1. A 15-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. The nurse conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?

• "I like the way I look. I just need to keep my weight down because I'm a cheerleader."
• "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends."
• "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls"
• "I do diet around my periods; otherwise, I just get so bloated."

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2. A tearful parent brings a child to the ED for taking an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician?

• The ingested children's chewable vitamins contain iron.
• The child has been treated several times for ingestion of toxic substances.
• The child has been treated several times for accidental injuries.
• The child was nauseated and vomited once at home.

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3. Here are teenagers today who engage In sex without realizing the repercussions of their actions. Witch of the parental response would be appropriate for this problem?

• Providing regular and open communication
• Limiting the number of teenager's social activities
• Enforcing stricter rules and punishment
• Screening the teenager's company of friends

4. After teaching the client with severe rheumatoid arthritis about the newly prescribed medication methotrexate (Rheumatrex O), which of the following statements indicates the need for further teaching?

• "I will take my vitamins while I am on this drug”
• "I must not drink any alcohol while I'm taking this drug"
• "I should brush my teeth after every meal"
• "I will continue taking my birth control pills"

5. The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

• Intactskin
• Full-thickness skin loss
• Exposed bone, tendon, or muscle
• Partial-thickness skin loss of the dermis

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6. The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. 1.Initiate confinement measures. 2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client. 5.Allow the client to take control

• 1,2,3
• 2,3,4
• 3,4,5
• 1,3,5

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7. Situation: A research study was under taken in order to identify and analyze a disabled boy's coping reaction pattern during stress. Q. To ensure reliability of the study, the investigator analysis and interpretations were:

• subjected to statistical treatment
• correlated with a list coping behaviors
• subjected to an inter-observe agreement
• scored and compared standard criteria

8. A nurse plans to teach a group of 20 to 25-year-old women about oral contraceptives. The nurse should instruct that oral contraceptives may:

• Increase the risk of pelvic inflammatory disease
• Cause acne to worsen
• Decrease the risk of breast and cervical cancer
• Decrease the risk of endometriosis

9. The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:

• Nasal congestion
• Abdominal tenderness
• Muscle tetany
• Oliguria

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10. The nurse is caring for a client with an autoimmune disorder at a medical clinic, where alternative medicine is used as an adjunct to traditional therapies. Which information should the nurse teach the client to help foster a sense of control over his symptoms?

• Pathophysiology of disease process
• Principles of good nutrition
• Side effects of medications
• Stress management techniques

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11. For which of the following clients would the nurse expect that an intrauterine device would not be recommended?

• Woman over age 35
• Nulliparous woman
• Promiscuous young adult
• Postpartum client

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12. Mario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 μL to 5,000 μL is noted?

• Pancytopenia
• Idiopathic thrombocytopenic purpura (ITP)
• Disseminated intravascular coagulation (DIG)
• Heparin-associated thrombosis and thrombocytopenia (HATT)

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13. Benztropine (Cogentin) is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by:

• decreasing the anxiety causing muscle rigidity.
• blocking the cholinergic activity in the central nervous system (CNS).
• increasing the level of acetylcholine in the CNS.
• increasing norepinephrine in the CNS.

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14. The nurse identifies ventricular tachycardia on the heart monitor. The patient has a pulse. The nurse should immediately:

• Administer atropine sulfate
• Check the potassium level
• Prepare to administer an antiarrhythmic medication
• Defibrillate at 360 joules

15. The client with AIDS should be taught to:

• Avoid warm climates.
• Refrain from taking herbals.
• Report any changes in skin color.
• Avoid exercising.

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16. Situation: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the IMCL Using IMCI Chart, this child can be manage with:

• Treat the child with paracetamol and follow up in 2 days if the fever persist
• Give the first dose of antibiotic, give Vit. A, apply Gentian Violet for mouth ulcers and refer urgently to hospital
• Give 100,000 international units of Vit. A
• Give Vit. A, apply Gentian violet for mouth ulcers and follow up in 2 days

17. The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching?

• "It is okay if I skip meals now and then."
• "I need to constantly watch for signs of low blood sugar"
• "I need to let my health care provider know if I get unusually tired."
• "I will be sure to not drink alcohol excessively while on this medication.”

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18. Situation: Ella is pregnant with her first baby. She went to the clinic for check-up Q. A nurse has just been told by a physician that an order has been written to administer an iron injection to an adult client. The nurse plans to administer the medication In which of the following locations?

• In the gluteal muscle using Z-track technique
• In the deltoid muscle using an air lock
• I n the subcutaneous tissue of the abdomen
• in the anterolateral thigh using a 5/8 inch needle

19. A patient admitted to the hospital for pneumonia finishes a course of levofloxacin, lungs are clear and the patient Is no longer coughing. Which of the following post-discharge laboratory results best indicates desired outcome?

• Normal white blood cell count
• Normal hematocrit count
• Normal platelet level
• Normal potassium level

20. A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3 to 4 hours as needed for pain. The combination of the two medications produces a/an:

• Agonist effect
• Synergistic effect
• Antagonist effect
• Excitatory effect

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21. In assessing the abdomen, Which of the following is the correct sequence of the physical

• Inspection, Auscultation, Percussion, Palpation
• Palpation, Auscultation, Percussion, Inspection
• Inspection, Palpation, Auscultation, Percussion
• Inspection, Auscultation, Palpation, Percussion

22. A young girl that living with her parents and her grandfather going to bad hygienic school she affected with a virus what the possible cause for her disease:

• The virus transferred to her from the school
• The summer wither is the cause
• The virus transferred from the unclean city she lives in.
• The crowded home.

23. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

• Tracheal
• Fine crackles
• Coarse crackles
• Friction rubs

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24. Situation: During the morning endorsement, the outgoing nurse informed the nursing staff that Regina, 5 years old, was given Flurazepam (Dalmane) 15 mg at 10:00pm because she had trouble going to sleep. Before approaching Regina, the nurse read the observation of the night nurse. Q. Regina commits to herself that she understood and will observe all the medicine precautions by:

• affixing her signature to the teaching plan that she has understood the nurse
• committing what she learned to her memory
• verbally agreeing with the nurse
• relying on her husband to remember the precautions

25. The nurse understands that the diagnosis of oral cancer is confirmed with:

• Biopsy
• Gram Stain
• Oral culture
• Oral washings for cytology

26. A client with catatonic schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority?

• Assist the client with feeding.
• Assist the client with showering.
• Reassure the client about safety.
• Encourage socialization with peers.

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27. Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical. Q. Once the flames are extinguished, it is most important:

• cover client with warm blanket
• Give him sips of water
• Calculate the extent of this burns
• Assess the Sergio's breathing

28. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

• Hemoglobin, 8.0 g/dL (80 mmol/L)
• Sodium, 145 mEq/L (145 mmol/L)
• Serum creatinine, 0.8 mg/dL (70.6 pmol/L)
• Platelets, 210,000 cells/mm3

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29. Which of the following patients is at greater risk for contracting an infection?

• A patient with leukopenia
• A patient receiving broad-spectrum antibiotics
• A postoperative patient who has undergone orthopedic surgery
• A newly diagnosed diabetic patient

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30. Which of the following tests should be performed before beginning a prescription of Accutane?

• Check the calcium level.
• Perform a pregnancy test.
• Monitor apical pulse.
• Obtain a creatinine level.

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31. A nurse is discharging a patient after hospitalization due to myocarditis. Which of the following statements should be included in discharge teaching?

• There is usually some residual heart enlargement
• May resume previous activities as before hospitalization
• Avoid immunizations against infectious disease
• Rapidly beating heart is a common side effect of the illness and is not dangerous

32. 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:

• has very low complication rate
• maintains reduction and overall hand function
• is less bothersome than a cast
• is best for older people

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33. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response sets in. Sympathetic nervous system releases norepinephrine while the adrenal medulla secretes epinephrine. Which of the following is true with regards to that statement?

• Pupils will constrict
• Client will be lethargic
• Lungs will bronchodilate
• Gastric motility will increase

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34. Instrument which is used to examine the eye structure is called:

• Ophthalmoscope
• Laryngoscope
• Otoscope
• Bronchoscope

35. The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:

• Hip
• Ankle
• Earlobe
• Chin

36. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?

• Call for help.
• Obtain vital signs
• Ask the client to "lift up"
• Apply gloves and assess the groin site

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37. A patient is recently diagnosed with Herpes Zoster. The nurse establishing the care plan would MOST likely assign the highest priority to which of the following nursing diagnosis?

• Anxiety
• Peripheral neurovascular dysfunction
• Social Isolation
• Acute pain

38. The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?

• Restricting fluids
• Placing a pillow under the knees
• Encouraging active range-of-motion exercises
• Applying a heating pad to the lower extremities

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39. Situation: A client is brought into the emergency department with brain stem contusion Q. After a thorough assessment and laboratory works shall shows serum ketones and serum glucose level above 300 mg/dl, what condition would be diagnosed to patient?

• Diabetes insipidus
• Diabetes ketoacidosis
• Hypoglycemia
• Somogyi phenomena

40. Which of the following if done by a nurse indicates deviation from the standards of NGT feeding?

• Do not give the feeding and notify the doctor of residual of the last feeding is greater than or equal to 50 ml
• Height of the feeding should be 12 inches about the tube point of insertion to allow slow introduction of feeding
• Ask the client to position in supine position immediately after feeding to prevent dumping syndrome
• Clamp the NGT before all of the water is instilled to prevent air entry in the stomach

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41. The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

• Apply restraints to the client.
• Ask the family to stay with the client.
• Place a clock and calendar in the client's room.
• Ask the laboratory to perform electrolyte studies.

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42. SITUATION: Wide knowledge about the human ear, it's parts and it's functions will help a nurse assess and analyze changes in the adult client's health. Q. Nurse Anna is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful?

• I will try to eat foods that are low in sodium and limit my fluid intake
• I must drink at least 3,000ml of fluids per day
• I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
• I will not eat turnips, red meat and raddish

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43. The presence of the liver causes which anatomical difference of the Kidneys and the Lungs?

• Left kidney slightly lower. Left lung slightly shorter
• Left kidney slightly higher, Left lung slightly shorter
• Right kidney lower, Right lung shorter
• Right kidney higher, Right lung shorter

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44. A client is prescribed levothyroxine (Synthroid) daily. The most important instruction to give the client for administration of this drug is:

• Taper dose and discontinue if mental and emotional statuses stabilize
• Take it at bedtime to avoid the side effects of nausea and flatus
• Call the M.D. immediately at the onset of palpitations or nervousness
• Decrease intake of juices and fruits with high potassium and calcium contents

45. A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke?

• Elbow contracture secondary to spasticity
• Loss of muscle contraction decreasing venous return
• Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
• Hypoalbuminemia due to protein escaping from an inflamed glomerulus

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46. A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?

• Lying recumbent following meals
• Consuming small, frequent, bland meals
• Taking H2-receptor antagonist medication
• Raising the head of the bed on 6-inch (15 cm) blocks

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47. A patient visits the clinic for the first time. Inorder to perform an accurate and complete assessment, which of the following would be the nurse first step?

• Obtain a temperature, pulse and respiration
• Obtain a complete history
• Obtain a blood pressure
• Perform a review of systems

48. A 3 year old child is brought to the office by the parents who have been toilet training the child for the past 5 months, with little success. The parent has been using rewards for the keeping the parent clean and dry. Today the parent realizes that the child abdomen was very firm, the appetite was poor, and there had not been bowel movement for 6 days. With a nursing diagnosis of alteration in bowel elimination, what is BEST goal?

• The child will recognize the urge to defecate daily
• The parent will use praise when the child defecates in the toilet
• Predictable, regular bowel habits will be restored and maintained
• Toilet training will be delayed until the child is cognitively ready

49. A 60 year old female client who lives alone tells the nurse at the community health center "I really don't need anyone to talk to". The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?

• Displacement
• Projection
• Sublimation
• Denial

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50. SITUATION: Marvin, A male patient diagnosed with colon cancer was newly put in colostomy. Q. The nurse knew that the normal color of Marvin's stoma should be:

• Brick Red
• Gray
• Pale Pink
• Blue