion contracture?
a. Turn from side to side every 1 to 2 hours.
b. Sit in a chair for 30 minutes three times a day.
c. Lie on the abdomen 30 minutes four times daily.
d. Perform quadriceps muscle setting exercises twice daily.

Rationale: The hips are in extension when the client is prone; this keeps the hips from flexing.
Turning In the left side-lying position the right hip will be flexed, promoting contracture formation.
Sitting promotes flexion contracture formation. Muscle setting exercises is not related to the
prevention of hip-flexion contractures.

47. When should the nurse begin the process of rehabilitation when a client is scheduled for an
amputation?
a. Before the surgery
b. During the convalescent phase
c. On discharge from the hospital
d. When it is time for a prosthesis

Rationale: Rehabilitation should begin immediately. This includes preoperative discussion of the nature
of the operation and rehabilitation techniques.
b, c, d This is too late; valuable rehabilitation time has been wasted.

48. The nurse questions a client with rheumatoid arthritis about pain. When should the nurse expect
the client to experience increased pain and limited movement of the joints?
a. After assistive exercise.
b. When the room is cool.
c. In the morning on awakening.
d. When the latex fixation test is positive.

Rationale: Inactivity over an extended time increases stiffness and pain in joints.

49. What does the nurse determine is the most likely cause of renal calculi in clients with
paraplegia?
a. High fluid intake
b. Increased intake of calcium
c. Inadequate kidney function
d. Accelerated bone demineralization

Rationale: Calcium that has left the bones as a response to prolonged inactivity enters the blood and
may precipitate in the kidneys, forming calculi. Kidney stones (also called renal calculi, nephrolithiasis or
urolithiasis) are hard deposits made of minerals and salts that form inside your kidney Paraplegia is a
term used to describe the inability to voluntarily move the lower parts of the body.

50. Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching
the patient to care for the injury, the nurse tells the patient to
a. Apply a heating pad to reduce muscle spasms.
b. Wear an elastic compression bandage continuously.
c. Use pillows to keep the arm elevated above the heart.
d. Gently exercise the joint to prevent muscle shortening.

Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours,
cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist
should be rested and kept immobile to prevent further swelling or injury.
 NS 1 QUIZ 14 NEUROLOGIC

Name: _______________________ Section: ___________ Date: ___________

Multiple Choice.

1. A patient is experiencing hyperventilation and has a PaCO2 level of 52. The

patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level
will?
A. Cause vasoconstriction and decrease the ICP
B. Promote diuresis and decrease the ICP
C. Cause vasodilation and increase the ICP
D. Cause vasodilation and decrease the ICP

RATIONALE: C. An elevated carbon dioxide level (52 is high…normal 35-

45) in the blood will cause vasodilation (NOT constriction), which will
increase ICP (normal ICP 5 to 15 mmHg). Therefore, many patients with
severe ICP may need to be mechanical ventilated so PaCO2 levels can be
lowered (30-35), which will lead to vasoconstriction and decrease ICP
(with constriction there is less blood volume and flow going to the brain
and this helps decrease pressure)….remember Monro-Kellie hypothesis.

2. Which finding below represents a positive Romberg Sign in a patient with

multiple sclerosis?
A. The patient report dark spots in the visual fields during the confrontation
visual field test.
B. When the patient closes the eyes and stands with their feet together they
start to lose their balance and sway back and forth.
C. The patient’s sign and symptoms increase when expose to hot
temperatures.
D. The patient reports an electric shock feeling when the head and neck are
moved downward.

RATIONALE: B. This is an example of a positive Romberg’s Sign.

3. A patient with a spinal cord injury is recovering from spinal shock. The nurse
realizes that the patient should not develop a full bladder because what
emergency condition can occur if it is not corrected quickly?
A. Autonomic dysreflexia
B. Autonomic crisis
C. Autonomic shutdown
D. Autonomic failure

RATIONALE: A. Be attuned to the prevention of a distended bladder when

caring for spinal cord injury (SCI) patients in order to prevent this chain
of events that lead to autonomic dysreflexia. Track urinary output
 carefully. Routine use of bladder scanning can help prevent the
occurrence. Other causes of autonomic dysreflexia are impacted stool and
skin pressure. Autonomic crisis, autonomic shutdown, and autonomic
failure are not terms used to describe common complications of spinal
injury associated with bladder distension.

4. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak
to move on his own. To help the client avoid pressure ulcers, Nurse Celia
should:
A. Turn him frequently.
B. Reduce the client's fluid intake.
C. Encourage the client to use a footboard.
D. Perform passive range-of-motion (ROM) exercises.
RATIONALE: A. The most important intervention to prevent pressure
ulcers is frequent position changes, which relieve pressure on the skin and
underlying tissues. If pressure isn't relieved, capillaries become occluded,
reducing circulation and oxygenation of the tissues and resulting in cell
death and ulcer formation. During passive ROM exercises, the nurse
moves each joint through its range of movement, which improves joint
mobility and circulation to the affected area but doesn't prevent pressure
ulcers. Adequate hydration is necessary to maintain healthy skin and
ensure tissue repair. A footboard prevents plantar flexion and footdrop by
maintaining the foot in a dorsiflexed position.

5. You’re performing a head-to-toe assessment on a patient with multiple

sclerosis. When you ask the patient to move the head and neck downward
the patient reports an “electric shock” sensation that travels down the body.
You would report your finding to the doctor that the patient is experiencing:
A. Romberg’s Sign
B. Lhermitte’s Sign
C. Uhthoff’s Sign
D. Homan’s Sign

RATIONALE: B. This finding is known as Lhermitte’s Sign.

6. The nurse is caring for a patient with increased intracranial pressure (IICP).
The nurse realizes that some nursing actions are contraindicated with IICP.
Which nursing action should be avoided?
A. Reposition the patient every two hours.
B. Position the patient with the head elevated 30 degrees.
C. Suction the airway every two hours per standing orders.
D. Provide continuous oxygen as ordered.
 RATIONALE: C. Suctioning further increases intracranial pressure;
therefore, suctioning should be done to maintain a patent airway but not
as a matter of routine. Maintaining patient comfort by frequent
repositioning as well as keeping the head elevated 30 degrees will help to
prevent (or even reduce) IICP. Keeping the patient properly oxygenated
may also help to control ICP.

7. A client who recently had a cerebrovascular accident requires a cane to

ambulate. When teaching about cane use, the rationale for holding a cane on
the uninvolved side is to:
A. prevent leaning
B. maintain stride length
C. prevent edema
D. distribute weight away from the involved side

RATIONALE: D. Holding a cane on the uninvolved side distributes weight

away from the involved side. Holding the cane close to the body prevents
leaning. Use of a cane won’t maintain stride length or prevent edema.

8. A patient with multiple sclerosis has issues with completely emptying the
bladder. The physician orders the patient to take ___________, which will
help with bladder emptying.
A. Bethanechol
B. Oxybutynin
C. Avonex
D. Amantadine

RATIONALE: A. This medication is a cholinergic medication that will help

with bladder emptying.

9. Which patient is at highest risk for a spinal cord injury?

A. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
B. 20-year-old female with a history of substance abuse
C. 50-year-old female with osteoporosis
D. 35-year-old male who coaches a soccer team

RATIONALE: A. The three major risk factors for spinal cord injuries (SCI)
are age (young adults), gender (higher incidence in males), and alcohol or
drug abuse. Females tend to engage in less risk-taking behavior than
young men.

[Link]’re providing education to a group of nursing students about ICP. You

explain that when cerebral perfusion pressure falls too low the brain is not
 properly perfused and brain tissue dies. A student asks, “What is a normal
cerebral perfusion pressure level?” Your response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg

RATIONALE: B. This is a normal CPP. Option A represents a normal

intracranial pressure.

11.A patient is receiving Interferon Beta for treatment of multiple sclerosis. As

the nurse you will stress the importance of?
A. Physical exercise to improve fatigue
B. Low fat diet
C. Hand hygiene and avoiding infection
D. Reporting ideation of suicide
E.
RATIONALE: C. Interferon Beta decreases the number of relapses of
symptoms in MS patients by decreasing the immune system response,
but it lowers the white blood cells count. Hence, there is a risk of
infection. It is very important the nurse stresses the importance of hand
hygiene and avoiding infection.

[Link] nurse understands that when the spinal cord is injured, ischemia results
and edema occurs. How should the nurse explain to the patient the reason
that the extent of injury cannot be determined for several days to a week?
A. "Tissue repair does not begin for 72 hours."
B. "The edema extends the level of injury for two cord segments above and
below the affected level."
C. "Neurons need time to regenerate so stating the injury early is not
predictive of how the patient progresses."
D. "Necrosis of gray and white matter does not occur until days after the
injury."

RATIONALE: B. Within 24 hours necrosis of both gray and white matter

begins if ischemia has been prolonged and the function of nerves passing
through the injured area is lost. Because the edema extends above and
below the area affected, the extent of injury cannot be determined until
after the edema is controlled. Neurons do not regenerate, and the edema
is the factor that limits the ability to predict extent of injury.

[Link] nurse is assessing a 48-year-old client diagnosed with multiple sclerosis.

Which clinical manifestation warrants immediate intervention?
A. The client has scanning speech and diplopia.
 B. The client has dysarthria and scotomas.
C. The client has muscle weakness and spasticity.
D. The client has a congested cough and dysphagia.

RATIONALE: D. Dysphagia is a common problem of clients diagnosed with

multiple sclerosis,and this places the client at risk for aspiration
pneumonia. Some clients diagnosed with multiple sclerosis eventually
become immobile and are at risk for pneumonia.

[Link] patient below is at MOST risk for increased intracranial pressure?

A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery.

RATIONALE: B. Remember head trauma, cerebral hemorrhage,

hematoma, hydrocephalus, tumor, encephalitis etc. can all increase ICP.

[Link] client newly diagnosed with multiple sclerosis (MS) states, "I don't
understand how I got multiple sclerosis. Is it genetic?" On which statement
should the nurse base the response?
A. Genetics may play a role in susceptibility to MS, but the disease may be
caused by a virus.
B. There is no evidence suggesting there is any chromosomal involvement in
developing MS.
C. Multiple sclerosis is caused by a recessive gene, so both parents had to
have the gene for the client to get MS.
D. Multiple sclerosis is caused by an autosomal dominant gene on the Y
chromosome,so only fathers can pass it on.

RATIONALE: A. The exact cause of MS is not known,but there is a theory

stating a slow virus is partially responsible. A failure of apart of the
immune system may also beat fault. A genetic predisposition involving
chromosomes 2, 3, 7, 11, 17, 19, and X may be involved.

[Link] a male client experienced a cerebrovascular accident (CVA) that damaged

the hypothalamus, the nurse would anticipate that the client has problems
with:
A. visual acuity.
B. balance and equilibrium.
C. thinking and reasoning.
D. body temperature control.
 RATIONALE: D. The body’s thermostat is located in the hypothalamus;
therefore, injury to that area can cause problems of body temperature
control. Balance and equilibrium problems are related to cerebellar
damage. Visual acuity problems would occur following occipital or optic
nerve injury. Thinking and reasoning problems are the result of injury to
the cerebrum.

[Link] 30-year-old female client is admitted with complaints of numbness,

tingling, a crawling sensation affecting the extremities, and double vision
which has occurred two (2) times in the month. Which question is most
important for the nurse to ask the client?
A. "Have you experienced any difficulty with your menstrual cycle?"
B. "Have you noticed a rash across the bridge of your nose?"
C. "Do you get tired easily and sometimes have problems swallowing?"
D. "Are you taking birth control pills to prevent conception?"

RATIONALE: C. These are clinical manifestation of MS and can go un

diagnosed for years be-cause of the remitting-relapsing nature of the
disease. Fatigue and difficulty swallowing are other symptoms of MS.

18.A patient with a spinal cord injury (SCI) has complete paralysis of the upper
extremities and complete paralysis of the lower part of the body. The nurse
should use which medical term to adequately describe this in documentation?
A. Hemiplegia
B. Paresthesia
C. Paraplegia
D. Quadriplegia

RATIONALE: D. Quadriplegia describes complete paralysis of the upper

extremities and complete paralysis of the lower part of the body.
Hemiplegia describes paralysis on one side of the body. Paresthesia does
not indicate paralysis. Paraplegia is paralysis of the lower body.

[Link] nurse enters the room of a client diagnosed with acute exacerbation of
multiple sclerosis and finds the client crying. Which statement is the most
therapeutic response for the nurse to make?
A. "Why are you crying? The medication will help the disease."
B. "You seem upset. I will sit down and we can talk for a while."
C. "Multiple sclerosis is a disease that has good times and bad times."
D. "I will have the chaplain come and stay with you for a while."

RATIONALE: B. This is stating a fact and offering self. Both are

therapeutic techniques for conversations.
20.A patient with increased ICP has the following vital signs: blood pressure
99/60, HR 65, Temperature 101.6 ‘F, respirations 14, oxygen saturation of
95%. ICP reading is 21 mmHg. Based on these findings you would?
A. Administered PRN dose of a vasopressor
B. Administer 2 L of oxygen
C. Remove extra blankets and give the patient a cool bath
D. Perform suctioning

RATIONALE: C. It is important to monitor the patient for hyperthermia (a

fever). A fever increases ICP and cerebral blood volume, and metabolic
needs of the patient. The nurse can administer antipyretics per MD order,
remove extra blankets, decrease room temperature, give a cool bath or
use a cooling system. Remember it is important to prevent shivering (this
also increases metabolic needs and ICP).

[Link] client diagnosed with multiple sclerosis is scheduled for a magnetic

resonance imaging (MRI) scan of the head. Which information should the
nurse teach the client about the test?
A. The client will have wires attached to the scalp and lights will flash off and
on.
B. The machine will be loud and the client must not move the head during
the test.
C. The client will drink a contrast medium 30 minutes to one (1) hour before
the test.
D. The test will be repeated at intervals during a five (5) - to six (6)-hour
period.

RATIONALE: B. MRI scans require the client to lie still and not move the
body; the client should be warned about the loud noise

22.A patient has a ventriculostomy. Which finding would you immediately report
to the doctor?
A. Temperature 98.4 ‘F
B. CPP 70 mmHg
C. ICP 24 mmHg
D. PaCO2 35

RATIONALE: C. A ventriculostomy is a catheter inserted in the area of the

lateral ventricle to assess ICP. It will help drain CSF during increase
pressure readings and measure ICP. The nurse must monitor for ICP
levels greater than 20 mmHg and report it to the doctor.
[Link] 45-year-old client is diagnosed with primary progressive multiple
sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving
related to progressive loss." Which intervention should be implemented?
A. Consult the physical therapist for assistive devices for mobility.
B. Determine if the client has a legal power of attorney.
C. Ask if the client would like to talk to the hospital chaplain.
D. Discuss the client's wishes regarding end-of-life care.

RATIONALE: D. The client should make personal choices about end-of-life

issues while it is possible to do so. This client is progressing toward
immobility and all the complications related to it.

[Link] ventricular drains monitor ICP and are inserted where?

A. Subarachnoid space
B. Lateral Ventricle
C. Epidural space
D. Right Ventricle

RATIONALE: B. External ventricular drains (also called ventriculostomy)

are inserted in the lateral ventricle.

[Link] home health nurse is caring for the client newly diagnosed with multiple
sclerosis. Which client issue is of most importance?
A. The client refuses to have a gastrostomy feeding.
B. The client wants to discuss if she should tell her fiancé.
C. The client tells the nurse life is not worth living anymore
D. The client needs the flu and pneumonia vaccines.

RATIONALE: C. A potential suicide statement is priority for the nurse

when caring for the client with MS.

[Link] of the following is contraindicated in a patient with increased ICP?

A. Lumbar puncture
B. Midline position of the head
C. Hyperosmotic diuretics
D. Barbiturates medications

RATIONALE: A. LPs are avoided in patients with ICP because they can
lead to possible brain herniation.

[Link] nurse and a licensed practical nurse (LPN) are caring for a group of
clients. Which nursing task should not be assigned to the LPN?
A. Administer a skeletal muscle relaxant to a client diagnosed with low back
pain.
 B. Discuss bowel regimen medications with the HCP for the client on strict
bed rest.
C. Draw morning blood work on the client diagnosed with bacterial
meningitis.
D. Teach self-catheterization to the client diagnosed with multiple sclerosis.

RATIONALE: D. The nurse should not assign assessing, teaching, or

evaluation to the LPN. Evaluating the client's ability to per-form self-
catheterization should not be assigned to the LPN

[Link]’re collecting vital signs on a patient with ICP. The patient has a
Glascoma Scale rating of 4. How will you assess the patient’s temperature?
A. Rectal
B. Oral
C. Axillary
D. None of the above

RATIONALE: A. This GCS rating demonstrates the patient is unconscious.

If a patient is unconscious the nurse should take the patient’s
temperature either via the rectal, tympanic, or temporal method. Oral and
axillary are not reliable.

[Link] male client diagnosed with multiple sclerosis states he has been
investigating alternative therapies to treat his disease. Which intervention is
most appropriate by the nurse?
A. Encourage the therapy if it is not contraindicated by the medical regimen.
B. Tell the client only the health-care provider should discuss this with him.
C. Ask how his significant other feels about this deviation from the medical
regimen.
D. Suggest the client research an investigational therapy instead.

RATIONALE: A. The nurse should listen without being judgmental about

any alternative therapy the client is considering. Alternative therapies,
such as massage and relaxation, are frequently beneficial and enhance
the medical regimen.

30.A patient who experienced a cerebral hemorrhage is at risk for developing

increased ICP. Which sign and symptom below is the EARLIEST indicator the
patient is having this complication?
A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size
 RATIONALE: C. Mental status changes are the earliest indicator a patient
is experiencing increased ICP. All the other signs and symptoms listed
happen later.

[Link] client diagnosed with an acute exacerbation of multiple sclerosis is

placed on high-dose intravenous injections of corticosteroid medication.
Which nursing intervention should be implemented?
A. Discuss discontinuing the proton pump inhibitor with the HCP.
B. Hold the medication until after all cultures have been obtained.
C. Monitor the client's serum blood glucose levels frequently
D. Provide supplemental dietary sodium with the client's meals.

RATIONALE: C. Steroids interfere with glucose metabolism by blocking

the action of insulin;therefore, the blood glucose levels should be
monitored.

[Link]’re maintaining an external ventricular drain. The ICP readings should be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg

RATIONALE: A. Normal ICP should be 5 to 15 mmHg.

33.A client diagnosed with multiple sclerosis has an acute onset of visual
changes, fatigue, and leg weakness. The client says that the last time this
happened, recovery occurred in a few weeks. Which classification of multiple
sclerosis is the client experiencing?
A. Progressive-relapsing
B. Secondary-progressive
C. Relapsing-remitting
D. Primary-progressive

RATIONALE: C. There are four classifications of multiple sclerosis. The

client has an exacerbation of symptoms and has a history of full recovery.
This is classified as relapsing-remitting and is the most common type.
Primary-progressive is a steady worsening of the disease with occasional
minor recovery. Secondary-progressive begins as relapsing-remitting but
the disease becomes worse between exacerbations. Progressive-relapsing
is rare, with the disease progressing from the onset with periods of
exacerbation.

[Link] patient below with ICP is experiencing Cushing’s Triad? A patient with
the following:
 A. BP 150/112, HR 110, RR 8
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12

RATIONALE: C. These vital signs represent Cushing’s triad. There is an

increase in the systolic pressure, widening pulse pressure of 140 (200-
60=140), bradycardia, and bradypnea.

[Link] patient is scheduled for a lumbar puncture to help diagnose multiple

sclerosis. The patient wants clarification about what will be found in the
cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of
MS. You explain that ____________ will be present in the fluid if MS is
present.
A. High amounts of igm
B. Oligoclonal bands
C. Low amounts of WBC
D. Oblong red blood cells and glucose

RATIONALE: B. These specific proteins, oligoclonal bands, which are

immunoglobulins will be found in the CSF. This demonstrates there is
inflammation in the CNS and is a common finding in multiple sclerosis.

36.A client with a history of relapsing-remitting multiple sclerosis is expecting

her first child. What would be indicated for this client?
A. Suggest reproductive counseling, as multiple sclerosis can be genetic.
B. Instruct to expect a period of remission after delivery of the baby.
C. Instruct to expect an exacerbation of symptoms while pregnant.
D. Discuss pain control during labor, as contractions will be severe.

RATIONALE: A. A definite genetic factor has not been established;

however, studies suggest that genetic factors make some individuals
more susceptible to the disorder than others. Reproductive counseling
would be recommended for this client. Pregnancy often brings about
remission of multiple sclerosis, but with a slightly increased relapse rate
postpartum. The strength of uterine contractions in a client with multiple
sclerosis is not severe, and because clients often have lessened sensation,
labor may be almost painless.

37. The patient has a blood pressure of 130/88 and ICP reading of 12. What is
the patient’s cerebral perfusion pressure, and how do you interpret this as
the nurse?
A. 90 mmHg, normal
B. 62 mmHg, abnormal
 C. 36 mmHg, abnormal
D. 56 mmHg, normal

RATIONALE: A. CPP is calculated by the following formula: CPP=MAP-ICP.

The patient’s CPP is 90 and this is normal. A normal CPP is 60-100 mmHg.

38.A client with relapsing-remitting multiple sclerosis tells the nurse that even
though the primary symptoms of exacerbation are leg spasms and blurred
vision, the hardest part is trying to get through the day because of being so
tired. Which diagnosis should the nurse identify as a priority for this client?
A. Fatigue
B. Disturbed Sensory Perception
C. Impaired Physical Mobility
D. Self-Care Deficit

RATIONALE: A. The client states that the worst part of the disease
exacerbation is being tired even though leg spasms and blurred vision are
present. The nurse should identify the diagnosis of Fatigue as being a
priority for this client. The diagnoses of Impaired Physical Mobility
because of the leg spasms and Disturbed Sensory Perception because of
the blurred vision are additional nursing diagnoses applicable for this
client, but they are not the priority based on the client's statement. The
client may or may not have a Self-Care Deficit.

[Link] to question 12, the patient’s blood pressure is 130/88. What is the
patient’s mean arterial pressure (MAP)?
A. 42
B. 74
C. 102
D. 88

RATIONALE: C. MAP is calculated by taking the DBP (88) and multiplying

it by 2. This equals 176. Then take this number and add the SBP (130).
This equals 306. Then take this number and divide by 3, which equal 102.

40.A client admitted with an exacerbation of multiple sclerosis is demonstrating

frustration with eating because hand and arm spasms prevent the proper use
of utensils. What should the nurse do to assist this client?
A. Consult with Occupational Therapy regarding assistive devices for meals.
B. Counsel the client to select finger foods for meals.
C. Plan time to feed the client.
D. Consult with Physical Therapy regarding hand and arm exercises.
 RATIONALE: A. Since the ability to feed oneself is essential to positive
self-concept and self-esteem, the nurse should consult with Occupational
Therapy for devices that the client can use to maintain independence at
meal times. The nurse should not counsel the client to select finger foods
for meals, or feed the client. This would not support the client's self-
concept and self-esteem needs. Physical Therapy might be consulted for
hand splints, but hand and arm exercises might not be beneficial for this
client.

[Link] patient is at highest risk for a spinal cord injury?

A. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
B. 20-year-old female with a history of substance abuse
C. 50-year-old female with osteoporosis
D. 35-year-old male who coaches a soccer team

RATIONALE: A. The three major risk factors for spinal cord injuries (SCI)
are age (young adults), gender (higher incidence in males), and alcohol or
drug abuse. Females tend to engage in less risk-taking behavior than
young men.

[Link] positioning a patient in bed with increased ICP, it important to avoid?

A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips

RATIONALE: D. Avoid flexing the hips because this can increase intra-
abdominal/thoracic pressure, which will increase ICP.

43.A client with multiple sclerosis is observed transferring from the bed to a
motorized wheelchair and applying splints to the lower extremities before
entering the bathroom to perform morning self-care. What could the nurse
conclude regarding this observation?
A. The client uses assistive devices to optimize autonomy.
B. The client needs instruction to conduct morning care before applying
splints to lower extremities.
C. The client is dependent upon assistive devices.
D. The client is reliant upon assistive devices for independent.

RATIONALE: A. The nurse observed the client independently transfer from

the bed to a motorized wheelchair, apply splints, and enter the bathroom
to perform morning self-care. This is evidence that the client uses
assistive devices to optimize autonomy. The statement "Client is reliant
upon assistive devices for independence" indicates that the client is not
 autonomous. The statement "Client is dependent upon assistive devices"
also indicates the client is not autonomous. The statement "Client needs
instruction to conduct morning care before applying splints to lower
extremities" does not take into consideration the client's preference,
which might be to apply the splints before doing self-care.

[Link] the eye assessment of a patient with increased ICP, you need to
assess the oculocephalic reflex. If the patient has brain stem damage what
response will you find?
A. The eyes will roll down as the head is moved side to side.
B. The eyes will move in the opposite direction as the head is moved side to
side.
C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved side to
side.

RATIONALE: D. This is known as a negative doll’s eye and represents

brain stem damage. It is a very bad sign.

[Link] nurse understands that when the spinal cord is injured, ischemia results
and edema occurs. How should the nurse explain to the patient the reason
that the extent of injury cannot be determined for several days to a week?
A. "Tissue repair does not begin for 72 hours."
B. "The edema extends the level of injury for two cord segments above and
below the affected level."
C. "Neurons need time to regenerate so stating the injury early is not
predictive of how the patient progresses."
D. "Necrosis of gray and white matter does not occur until days after the
injury."

Rationale: B. Within 24 hours necrosis of both gray and white matter

begins if ischemia has been prolonged and the function of nerves passing
through the injured area is lost. Because the edema extends above and
below the area affected, the extent of injury cannot be determined until
after the edema is controlled. Neurons do not regenerate, and the edema
is the factor that limits the ability to predict extent of injury.

46.A client with multiple sclerosis is prescribed diazepam (Valium). What

assessment finding indicates that the medication is effective for the client?
A. Muscle spasticity is reduced.
B. Blood glucose level is within normal limits.
C. The client states that muscles are weak.
D. Ophthalmologic examination shows no evidence of cataracts.
 RATIONALE: A. Diazepam (Valium) is a muscle relaxant commonly used
for clients with multiple sclerosis. Diazepam (Valium) does not cause
muscle weakness. Evidence of medication effectiveness would be an
observed reduction in muscle spasticity. Glucose intolerance would be
assessed if the client were prescribed an adrenal corticosteroid. Cataract
development is also a side effect of adrenal corticosteroids.

47.A patient is receiving Mannitol for increased ICP. Which statement is

INCORRECT about this medication?
A. Mannitol will remove water from the brain and place it in the blood to be
removed from the body.
B. Mannitol will cause water and electrolyte reabsorption in the renal
tubules.
C. When a patient receives Mannitol the nurse must monitor the patient for
both fluid volume overload and depletion.
D. Mannitol is not for patients who are experiencing anuria.

RATIONALE: B. All the other options are correct. Mannitol will PREVENT
(not cause) water and electrolytes (specifically sodium and chloride) from
being reabsorbed….hence it will leave the body as urine.

[Link] nurse is planning care for a client with multiple sclerosis. Which
intervention would address the nursing diagnosis of Fatigue?
A. Encourage increased activity.
B. Schedule physical therapy three times a day.
C. Plan activities with sufficient rest periods.
D. Group activities together so care will not be interrupted.

RATIONALE: C. Interventions to address the client's diagnosis of Fatigue

include assessing the level of fatigue, arranging activities to include rest
periods, and assisting the client to set priorities regarding activities.
Activities should not be grouped together. Increased activity will not help
the client with fatigue. Physical therapy three times a day may be too
aggressive for this client.

[Link] assessment finding requires immediate intervention if found while a

patient is receiving Mannitol?
A. An ICP of 10 mmHg
B. Crackles throughout lung fields
C. BP 110/72
D. Patient complains of dry mouth and thirst
 RATIONALE: B. Mannitol can cause fluid volume overload that leads to
heart failure and pulmonary edema. Crackles in the lung fields represent
pulmonary edema and requires immediate intervention. Option A is a
normal ICP reading and shows the mannitol is being effective. BP is within
normal limits, and dry mouth/thirst will occur with this medication
because remember we are trying to dehydrate the brain to keep edema
and intracranial pressure decreased.

50.A patient with a spinal cord injury (SCI) has complete paralysis of the upper
extremities and complete paralysis of the lower part of the body. The nurse
should use which medical term to adequately describe this in documentation?
A. hemiplegia
B. paresthesia
C. paraplegia
D. quadriplegia

Rationale: D. Quadriplegia describes complete paralysis of the upper

extremities and complete paralysis of the lower part of the body.
Hemiplegia describes paralysis on one side of the body. Paresthesia does
not indicate paralysis. Paraplegia is paralysis of the lower body.

Prepared by: Dr. Jhonnifer A. Abarao,

DHCM, MAN, USRN, RN, LPT, CHA,

“Not all angels have wings … some have scrubs.” —Unknown