PNLE I for Foundation of
Answer :(A) Have condescending trust and confidence in
Professional Nursing Practice
Answers and Rationales
1. Answer: (D) The actions of a reasonably prudent nurse
with similar education and experience. The standard of
care is determined by the average degree of skill, care, and
diligence by nurses in similar circumstances.
2. Answer: (B) I.M. With a platelet count of 22,000/μl, the
clients tends to bleed easily. Therefore, the nurse should
avoid using the I.M. route because the area is a highly
vascular and can bleed readily when penetrated by
a needle. The bleeding can be difficult to stop.
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” The nurse
should always place a zero before a decimal point so that
no one misreads the figure, which could result in a dosage
error. The nurse should never insert a zero at the end of a
dosage that includes a decimal point because this could be
misread, possibly leading to a tenfold increase in the
dosage.
4. Answer: (A) Ineffective peripheral tissue perfusion related
to venous congestion. Ineffective peripheral tissue
perfusion related to venous congestion takes the highest
priority because venous inflammation and clot formation
impede blood flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client
who is complaining of nausea. Nausea is a symptom of
impending myocardial infarction (MI) and should be
assessed immediately so that treatment can be
instituted and further damage to the heart is avoided.
6. Answer: (C) Check circulation every 15-30
minutes. Restraints encircle the limbs, which place the
client at risk for circulation being restricted to the distal
areas of the extremities. Checking the client’s circulation
every 15-30 minutes will allow the nurse to adjust the
restraints before injury from decreased blood flow occurs.
7. Answer: (A) Prevent stress ulcer. Curling’s ulcer occurs as a
generalized stress response in burn patients. This results in
a decreased production of mucus and increased secretion
of gastric acid. The best treatment for this prophylactic use
of antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record hourly urine
output. Normal urine output for an adult is approximately 1
ml/minute (60 ml/hour). Therefore, this client’s output is
normal. Beyond continued evaluation, no nursing action is
warranted.
9. Answer: (B) “My ankle feels warm”. Ice application
decreases pain and swelling. Continued or increased pain,
redness, and increased warmth are signs of inflammation
that shouldn’t occur after ice application
10. Answer: (B) Hyperkalemia. A loop diuretic removes water
and, along with it, sodium and potassium. This may result
in hypokalemia, hypovolemia, and hyponatremia.
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11.
their subordinates. Benevolent-authoritative managers
pretentiously show their trust and confidence to their
followers.
12. Answer: (A) Provides continuous, coordinated and
comprehensive nursing services. Functional nursing is
focused on tasks and activities and not on the care of the
patients.
13. Answer: (B) Standard written order. This is a standard
written order. Prescribers write a single order for
medications given only once. A stat order is written
for medications given immediately for an urgent client
problem. A standing order, also known as a protocol,
establishes guidelines for treating a particular disease or
set of symptoms in special care areas such as the coronary
care unit. Facilities also may institute medication protocols
that specifically designate drugs that a nurse may not give.
14. Answer: (D) Liquid or semi-liquid stools. Passage of liquid
or semi-liquid stools results from seepage of unformed
bowel contents around the impacted stool in the rectum.
Clients with fecal impaction don’t pass hard, brown, formed
stools because the feces can’t move past the impaction.
These clients typically report the urge to defecate (although
they can’t pass stool) and a decreased appetite.
15. Answer: (C) Pulling the helix up and back. To perform an
otoscopic examination on an adult, the nurse grasps the
helix of the ear and pulls it up and back to straighten the
ear canal. For a child, the nurse grasps the helix and pulls it
down to straighten the ear canal. Pulling the lobule in any
direction wouldn’t straighten the ear canal for
visualization.
16. Answer: (A) Protect the irritated skin from
sunlight. Irradiated skin is very sensitive and must be
protected with clothing or sunblock. The priority approach
is the avoidance of strong sunlight.
17. Answer: (C) Assist the client in removing dentures and nail
polish. Dentures, hairpins, and combs must be removed.
Nail polish must be removed so that cyanosis can be easily
monitored by observing the nail beds.
18. Answer: (D) Sudden onset of continuous epigastric and
back pain. The autodigestion of tissue by the pancreatic
enzymes results in pain from inflammation, edema, and
possible hemorrhage. Continuous, unrelieved epigastric or
back pain reflects the inflammatory process in the
pancreas.
19. Answer: (B) Provide high-protein, high-carbohydrate
diet. A positive nitrogen balance is important for meeting
metabolic needs, tissue repair, and resistance to infection.
Caloric goals may be as high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate. The baseline
must be established to recognize the signs of an
anaphylactic or hemolytic reaction to the transfusion.
21. Answer: (D) Immobilize the leg before moving the client. If
the nurse suspects a fracture, splinting the area before
 moving the client is imperative. The nurse should call for
emergency help if the client is not hospitalized and call for
a physician for the hospitalized client.
22. Answer: (B) Admit the client into a private room. The client
who has a radiation implant is placed in a private room and
has a limited number of visitors. This reduces the exposure
of others to the radiation.
23. Answer: (C) Risk for infection. Agranulocytosis is
characterized by a reduced number of leukocytes
(leucopenia) and neutrophils (neutropenia) in the blood.
The client is at high risk for infection because of the
decreased body defenses against microorganisms. Deficient
knowledge related to the nature of the disorder may be
appropriate diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in the
Trendelenburg position. Lying on the left side may prevent
air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic pressure,
which decreases the amount of blood pulled into the vena
cava during aspiration.
25. Answer: (A) Autocratic. The autocratic style of leadership is
a task-oriented and directive.
26. Answer: (D) 2.5 cc. 2.5 cc is to be added, because only a 500
cc bag of solution is being medicated instead of a 1 liter.
27. Answer: (A) 50 cc/ hour. A rate of 50 cc/hr. The child is to
receive 400 cc over a period of 8 hours = 50 cc/hr.
28. Answer: (B) Assess the client for presence of
pain. Assessing the client for pain is a very important
measure. Postoperative pain is an indication of
complication. The nurse should also assess the client for
pain to provide for the client’s comfort.
29. Answer: (A) BP – 80/60, Pulse – 110 irregular. The classic
signs of cardiogenic shock are low blood pressure, rapid
and weak irregular pulse, cold, clammy skin, decreased
urinary output, and cerebral hypoxia.
30. Answer: (A) Take the proper equipment, place the client in
a comfortable position, and record the appropriate
information in the client’s chart. It is a general or
comprehensive statement about the correct procedure, and
it includes the basic ideas which are found in the other
options
31. Answer: (B) Evaluation. Evaluation includes observing the
person, asking questions, and comparing the patient’s
behavioral responses with the expected outcomes.
32. Answer: (C) History of present illness. The history of
present illness is the single most important factor in
assisting the health professional in arriving at a diagnosis
or determining the person’s needs.
33. Answer: (A) Trochanter roll extending from the crest of the
ileum to the mid-thigh. A trochanter roll, properly placed,
provides resistance to the external rotation of the hip.
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34. Answer: (C) Stage III. Clinically, a deep crater or without
undermining of adjacent tissue is noted.
35. Answer: (A) Second intention healing. When wounds
dehisce, they will allowed to heal by secondary intention
36. Answer: (D) Tachycardia. With an extracellular fluid or
plasma volume deficit, compensatory mechanisms
stimulate the heart, causing an increase in heart rate.
37. Answer: (A) 0.75. To determine the number of milliliters
the client should receive, the nurse uses the fraction
method in the following equation.
 75 mg/X ml = 100 mg/1 ml
 To solve for X, cross-multiply:
 75 mg x 1 ml = X ml x 100 mg
 75 = 100X
 75/100 = X
 0.75 ml (or ¾ ml) = X
38. Answer: (D) it’s a measure of effect, not a standard measure
of weight or quantity. An insulin unit is a measure of effect,
not a standard measure of weight or quantity. Different
drugs measured in units may have no relationship to one
another in quality or quantity.
39. Answer: (B) 38.9 °C. To convert Fahrenheit degreed to
Centigrade, use this formula
 °C = (°F – 32) ÷ 1.8
 °C = (102 – 32) ÷ 1.8
 °C = 70 ÷ 1.8
 °C = 38.9
40. Answer: (C) Failing eyesight, especially close vision. Failing
eyesight, especially close vision, is one of the first signs of
aging in middle life (ages 46 to 64). More frequent aches
and pains begin in the early late years (ages 65 to 79).
Increase in loss of muscle tone occurs in later years (age 80
and older).
41. Answer: (A) Checking and taping all connections. Air leaks
commonly occur if the system isn’t secure. Checking all
connections and taping them will prevent air leaks. The
chest drainage system is kept lower to promote drainage –
not to prevent leaks.
42. Answer: (A) Check the client’s identification band. Checking
the client’s identification band is the safest way to verify a
client’s identity because the band is assigned on admission
and isn’t be removed at any time. (If it is removed, it must
be replaced). Asking the client’s name or having the client
repeated his name would be appropriate only for a client
 who’s alert, oriented, and able to understand what is being
said, but isn’t the safe standard of practice. Names on bed
aren’t always reliable
43. Answer: (B) 32 drops/minute. Giving 1,000 ml over 8 hours
is the same as giving 125 ml over 1 hour (60 minutes). Find
the number of milliliters per minute as follows:
 125/60 minutes = X/1 minute
 60X = 125 = 2.1 ml/minute
 To find the number of drops per minute:
 2.1 ml/X gtt = 1 ml/ 15 gtt
 X = 32 gtt/minute, or 32 drops/minute
44. Answer: (A) Clamp the catheter. If a central venous
catheter becomes disconnected, the nurse should
immediately apply a catheter clamp, if available. If a clamp
isn’t available, the nurse can place a sterile syringe or
catheter plug in the catheter hub. After cleaning the hub
with alcohol or povidone-iodine solution, the nurse must
replace the I.V. extension and restart the infusion.
45. Answer: (D) Auscultation, percussion, and palpation.The
correct order of assessment for examining the abdomen is
inspection, auscultation, percussion, and palpation. The
reason for this approach is that the less intrusive
techniques should be performed before the more intrusive
techniques. Percussion and palpation can alter natural
findings during auscultation.
46. Answer: (D) Ulnar surface of the hand. The nurse uses the
ulnar surface, or ball, of the hand to asses tactile fremitus,
thrills, and vocal vibrations through the chest wall.
The fingertips and finger pads best distinguish texture and
shape. The dorsal surface best feels warmth.
47. Answer: (C) Formative. Formative (or concurrent)
evaluation occurs continuously throughout the teaching
and learning process. One benefit is that the nurse can
adjust teaching strategies as necessary to enhance learning.
Summative, or retrospective, evaluation occurs at the
conclusion of the teaching and learning session.
Informative is not a type of evaluation.
48. Answer: (B) Once per year. Yearly mammograms should
begin at age 40 and continue for as long as the woman is in
good health. If health risks, such as family history, genetic
tendency, or past breast cancer, exist, more
frequent examinations may be necessary.
49. Answer: (A) Respiratory acidosis. The client has a below-
normal (acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide (Paco2) value,
indicating respiratory acidosis. In respiratory alkalosis, the
pH value is above normal and in the Paco2 value is below
normal. In metabolic acidosis, the pH and bicarbonate
(Hco3) values are below normal. In metabolic alkalosis, the
pH and Hco3 values are above normal.
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50. Answer: (B) To provide support for the client and family in
coping with terminal illness. Hospices provide supportive
care for terminally ill clients and their families. Hospice
care doesn’t focus on counseling regarding health care
costs. Most client referred to hospices have been treated for
their disease without success and will receive only
palliative care in the hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer
and applying a protective dressing as necessary. Washing
the area with normal saline solution and applying a
protective dressing are within the nurse’s realm of
interventions and will protect the area. Using a povidone-
iodine wash and an antibiotic cream require a physician’s
order. Massaging with an astringent can further damage
the skin.
52. Answer: (D) Foot. An elastic bandage should be applied
form the distal area to the proximal area. This method
promotes venous return. In this case, the nurse should
begin applying the bandage at the client’s foot. Beginning at
the ankle, lower thigh, or knee does not promote venous
return.
53. Answer: (B) Hypokalemia. Insulin administration causes
glucose and potassium to move into the cells, causing
hypokalemia.
54. Answer: (A) Throbbing headache or dizziness. Headache
and dizziness often occur when nitroglycerin is taken at the
beginning of therapy. However, the client usually develops
tolerance
55. Answer: (D) Check the client’s level of
consciousness. Determining unresponsiveness is the first
step assessment action to take. When a client is in
ventricular tachycardia, there is a significant decrease in
cardiac output. However, checking the unresponsiveness
ensures whether the client is affected by the decreased
cardiac output.
56. Answer: (B) On the affected side of the client. When
walking with clients, the nurse should stand on the affected
side and grasp the security belt in the midspine area of the
small of the back. The nurse should position the free hand
at the shoulder area so that the client can be pulled toward
the nurse in the event that there is a forward fall. The client
is instructed to look up and outward rather than at his or
her feet.
57. Answer: (A) Urine output: 45 ml/hr. adequate perfusion
must be maintained to all vital organs in order for the client
to remain visible as an organ donor. A urine output of 45 ml
per hour indicates adequate renal perfusion. Low blood
pressure and delayed capillary refill time are circulatory
system indicators of inadequate perfusion. A serum pH of
7.32 is acidotic, which adversely affects all body tissues.
58. Answer: (D ) Obtaining the specimen from the urinary
drainage bag. A urine specimen is not taken from the
urinary drainage bag. Urine undergoes chemical changes
while sitting in the bag and does not necessarily reflect the
current client status. In addition, it may become
contaminated with bacteria from opening the system.
59. Answer: (B) Cover the client, place the call light within
reach, and answer the phone call. Because telephone call is
an emergency, the nurse may need to answer it. The other
appropriate action is to ask another nurse to accept the call.
However, is not one of the options? To maintain privacy
and safety, the nurse covers the client and places the call
light within the client’s reach. Additionally, the client’s door
should be closed or the room curtains pulled around the
bathing area.
60. Answer: (C) Use a sterile plastic container for obtaining the
specimen. Sputum specimens for culture and sensitivity
testing need to be obtained using sterile techniques
because the test is done to determine the presence of
organisms. If the procedure for obtaining the specimen is
not sterile, then the specimen is not sterile, then the
specimen would be contaminated and the results of the test
would be invalid.
61. Answer: (A) Puts all the four points of the walker flat on the
floor, puts weight on the hand pieces, and then walks into
it. When the client uses a walker, the nurse stands adjacent
to the affected side. The client is instructed to put all four
points of the walker 2 feet forward flat on the floor before
putting weight on hand pieces. This will ensure client safety
and prevent stress cracks in the walker. The client is then
instructed to move the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the incorrect
information and then initials the change. To correct an
error documented in a medical record, the nurse draws one
line through the incorrect information and then initials the
error. An error is never erased and correction fluid is never
used in the medical record.
63. Answer: (C) Secures the client safety belts after
transferring to the stretcher. During the transfer of the
client after the surgical procedure is complete, the nurse
should avoid exposure of the client because of the risk for
potential heat loss. Hurried movements and rapid changes
in the position should be avoided because these predispose
the client to hypotension. At the time of the transfer from
the surgery table to the stretcher, the client is still affected
by the effects of the anesthesia; therefore, the client should
not move self. Safety belts can prevent the client from
falling off the stretcher.
64. Answer: (B) Gown and gloves. Contact precautions require
the use of gloves and a gown if direct client contact is
anticipated. Goggles are not necessary unless the nurse
anticipates the splashes of blood, body fluids, secretions, or
excretions may occur. Shoe protectors are not necessary.
65. Answer: (C) Quad cane. Crutches and a walker can be
difficult to maneuver for a client with weakness on one
side. A cane is better suited for client with weakness of the
arm and leg on one side. However, the quad cane would
provide the most stability because of the structure of the
cane and because a quad cane has four legs.
66. Answer: (D) Left side-lying with the head of the bed
elevated 45 degrees. To facilitate removal of fluid from the
chest wall, the client is positioned sitting at the edge of the
bed leaning over the bedside table with the feet supported
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on a stool. If the client is unable to sit up, the client is
positioned lying in bed on the unaffected side with the head
of the bed elevated 30 to 45 degrees.
67. Answer: (D) Reliability Reliability is consistency of the
research instrument. It refers to the repeatability of the
instrument in extracting the same responses upon its
repeated administration.
68. Answer: (A) Keep the identities of the subject
secret. Keeping the identities of the research subject secret
will ensure anonymity because this will hinder providing
link between the information given to whoever is its
source.
69. Answer: (A) Descriptive- correlational. Descriptive-
correlational study is the most appropriate for this study
because it studies the variables that could be the
antecedents of the increased incidence of nosocomial
infection.
70. Answer: (C) Use of laboratory data. Incidence of
nosocomial infection is best collected through the use of
biophysiologic measures, particularly in vitro
measurements, hence laboratory data is essential.
71. Answer: (B) Quasi-experiment. Quasi-experiment is done
when randomization and control of the variables are not
possible.
72. Answer: (C) Primary source. This refers to a primary
source which is a direct account of the investigation done
by the investigator. In contrast to this is a secondary
source, which is written by someone other than the original
researcher.
73. Answer: (A) Non-maleficence. Non-maleficence means do
not cause harm or do any action that will cause any harm to
the patient/client. To do good is referred as beneficence.
74. Answer: (C) Res ipsa loquitor. Res ipsa loquitor literally
means the thing speaks for itself. This means in operational
terms that the injury caused is the proof that there was a
negligent act.
75. Answer: (B) The Board can investigate violations of the
nursing law and code of ethics. Quasi-judicial power means
that the Board of Nursing has the authority to investigate
violations of the nursing law and can issue summons,
subpoena or subpoena duces tecum as needed.
76. Answer: (C) May apply for re-issuance of his/her license
based on certain conditions stipulated in RA 9173. RA 9173
sec. 24 states that for equity and justice, a revoked license
maybe re-issued provided that the following conditions are
met: a) the cause for revocation of license has already been
corrected or removed; and, b) at least four years has
elapsed since the license has been revoked.
77. Answer: (B) Review related literature. After formulating
and delimiting the research problem, the researcher
conducts a review of related literature to determine the
extent of what has been done on the study by previous
researchers.
78. Answer: (B) Hawthorne effect. Hawthorne effect is based
on the study of Elton Mayo and company about the effect of
an intervention done to improve the working conditions of
the workers on their productivity. It resulted to an
increased productivity but not due to the intervention but
due to the psychological effects of being observed. They
performed differently because they were under
observation.
79. Answer: (B) Determines the different nationality of
patients frequently admitted and decides to get
representations samples from each. Judgment sampling
involves including samples according to the knowledge of
the investigator about the participants in the study.
80. Answer: (B) Madeleine Leininger. Madeleine Leininger
developed the theory on transcultural theory based on her
observations on the behavior of selected people within a
culture.
81. Answer: (A) Random. Random sampling gives equal chance
for all the elements in the population to be picked as part of
the sample.
82. Answer: (A) Degree of agreement and disagreement. Likert
scale is a 5-point summated scale used to determine the
degree of agreement or disagreement of the respondents to
a statement in a study
83. Answer: (B) Sr. Callista Roy. Sr. Callista Roy developed the
Adaptation Model which involves the physiologic mode,
self-concept mode, role function mode and dependence
mode.
84. Answer: (A) Span of control. Span of control refers to the
number of workers who report directly to a manager.
85. Answer: (B) Autonomy. Informed consent means that the
patient fully understands about the surgery, including the
risks involved and the alternative solutions. In giving
consent it is done with full knowledge and is given freely.
The action of allowing the patient to decide whether a
surgery is to be done or not exemplifies the bioethical
principle of autonomy.
86. Answer: (C) Avoid wearing canvas shoes. The client should
be instructed to avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn, cause
skin irritation and breakdown. Both cotton and cornstarch
absorb perspiration. The client should be instructed to cut
toenails straight across with nail clippers.
87. Answer: (D) Ground beef patties. Meat is an excellent
source of complete protein, which this client needs to
repair the tissue breakdown caused by pressure
ulcers. Oranges and broccoli supply vitamin C but not
protein. Ice cream supplies only some incomplete protein,
making it less helpful in tissue repair.
88. Answer: (D) Sims’ left lateral. The Sims’ left lateral position
is the most common position used to administer a
cleansing enema because it allows gravity to aid the flow of
fluid along the curve of the sigmoid colon. If the client can’t
assume this position nor has poor sphincter control, the
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dorsal recumbent or right lateral position may be used. The
supine and prone positions are inappropriate and
uncomfortable for the client.
89. Answer: (A) Arrange for typing and cross matching of the
client’s blood. The nurse first arranges for typing and cross
matching of the client’s blood to ensure compatibility with
donor blood. The other options,although appropriate when
preparing to administer a blood transfusion, come later.
90. Answer: (A) Independent. Nursing interventions are
classified as independent, interdependent, or dependent.
Altering the drug schedule to coincide with the client’s
daily routine represents an independent intervention,
whereas consulting with the physician and pharmacist to
change a client’s medication because of adverse reactions
represents an interdependent intervention. Administering
an already-prescribed drug on time is a dependent
intervention. An intradependent nursing intervention
doesn’t exist.
91. Answer: (D) Evaluation. The nursing actions described
constitute evaluation of the expected outcomes. The
findings show that the expected outcomes have been
achieved. Assessment consists of the client’s history,
physical examination, and laboratory studies. Analysis
consists of considering assessment information to derive
the appropriate nursing diagnosis. Implementation is the
phase of the nursing process where the nurse puts the plan
of care into action.
92. Answer: (B) To observe the lower extremities. Elastic
stockings are used to promote venous return. The nurse
needs to remove them once per day to observe the
condition of the skin underneath the stockings. Applying
the stockings increases blood flow to the heart. When the
stockings are in place, the leg muscles can still stretch and
relax, and the veins can fill with blood.
93. Answer:(A) Instructing the client to report any itching,
swelling, or dyspnea. Because administration of blood or
blood products may cause serious adverse effects such as
allergic reactions, the nurse must monitor the client for
these effects. Signs and symptoms of life-threatening
allergic reactions include itching, swelling, and dyspnea.
Although the nurse should inform the client of the duration
of the transfusion and should document its administration,
these actions are less critical to the client’s immediate
health. The nurse should assess vital signs at least hourly
during the transfusion.
94. Answer: (B) Decrease the rate of feedings and the
concentration of the formula. Complaints of abdominal
discomfort and nausea are common in clients receiving
tube feedings. Decreasing the rate of the feeding and the
concentration of the formula should decrease the client’s
discomfort. Feedings are normally given at room
temperature to minimize abdominal cramping. To prevent
aspiration during feeding, the head of the client’s bed
should be elevated at least 30 degrees. Also, to prevent
bacterial growth, feeding containers should be routinely
changed every 8 to 12 hours.
95. Answer: (D) Roll the vial gently between the palms. Rolling
the vial gently between the palms produces heat, which
helps dissolve the medication. Doing nothing or inverting
the vial wouldn’t help dissolve the medication. Shaking the
vial vigorously could cause the medication to break down,
altering its action.
96. Answer: (B) Assist the client to the semi-Fowler position if
possible. By assisting the client to the semi-Fowler position,
the nurse promotes easier chest expansion, breathing, and
oxygen intake. The nurse should secure the elastic band so
that the face mask fits comfortably and snugly rather than
tightly, which could lead to irritation. The nurse should
apply the face mask from the client’s nose down to the chin
— not vice versa. The nurse should check the connectors
between the oxygen equipment and humidifier to ensure
that they’re airtight; loosened connectors can cause loss of
oxygen.
97. Answer: (B) 4 hours. A unit of packed RBCs may be given
over a period of between 1 and 4 hours. It shouldn’t infuse
for longer than 4 hours because the risk of contamination
and sepsis increases after that time. Discard or return to
the blood bank any blood not given within this time,
according to facility policy.
98. Answer: (B) Immediately before administering the next
dose. Measuring the blood drug concentration helps
determine whether the dosing has achieved the therapeutic
goal. For measurement of the trough, or lowest, blood level
of a drug, the nurse draws a blood sample immediately
before administering the next dose. Depending on the
drug’s duration of action and half-life, peak blood drug
levels typically are drawn after administering the next
dose.
99. Answer: (A) The nurse can implement medication orders
quickly. A floor stock system enables the nurse to
implement medication orders quickly. It doesn’t allow for
pharmacist input, nor does it minimize transcription errors
or reinforce accurate calculations.
100.Answer: (C) Shifting dullness over the abdomen. Shifting
dullness over the abdomen indicates ascites,
an abnormal finding. The other options are normal
abdominal findings.
PNLE II for Community Health Nursing and Care
of the Mother and Child
Answers and Rationales
1. Answer: (A) Inevitable. An inevitable abortion is
termination of pregnancy that cannot be prevented.
Moderate to severe bleeding with mild cramping
6
and cervical dilation would be noted in this type of
abortion.
2. Answer: (B) History of syphilis. Maternal infections such
as syphilis, toxoplasmosis, and rubella are causes of
spontaneous abortion.
3. Answer: (C) Monitoring apical pulse. Nursing care for the
client with a possible ectopic pregnancy is focused on
preventing or identifying hypovolemic shock and
controlling pain. An elevated pulse rate is an indicator of
shock.
4. Answer: (B) Increased caloric intake. Glucose crosses the
placenta, but insulin does not. High fetal demands for
glucose, combined with the insulin resistance caused
by hormonal changes in the last half of pregnancy can
result in elevation of maternal blood glucose levels. This
increases the mother’s demand for insulin and is referred
to as the diabetogenic effect of pregnancy.
5. Answer: (A) Excessive fetal activity. The most common
signs and symptoms of hydatidiform mole includes
elevated levels of human chorionic gonadotropin,
vaginal bleeding, larger than normal uterus for gestational
age, failure to detect fetal heart activity even with
sensitive instruments, excessive nausea and vomiting, and
early development of pregnancy-induced
hypertension. Fetal activity would not be noted.
6. Answer: (B) Absent patellar reflexes. Absence of patellar
reflexes is an indicator of hypermagnesemia, which
requires administration of calcium gluconate.
7. Answer: (C) Presenting part in 2 cm below the plane of the
ischial spines. Fetus at station plus two indicates that the
presenting part is 2 cm below the plane of the ischial
spines.
8. Answer: (A) Contractions every 1 ½ minutes lasting 70-80
seconds. Contractions every 1 ½ minutes lasting 70-80
seconds, is indicative of hyperstimulation of the uterus,
which could result in injury to the mother and the fetus if
Pitocin is not discontinued.
9. Answer: (C) EKG tracings. A potential side effect of
calcium gluconate administration is cardiac arrest.
Continuous monitoring of cardiac activity (EKG) throught
administration of calcium gluconate is an essential part of
care.
10. Answer: (D) First low transverse caesarean was for
breech position. Fetus in this pregnancy is in a vertex
presentation. This type of client has no obstetrical
indication for a caesarean section as she did with her first
caesarean delivery.
11. Answer: (A) Talk to the mother first and then to the
toddler. When dealing with a crying toddler, the best
approach is to talk to the mother and ignore the toddler
first. This approach helps the toddler get used to the nurse
before she attempts any procedures. It also gives the
toddler an opportunity to see that the mother trusts the
nurse.
12. Answer: (D) Place the infant’s arms in soft elbow
restraints. Soft restraints from the upper arm to the wrist
prevent the infant from touching her lip but allow him to
hold a favorite item such as a blanket. Because they could
damage the operative site, such as objects as pacifiers,
suction catheters, and small spoons shouldn’t be placed in
a baby’s mouth after cleft repair. A baby in a prone
position may rub her face on the sheets and traumatize
the operative site. The suture line should be cleaned
gently to prevent infection, which could interfere with
healing and damage the cosmetic appearance of the
repair.
13. Answer: (B) Allow the infant to rest before
feeding. Because feeding requires so much energy, an
infant with heart failure should rest before feeding.
14. Answer: (C) Iron-rich formula only. The infants at age 5
months should receive iron-rich formula and that they
shouldn’t receive solid food, even baby food until age 6
months.
15. Answer: (D) 10 months. A 10 month old infant can sit
alone and understands object permanence, so he would
look for the hidden toy. At age 4 to 6 months, infants can’t
sit securely alone. At age 8 months, infants can sit securely
alone but cannot understand the permanence of objects.
16. Answer: (D) Public health nursing focuses on preventive,
not curative, services. The catchments area in PHN
consists of a residential community, many of whom are
well individuals who have greater need for preventive
rather than curative services.
17. Answer: (B) Efficiency. Efficiency is determining whether
the goals were attained at the least possible cost.
18. Answer: (D) Rural Health Unit. R.A. 7160 devolved basic
health services to local government units (LGU’s ). The
public health nurse is an employee of the LGU.
19. Answer: (A) Mayor. The local executive serves as the
chairman of the Municipal Health Board.
20. Answer: (A) 1. Each rural health midwife is given a
population assignment of about 5,000.
21. Answer: (B) Health education and community organizing
are necessary in providing community health
services. The community health nurse develops the health
capability of people through health education and
community organizing activities.
22. Answer: (B) Measles. Presidential Proclamation No. 4 is on
the Ligtas Tigdas Program.
23. Answer: (D) Core group formation. In core group
formation, the nurse is able to transfer the technology of
community organizing to the potential or informal
community leaders through a training program.
24. Answer: (D) To maximize the community’s resources in
dealing with health problems. Community organizing is a
7
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.
25. Answer: (D) Terminal. Tertiary prevention involves
rehabilitation, prevention of permanent disability and
disability limitation appropriate for convalescents, the
disabled, complicated cases and the terminally ill (those in
the terminal stage of a disease).
26. Answer: (A) Intrauterine fetal death. Intrauterine fetal
death, abruptio placentae, septic shock, and amniotic fluid
embolism may trigger normal clotting mechanisms; if
clotting factors are depleted, DIC may occur. Placenta
accreta, dysfunctional labor, and premature rupture of the
membranes aren’t associated with DIC.
27. Answer: (C) 120 to 160 beats/minute. A rate of 120 to 160
beats/minute in the fetal heart appropriate for filling the
heart with blood and pumping it out to the system.
28. Answer: (A) Change the diaper more often. Decreasing the
amount of time the skin comes contact with wet soiled
diapers will help heal the irritation.
29. Answer: (D) Endocardial cushion defect. Endocardial
cushion defects are seen most in children with Down
syndrome, asplenia, or polysplenia.
30. Answer: (B) Decreased urine output. Decreased urine
output may occur in clients receiving I.V. magnesium and
should be monitored closely to keep urine output
at greater than 30 ml/hour, because magnesium is
excreted through the kidneys and can easily accumulate to
toxic levels.
31. Answer: (A) Menorrhagia. Menorrhagia is an excessive
menstrual period.
32. Answer: (C) Blood typing. Blood type would be a critical
value to have because the risk of blood loss is always a
potential complication during the labor and delivery
process. Approximately 40% of a woman’s cardiac output
is delivered to the uterus, therefore, blood loss can occur
quite rapidly in the event of uncontrolled bleeding.
33. Answer: (D) Physiologic anemia. Hemoglobin values and
hematocrit decrease during pregnancy as the increase in
plasma volume exceeds the increase in red blood cell
production.
34. Answer: (D) A 2 year old infant with stridorous breath
sounds, sitting up in his mother’s arms and drooling. The
infant with the airway emergency should be treated first,
because of the risk of epiglottitis.
35. Answer: (A) Placenta previa. Placenta previa with painless
vaginal bleeding.
36. Answer: (D) Early in the morning. Based on the nurse’s
knowledge of microbiology, the specimen should be
collected early in the morning. The rationale for
 this timing is that, because the female worm lays eggs at
night around the perineal area, the first bowel movement
of the day will yield the best results. The specific type of
stool specimen used in the diagnosis of pinworms is called
the tape test.
37. Answer: (A) Irritability and seizures. Lead poisoning
primarily affects the CNS, causing increased intracranial
pressure. This condition results in irritability and changes
in level of consciousness, as well as seizure disorders,
hyperactivity, and learning disabilities.
38. Answer: (D) “I really need to use the diaphragm and jelly
most during the middle of my menstrual cycle”. The
woman must understand that, although the “fertile”
period is approximately mid-cycle, hormonal variations do
occur and can result in early or late ovulation. To be
effective, the diaphragm should be inserted before every
intercourse.
39. Answer: (C) Restlessness. In a child, restlessness is the
earliest sign of hypoxia. Late signs of hypoxia in a child are
associated with a change in color, such as pallor or
cyanosis.
40. Answer: (B) Walk one step ahead, with the child’s hand on
the nurse’s elbow. This procedure is generally
recommended to follow in guiding a person who is blind.
41. Answer: (A) Loud, machinery-like murmur. A loud,
machinery-like murmur is a characteristic finding
associated with patent ductus arteriosus.
42. Answer: (C) More oxygen, and the newborn’s metabolic
rate increases. When cold, the infant requires more
oxygen and there is an increase in metabolic rate. Non-
shievering thermogenesis is a complex process that
increases the metabolic rate and rate of oxygen
consumption, therefore, the newborn increase heat
production.
43. Answer: (D) Voided. Before administering potassium I.V.
to any client, the nurse must first check that the client’s
kidneys are functioning and that the client is voiding. If
the client is not voiding, the nurse should withhold
the potassium and notify the physician.
44. Answer: (C) Laundry detergent. Eczema or dermatitis is
an allergic skin reaction caused by an offending allergen.
The topical allergen that is the most common causative
factor is laundry detergent.
45. Answer: (A) 6 inches. This distance allows for easy flow of
the formula by gravity, but the flow will be slow enough
not to overload the stomach too rapidly.
46. Answer: (A) The older one gets, the more susceptible he
becomes to the complications of chicken pox. Chicken pox
is usually more severe in adults than in children.
Complications, such as pneumonia, are higher in incidence
in adults.
47. Answer: (D) Consult a physician who may give them
rubella immunoglobulin. Rubella vaccine is made up of
8
attenuated German measles viruses. This is
contraindicated in pregnancy. Immune globulin, a specific
prophylactic against German measles, may be given to
pregnant women.
48. Answer: (A) Contact tracing. Contact tracing is the most
practical and reliable method of finding possible sources
of person-to-person transmitted infections, such as
sexually transmitted diseases.
49. Answer: (D) Leptospirosis. Leptospirosis is transmitted
through contact with the skin or mucous membrane with
water or moist soil contaminated with urine of infected
animals, like rats.
50. Answer: (B) Cholera. Passage of profuse watery stools is
the major symptom of cholera. Both amebic and bacillary
dysentery are characterized by the presence of blood
and/or mucus in the stools. Giardiasis is characterized by
fat malabsorption and, therefore, steatorrhea.
51. Answer: (A) Hemophilus influenzae. Hemophilus
meningitis is unusual over the age of 5 years. In
developing countries, the peak incidence is in children less
than 6 months of age. Morbillivirus is the etiology of
measles. Streptococcus pneumoniae and Neisseria
meningitidis may cause meningitis, but age distribution is
not specific in young children.
52. Answer: (B) Buccal mucosa. Koplik’s spot may be seen on
the mucosa of the mouth or the throat.
53. Answer: (A) 3 seconds. Adequate blood supply to the area
allows the return of the color of the nailbed within 3
seconds.
54. Answer: (B) Severe dehydration. The order of priority in
the management of severe dehydration is as follows:
intravenous fluid therapy, referral to a facility where IV
fluids can be initiated within 30 minutes, Oresol or
nasogastric tube. When the foregoing measures are not
possible or effective, then urgent referral to the hospital is
done.
55. Answer: (A) 45 infants. To estimate the number of infants,
multiply total population by 3%.
56. Answer: (A) DPT. DPT is sensitive to freezing. The
appropriate storage temperature of DPT is 2 to 8° C only.
OPV and measles vaccine are highly sensitive to heat and
require freezing. MMR is not an immunization in the
Expanded Program on Immunization.
57. Answer: (C) Proper use of sanitary toilets. The ova of the
parasite get out of the human body together with feces.
Cutting the cycle at this stage is the most effective way of
preventing the spread of the disease to susceptible hosts.
58. Answer: (D) 5 skin lesions, positive slit skin smear. A
multibacillary leprosy case is one who has a positive slit
skin smear and at least 5 skin lesions.
59. Answer: (C) Thickened painful nerves. The lesion of
leprosy is not macular. It is characterized by a change in
skin color (either reddish or whitish) and loss of
sensation, sweating and hair growth over the lesion.
Inability to close the eyelids (lagophthalmos) and sinking
of the nosebridge are late symptoms.
60. Answer: (B) Ask where the family resides. 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 she was
brought and whether she stayed overnight in that area.
61. Answer: (A) Inability to drink. A sick child aged 2 months
to 5 years must be referred urgently to a hospital if he/she
has one or more of the following signs: not able to feed or
drink, vomits everything, convulsions, abnormally sleepy
or difficult to awaken.
62. Answer: (A) Refer the child urgently to a hospital for
confinement. “Baggy pants” is a sign of severe marasmus.
The best management is urgent referral to a hospital.
63. Answer: (D) Let the child rest for 10 minutes then
continue giving Oresol more slowly. If the child vomits
persistently, that is, he vomits everything that he takes in,
he has to be referred urgently to a hospital. Otherwise,
vomiting is managed by letting the child rest for 10
minutes and then continuing with Oresol administration.
Teach the mother to give Oresol more slowly.
64. Answer: (B) Some dehydration. Using the assessment
guidelines of IMCI, a child (2 months to 5 years old) with
diarrhea is classified as having SOME DEHYDRATION if he
shows 2 or more of the following signs: restless or
irritable, sunken eyes, the skin goes back slow after a skin
pinch.
65. Answer: (C) Normal. In IMCI, a respiratory rate of
50/minute or more is fast breathing for an infant aged 2 to
12 months.
66. Answer: (A) 1 year. The baby will have passive natural
immunity by placental transfer of antibodies. The mother
will have active artificial immunity lasting for about 10
years. 5 doses will give the mother lifetime protection.
67. Answer: (B) 4 hours. While the unused portion of other
biologicals in EPI may be given until the end of the day,
only BCG is discarded 4 hours after reconstitution. This is
why BCG immunization is scheduled only in the morning.
68. Answer: (B) 6 months. After 6 months, the baby’s nutrient
needs, especially the baby’s iron requirement, can no
longer be provided by mother’s milk alone.
69. Answer: (C) 24 weeks. At approximately 23 to 24 weeks’
gestation, the lungs are developed enough to sometimes
maintain extrauterine life. The lungs are the most
immature system during the gestation period. Medical
care for premature labor begins much earlier
(aggressively at 21 weeks’ gestation)
9
70. Answer: (B) Sudden infant death syndrome (SIDS). Supine
positioning is recommended to reduce the risk of SIDS in
infancy. The risk of aspiration is slightly increased with
the supine position. Suffocation would be less likely with
an infant supine than prone and the position for GER
requires the head of the bed to be elevated.
71. Answer: (C) Decreased temperature. Temperature
instability, especially when it results in a low temperature
in the neonate, may be a sign of infection. The
neonate’s color often changes with an infection process
but generally becomes ashen or mottled. The neonate with
an infection will usually show a decrease in activity level
or lethargy.
72. Answer: (D) Polycythemia probably due to chronic fetal
hypoxia. The small-for-gestation neonate is at risk for
developing polycythemia during the transitional period in
an attempt to decreasehypoxia. The neonates are also at
increased risk for developing hypoglycemia and
hypothermia due to decreased glycogen stores.
73. Answer: (C) Desquamation of the epidermis. Postdate
fetuses lose the vernix caseosa, and the epidermis may
become desquamated. These neonates are usually very
alert. Lanugo is missing in the postdate neonate.
74. Answer: (C) Respiratory depression. Magnesium sulfate
crosses the placenta and adverse neonatal effects are
respiratory depression, hypotonia, and bradycardia. The
serum blood sugar isn’t affected by magnesium sulfate.
The neonate would be floppy, not jittery.
75. Answer: (C) Respiratory rate 40 to 60 breaths/minute. A
respiratory rate 40 to 60 breaths/minute is normal for a
neonate during the transitional period. Nasal flaring,
respiratory rate more than 60 breaths/minute, and
audible grunting are signs of respiratory distress.
76. Answer: (C) Keep the cord dry and open to air. Keeping
the cord dry and open to air helps reduce infection and
hastens drying. Infants aren’t given tub bath but are
sponged off until the cord falls off. Petroleum jelly
prevents the cord from drying and encourages infection.
Peroxide could be painful and isn’t recommended.
77. Answer: (B) Conjunctival hemorrhage. Conjunctival
hemorrhages are commonly seen in neonates secondary
to the cranial pressure applied during the birth process.
Bulging fontanelles are a sign of intracranial pressure.
Simian creases are present in 40% of the neonates with
trisomy 21. Cystic hygroma is a neck mass that can affect
the airway.
78. Answer: (B) To assess for prolapsed cord. After a client
has an amniotomy, the nurse should assure that the cord
isn’t prolapsed and that the baby tolerated the procedure
well. The most effective way to do this is to check the fetal
heart rate. Fetal well-being is assessed via a nonstress test.
Fetal position is determined by vaginal examination.
Artificial rupture of membranes doesn’t indicate an
imminent delivery.
79. Answer: (D) The parents’ interactions with each
other. Parental interaction will provide the nurse with a
good assessment of the stability of the family’s home life
but it has no indication for parental bonding. Willingness
to touch and hold the newborn, expressing interest about
the newborn’s size, and indicating a desire to see the
newborn are behaviors indicating parental bonding.
80. Answer: (B) Instructing the client to use two or more
peripads to cushion the area. Using two or more peripads
would do little to reduce the pain or promote perineal
healing. Cold applications, sitz baths, and Kegel exercises
are important measures when the client has a fourth-
degree laceration.
81. Answer: (C) “What is your expected due date?” When
obtaining the history of a client who may be in labor, the
nurse’s highest priority is to determine her current status,
particularly her due date, gravidity, and parity. Gravidity
and parity affect the duration of labor and the potential for
labor complications. Later, the nurse should ask about
chronic illnesses, allergies, and support persons.
82. Answer: (D) Aspirate the neonate’s nose and mouth with a
bulb syringe. The nurse’s first action should be to clear the
neonate’s airway with a bulb syringe. After the airway is
clear and the neonate’s color improves, the nurse should
comfort and calm the neonate. If the problem recurs or the
neonate’s color doesn’t improve readily, the nurse should
notify the physician. Administering oxygen when the
airway isn’t clear would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an
amniotic fluid index. It isn’t within a nurse’s scope of
practice to perform and interpret a bedside ultrasound
under these conditions and without specialized training.
Observing for pooling of straw-colored fluid, checking
vaginal discharge with nitrazine paper, and observing for
flakes of vernix are appropriate assessments for
determining whether a client has ruptured membranes.
84. Answer: (C) Monitor partial pressure of oxygen (Pao2)
levels. Monitoring PaO2 levels and reducing the oxygen
concentration to keep PaO2 within normal limits reduces
the risk of retinopathy of prematurity in a premature
infant receiving oxygen. Covering the infant’s eyes and
humidifying the oxygen don’t reduce the risk of
retinopathy of prematurity. Because cooling increases the
risk of acidosis, the infant should be kept warm so that his
respiratory distress isn’t aggravated.
85. Answer: (A) 110 to 130 calories per kg. Calories per kg is
the accepted way of determined appropriate nutritional
intake for a newborn. The recommended calorie
requirement is 110 to 130 calories per kg of newborn
body weight. This level will maintain a consistent blood
glucose level and provide enough calories for continued
growth and development.
86. Answer: (C) 30 to 32 weeks. Individual twins usually grow
at the same rate as singletons until 30 to 32 weeks’
gestation, then twins don’t’ gain weight as rapidly as
singletons of the same gestational age. The placenta can
no longer keep pace with the nutritional requirements of
10
both fetuses after 32 weeks, so there’s some growth
retardation in twins if they remain in utero at 38 to 40
weeks.
87. Answer: (A) conjoined twins. The type of placenta that
develops in monozygotic twins depends on the time at
which cleavage of the ovum occurs. Cleavage in conjoined
twins occurs more than 13 days after fertilization.
Cleavage that occurs less than 3 day after fertilization
results in diamniotic dicchorionic twins. Cleavage that
occurs between days 3 and 8 results in diamniotic
monochorionic twins. Cleavage that occurs between days
8 to 13 result in monoamniotic monochorionic twins.
88. Answer: (D) Ultrasound. Once the mother and the fetus
are stabilized, ultrasound evaluation of the placenta
should be done to determine the cause of the bleeding.
Amniocentesis is contraindicated in placenta previa. A
digital or speculum examination shouldn’t be done as this
may lead to severe bleeding or hemorrhage. External fetal
monitoring won’t detect a placenta previa, although it will
detect fetal distress, which may result from blood loss or
placenta separation.
89. Answer: (A) Increased tidal volume. A pregnant client
breathes deeper, which increases the tidal volume of gas
moved in and out of the respiratory tract with each breath.
The expiratory volume and residual volume decrease as
the pregnancy progresses. The inspiratory capacity
increases during pregnancy. The increased oxygen
consumption in the pregnant client is 15% to 20% greater
than in the nonpregnant state.
90. Answer: (A) Diet. Clients with gestational diabetes are
usually managed by diet alone to control their glucose
intolerance. Oral hypoglycemic drugs are contraindicated
in pregnancy. Long-acting insulin usually isn’t needed for
blood glucose control in the client with gestational
diabetes.
91. Answer: (D) Seizure. The anticonvulsant mechanism of
magnesium is believes to depress seizure foci in the brain
and peripheral neuromuscular blockade.
Hypomagnesemia isn’t a complication of preeclampsia.
Antihypertensive drug other than magnesium are
preferred for sustained hypertension. Magnesium doesn’t
help prevent hemorrhage in preeclamptic clients.
92. Answer: (C) I.V. fluids. A sickle cell crisis during pregnancy
is usually managed by exchange transfusion oxygen, and
L.V. Fluids. The client usually needs a stronger analgesic
than acetaminophen to control the pain of a crisis.
Antihypertensive drugs usually aren’t necessary. Diuretic
wouldn’t be used unless fluid overload resulted.
93. Answer: (A) Calcium gluconate (Kalcinate). Calcium
gluconate is the antidote for magnesium toxicity. Ten
milliliters of 10% calcium gluconate is given L.V. push
over 3 to 5 minutes. Hydralazine is given for sustained
elevated blood pressure in preeclamptic clients. Rho (D)
immune globulin is given to women with Rh-negative
blood to prevent antibody formation from RH-positive
conceptions. Naloxone is used to correct narcotic toxicity.
 94. Answer: (B) An indurated wheal over 10 mm in diameter
appears in 48 to 72 hours. A positive PPD result would be
an indurated wheal over 10 mm in diameter that appears
in 48 to 72 hours. The area must be a raised wheal, not a
flat circumcised area to be considered positive.
95. Answer: (C) Pyelonephritis. The symptoms indicate acute
pyelonephritis, a serious condition in a pregnant client.
UTI symptoms include dysuria, urgency, frequency, and
suprapubic tenderness. Asymptomatic bacteriuria doesn’t
cause symptoms. Bacterial vaginosis causes milky white
vaginal discharge but no systemic symptoms.
96. Answer: (B) Rh-positive fetal blood crosses into maternal
blood, stimulating maternal antibodies. Rh
isoimmunization occurs when Rh-positive fetal blood cells
cross into the maternal circulation and stimulate maternal
antibody production. In subsequent pregnancies with Rh-
positive fetuses, maternal antibodies may cross back into
the fetal circulation and destroy the fetal blood cells.
97. Answer: (C) Supine position. The supine position causes
compression of the client’s aorta and inferior vena cava by
the fetus. This, in turn, inhibits maternal circulation,
leading to maternal hypotension and, ultimately, fetal
hypoxia. The other positions promote comfort and aid
labor progress. For instance, the lateral, or side-lying,
position improves maternal and fetal circulation,
enhances comfort, increases maternal relaxation, reduces
muscle tension, and eliminates pressure points. The
squatting position promotes comfort by taking advantage
of gravity. The standing position also takes advantage of
gravity and aligns the fetus with the pelvic angle.
98. Answer: (B) Irritability and poor sucking. Neonates of
heroin-addicted mothers are physically dependent on the
drug and experience withdrawal when the drug is
no longer supplied. Signs of heroin withdrawal include
irritability, poor sucking, and restlessness. Lethargy isn’t
associated with neonatal heroin addiction. A flattened
nose, small eyes, and thin lips are seen in infants with fetal
alcohol syndrome. Heroin use during pregnancy hasn’t
been linked to specific congenital anomalies.
99. Answer: (A) 7th to 9th day postpartum. The normal
involutional process returns the uterus to the pelvic cavity
in 7 to 9 days. A significant involutional complication is
the failure of the uterus to return to the pelvic cavity
within the prescribed time period. This is known as
subinvolution.
100. Answer: (B) Uterine atony. Multiple fetuses, extended
labor stimulation with oxytocin, and traumatic delivery
commonly are associated with uterine atony, which may
lead to postpartum hemorrhage. Uterine inversion may
precede or follow delivery and commonly results from
apparent excessive traction on the umbilical cord and
attempts to deliver the placenta manually. Uterine
involution and some uterine discomfort are normal after
delivery.
PNLE III for Care of Clients with Physiologic and
Psychosocial Alterations (Part 1)
11
Answers and Rationales
1. Answer: (C) Loose, bloody. Normal bowel function and
soft-formed stool usually do not occur until around the
seventh day following surgery. The stool consistency is
related to how much water is being absorbed.
2. Answer: (A) On the client’s right side. The client has left
visual field blindness. The client will see only from the
right side.
3. Answer: (C) Check respirations, stabilize spine, and
check circulation. Checking the airway would be
priority, and a neck injury should be suspected.
4. Answer: (D) Decreasing venous return through
vasodilation. The significant effect of nitroglycerin is
vasodilation and decreased venous return, so the heart
does not have to work hard.
5. Answer: (A) Call for help and note the time. Having
established, by stimulating the client, that the client
is unconscious rather than sleep, the nurse should
immediately call for help. This may be done by dialing
the operator from the client’s phone and giving the
hospital code for cardiac arrest and the client’s room
number to the operator, of if the phone is not available,
by pulling the emergency call button. Noting the time is
important baseline information for cardiac
arrest procedure.
6. Answer: (C) Make sure that the client takes food and
medications at prescribed intervals. Food and drug
therapy will prevent the accumulation of hydrochloric
acid, or will neutralize and buffer the acid that
does accumulate.
7. Answer: (B) Continue treatment as ordered. The effects
of heparin are monitored by the PTT is normally 30 to
45 seconds; the therapeutic level is 1.5 to 2 times the
normal level.
8. Answer: (B) In the operating room. The stoma drainage
bag is applied in the operating room. Drainage from the
ileostomy contains secretions that are rich in
digestive enzymes and highly irritating to the skin.
Protection of the skin from the effects of these enzymes
is begun at once. Skin exposed to these enzymes even
for a short time becomes reddened, painful,
and excoriated.
9. Answer: (B) Flat on back. To avoid the complication of a
painful spinal headache that can last for several days,
the client is kept in flat in a supine position
for approximately 4 to 12 hours postoperatively.
Headaches are believed to be causes by the seepage of
cerebral spinal fluid from the puncture site. By keeping
the client flat, cerebral spinal fluid pressures are
equalized, which avoids trauma to the neurons.
10. Answer: (C) The client is oriented when aroused from
sleep, and goes back to sleep immediately. This finding
suggest that the level of consciousness is decreasing.
11. Answer: (A) Altered mental status and
dehydration. Fever, chills, hemortysis, dyspnea, cough,
and pleuritic chest pain are the common symptoms of
pneumonia, but elderly clients may first appear with
only an altered lentil status and dehydration due to a
blunted immune response.
12. Answer: (B) Chills, fever, night sweats, and
hemoptysis. Typical signs and symptoms are chills,
fever, night sweats, and hemoptysis. Chest pain may be
present from coughing, but isn’t usual. Clients with TB
typically have low-grade fevers, not higher than 102°F
(38.9°C). Nausea, headache, and photophobia aren’t
usual TB symptoms.
13. Answer:(A) Acute asthma. Based on the client’s history
and symptoms, acute asthma is the most likely
diagnosis. He’s unlikely to have bronchial
pneumonia without a productive cough and fever and
he’s too young to have developed (COPD) and
emphysema.
14. Answer: (B) Respiratory arrest. Narcotics can cause
respiratory arrest if given in large quantities. It’s
unlikely the client will have asthma attack or a seizure
or wake up on his own.
15. Answer: (D) Decreased vital capacity. Reduction in vital
capacity is a normal physiologic changes include
decreased elastic recoil of the lungs, fewer functional
capillaries in the alveoli, and an increased in residual
volume.
16. Answer: (C) Presence of premature ventricular
contractions (PVCs) on a cardiac monitor. Lidocaine
drips are commonly used to treat clients
whose arrhythmias haven’t been controlled with oral
medication and who are having PVCs that are visible on
the cardiac monitor. SaO2, blood pressure, and ICP are
important factors but aren’t as significant as PVCs in the
situation.
17. Answer: (B) Avoid foods high in vitamin K. The client
should avoid consuming large amounts of vitamin
K because vitamin K can interfere with anticoagulation.
The client may need to report diarrhea, but isn’t effect
of taking an anticoagulant. An electric razor-not a
straight razor-should be used to prevent cuts that
cause bleeding. Aspirin may increase the risk of
bleeding; acetaminophen should be used to pain relief.
18. Answer: (C) Clipping the hair in the area. Hair can be a
source of infection and should be removed by clipping.
Shaving the area can cause skin abrasions and
depilatories can irritate the skin.
19. Answer: (A) Bone fracture. Bone fracture is a major
complication of osteoporosis that results when loss of
calcium and phosphate increased the fragility of bones.
Estrogen deficiencies result from menopause-not
12
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.
20. Answer: (C) Changes from previous
examinations. Women are instructed to examine
themselves to discover changes that have occurred in
the breast. Only a physician can diagnose lumps that are
cancerous, areas of thickness or fullness that signal
the presence of a malignancy, or masses that are
fibrocystic as opposed to malignant.
21. Answer: (C) Balance the client’s periods of activity and
rest. A client with hyperthyroidism needs to be
encouraged to balance periods of activity and rest.
Many clients with hyperthyroidism are hyperactive and
complain of feeling very warm.
22. Answer: (B) Increase his activity level. The client should
be encouraged to increase his activity level. Maintaining
an ideal weight; following a low-cholesterol, low sodium
diet; and avoiding stress are all important factors in
decreasing the risk of atherosclerosis.
23. Answer: (A) Laminectomy. The client who has had
spinal surgery, such as laminectomy, must be log rolled
to keep the spinal column straight when
turning. Thoracotomy and cystectomy may turn
themselves or may be assisted into a comfortable
position. Under normal
circumstances, hemorrhoidectomy is an outpatient
procedure, and the client may resume normal activities
immediately after surgery.
24. Answer: (D) Avoiding straining during bowel movement
or bending at the waist. The client should avoid
straining, lifting heavy objects, and coughing harshly
because these activities increase intraocular
pressure. Typically, the client is instructed to avoid
lifting objects weighing more than 15 lb (7kg) – not 5lb.
instruct the client when lying in bed to lie on either the
side or back. The client should avoid bright light by
wearing sunglasses.
25. Answer: (D) Before age 20. Testicular cancer commonly
occurs in men between ages 20 and 30. A male client
should be taught how to perform testicular
selfexamination before age 20, preferably when he
enters his teens.
26. Answer: (B) Place a saline-soaked sterile dressing on
the wound. The nurse should first place saline-soaked
sterile dressings on the open wound to prevent tissue
drying and possible infection. Then the nurse should
call the physician and take the client’s vital signs.
The dehiscence needs to be surgically closed, so the
nurse should never try to close it.
27. Answer: (A) A progressively deeper breaths followed by
shallower breaths with apneic periods. Cheyne-Strokes
respirations are breaths that become progressively
 deeper fallowed by shallower respirations with
apneas periods. Biot’s respirations are rapid, deep
breathing with abrupt pauses between each breath, and
equal depth between each breath.
Kussmaul’s respirations are rapid, deep breathing
without pauses. Tachypnea is shallow breathing with
increased respiratory rate.
28. Answer: (B) Fine crackles. Fine crackles are caused by
fluid in the alveoli and commonly occur in clients with
heart failure. Tracheal breath sounds are
auscultated over the trachea. Coarse crackles are caused
by secretion accumulation in the airways. Friction rubs
occur with pleural inflammation.
29. Answer: (B) The airways are so swollen that no air
cannot get through. During an acute attack, wheezing
may stop and breath sounds become inaudible because
the airways are so swollen that air can’t get through. If
the attack is over and swelling has decreased, there
would be no more wheezing and less emergent concern.
Crackles do not replace wheezes during an acute
asthma attack.
30. Answer: (D) Place the client on his side, remove
dangerous objects, and protect his head. During the
active seizure phase, initiate precautions by placing the
client on his side, removing dangerous objects, and
protecting his head from injury. A bite block should
never be inserted during the active seizure phase.
Insertion can break the teeth and lead to aspiration.
31. Answer: (B) Kinked or obstructed chest tube. Kinking
and blockage of the chest tube is a common cause of a
tension pneumothorax. Infection and excessive
drainage won’t cause a tension pneumothorax.
Excessive water won’t affect the chest tube drainage.
32. Answer: (D) Stay with him but not intervene at this
time. If the client is coughing, he should be able to
dislodge the object or cause a complete obstruction. If
complete obstruction occurs, the nurse should perform
the abdominal thrust maneuver with the
client standing. If the client is unconscious, she should
lay him down. A nurse should never leave a choking
client alone.
33. Answer: (B) Current health promotion
activities. Recognizing an individual’s positive health
measures is very useful. General health in the previous
10 years is important, however, the current activities of
an 84 year old client are most significant in
planning care. Family history of disease for a client in
later years is of minor significance. Marital status
information may be important for discharge planning
but is not as significant for addressing the immediate
medical problem.
34. Answer: (C) Place the client in a side lying position, with
the head of the bed lowered. The client should be
positioned in a side-lying position with the head of the
bed lowered to prevent aspiration. A small amount
of toothpaste should be used and the mouth swabbed or
suctioned to remove pooled secretions. Lemon glycerin
13
can be drying if used for extended periods. Brushing the
teeth with the client lying supine may lead to aspiration.
Hydrogen peroxide is caustic to tissues and should not
be used.
35. Answer: (C) Pneumonia. Fever productive cough and
pleuritic chest pain are common signs and symptoms of
pneumonia. The client with ARDS has dyspnea and
hypoxia with worsening hypoxia over time, if not
treated aggressively. Pleuritic chest pain varies with
respiration, unlike the constant chest pain during an MI;
so this client most likely isn’t having an MI. the client
with TB typically has a cough producing blood-tinged
sputum. A sputum culture should be obtained to
confirm the nurse’s suspicions.
36. Answer: (C) A 43-yesr-old homeless man with a history
of alcoholism. Clients who are economically
disadvantaged, malnourished, and have reduced
immunity, such as a client with a history of
alcoholism, are at extremely high risk for developing
TB. A high school student, daycare worker, and
businessman probably have a much low risk
of contracting TB.
37. Answer: (C ) To determine the extent of lesions. If the
lesions are large enough, the chest X-ray will show
their presence in the lungs. Sputum culture confirms the
diagnosis. There can be false-positive and false-negative
skin test results. A chest X-ray can’t determine if this is a
primary or secondary infection.
38. Answer: (B) Bronchodilators. Bronchodilators are the
first line of treatment for asthma because broncho-
constriction is the cause of reduced airflow. Beta
adrenergic blockers aren’t used to treat asthma and can
cause bronchoconstriction. Inhaled oral steroids may be
given to reduce the inflammation but aren’t used for
emergency relief.
39. Answer: (C) Chronic obstructive bronchitis. Because of
this extensive smoking history and symptoms the client
most likely has chronic obstructive bronchitis. Client
with ARDS have acute symptoms of hypoxia and
typically need large amounts of oxygen. Clients with
asthma and emphysema tend not to have chronic cough
or peripheral edema.
40. Answer: (A) The patient is under local anesthesia
during the procedure. Before the procedure, the patient
is administered with drugs that would help to prevent
infection and rejection of the transplanted cells such as
antibiotics, cytotoxic, and corticosteroids. During the
transplant, the patient is placed under general
anesthesia.
41. Answer: (D) Raise the side rails. A patient who is
disoriented is at risk of falling out of bed. The initial
action of the nurse should be raising the side rails to
ensure patients safety.
42. Answer: (A) Crowd red blood cells. The excessive
production of white blood cells crowd out red blood
cells production which causes anemia to occur.
43. Answer: (B) Leukocytosis. Chronic Lymphocytic
leukemia (CLL) is characterized by increased
production of leukocytes and lymphocytes resulting
in leukocytosis, and proliferation of these cells within
the bone marrow, spleen and liver.
44. Answer: (A) Explain the risks of not having the
surgery. The best initial response is to explain the risks
of not having the surgery. If the client understands the
risks but still refuses the nurse should notify the
physician and the nurse supervisor and then record
the client’s refusal in the nurses’ notes.
45. Answer: (D) The 75-year-old client who was admitted 1
hour ago with new-onset atrial fibrillation and is
receiving L.V. dilitiazem (Cardizem). The client with
atrial fibrillation has the greatest potential to become
unstable and is on L.V. medication that requires close
monitoring. After assessing this client, the nurse should
assess the client with thrombophlebitis who is receiving
a heparin infusion, and then the 58- year-old client
admitted 2 days ago with heart failure (his signs
and symptoms are resolving and don’t require
immediate attention). The lowest priority is the 89-
year-old with end stage right-sided heart failure, who
requires time-consuming supportive measures.
46. Answer: (C) Cocaine. Because of the client’s age and
negative medical history, the nurse should question her
about cocaine use. Cocaine increases myocardial oxygen
consumption and can cause coronary artery
spasm, leading to tachycardia, ventricular fibrillation,
myocardial ischemia, and myocardial infarction.
Barbiturate overdose may trigger
respiratory depression and slow pulse. Opioids can
cause marked respiratory depression, while
benzodiazepines can cause drowsiness and confusion.
47. Answer: (B) Nonmobile mass with irregular
edges. Breast cancer tumors are fixed, hard, and poorly
delineated with irregular edges. A mobile mass that is
soft and easily delineated is most often a fluid-filled
benign cyst. Axillary lymph nodes may or may not be
palpable on initial detection of a cancerous mass. Nipple
retraction — not eversion — may be a sign of cancer.
48. Answer: (C) Radiation. The usual treatment for vaginal
cancer is external or intravaginal radiation therapy.
Less often, surgery is performed. Chemotherapy
typically is prescribed only if vaginal cancer is
diagnosed in an early stage, which is rare.
Immunotherapy isn’t used to treat vaginal cancer.
49. Answer: (B) Carcinoma in situ, no abnormal regional
lymph nodes, and no evidence of distant metastasis. TIS,
N0, M0 denotes carcinoma in situ, no abnormal
regional lymph nodes, and no evidence of distant
metastasis. No evidence of primary tumor, no abnormal
regional lymph nodes, and no evidence of distant
metastasis is classified as T0, N0, M0. If the tumor and
regional lymph nodes can’t be assessed and no evidence
of metastasis exists, the lesion is classified as TX, NX,
M0. A progressive increase in tumor size, no
demonstrable metastasis of the regional lymph nodes,
14
and ascending degrees of distant metastasis is classified
as T1, T2, T3, or T4; N0; and M1, M2, or M3.
50. Answer: (D) “Keep the stoma moist.” The nurse should
instruct the client to keep the stoma moist, such as by
applying a thin layer of petroleum jelly around the
edges, because a dry stoma may become irritated. The
nurse should recommend placing a stoma bib over the
stoma to filter and warm air before it enters the stoma.
The client should begin performing stoma care
without assistance as soon as possible to gain
independence in self-care activities.
51. Answer: (B) Lung cancer. Lung cancer is the most
deadly type of cancer in both women and men. Breast
cancer ranks second in women, followed (in
descending order) by colon and rectal cancer,
pancreatic cancer, ovarian cancer, uterine cancer,
lymphoma, leukemia, liver cancer, brain cancer,
stomach cancer, and multiple myeloma.
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis
on the affected side of the face. Horner’s syndrome,
which occurs when a lung tumor invades the ribs and
affects the sympathetic nerve ganglia, is characterized
by miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face. Chest pain, dyspnea, cough,
weight loss, and fever are associated with pleural
tumors. Arm and shoulder pain and atrophy of the arm
and hand muscles on the affected side suggest
Pancoast’s tumor, a lung tumor involving the first
thoracic and eighth cervical nerves within the brachial
plexus. Hoarseness in a client with lung cancer suggests
that the tumor has extended to the recurrent laryngeal
nerve; dysphagia suggests that the lung tumor is
compressing the esophagus.
53. Answer: (A) prostate-specific antigen, which is used to
screen for prostate cancer. PSA stands for prostate-
specific antigen, which is used to screen for prostate
cancer. The other answers are incorrect.
54. Answer: (D) “Remain supine for the time specified by
the physician.” The nurse should instruct the client to
remain supine for the time specified by the physician.
Local anesthetics used in a subarachnoid block don’t
alter the gag reflex. No interactions between local
anesthetics and food occur. Local anesthetics don’t
cause hematuria.
55. Answer: (C) Sigmoidoscopy. Used to visualize the lower
GI tract, sigmoidoscopy and proctoscopy aid in the
detection of two-thirds of all colorectal cancers. Stool
Hematest detects blood, which is a sign of colorectal
cancer; however, the test doesn’t confirm the diagnosis.
CEA may be elevated in colorectal cancer but isn’t
considered a confirming test. An abdominal CT scan is
used to stage the presence of colorectal cancer.
56. Answer: (B) A fixed nodular mass with dimpling of the
overlying skin. A fixed nodular mass with dimpling of
the overlying skin is common during late stages of
breast cancer. Many women have slightly asymmetrical
breasts. Bloody nipple discharge is a sign of
 intraductal papilloma, a benign condition. Multiple firm,
round, freely movable masses that change with the
menstrual cycle indicate fibrocystic breasts, a
benign condition.
57. Answer: (A) Liver. The liver is one of the five most
common cancer metastasis sites. The others are the
lymph nodes, lung, bone, and brain. The
colon, reproductive tract, and WBCs are occasional
metastasis sites.
58. Answer: (D) The client wears a watch and wedding
band. During an MRI, the client should wear no metal
objects, such as jewelry, because the strong magnetic
field can pull on them, causing injury to the client and (if
they fly off) to others. The client must lie still during the
MRI but can talk to those performing the test by way of
the microphone inside the scanner tunnel. The client
should hear thumping sounds, which are caused by the
sound waves thumping on the magnetic field.
59. Answer: (C) The recommended daily allowance of
calcium may be found in a wide variety of
foods. Premenopausal women require 1,000 mg of
calcium per day. Postmenopausal women require 1,500
mg per day. It’s often, though not always, possible to get
the recommended daily requirement in the foods we
eat. Supplements are available but not always
necessary. Osteoporosis doesn’t show up on ordinary X-
rays until 30% of the bone loss has occurred. Bone
densitometry can detect bone loss of 3% or less. This
test is sometimes recommended routinely for women
over 35 who are at risk. Strenuous exercise won’t cause
fractures.
60. Answer: (C) Joint flexion of less than 50%. Arthroscopy
is contraindicated in clients with joint flexion of less
than 50% because of technical problems in inserting the
instrument into the joint to see it clearly. Other
contraindications for this procedure include skin and
wound infections. Joint pain may be an indication, not
a contraindication, for arthroscopy. Joint deformity and
joint stiffness aren’t contraindications for this
procedure.
61. Answer: (D) Gouty arthritis. Gouty arthritis, a metabolic
disease, is characterized by urate deposits and pain in
the joints, especially those in the feet and legs.
Urate deposits don’t occur in septic or traumatic
arthritis. Septic arthritis results from bacterial invasion
of a joint and leads to inflammation of the
synovial lining. Traumatic arthritis results from blunt
trauma to a joint or ligament. Intermittent arthritis is a
rare, benign condition marked by regular, recurrent
joint effusions, especially in the knees.
62. Answer: (B) 30 ml/hour. An infusion prepared with
25,000 units of heparin in 500 ml of saline solution
yields 50 units of heparin per milliliter of solution.
The equation is set up as 50 units times X (the unknown
quantity) equals 1,500 units/hour, X equals 30 ml/hour.
63. Answer: (B) Loss of muscle contraction decreasing
venous return. In clients with hemiplegia or
15
hemiparesis loss of muscle contraction decreases
venous return and may cause swelling of the affected
extremity. Contractures, or bony calcifications may
occur with a stroke, but don’t appear with swelling. DVT
may develop in clients with a stroke but is more likely
to occur in the lower extremities. A stroke isn’t linked to
protein loss.
64. Answer: (B) It appears on the distal interphalangeal
joint. Heberden’s nodes appear on the distal
interphalageal joint on both men and women.
Bouchard’s node appears on the dorsolateral aspect of
the proximal interphalangeal joint.
65. Answer: (B) Osteoarthritis is a localized disease
rheumatoid arthritis is systemic. Osteoarthritis is a
localized disease, rheumatoid arthritis is systemic.
Osteoarthritis isn’t gender-specific, but rheumatoid
arthritis is. Clients have dislocations and subluxations in
both disorders.
66. Answer: (C) The cane should be used on the unaffected
side. A cane should be used on the unaffected side. A
client with osteoarthritis should be encouraged to
ambulate with a cane, walker, or other assistive device
as needed; their use takes weight and stress off joints.
67. Answer: (A) 9 U regular insulin and 21 U neutral
protamine Hagedorn (NPH). A 70/30 insulin
preparation is 70% NPH and 30% regular insulin.
Therefore, a correct substitution requires mixing 21 U
of NPH and 9 U of regular insulin. The other choices are
incorrect dosages for the prescribed insulin.
68. Answer: (C) colchicines. A disease characterized by joint
inflammation (especially in the great toe), gout is
caused by urate crystal deposits in the joints.
The physician prescribes colchicine to reduce these
deposits and thus ease joint inflammation. Although
aspirin is used to reduce joint inflammation and pain in
clients with osteoarthritis and rheumatoid arthritis, it
isn’t indicated for gout because it has no effect on urate
crystal formation. Furosemide, a diuretic, doesn’t
relieve gout. Calcium gluconate is used to reverse a
negative calcium balance and relieve muscle cramps,
not to treat gout.
69. Answer: (A) Adrenal cortex. Excessive secretion of
aldosterone in the adrenal cortex is responsible for the
client’s hypertension. This hormone acts on the
renal tubule, where it promotes reabsorption of sodium
and excretion of potassium and hydrogen ions. The
pancreas mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes
the catecholamines — epinephrine and norepinephrine.
The parathyroids secrete parathyroid hormone.
70. Answer: (C) They debride the wound and promote
healing by secondary intention. For this client, wet-to-
dry dressings are most appropriate because they clean
the foot ulcer by debriding exudate and necrotic tissue,
thus promoting healing by secondary intention. Moist,
transparent dressings contain exudate and provide a
moist wound environment. Hydrocolloid dressings
 prevent the entrance of microorganisms and minimize
wound discomfort. Dry sterile dressings protect the
wound from mechanical trauma and promote healing.
71. Answer: (A) Hyperkalemia. In adrenal insufficiency, the
client has hyperkalemia due to reduced aldosterone
secretion. BUN increases as the glomerular
filtration rate is reduced. Hyponatremia is caused by
reduced aldosterone secretion. Reduced cortisol
secretion leads to impaired glyconeogenesis and a
reduction of glycogen in the liver and muscle,
causing hypoglycemia.
72. Answer: (C) Restricting fluids. To reduce water
retention in a client with the SIADH, the nurse should
restrict fluids. Administering fluids by any route would
further increase the client’s already heightened fluid
load.
73. Answer: (D) glycosylated hemoglobin level. Because
some of the glucose in the bloodstream attaches
to some of the hemoglobin and stays attached during
the 120-day life span of red blood cells, glycosylated
hemoglobin levels provide information about blood
glucose levels during the previous 3 months. Fasting
blood glucose and urine glucose levels only give
information about glucose levels at the point in time
when they were obtained. Serum fructosamine levels
provide information about blood glucose control over
the past 2 to 3 weeks.
74. Answer: (C) 4:00 pm. NPH is an intermediate-acting
insulin that peaks 8 to 12 hours after administration.
Because the nurse administered NPH insulin at 7 a.m.,
the client is at greatest risk for hypoglycemia from 3
p.m. to 7 p.m.
75. Answer: (A) Glucocorticoids and androgens. The
adrenal glands have two divisions, the cortex
and medulla. The cortex produces three types of
hormones: glucocorticoids, mineralocorticoids, and
androgens. The medulla produces catecholamines —
epinephrine and norepinephrine.
76. Answer: (A) Hypocalcemia. Hypocalcemia may follow
thyroid surgery if the parathyroid glands were removed
accidentally. Signs and symptoms of hypocalcemia may
be delayed for up to 7 days after surgery. Thyroid
surgery doesn’t directly cause serum sodium,
potassium, or magnesium abnormalities. Hyponatremia
may occur if the client inadvertently received too much
fluid; however, this can happen to any surgical client
receiving I.V. fluid therapy, not just one recovering from
thyroid surgery. Hyperkalemia and hypermagnesemia
usually are associated with reduced renal excretion
of potassium and magnesium, not thyroid surgery.
77. Answer: (D) Carcinoembryonic antigen level. In clients
who smoke, the level of carcinoembryonic antigen
is elevated. Therefore, it can’t be used as a general
indicator of cancer. However, it is helpful in monitoring
cancer treatment because the level usually falls to
normal within 1 month if treatment is successful.
An elevated acid phosphatase level may indicate
16
prostate cancer. An elevated alkaline phosphatase level
may reflect bone metastasis. An elevated serum
calcitonin level usually signals thyroid cancer.
78. Answer: (B) Dyspnea, tachycardia, and pallor. Signs of
iron-deficiency anemia include dyspnea,
tachycardia, and pallor as well as fatigue, listlessness,
irritability, and headache. Night sweats, weight loss, and
diarrhea may signal acquired
immunodeficiency syndrome (AIDS). Nausea, vomiting,
and anorexia may be signs of hepatitis B. Itching, rash,
and jaundice may result from an allergic or hemolytic
reaction.
79. Answer: (D) “I’ll need to have a C-section if I become
pregnant and have a baby.” The human
immunodeficiency virus (HIV) is transmitted
from mother to child via the transplacental route, but a
Cesarean section delivery isn’t necessary when the
mother is HIV-positive. The use of birth control will
prevent the conception of a child who might have HIV.
It’s true that a mother who’s HIV positive can give birth
to a baby who’s HIV negative.
80. Answer: (C) “Avoid sharing such articles as
toothbrushes and razors.” The human
immunodeficiency virus (HIV), which causes AIDS, is
most concentrated in the blood. For this reason, the
client shouldn’t share personal articles that may be
blood-contaminated, such as toothbrushes and razors,
with other family members. HIV isn’t transmitted by
bathing or by eating from plates, utensils, or serving
dishes used by a person with AIDS.
81. Answer: (B) Pallor, tachycardia, and a sore
tongue. Pallor, tachycardia, and a sore tongue are all
characteristic findings in pernicious anemia. Other
clinical manifestations include anorexia; weight loss; a
smooth, beefy red tongue; a wide pulse
pressure; palpitations; angina; weakness; fatigue; and
paresthesia of the hands and feet. Bradycardia, reduced
pulse pressure, weight gain, and double vision aren’t
characteristic findings in pernicious anemia.
82. Answer: (B) Administer epinephrine, as prescribed, and
prepare to intubate the client if necessary. To reverse
anaphylactic shock, the nurse first should administer
epinephrine, a potent bronchodilator as prescribed.
The physician is likely to order additional medications,
such as antihistamines and corticosteroids; if these
medications don’t relieve the respiratory compromise
associated with anaphylaxis, the nurse should prepare
to intubate the client. No antidote for penicillin exists;
however, the nurse should continue to monitor the
client’s vital signs. A client who remains hypotensive
may need fluid resuscitation and fluid intake and
output monitoring; however, administering epinephrine
is the first priority.
83. Answer: (D) bilateral hearing loss. Prolonged use of
aspirin and other salicylates sometimes causes bilateral
hearing loss of 30 to 40 decibels. Usually, this
adverse effect resolves within 2 weeks after the therapy
is discontinued. Aspirin doesn’t lead to weight gain or
 fine motor tremors. Large or toxic salicylate doses may
cause respiratory alkalosis, not respiratory acidosis.
84. Answer: (D) Lymphocyte. The lymphocyte provides
adaptive immunity — recognition of a foreign antigen
and formation of memory cells against the
antigen. Adaptive immunity is mediated by B and T
lymphocytes and can be acquired actively or passively.
The neutrophil is crucial to phagocytosis. The basophil
plays an important role in the release of
inflammatory mediators. The monocyte functions in
phagocytosis and monokine production.
85. Answer: (A) moisture replacement. Sjogren’s syndrome
is an autoimmune disorder leading to progressive loss
of lubrication of the skin, GI tract, ears, nose, and
vagina. Moisture replacement is the mainstay of
therapy. Though malnutrition and electrolyte imbalance
may occur as a result of Sjogren’s syndrome’s effect on
the GI tract, it isn’t the predominant problem.
Arrhythmias aren’t a problem associated with Sjogren’s
syndrome.
86. Answer: (C) stool for Clostridium difficile
test. Immunosuppressed clients — for example, clients
receiving chemotherapy, — are at risk for infection with
C. difficile, which causes “horse barn” smelling diarrhea.
Successful treatment begins with an accurate diagnosis,
which includes a stool test. The ELISA test is diagnostic
for human immunodeficiency virus (HIV) and isn’t
indicated in this case. An electrolyte panel and
hemogram may be useful in the overall evaluation of a
client but aren’t diagnostic for specific causes of
diarrhea. A flat plate of the abdomen may provide useful
information about bowel function but isn’t indicated in
the case of “horse barn” smelling diarrhea.
87. Answer: (D) Western blot test with ELISA. HIV infection
is detected by analyzing blood for antibodies to HIV,
which form approximately 2 to 12 weeks after exposure
to HIV and denote infection. The Western blot test —
electrophoresis of antibody proteins — is more than
98% accurate in detecting HIV antibodies when used in
conjunction with the ELISA. It isn’t specific when used
alone. Erosette immunofluorescence is used to detect
viruses in general; it doesn’t confirm HIV infection.
Quantification of T-lymphocytes is a useful monitoring
test but isn’t diagnostic for HIV. The ELISA test detects
HIV antibody particles but may yield inaccurate results;
a positive ELISA result must be confirmed by the
Western blot test.
88. Answer: (C) Abnormally low hematocrit (HCT) and
hemoglobin (Hb) levels. Low preoperative HCT and Hb
levels indicate the client may require a blood
transfusion before surgery. If the HCT and Hb
levels decrease during surgery because of blood loss,
the potential need for a transfusion increases. Possible
renal failure is indicated by elevated BUN or creatinine
levels. Urine constituents aren’t found in the
blood. Coagulation is determined by the presence of
appropriate clotting factors, not electrolytes.
17
89. Answer: (A) Platelet count, prothrombin time, and
partial thromboplastin time. The diagnosis of DIC is
based on the results of laboratory studies of
prothrombin time, platelet count, thrombin time,
partial thromboplastin time, and fibrinogen level as well
as client history and other assessment factors. Blood
glucose levels, WBC count, calcium levels,
and potassium levels aren’t used to confirm a diagnosis
of DIC.
90. Answer: (D) Strawberries. Common food allergens
include berries, peanuts, Brazil nuts, cashews, shellfish,
and eggs. Bread, carrots, and oranges rarely
cause allergic reactions.
91. Answer: (B) A client with cast on the right leg who
states, “I have a funny feeling in my right leg.” It may
indicate neurovascular compromise, requires
immediate assessment.
92. Answer: (D) A 62-year-old who had an abdominal-
perineal resection three days ago; client complaints of
chills. The client is at risk for peritonitis; should be
assessed for further symptoms and infection.
93. Answer: (C) The client spontaneously flexes his wrist
when the blood pressure is obtained. Carpal spasms
indicate hypocalcemia.
94. Answer: (D) Use comfort measures and pillows to
position the client.Using comfort measures and pillows
to position the client is a non-pharmacological methods
of pain relief.
95. Answer: (B) Warm the dialysate solution. Cold dialysate
increases discomfort. The solution should be warmed to
body temperature in warmer or heating pad; don’t
use microwave oven.
96. Answer: (C) The client holds the cane with his left hand,
moves the cane forward followed by the right leg, and
then moves the left leg. The cane acts as a support and
aids in weight bearing for the weaker right leg.
97. Answer: (A) Ask the woman’s family to provide
personal items such as photos or mementos.Photos and
mementos provide visual stimulation to reduce sensory
deprivation.
98. Answer: (B) The client lifts the walker, moves it forward
10 inches, and then takes several small steps forward. A
walker needs to be picked up, placed down on all legs.
99. Answer: (C) Isolation from their families and familiar
surroundings. Gradual loss of sight, hearing, and taste
interferes with normal functioning.
100. Answer: (A) Encourage the client to perform pursed lip
breathing. Purse lip breathing prevents the collapse of
lung unit and helps client control rate and depth of
breathing.

PNLE IV for Care of Clients with Physiologic and
Psychosocial Alterations (Part 2)
Answers and Rationales
1. Answer: (C) Hypertension. Hypertension, along with
fever, and tenderness over the grafted kidney, reflects
acute rejection.
2. Answer: (A) Pain. Sharp, severe pain (renal colic)
radiating toward the genitalia and thigh is caused by
uretheral distention and smooth muscle spasm; relief
form pain is the priority.
3. Answer: (D) Decrease the size and vascularity of the
thyroid gland. Lugol’s solution provides iodine, which
aids in decreasing the vascularity of the thyroid gland,
which limits the risk of hemorrhage when surgery is
performed.
4. Answer: (A) Liver Disease. The client with liver disease
has a decreased ability to metabolize carbohydrates
because of a decreased ability to form
glycogen (glycogenesis) and to form glucose from
glycogen.
5. Answer: (C) Leukopenia. Leukopenia, a reduction in
WBCs, is a systemic effect of chemotherapy as a result of
myelosuppression.
6. Answer: (C) Avoid foods that in the past caused
flatus. Foods that bothered a person preoperatively will
continue to do so after a colostomy.
7. Answer: (B) Keep the irrigating container less than 18
inches above the stoma.” This height permits the
solution to flow slowly with little force so that excessive
peristalsis is not immediately precipitated.
8. Answer: (A) Administer Kayexalate. Kayexalate,a
potassium exchange resin, permits sodium to
be exchanged for potassium in the intestine, reducing
the serum potassium level.
9. Answer:(B) 28 gtt/min. This is the correct flow rate;
multiply the amount to be infused (2000 ml) by the
drop factor (10) and divide the result by the amount
of time in minutes (12 hours x 60 minutes)
10. Answer: (D) Upper trunk. The percentage designated
for each burned part of the body using the rule of nines:
Head and neck 9%; Right upper extremity 9%;
Left upper extremity 9%; Anterior trunk 18%; Posterior
18
trunk 18%; Right lower extremity 18%; Left lower
extremity 18%; Perineum 1%.
11. Answer: (C) Bleeding from ears. The nurse needs to
perform a thorough assessment that could indicate
alterations in cerebral function, increased intracranial
pressures, fractures and bleeding. Bleeding from the
ears occurs only with basal skull fractures that can
easily contribute to increased intracranial pressure
and brain herniation.
12. Answer: (D) may engage in contact sports. The client
should be advised by the nurse to avoid contact sports.
This will prevent trauma to the area of the pacemaker
generator.
13. Answer: (A) Oxygen at 1-2L/min is given to maintain
the hypoxic stimulus for breathing. COPD causes a
chronic CO2 retention that renders the medulla
insensitive to the CO2 stimulation for breathing. The
hypoxic state of the client then becomes the stimulus for
breathing. Giving the client oxygen in low
concentrations will maintain the client’s hypoxic drive.
14. Answer: (B) Facilitate ventilation of the left lung. Since
only a partial pneumonectomy is done, there is a
need to promote expansion of this remaining Left lung
by positioning the client on the opposite unoperated
side.
15. Answer: (A) Food and fluids will be withheld for at least
2 hours. Prior to bronchoscopy, the doctors sprays the
back of the throat with anesthetic to minimize the gag
reflex and thus facilitate the insertion of the
bronchoscope. Giving the client food and drink after
the procedure without checking on the return of the gag
reflex can cause the client to aspirate. The gag reflex
usually returns after two hours.
16. Answer: (C) hyperkalemia. Hyperkalemia is a common
complication of acute renal failure. It’s life-threatening
if immediate action isn’t taken to reverse it.
The administration of glucose and regular insulin, with
sodium bicarbonate if necessary, can temporarily
prevent cardiac arrest by moving potassium into the
cells and temporarily reducing serum potassium
levels. Hypernatremia, hypokalemia, and hypercalcemia
don’t usually occur with acute renal failure and aren’t
treated with glucose, insulin, or sodium bicarbonate.
17. Answer: (A) This condition puts her at a higher risk for
cervical cancer; therefore, she should have a
Papanicolaou (Pap) smear annually. Women with
condylomata acuminata are at risk for cancer of the
cervix and vulva. Yearly Pap smears are very important
for early detection. Because condylomata acuminata is a
virus, there is no permanent cure. Because condylomata
acuminata can occur on the vulva, a condom won’t
protect sexual partners. HPV can be transmitted to
other parts of the body, such as the mouth, oropharynx,
and larynx.
18. Answer: (A) The left kidney usually is slightly higher
than the right one. The left kidney usually is slightly
 higher than the right one. An adrenal gland lies atop
each kidney. The average kidney
measures approximately 11 cm (4-3/8″) long, 5 to 5.8
cm (2″ to 2¼”) wide, and 2.5 cm (1″) thick. The kidneys
are located retroperitoneally, in the posterior aspect of
the abdomen, on either side of the vertebral column.
They lie between the 12th thoracic and 3rd lumbar
vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and
serum creatinine 6.5 mg/dl. The normal BUN level
ranges 8 to 23 mg/dl; the normal serum creatinine level
ranges from 0.7 to 1.5 mg/dl. The test results in option
C are abnormally elevated, reflecting CRF and the
kidneys’ decreased ability to remove nonprotein
nitrogen waste from the blood. CRF causes decreased
pH and increased hydrogen ions — not vice versa. CRF
also increases serum levels of potassium, magnesium,
and phosphorous, and decreases serum levels of
calcium. A uric acid analysis of 3.5 mg/dl falls within the
normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75%
also falls with the normal range of 60% to 75%.
20. Answer: (D) Alteration in the size, shape, and
organization of differentiated cells. Dysplasia refers to
an alteration in the size, shape, and organization of
differentiated cells. The presence of
completely undifferentiated tumor cells that don’t
resemble cells of the tissues of their origin is called
anaplasia. An increase in the number of normal cells in
a normal arrangement in a tissue or an organ is called
hyperplasia. Replacement of one type of fully
differentiated cell by another in tissues where the
second type normally isn’t found is called metaplasia.
21. Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the
most common cancer associated with AIDS. Squamous
cell carcinoma, multiple myeloma, and leukemia
may occur in anyone and aren’t associated specifically
with AIDS.
22. Answer: (C) To prevent cerebrospinal fluid (CSF)
leakage. The client receiving a subarachnoid block
requires special positioning to prevent CSF leakage and
headache and to ensure proper anesthetic distribution.
Proper positioning doesn’t help prevent
confusion, seizures, or cardiac arrhythmias.
23. Answer: (A) Auscultate bowel sounds. If abdominal
distention is accompanied by nausea, the nurse must
first auscultate bowel sounds. If bowel sounds are
absent, the nurse should suspect gastric or small
intestine dilation and these findings must be reported
to the physician. Palpation should be avoided
postoperatively with abdominal distention. If peristalsis
is absent, changing positions and inserting a rectal tube
won’t relieve the client’s discomfort.
24. Answer: (B) Lying on the left side with knees bent. For a
colonoscopy, the nurse initially should position the
client on the left side with knees bent. Placing the client
on the right side with legs straight, prone with the torso
elevated, or bent over with hands touching the floor
19
wouldn’t allow proper visualization of the large
intestine.
25. Answer: (A) Blood supply to the stoma has been
interrupted. An ileostomy stoma forms as the ileum is
brought through the abdominal wall to the surface skin,
creating an artificial opening for waste elimination. The
stoma should appear cherry red, indicating
adequate arterial perfusion. A dusky stoma suggests
decreased perfusion, which may result from
interruption of the stoma’s blood supply and may lead
to tissue damage or necrosis. A dusky stoma isn’t a
normal finding. Adjusting the ostomy bag wouldn’t
affect stoma color, which depends on blood supply to
the area. An intestinal obstruction also wouldn’t change
stoma color.
26. Answer: (A) Applying knee splints. Applying knee
splints prevents leg contractures by holding the joints in
a position of function. Elevating the foot of the bed can’t
prevent contractures because this action doesn’t hold
the joints in a position of function. Hyperextending a
body part for an extended time is inappropriate because
it can cause contractures. Performing shoulder range-
of-motion exercises can prevent contractures in the
shoulders, but not in the legs.
27. Answer: (B) Urine output of 20 ml/hour. A urine output
of less than 40 ml/hour in a client with burns indicates
a fluid volume deficit. This client’s PaO2 value falls
within the normal range (80 to 100 mm Hg). White
pulmonary secretions also are normal. The client’s
rectal temperature isn’t significantly elevated
and probably results from the fluid volume deficit.
28. Answer: (A) Turn him frequently. 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.
29. Answer: (C) In long, even, outward, and downward
strokes in the direction of hair growth. When applying a
topical agent, the nurse should begin at the midline and
use long, even, outward, and downward strokes in
the direction of hair growth. This application pattern
reduces the risk of follicle irritation and skin
inflammation.
30. Answer: (A) Beta -adrenergic blockers. Beta-adrenergic
blockers work by blocking beta receptors in the
myocardium, reducing the response to catecholamines
and sympathetic nerve stimulation. They protect the
myocardium, helping to reduce the risk of another
infraction by decreasing myocardial oxygen demand.
 Calcium channel blockers reduce the workload of the
heart by decreasing the heart rate. Narcotics reduce
myocardial oxygen demand, promote vasodilation, and
decrease anxiety. Nitrates reduce myocardial oxygen
consumption bt decreasing left ventricular end diastolic
pressure (preload) and systemic vascular resistance
(afterload).
31. Answer: (C) Raised 30 degrees. Jugular venous pressure
is measured with a centimeter ruler to obtain the
vertical distance between the sternal angle and the
point of highest pulsation with the head of the bed
inclined between 15 to 30 degrees. Increased pressure
can’t be seen when the client is supine or when the head
of the bed is raised 10 degrees because the point
that marks the pressure level is above the jaw
(therefore, not visible). In high Fowler’s position, the
veins would be barely discernible above the clavicle.
32. Answer: (D) Inotropic agents. Inotropic agents are
administered to increase the force of the heart’s
contractions, thereby increasing ventricular
contractility and ultimately increasing cardiac output.
Beta-adrenergic blockers and calcium channel blockers
decrease the heart rate and ultimately decreased
the workload of the heart. Diuretics are administered to
decrease the overall vascular volume, also decreasing
the workload of the heart.
33. Answer: (B) Less than 30% of calories form fat. A client
with low serum HDL and high serum LDL levels
should get less than 30% of daily calories from fat. The
other modifications are appropriate for this client.
34. Answer: (C) The emergency department nurse calls up
the latest electrocardiogram results to check the client’s
progress. The emergency department nurse is no longer
directly involved with the client’s care and thus has no
legal right to information about his present condition.
Anyone directly involved in his care (such as the
telemetry nurse and the on-call physician) has the right
to information about his condition. Because the client
requested that the nurse update his wife on his
condition, doing so doesn’t breach confidentiality.
35. Answer: (B) Check endotracheal tube placement. ET
tube placement should be confirmed as soon as the
client arrives in the emergency department. Once the
airways is secured, oxygenation and ventilation should
be confirmed using an end-tidal carbon dioxide monitor
and pulse oximetry. Next, the nurse should make
sure L.V. access is established. If the client experiences
symptomatic bradycardia, atropine is administered as
ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3
mg. Then the nurse should try to find the cause of the
client’s arrest by obtaining an ABG sample. Amiodarone
is indicated for ventricular tachycardia, ventricular
fibrillation and atrial flutter – not symptomatic
bradycardia.
36. Answer: (C) 95 mm Hg. Use the following formula to
calculate MAP
 MAP = systolic + 2 (diastolic) /3
20
 MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
 MAP=286 mm HG/ 3
 MAP=95 mm Hg
37. Answer: (C) Electrocardiogram, complete blood count,
testing for occult blood, comprehensive serum
metabolic panel. An electrocardiogram evaluates the
complaints of chest pain, laboratory tests determines
anemia, and the stool test for occult blood determines
blood in the stool. Cardiac monitoring, oxygen, and
creatine kinase and lactate dehydrogenase levels are
appropriate for a cardiac primary problem. A basic
metabolic panel and alkaline phosphatase and aspartate
aminotransferase levels assess liver function.
Prothrombin time, partial thromboplastin time,
fibrinogen and fibrin split products are measured to
verify bleeding dyscrasias, An
electroencephalogram evaluates brain electrical
activity.
38. Answer: (D) Heparin-associated thrombosis and
thrombocytopenia (HATT). HATT may occur after CABG
surgery due to heparin use during surgery. Although
DIC and ITP cause platelet aggregation and bleeding,
neither is common in a client after revascularization
surgery. Pancytopenia is a reduction in all blood cells.
39. Answer: (B) Corticosteroids. Corticosteroid therapy can
decrease antibody production and phagocytosis of the
antibody-coated platelets, retaining more
functioning platelets. Methotrexate can cause
thrombocytopenia. Vitamin K is used to treat an
excessive anticoagulate state from warfarin overload,
and ASA decreases platelet aggregation.
40. Answer: (D) Xenogeneic. An xenogeneic transplant is
between is between human and another species. A
syngeneic transplant is between identical
twins, allogeneic transplant is between two humans,
and autologous is a transplant from the same individual.
41. Answer: (B). Tissue thromboplastin is released when
damaged tissue comes in contact with clotting factors.
Calcium is released to assist the conversion of factors X
to Xa. Conversion of factors XII to XIIa and VIII to VIII a
are part of the intrinsic pathway.
42. Answer: (C) Essential thrombocytopenia. Essential
thrombocytopenia is linked to immunologic
disorders, such as SLE and human immunodeficiency
vitus. The disorder known as von Willebrand’s disease
is a type of hemophilia and isn’t linked to SLE. Moderate
to severe anemia is associated with SLE, not
polycythermia. Dressler’s syndrome is pericarditis that
occurs after a myocardial infarction and isn’t linked to
SLE.
43. Answer: (B) Night sweat. In stage 1, symptoms include a
single enlarged lymph node (usually), unexplained
fever, night sweats, malaise, and generalized pruritis.
Although splenomegaly may be present in some clients,
night sweats are generally more prevalent. Pericarditis
 isn’t associated with Hodgkin’s disease, nor is
hypothermia. Moreover, splenomegaly and pericarditis
aren’t symptoms. Persistent hypothermia is associated
with Hodgkin’s but isn’t an early sign of the disease.
44. Answer: (D) Breath sounds. Pneumonia, both viral and
fungal, is a common cause of death in clients with
neutropenia, so frequent assessment of respiratory rate
and breath sounds is required. Although assessing
blood pressure, bowel sounds, and heart sounds is
important, it won’t help detect pneumonia.
45. Answer: (B) Muscle spasm. Back pain or paresthesia in
the lower extremities may indicate impending spinal
cord compression from a spinal tumor. This should
be recognized and treated promptly as progression of
the tumor may result in paraplegia. The other options,
which reflect parts of the nervous system, aren’t usually
affected by MM.
46. Answer: (C)10 years. Epidermiologic studies show the
average time from initial contact with HIV to the
development of AIDS is 10 years.
47. Answer: (A) Low platelet count. In DIC, platelets and
clotting factors are consumed, resulting
in microthrombi and excessive bleeding. As clots form,
fibrinogen levels decrease and the prothrombin time
increases. Fibrin degeneration products increase as
fibrinolysis takes places.
48. Answer: (D) Hodgkin’s disease. Hodgkin’s disease
typically causes fever night sweats, weight loss, and
lymph mode enlargement. Influenza doesn’t last for
months. Clients with sickle cell anemia manifest signs
and symptoms of chronic anemia with pallor of the
mucous membrane, fatigue, and decreased tolerance for
exercise; they don’t show fever, night sweats, weight
loss or lymph node enlargement. Leukemia doesn’t
cause lymph node enlargement.
49. Answer: (C) A Rh-negative. Human blood can
sometimes contain an inherited D antigen. Persons with
the D antigen have Rh-positive blood type; those lacking
the antigen have Rh-negative blood. It’s important that
a person with Rhnegative blood receives Rh-negative
blood. If Rh-positive blood is administered to an Rh-
negative person, the recipient develops anti-
Rh agglutinins, and sub sequent transfusions with Rh-
positive blood may cause serious reactions with
clumping and hemolysis of red blood cells.
50. Answer: (B) “I will call my doctor if Stacy has persistent
vomiting and diarrhea”. Persistent (more than 24
hours) vomiting, anorexia, and diarrhea are signs of
toxicity and the patient should stop the medication and
notify the health care provider. The other
manifestations are expected side effects of
chemotherapy.
51. Answer: (D) “This is only temporary; Stacy will re-grow
new hair in 3-6 months, but may be different in
texture”. This is the appropriate response. The nurse
should help the mother how to cope with her own
21
feelings regarding the child’s disease so as not to affect
the child negatively. When the hair grows back, it is still
of the same color and texture.
52. Answer: (B) Apply viscous Lidocaine to oral ulcers as
needed. Stomatitis can cause pain and this can be
relieved by applying topical anesthetics such as
lidocaine before mouth care. When the patient is
already comfortable, the nurse can proceed with
providing the patient with oral rinses of saline solution
mixed with equal part of water or hydrogen peroxide
mixed water in 1:3 concentrations to promote
oral hygiene. Every 2-4 hours.
53. Answer: (C) Immediately discontinue the
infusion. Edema or swelling at the IV site is a sign that
the needle has been dislodged and the IV solution is
leaking into the tissues causing the edema. The patient
feels pain as the nerves are irritated by pressure
and the IV solution. The first action of the nurse would
be to discontinue the infusion right away to prevent
further edema and other complication.
54. Answer: (C) Chronic obstructive bronchitis. Clients with
chronic obstructive bronchitis appear bloated;
they have large barrel chest and peripheral edema,
cyanotic nail beds, and at times, circumoral cyanosis.
Clients with ARDS are acutely short of breath and
frequently need intubation for mechanical ventilation
and large amount of oxygen. Clients with asthma don’t
exhibit characteristics of chronic disease, and clients
with emphysema appear pink and cachectic.
55. Answer: (D) Emphysema. Because of the large amount
of energy it takes to breathe, clients with emphysema
are usually cachectic. They’re pink and usually breathe
through pursed lips, hence the term “puffer.” Clients
with ARDS are usually acutely short of breath. Clients
with asthma don’t have any particular characteristics,
and clients with chronic obstructive bronchitis are
bloated and cyanotic in appearance.
56. Answer: D 80 mm Hg. A client about to go into
respiratory arrest will have inefficient ventilation and
will be retaining carbon dioxide. The value expected
would be around 80 mm Hg. All other values are lower
than expected.
57. Answer: (C) Respiratory acidosis. Because Paco2 is high
at 80 mm Hg and the metabolic measure, HCO3- is
normal, the client has respiratory acidosis. The pH
is less than 7.35, academic, which eliminates metabolic
and respiratory alkalosis as possibilities. If the HCO3-
was below 22 mEq/L the client would have metabolic
acidosis.
58. Answer: (C) Respiratory failure. The client was reacting
to the drug with respiratory signs of impending
anaphylaxis, which could lead to eventually respiratory
failure. Although the signs are also related to an asthma
attack or a pulmonary embolism, consider the new drug
first. Rheumatoid arthritis doesn’t manifest these signs.
59. Answer: (D) Elevated serum aminotransferase. Hepatic
cell death causes release of liver enzymes
alanine aminotransferase (ALT), aspartate
aminotransferase (AST) and lactate dehydrogenase
(LDH) into the circulation. Liver cirrhosis is a chronic
and irreversible disease of the liver characterized by
generalized inflammation and fibrosis of the liver
tissues.
60. Answer: (A) Impaired clotting mechanism. Cirrhosis of
the liver results in decreased Vitamin K absorption and
formation of clotting factors resulting in impaired
clotting mechanism.
61. Answer: (B) Altered level of consciousness. Changes in
behavior and level of consciousness are the first sins of
hepatic encephalopathy. Hepatic encephalopathy is
caused by liver failure and develops when the liver is
unable to convert protein metabolic product ammonia
to urea. This results in accumulation of ammonia
and other toxic in the blood that damages the cells.
62. Answer: (C) “I’ll lower the dosage as ordered so the
drug causes only 2 to 4 stools a day”. Lactulose is given
to a patients with hepatic encephalopathy to reduce
absorption of ammonia in the intestines by binding with
ammonia and promoting more frequent bowel
movements. If the patient experience diarrhea, it
indicates over dosage and the nurse must reduce the
amount of medication given to the patient. The stool
will be mashy or soft. Lactulose is also very sweet and
may cause cramping and bloating.
63. Answer: (B) Severe lower back pain, decreased blood
pressure, decreased RBC count, increased WBC
count.Severe lower back pain indicates an aneurysm
rupture, secondary to pressure being applied within the
abdominal cavity. When ruptured occurs, the pain is
constant because it can’t be alleviated until the
aneurysm is repaired. Blood pressure decreases due to
the loss of blood. After the aneurysm ruptures, the
vasculature is interrupted and blood volume is lost, so
blood pressure wouldn’t increase. For the same reason,
the RBC count is decreased – not increased. The WBC
count increases as cell migrate to the site of injury.
64. Answer: (D) Apply gloves and assess the groin
site. Observing standard precautions is the first priority
when dealing with any blood fluid. Assessment of the
groin site is the second priority. This establishes where
the blood is coming from and determineshow much
blood has been lost. The goal in this situation is to stop
the bleeding. The nurse would call for help if it were
warranted after the assessment of the situation. After
determining the extent of the bleeding, vital signs
assessment is important. The nurse should never move
the client, in case a clot has formed. Moving can disturb
the clot and cause rebleeding.
65. Answer: (D) Percutaneous transluminal coronary
angioplasty (PTCA). PTCA can alleviate the blockage
and restore blood flow and oxygenation. An
echocardiogram is a noninvasive diagnosis
test. Nitroglycerin is an oral sublingual medication.
22
Cardiac catheterization is a diagnostic tool – not a
treatment.
66. Answer: (B) Cardiogenic shock. Cardiogenic shock is
shock related to ineffective pumping of the heart.
Anaphylactic shock results from an allergic reaction.
Distributive shock results from changes in the
intravascular volume distribution and is usually
associated with increased cardiac output. MI isn’t a
shock state, though a severe MI can lead to shock.
67. Answer: (C) Kidneys’ excretion of sodium and
water. The kidneys respond to rise in blood pressure by
excreting sodium and excess water. This response
ultimately affects sysmolic blood pressure by regulating
blood volume. Sodium or water retention would only
further increase blood pressure. Sodium and water
travel together across the membrane in the kidneys;
one can’t travel without the other.
68. Answer: (D) It inhibits reabsorption of sodium and
water in the loop of Henle. Furosemide is a loop diuretic
that inhibits sodium and water reabsorption in the loop
Henle, thereby causing a decrease in blood pressure.
Vasodilators cause dilation of peripheral blood vessels,
directly relaxing vascular smooth muscle and
decreasing blood pressure. Adrenergic blockers
decrease sympathetic cardioacceleration and decrease
blood pressure. Angiotensin-converting enzyme
inhibitors decrease blood pressure due to their action
on angiotensin.
69. Answer: (C) Pancytopenia, elevated antinuclear
antibody (ANA) titer. Laboratory findings for clients
with SLE usually show pancytopenia, elevated ANA
titer, and decreased serum complement levels. Clients
may have elevated BUN and creatinine levels
from nephritis, but the increase does not indicate SLE.
70. Answer: (C) Narcotics are avoided after a head injury
because they may hide a worsening condition. Narcotics
may mask changes in the level of consciousness that
indicate increased ICP and shouldn’t acetaminophen is
strong enough ignores the mother’s question and
therefore isn’t appropriate. Aspirin is contraindicated in
conditions that may have bleeding, such as trauma,
and for children or young adults with viral illnesses due
to the danger of Reye’s syndrome. Stronger medications
may not necessarily lead to vomiting but will sedate the
client, thereby masking changes in his level
of consciousness.
71. Answer: (A) Appropriate; lowering carbon dioxide
(CO2) reduces intracranial pressure (ICP). A normal
Paco2 value is 35 to 45 mm Hg CO2 has vasodilating
properties; therefore, lowering Paco2 through
hyperventilation will lower ICP caused by dilated
cerebral vessels. Oxygenation is evaluated through Pao2
and oxygen saturation. Alveolar hypoventilation would
be reflected in an increased Paco2.
72. Answer: (B) A 33-year-old client with a recent diagnosis
of Guillain-Barre syndrome . Guillain-Barre syndrome is
characterized by ascending paralysis and potential
 respiratory failure. The order of client
assessment should follow client priorities, with disorder
of airways, breathing, and then circulation. There’s no
information to suggest the postmyocardial
infarction client has an arrhythmia or other
complication. There’s no evidence to suggest
hemorrhage or perforation for the remaining clients as
a priority of care.
73. Answer: (C) Decreases inflammation. Then action of
colchicines is to decrease inflammation by reducing the
migration of leukocytes to synovial fluid. Colchicine
doesn’t replace estrogen, decrease infection, or
decrease bone demineralization.
74. Answer: (C) Osteoarthritis is the most common form of
arthritis. Osteoarthritis is the most common form of
arthritis and can be extremely debilitating. It can afflict
people of any age, although most are elderly.
75. Answer: (C) Myxedema coma. Myxedema coma, severe
hypothyroidism, is a life-threatening condition that may
develop if thyroid replacement medication isn’t
taken. Exophthalmos, protrusion of the eyeballs, is seen
with hyperthyroidism. Thyroid storm is life-threatening
but is caused by severe hyperthyroidism. Tibial
myxedema, peripheral mucinous edema involving the
lower leg, is associated with hypothyroidism but isn’t
life-threatening.
76. Answer: (B) An irregular apical pulse. Because
Cushing’s syndrome causes
aldosterone overproduction, which increases urinary
potassium loss, the disorder may lead to hypokalemia.
Therefore, the nurse should immediately report
signs and symptoms of hypokalemia, such as an
irregular apical pulse, to the physician. Edema is an
expected finding because aldosterone overproduction
causes sodium and fluid retention. Dry
mucous membranes and frequent urination signal
dehydration, which isn’t associated with Cushing’s
syndrome.
77. Answer: (D) Below-normal urine osmolality level,
above-normal serum osmolality level. In diabetes
insipidus, excessive polyuria causes dilute
urine, resulting in a below-normal urine osmolality
level. At the same time, polyuria depletes the body of
water, causing dehydration that leads to an above-
normal serum osmolality level. For the same reasons,
diabetes insipidus doesn’t cause above-normal urine
osmolality or below-normal serum osmolality levels.
78. Answer: (A) “I can avoid getting sick by not becoming
dehydrated and by paying attention to my need to
urinate, drink, or eat more than usual.” Inadequate fluid
intake during hyperglycemic episodes often leads to
HHNS. By recognizing the signs of hyperglycemia
(polyuria, polydipsia, and polyphagia) and increasing
fluid intake, the client may prevent HHNS. Drinking a
glass of nondiet soda would be appropriate
for hypoglycemia. A client whose diabetes is controlled
with oral antidiabetic agents usually doesn’t need to
monitor blood glucose levels. A highcarbohydrate diet
23
would exacerbate the client’s condition, particularly
if fluid intake is low.
79. Answer: (D)
Hyperparathyroidism. Hyperparathyroidism is most
common in older women and is characterized by bone
pain and weakness from excess parathyroid hormone
(PTH). Clients also exhibit hypercaliuria-causing
polyuria. While clients with diabetes mellitus and
diabetes insipidus also have polyuria, they don’t have
bone pain and increased sleeping. Hypoparathyroidism
is characterized by urinary frequency rather than
polyuria.
80. Answer: (C) “I’ll take two-thirds of the dose when I
wake up and one-third in the late
afternoon.” Hydrocortisone, a glucocorticoid, should be
administered according to a schedule that closely
reflects the body’s own secretion of this hormone;
therefore, two-thirds of the dose of hydrocortisone
should be taken in the morning and one-third in the late
afternoon. This dosage schedule reduces adverse
effects.
81. Answer: (C) High corticotropin and high cortisol
levels. A corticotropin-secreting pituitary tumor would
cause high corticotropin and high cortisol levels. A high
corticotropin level with a low cortisol level and a low
corticotropin level with a low cortisol level would
be associated with hypocortisolism. Low corticotropin
and high cortisol levels would be seen if there was a
primary defect in the adrenal glands.
82. Answer: (D) Performing capillary glucose testing every
4 hours. The nurse should perform capillary glucose
testing every 4 hours because excess cortisol may cause
insulin resistance, placing the client at risk for
hyperglycemia. Urine ketone testing isn’t
indicated because the client does secrete insulin and,
therefore, isn’t at risk for ketosis. Urine specific gravity
isn’t indicated because although fluid balance can be
compromised, it usually isn’t dangerously
imbalanced. Temperature regulation may be affected by
excess cortisol and isn’t an accurate indicator of
infection.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at
4 p.m.. Regular insulin, which is a short-acting insulin,
has an onset of 15 to 30 minutes and a peak of 2 to 4
hours. Because the nurse gave the insulin at 2 p.m., the
expected onset would be from 2:15 p.m. to 2:30
p.m. and the peak from 4 p.m. to 6 p.m.
84. Answer: (A) No increase in the thyroid-stimulating
hormone (TSH) level after 30 minutes during the TSH
stimulation test. In the TSH test, failure of the TSH level
to rise after 30 minutes confirms hyperthyroidism. A
decreased TSH level indicates a pituitary deficiency of
this hormone. Below-normal levels of T3 and T4,
as detected by radioimmunoassay, signal
hypothyroidism. A below-normal T4 level also occurs in
malnutrition and liver disease and may result
from administration of phenytoin and certain other
drugs.
85. Answer: (B) “Rotate injection sites within the same
anatomic region, not among different regions.” The
nurse should instruct the client to rotate injection
sites within the same anatomic region. Rotating sites
among different regions may cause excessive day-to-
day variations in the blood glucose level; also, insulin
absorption differs from one region to the next. Insulin
should be injected only into healthy tissue lacking large
blood vessels, nerves, or scar tissue or other deviations.
Injecting insulin into areas of hypertrophy may delay
absorption. The client shouldn’t inject insulin into areas
of lipodystrophy (such as hypertrophy or atrophy); to
prevent lipodystrophy, the client should rotate injection
sites systematically. Exercise speeds drug absorption, so
the client shouldn’t inject insulin into sites
above muscles that will be exercised heavily.
86. Answer: (D) Below-normal serum potassium level. A
client with HHNS has an overall body deficit of
potassium resulting from diuresis, which occurs
secondary to the hyperosmolar, hyperglycemic state
caused by the relative insulin deficiency. An
elevated serum acetone level and serum ketone bodies
are characteristic of diabetic ketoacidosis. Metabolic
acidosis, not serum alkalosis, may occur in HHNS.
87. Answer: (D) Maintaining room temperature in the low-
normal range. Graves’ disease causes signs and
symptoms of hypermetabolism, such as heat
intolerance, diaphoresis, excessive thirst and appetite,
and weight loss. To reduce heat intolerance
and diaphoresis, the nurse should keep the client’s
room temperature in the low-normal range. To replace
fluids lost via diaphoresis, the nurse should encourage,
not restrict, intake of oral fluids. Placing extra blankets
on the bed of a client with heat intolerance would cause
discomfort. To provide needed energy and calories, the
nurse should encourage the client to eat high-
carbohydrate foods.
88. Answer: (A) Fracture of the distal radius. Colles’
fracture is a fracture of the distal radius, such as from a
fall on an outstretched hand. It’s most common in
women. Colles’ fracture doesn’t refer to a fracture of the
olecranon, humerus, or carpal scaphoid.
89. Answer: (B) Calcium and phosphorous. In osteoporosis,
bones lose calcium and phosphate salts, becoming
porous, brittle, and abnormally vulnerable to fracture.
Sodium and potassium aren’t involved in the
development of osteoporosis.
90. Answer: (A) Adult respiratory distress syndrome
(ARDS). Severe hypoxia after smoke inhalation is
typically related to ARDS. The other conditions listed
aren’t typically associated with smoke inhalation and
severe hypoxia.
91. Answer: (D) Fat embolism. Long bone fractures are
correlated with fat emboli, whichcause shortness of
breath and hypoxia. It’s unlikely the client
has developed asthma or bronchitis without a previous
history. He could develop atelectasis but it typically
doesn’t produce progressive hypoxia.
24
92. Answer: (D) Spontaneous pneumothorax. A
spontaneous pneumothorax occurs when the client’s
lung collapses, causing an acute decreased in the
amount of functional lung used in oxygenation. The
sudden collapse was the cause of his chest pain and
shortness of breath. An asthma attack would show
wheezing breath sounds, and bronchitis would have
rhonchi. Pneumonia would have bronchial breath
sounds over the area of consolidation.
93. Answer: (C) Pneumothorax. From the trauma the client
experienced, it’s unlikely he has bronchitis, pneumonia,
or TB; rhonchi with bronchitis, bronchial breath sounds
with TB would be heard.
94. Answer: (C) Serous fluids fills the space and
consolidates the region. Serous fluid fills the space and
eventually consolidates, preventing extensive
mediastinal shift of the heart and remaining lung.
Air can’t be left in the space. There’s no gel that can be
placed in the pleural space. The tissue from the other
lung can’t cross the mediastinum, although a temporary
mediastinal shift exits until the space is filled.
95. Answer: (A) Alveolar damage in the infracted area. The
infracted area produces alveolar damage that can lead
to the production of bloody sputum, sometimes in
massive amounts. Clot formation usually occurs in the
legs. There’s a loss of lung parenchyma and subsequent
scar tissue formation.
96. Answer: (D) Respiratory alkalosis. A client with massive
pulmonary embolism will have a large region and blow
off large amount of carbon dioxide, which crosses
the unaffected alveolar-capillary membrane more
readily than does oxygen and results in respiratory
alkalosis.
97. Answer: (A) Air leak. Bubbling in the water seal
chamber of a chest drainage system stems from an air
leak. In pneumothorax an air leak can occur as air
is pulled from the pleural space. Bubbling doesn’t
normally occur with either adequate or inadequate
suction or any preexisting bubbling in the water seal
chamber.
98. Answer: (B) 21. 3000 x 10 divided by 24 x 60.
99. Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x =
.12, x = 2.4 ml.
100. Answer: (D) “I should put on the stockings before
getting out of bed in the morning. Promote venous
return by applying external pressure on veins.
PNLE V for Care of Clients with Physiologic and
Psychosocial Alterations (Part 3)
Answers and Rationales
1. Answer: (D) Focusing. The nurse is using focusing by
suggesting that the client discuss a specific issue. The nurse
 didn’t restate the question, make observation, or ask
further question (exploring).
2. Answer: (D) Remove all other clients from the
dayroom. The nurse’s first priority is to consider the safety
of the clients in the therapeutic setting. The other actions
are appropriate responses after ensuring the safety of
other clients.
3. Answer: (A) The client is disruptive. Group activity
provides too much stimulation, which the client will not be
able to handle (harmful to self) and as a result will be
disruptive to others.
4. Answer: (C) Agree to talk with the mother and the father
together. By agreeing to talk with both parents, the nurse
can provide emotional support and further assess and
validate the family’s needs.
5. Answer: (A) Perceptual disorders. Frightening visual
hallucinations are especially common in clients
experiencing alcohol withdrawal.
6. Answer: (D) Suggest that it takes awhile before seeing the
results. The client needs a specific response; that it takes 2
to 3 weeks (a delayed effect) until the therapeutic blood
level is reached.
7. Answer: (C) Superego. This behavior shows a weak sense
of moral consciousness. According to Freudian theory,
personality disorders stem from a weak superego.
8. Answer: (C) Skeletal muscle paralysis. Anectine is a
depolarizing muscle relaxant causing paralysis. It is used to
reduce the intensity of muscle contractions during
the convulsive stage, thereby reducing the risk of bone
fractures or dislocation.
9. Answer: (D) Increase calories, carbohydrates, and
protein.This client increased protein for tissue building and
increased calories to replace what is burned up (usually via
carbohydrates).
10. Answer: (C) Acting overly solicitous toward the child. This
behavior is an example of reaction formation, a
coping mechanism.
11. Answer: (A) By designating times during which the client
can focus on the behavior. The nurse should designate
times during which the client can focus on the compulsive
behavior or obsessive thoughts. The nurse should urge the
client to reduce the frequency of the compulsive
behavior gradually, not rapidly. She shouldn’t call attention
to or try to prevent the behavior. Trying to prevent the
behavior may cause pain and terror in the client. The nurse
should encourage the client to verbalize anxieties to
help distract attention from the compulsive behavior.
12. Answer: (D) Exploring the meaning of the traumatic event
with the client. The client with PTSD needs encouragement
to examine and understand the meaning of the traumatic
event and consequent losses. Otherwise, symptoms may
worsen and the client may become depressed or engage in
self-destructive behavior such as substance abuse.
25
The client must explore the meaning of the event and won’t
heal without this, no matter how much time passes.
Behavioral techniques, such as relaxation therapy, may
help decrease the client’s anxiety and induce sleep. The
physician may prescribe antianxiety agents or
antidepressants cautiously to avoid dependence; sleep
medication is rarely appropriate. A special diet isn’t
indicated unless the client also has an eating disorder or a
nutritional problem.
13. Answer: (C) “Your problem is real but there is no physical
basis for it. We’ll work on what is going on in your life to
find out why it’s happened.” The nurse must be honest with
the client by telling her that the paralysis has no
physiologic cause while also conveying empathy
and acknowledging that her symptoms are real. The client
will benefit from psychiatric treatment, which will help her
understand the underlying cause of her symptoms. After
the psychological conflict is resolved, her symptoms will
disappear. Saying that it must be awful not to be able
to move her legs wouldn’t answer the client’s question;
knowing that the cause is psychological wouldn’t
necessarily make her feel better. Telling her that she has
developed paralysis to avoid leaving her parents or that her
personality caused her disorder wouldn’t help her
understand and resolve the underlying conflict.
14. Answer: (C) fluvoxamine (Luvox) and clomipramine
(Anafranil). The antidepressants fluvoxamine and
clomipramine have been effective in the treatment of OCD.
Librium and Valium may be helpful in treating anxiety
related to OCD but aren’t drugs of choice to treat the illness.
The other medications mentioned aren’t effective in the
treatment of OCD.
15. Answer: (A) A warning about the drugs delayed therapeutic
effect, which is from 14 to 30 days. The client should be
informed that the drug’s therapeutic effect might not be
reached for 14 to 30 days. The client must be instructed
to continue taking the drug as directed. Blood level checks
aren’t necessary. NMS hasn’t been reported with this drug,
but tachycardia is frequently reported.
16. Answer: (B) Severe anxiety and fear. Phobias cause severe
anxiety (such as a panic attack) that is out of proportion to
the threat of the feared object or situation. Physical signs
and symptoms of phobias include profuse sweating, poor
motor control, tachycardia, and elevated blood pressure.
Insomnia, an inability to concentrate, and weight loss are
common in depression. Withdrawal and failure to
distinguish reality from fantasy occur in schizophrenia.
17. Answer: (A) Antidepressants. Tricyclic and monoamine
oxidase (MAO) inhibitor antidepressants have been found
to be effective in treating clients with panic attacks. Why
these drugs help control panic attacks isn’t
clearly understood. Anticholinergic agents, which are
smooth-muscle relaxants, relieve physical symptoms of
anxiety but don’t relieve the anxiety itself. Antipsychotic
drugs are inappropriate because clients who
experience panic attacks aren’t psychotic. Mood stabilizers
aren’t indicated because panic attacks are rarely associated
with mood changes.
18. Answer: (B) 3 to 5 days. Monoamine oxidase inhibitors,
such as tranylcypromine, have an onset of action of
approximately 3 to 5 days. A full clinical response may be
delayed for 3 to 4 weeks. The therapeutic effects may
continue for 1 to 2 weeks after discontinuation.
19. Answer: (B) Providing emotional support and individual
counseling. Clients in the first stage of Alzheimer’s disease
are aware that something is happening to them and may
become overwhelmed and frightened. Therefore, nursing
care typically focuses on providing emotional support and
individual counseling. The other options are appropriate
during the second stage of Alzheimer’s disease, when
the client needs continuous monitoring to prevent minor
illnesses from progressing into major problems and when
maintaining adequate nutrition may become a challenge.
During this stage, offering nourishing finger foods helps
clients to feed themselves and maintain adequate nutrition.
20. Answer: (C) Emotional lability, euphoria, and impaired
memory. Signs of antianxiety agent overdose include
emotional lability, euphoria, and impaired memory.
Phencyclidine overdose can cause combativeness,
sweating, and confusion. Amphetamine overdose can result
in agitation, hyperactivity, and grandiose ideation.
Hallucinogen overdose can produce suspiciousness, dilated
pupils, and increased blood pressure.
21. Answer: (D) A low tolerance for frustration. Clients with an
antisocial personality disorder exhibit a low tolerance for
frustration, emotional immaturity, and a lack of
impulse control. They commonly have a history of
unemployment, miss work repeatedly, and quit work
without other plans for employment. They don’t feel guilt
about their behavior and commonly perceive themselves
as victims. They also display a lack of responsibility for the
outcome of their actions. Because of a lack of trust in
others, clients with antisocial personality disorder
commonly have difficulty developing stable,
close relationships.
22. Answer: (C) Methadone. Methadone is used to detoxify
opiate users because it binds with opioid receptors at many
sites in the central nervous system but doesn’t have the
same deterious effects as other opiates, such as cocaine,
heroin, and morphine. Barbiturates, amphetamines,
and benzodiazepines are highly addictive and would
require detoxification treatment.
23. Answer: (B) Hallucinations. Hallucinations are visual,
auditory, gustatory, tactile, or olfactory perceptions that
have no basis in reality. Delusions are false beliefs, rather
than perceptions, that the client accepts as real.
Loose associations are rapid shifts among unrelated ideas.
Neologisms are bizarre words that have meaning only to
the client.
24. Answer: (C) Set up a strict eating plan for the
client. Establishing a consistent eating plan and monitoring
the client’s weight are very important in this disorder. The
family and friends should be included in the client’s care.
The client should be monitored during meals-not given
privacy. Exercise must be limited and supervised.
26
25. Answer: (A) Highly important or famous. A delusion of
grandeur is a false belief that one is highly important or
famous. A delusion of persecution is a false belief that one
is being persecuted. A delusion of reference is a false belief
that one is connected to events unrelated to oneself or a
belief that one is responsible for the evil in the world.
26. Answer: (D) Listening attentively with a neutral attitude
and avoiding power struggles. The nurse should listen to
the client’s requests, express willingness to seriously
consider the request, and respond later. The nurse should
encourage the client to take short daytime naps because
he expends so much energy. The nurse shouldn’t try to
restrain the client when he feels the need to move around
as long as his activity isn’t harmful. High calorie finger
foods should be offered to supplement the client’s diet, if he
can’t remain seated long enough to eat a complete
meal. The nurse shouldn’t be forced to stay seated at the
table to finish a meal. The nurse should set limits in a calm,
clear, and self-confident tone of voice.
27. Answer: (D) Denial. Denial is unconscious defense
mechanism in which emotional conflict and anxiety is
avoided by refusing to acknowledge feelings, desires,
impulses, or external facts that are consciously
intolerable. Withdrawal is a common response to stress,
characterized by apathy. Logical thinking is the ability to
think rationally and make responsible decisions, which
would lead the client admitting the problem and
seeking help. Repression is suppressing past events from
the consciousness because of guilty association.
28. Answer: (B) Paranoid thoughts. Clients with schizotypal
personality disorder experience excessive social anxiety
that can lead to paranoid thoughts. Aggressive behavior is
uncommon, although these clients may experience
agitation with anxiety. Their behavior is emotionally cold
with a flattened affect, regardless of the situation. These
clients demonstrate a reduced capacity for close or
dependent relationships.
29. Answer: (C) Identify anxiety-causing situations. Bulimic
behavior is generally a maladaptive coping response
to stress and underlying issues. The client must identify
anxiety-causing situations that stimulate the bulimic
behavior and then learn new ways of coping with the
anxiety.
30. Answer: (A) Tension and irritability. An amphetamine is a
nervous system stimulant that is subject to abuse because
of its ability to produce wakefulness and euphoria.
An overdose increases tension and irritability. Options B
and C are incorrect because amphetamines stimulate
norepinephrine, which increase the heart rate and blood
flow. Diarrhea is a common adverse effect so option D in is
incorrect.
31. Answer: (B) “No, I do not hear your voices, but I believe you
can hear them”. The nurse, demonstrating knowledge and
understanding, accepts the client’s perceptions even
though they are hallucinatory.
32. Answer: (C) Confusion for a time after treatment. The
electrical energy passing through the cerebral
 cortex during ECT results in a temporary state of confusion
after treatment.
33. Answer: (D) Acceptance stage. Communication and
intervention during this stage are mainly nonverbal, as
when the client gestures to hold the nurse’s hand.
34. Answer: (D) A higher level of anxiety continuing for more
than 3 months. This is not an expected outcome of a crisis
because by definition a crisis would be resolved in 6 weeks.
35. Answer: (B) Staying in the sun. Haldol causes
photosensitivity. Severe sunburn can occur on exposure to
the sun.
36. Answer: (D) Moderate-level anxiety. A moderately anxious
person can ignore peripheral events and focuses on central
concerns.
37. Answer: (C) Diverse interest. Before onset of depression,
these clients usually have very narrow, limited interest.
38. Answer: (A) As their depression begins to improve. At this
point the client may have enough energy to plan
and execute an attempt.
39. Answer: (D) Disturbance in recalling recent events related
to cerebral hypoxia. Cell damage seems to interfere with
registering input stimuli, which affects the ability to
register and recall recent events; vascular dementia is
related to multiple vascular lesions of the cerebral cortex
and subcortical structure.
40. Answer: (D) Encouraging the client to have blood levels
checked as ordered. Blood levels must be checked monthly
or bimonthly when the client is on maintenance therapy
because there is only a small range between therapeutic
and toxic levels.
41. Answer: (B) Fine hand tremors or slurred speech. These
are common side effects of lithium carbonate.
42. Answer: (D) Presence. The constant presence of a nurse
provides emotional support because the client knows that
someone is attentive and available in case of an emergency.
43. Answer: (A) Client’s perception of the presenting
problem. The nurse can be most therapeutic by starting
where the client is, because it is the client’s concept of the
problem that serves as the starting point of the
relationship.
44. Answer: (B) Chocolate milk, aged cheese, and
yogurt’. These high-tyramine foods, when ingested in the
presence of an MAO inhibitor, cause a severe hypertensive
response.
45. Answer: (B) 4 to 6 weeks. Crisis is self-limiting and lasts
from 4 to 6 weeks.
46. Answer: (D) Males are more likely to use lethal methods
than are females. This finding is supported by research;
27
females account for 90% of suicide attempts but males are
three times more successful because of methods used.
47. Answer: (C) “Your cursing is interrupting the activity. Take
time out in your room for 10 minutes.” The nurse should
set limits on client behavior to ensure a comfortable
environment for all clients. The nurse should accept hostile
or quarrelsome client outbursts within limits without
becoming personally offended, as in option A. Option B is
incorrect because it implies that the client’s actions reflect
feelings toward the staff instead of the client’s own misery.
Judgmental remarks, such as option D, may decrease the
client’s self-esteem.
48. Answer: (C) lithium carbonate (Lithane). Lithium
carbonate, an antimania drug, is used to treat clients with
cyclical schizoaffective disorder, a psychotic disorder once
classified under schizophrenia that causes affective
symptoms, including maniclike activity. Lithium helps
control the affective component of this
disorder. Phenelzine is a monoamine oxidase inhibitor
prescribed for clients who don’t respond to other
antidepressant drugs such as
imipramine. Chlordiazepoxide, an antianxiety agent,
generally is contraindicated in psychotic clients.
Imipramine, primarily considered an antidepressant agent,
is also used to treat clients with agoraphobia and that
undergoing cocaine detoxification.
49. Answer: (B) Report a sore throat or fever to the physician
immediately. A sore throat and fever are indications of an
infection caused by agranulocytosis, a potentially life-
threatening complication of clozapine. Because of the risk
of agranulocytosis, white blood cell (WBC) counts
are necessary weekly, not monthly. If the WBC count drops
below 3,000/μl, the medication must be stopped.
Hypotension may occur in clients taking this medication.
Warn the client to stand up slowly to avoid dizziness
from orthostatic hypotension. The medication should be
continued, even when symptoms have been controlled. If
the medication must be stopped, it should be slowly
tapered over 1 to 2 weeks and only under the supervision
of a physician.
50. Answer: (C) Neuroleptic malignant syndrome. The client’s
signs and symptoms suggest neuroleptic malignant
syndrome, a life-threatening reaction to neuroleptic
medication that requires immediate treatment. Tardive
dyskinesia causes involuntary movements of the tongue,
mouth, facial muscles, and arm and leg muscles. Dystonia is
characterized by cramps and rigidity of the tongue, face,
neck, and back muscles. Akathisia causes restlessness,
anxiety, and jitteriness.
51. Answer: (B) Advising the client to sit up for 1 minute before
getting out of bed. To minimize the effects of amitriptyline-
induced orthostatic hypotension, the nurse should advise
the client to sit up for 1 minute before getting out of bed.
Orthostatic hypotension commonly occurs with tricyclic
antidepressant therapy. In these cases, the dosage may
be reduced or the physician may prescribe nortriptyline,
another tricyclic antidepressant. Orthostatic hypotension
disappears only when the drug is discontinued.
52. Answer: (D) Dysthymic disorder. Dysthymic disorder is
marked by feelings of depression lasting at least 2 years,
accompanied by at least two of the following
symptoms: sleep disturbance, appetite disturbance, low
energy or fatigue, low selfesteem, poor concentration,
difficulty making decisions, and hopelessness. These
symptoms may be relatively continuous or separated by
intervening periods of normal mood that last a few days to
a few weeks. Cyclothymic disorder is a chronic mood
disturbance of at least 2 years’ duration marked by
numerous periods of depression and hypomania. Atypical
affective disorder is characterized by manic signs
and symptoms. Major depression is a recurring, persistent
sadness or loss of interest or pleasure in almost all
activities, with signs and symptoms recurring for at least 2
weeks.
53. Answer: (C) 30 g mixed in 250 ml of water. The usual adult
dosage of activated charcoal is 5 to 10 times the estimated
weight of the drug or chemical ingested, or a minimum
dose of 30 g, mixed in 250 ml of water. Doses less than this
will be ineffective; doses greater than this can increase the
risk of adverse reactions, although toxicity doesn’t occur
with activated charcoal, even at the maximum dose.
54. Answer: (C) St. John’s wort. St. John’s wort has been found
to have serotonin-elevating properties, similar to
prescription antidepressants. Ginkgo biloba is prescribed
to enhance mental acuity. Echinacea has immune-
stimulating properties. Ephedra is a naturally occurring
stimulant that is similar to ephedrine.
55. Answer: (B) Sodium. Lithium is chemically similar to
sodium. If sodium levels are reduced, such as from
sweating or diuresis, lithium will be reabsorbed by the
kidneys, increasing the risk of toxicity. Clients taking
lithium shouldn’t restrict their intake of sodium and should
drink adequate amounts of fluid each day. The other
electrolytes are important for normal body functions but
sodium is most important to the absorption of lithium.
56. Answer: (D) It’s characterized by an acute onset and lasts
hours to a number of days. Delirium has an acute onset and
typically can last from several hours to several days.
57. Answer: (B) Impaired communication. Initially, memory
impairment may be the only cognitive deficit in a client
with Alzheimer’s disease. During the early stage of this
disease, subtle personality changes may also be present.
However, other than occasional irritable outbursts and lack
of spontaneity, the client is usually cooperative and exhibits
socially appropriate behavior. Signs of advancement to the
middle stage of Alzheimer’s disease include exacerbated
cognitive impairment with obvious personality changes
and impaired communication, such as inappropriate
conversation, actions, and responses. During the late stage,
the client can’t perform self-care activities and may become
mute.
58. Answer: (D) This medication may initially cause tiredness,
which should become less bothersome over time. Sedation
is a common early adverse effect of imipramine, a tricyclic
antidepressant, and usually decreases as tolerance
develops. Antidepressants aren’t habit forming and don’t
28
cause physical or psychological dependence. However,
after a long course of high-dose therapy, the dosage should
be decreased gradually to avoid mild withdrawal
symptoms. Serious adverse effects, although rare,
include myocardial infarction, heart failure, and
tachycardia. Dietary restrictions, such as avoiding aged
cheeses, yogurt, and chicken livers, are necessary for a
client taking a monoamine oxidase inhibitor, not a
tricyclic antidepressant.
59. Answer: (C) Monitor vital signs, serum electrolyte levels,
and acid-base balance. An anorexic client who requires
hospitalization is in poor physical condition from
starvation and may die as a result of
arrhythmias, hypothermia, malnutrition, infection, or
cardiac abnormalities secondary to electrolyte imbalances.
Therefore, monitoring the client’s vital signs,
serum electrolyte level, and acid base balance is crucial.
Option A may worsen anxiety. Option B is incorrect because
a weight obtained after breakfast is more accurate than one
obtained after the evening meal. Option D would reward
the client with attention for not eating and reinforce the
control issues that are central to the underlying
psychological problem; also, the client may record food and
fluid intake inaccurately.
60. Answer: (D) Opioid withdrawal. The symptoms listed are
specific to opioid withdrawal. Alcohol withdrawal would
show elevated vital signs. There is no real withdrawal from
cannibis. Symptoms of cocaine withdrawal include
depression, anxiety, and agitation.
61. Answer: (A) Regression. An adult who throws temper
tantrums, such as this one, is displaying regressive
behavior, or behavior that is appropriate at a younger age.
In projection, the client blames someone or something
other than the source. In reaction formation, the client acts
in opposition to his feelings. In intellectualization, the client
overuses rational explanations orabstract thinking to
decrease the significance of a feeling or event.
62. Answer: (A) Abnormal movements and involuntary
movements of the mouth, tongue, and face. Tardive
dyskinesia is a severe reaction associated with long term
use of antipsychotic medication. The clinical manifestations
include abnormal movements (dyskinesia) and involuntary
movements of the mouth, tongue (fly catcher tongue), and
face.
63. Answer: (C) Blurred vision. At lithium levels of 2 to 2.5
mEq/L the client will experienced blurred vision, muscle
twitching, severe hypotension, and persistent nausea and
vomiting. With levels between 1.5 and 2 mEq/L the
client experiencing vomiting, diarrhea, muscle weakness,
ataxia, dizziness, slurred speech, and confusion. At lithium
levels of 2.5 to 3 mEq/L or higher, urinary and fecal
incontinence occurs, as well as seizures,
cardiac dysrythmias, peripheral vascular collapse, and
death.
64. Answer: (C) No acts of aggression have been observed
within 1 hour after the release of two of the extremity
restraints. The best indicator that the behavior is
controlled, if the client exhibits no signs of aggression after
 partial release of restraints. Options A, B, and D do not
ensure that the client has controlled the behavior.
65. Answer: (A) increased attention span and
concentration. The medication has a paradoxic effect that
decrease hyperactivity and impulsivity among children
with ADHD. B, C, D. Side effects of Ritalin include anorexia,
insomnia, diarrhea and irritability.
66. Answer: (C) Moderate. The child with moderate mental
retardation has an I.Q. of 35- 50 Profound Mental
retardation has an I.Q. of below 20; Mild mental retardation
50-70 and Severe mental retardation has an I.Q. of 20-35.
67. Answer: (D) Rearrange the environment to activate the
child. The child with autistic disorder does not want
change. Maintaining a consistent environment is
therapeutic. A. Angry outburst can be re-channeling
through safe activities. B. Acceptance enhances a trusting
relationship. C. Ensure safety from self-destructive
behaviors like head banging and hair pulling.
68. Answer: (B) cocaine. The manifestations indicate
intoxication with cocaine, a CNS stimulant. A. Intoxication
with heroine is manifested by euphoria then impairment in
judgment, attention and the presence of
papillary constriction. C. Intoxication with hallucinogen like
LSD is manifested by grandiosity, hallucinations,
synesthesia and increase in vital signs D. Intoxication with
Marijuana, a cannabinoid is manifested by sensation
of slowed time, conjunctival redness, social withdrawal,
impaired judgment and hallucinations.
69. Answer: (B) insidious onset. Dementia has a gradual onset
and progressive deterioration. It causes pronounced
memory and cognitive disturbances. A,C and D are
all characteristics of delirium.
70. Answer: (C) Claustrophobia. Claustrophobia is fear of
closed space. A. Agoraphobia is fear of open space or being
a situation where escape is difficult. B. Social phobia is fear
of performing in the presence of others in a way that will
be humiliating or embarrassing. D. Xenophobia is fear of
strangers.
71. Answer: (A) Revealing personal information to the
client. Counter-transference is an emotional reaction of the
nurse on the client based on her unconscious needs and
conflicts. B and C. These are therapeutic approaches. D.
This is transference reaction where a client has an
emotional reaction towards the nurse based on her past.
72. Answer: (D) Hold the next dose and obtain an order for a
stat serum lithium level. Diarrhea and vomiting are
manifestations of Lithium toxicity. The next dose of lithium
should be withheld and test is done to validate the
observation. A. The manifestations are not due to drug
interaction. B. Cogentin is used to manage the extra
pyramidal symptom side effects of antipsychotics. C. The
common side effects of Lithium are fine hand tremors,
nausea, polyuria and polydipsia.
73. Answer: (C) A living, learning or working environment. A
therapeutic milieu refers to a broad conceptual approach
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in which all aspects of the environment are channeled to
provide a therapeutic environment for the client. The six
environmental elements include structure, safety, norms;
limit setting, balance and unit modification. A. Behavioral
approach in psychiatric care is based on the premise that
behavior can be learned or unlearned through the use
of reward and punishment. B. Cognitive approach to change
behavior is done by correcting distorted perceptions and
irrational beliefs to correct maladaptive behaviors. D. This
is not congruent with therapeutic milieu.
74. Answer: (B) Transference. Transference is a positive or
negative feeling associated with a significant person in the
client’s past that are unconsciously assigned to another A.
Splitting is a defense mechanism commonly seen in a
client with personality disorder in which the world is
perceived as all good or all bad C. Countert-transference is
a phenomenon where the nurse shifts feelings assigned to
someone in her past to the patient D. Resistance is the
client’s refusal to submit himself to the care of the nurse
75. Answer: (B) Adventitious. Adventitious crisis is a crisis
involving a traumatic event. It is not part of everyday life. A.
Situational crisis is from an external source that upset ones
psychological equilibrium C and D. Are the same. They are
transitional or developmental periods in life
76. Answer: (C) Major depression. The DSM-IV-TR classifies
major depression as an Axis I disorder. Borderline
personality disorder as an Axis II; obesity
and hypertension, Axis III.
77. Answer: (B) Transference. Transference is the unconscious
assignment of negative or positive feelings evoked by a
significant person in the client’s past to another person.
Intellectualization is a defense mechanism in which
the client avoids dealing with emotions by focusing on
facts. Triangulation refers to conflicts involving three
family members. Splitting is a defense mechanism
commonly seen in clients with personality disorder in
which the world is perceived as all good or all bad.
78. Answer: (B) Hypochondriasis. Complains of vague physical
symptoms that have no apparent medical causes are
characteristic of clients with hypochondriasis. In
many cases, the GI system is affected. Conversion disorders
are characterized by one or more neurologic symptoms.
The client’s symptoms don’t suggest severe anxiety. A client
experiencing sublimation channels maladaptive feelings or
impulses into socially acceptable behavior
79. Answer: (C) Hypochondriasis. Hypochodriasis in this case
is shown by the client’s belief that she has a serious illness,
although pathologic causes have been eliminated. The
disturbance usually lasts at lease 6 with identifiable
life stressor such as, in this case, course examinations.
Conversion disorders are characterized by one or more
neurologic symptoms. Depersonalization refers to
persistent recurrent episodes of feeling detached from
one’s self or body. Somatoform disorders generally have
a chronic course with few remissions.
80. Answer: (A) Triazolam (Halcion). Triazolam is one of a
group of sedative hypnotic medication that can be used for
 a limited time because of the risk of
dependence. Paroxetine is a scrotonin-specific reutake
inhibitor used for treatment of depression panic disorder,
and obsessive-compulsive disorder. Fluoxetine is a
scrotonin-specific reuptake inhibitor used for depressive
disorders and obsessive-compulsive disorders.
Risperidome is indicated for psychotic disorders.
81. Answer: (D) It promotes emotional support or attention for
the client. Secondary gain refers to the benefits of the
illness that allow the client to receive emotional support or
attention. Primary gain enables the client to avoid some
unpleasant activity. A dysfunctional family may disregard
the real issue, although some conflict is relieved.
Somatoform pain disorder is a preoccupation with pain in
the absence of physical disease.
82. Answer: (A) “I went to the mall with my friends last
Saturday”. Clients with panic disorder tent to be socially
withdrawn. Going to the mall is a sign of working on
avoidance behaviors. Hyperventilating is a key symptom of
panic disorder. Teaching breathing control is a
major intervention for clients with panic disorder. The
client taking medications for panic disorder; such as tricylic
antidepressants and benzodiazepines, must be weaned off
these drugs. Most clients with panic disorder
with agoraphobia don’t have nutritional problems.
83. Answer: (A) “I’m sleeping better and don’t have
nightmares” MAO inhibitors are used to treat sleep
problems, nightmares, and intrusive daytime thoughts in
individual with posttraumatic stress disorder. MAO
inhibitors aren’t used to help control flashbacks or
phobias or to decrease the craving for alcohol.
84. Answer: (D) Stopping the drug can cause withdrawal
symptoms. Stopping antianxiety drugs such as
benzodiazepines can cause the client to have withdrawal
symptoms. Stopping a benzodiazepine doesn’t tend to
cause depression, increase cognitive abilities, or
decrease sleeping difficulties.
85. Answer: (B) Behavioral difficulties. Adolescents tend to
demonstrate severe irritability and behavioral problems
rather than simply a depressed mood. Anxiety disorder is
more commonly associated with small children rather than
with adolescents. Cognitive impairment is typically
associated with delirium or dementia. Labile mood is more
characteristic of a client with cognitive impairment or
bipolar disorder.
86. Answer: (D) It’s a mood disorder similar to major
depression but of mild to moderate severity. Dysthymic
disorder is a mood disorder similar to major depression
but it remains mild to moderate in severity.
Cyclothymic disorder is a mood disorder characterized by a
mood range from moderate depression to hypomania.
Bipolar I disorder is characterized by a single manic
episode with no past major depressive episodes.
Seasonalaffective disorder is a form of depression
occurring in the fall and winter.
87. Answer: (A) Vascular dementia has more abrupt
onset. Vascular dementia differs from Alzheimer’s disease
30
in that it has a more abrupt onset and runs a highly variable
course. Personally change is common in Alzheimer’s
disease. The duration of delirium is usually brief. The
inability to carry out motor activities is common
in Alzheimer’s disease.
88. Answer: (C) Drug intoxication. This client was taking
several medications that have a propensity for producing
delirium; digoxin (a digitalis glycoxide), furosemide (a
thiazide diuretic), and diazepam (a
benzodiazepine). Sufficient supporting data don’t exist to
suspect the other options as causes.
89. Answer: (D) The client is experiencing visual
hallucination. The presence of a sensory stimulus
correlates with the definition of a hallucination, which is a
false sensory perception. Aphasia refers to a
communication problem. Dysarthria is difficulty in
speech production. Flight of ideas is rapid shifting from one
topic to another.
90. Answer: (D) The client looks at the shadow on a wall and
tells the nurse she sees frightening faces on the wall. Minor
memory problems are distinguished from dementia
by their minor severity and their lack of significant
interference with the client’s social or occupational
lifestyle. Other options would be included in the history
data but don’t directly correlate with the client’s lifestyle.
91. Answer: (D) Loose association. Loose associations are
conversations that constantly shift in topic. Concrete
thinking implies highly definitive thought processes.
Flight of ideas is characterized by conversation that’s
disorganized from the onset. Loose associations don’t
necessarily start in a cogently, then becomes loose.
92. Answer: (C) Paranoid. Because of their suspiciousness,
paranoid personalities ascribe malevolent activities to
others and tent to be defensive, becoming quarrelsome and
argumentative. Clients with antisocial personality disorder
can also be antagonistic and argumentative but are
less suspicious than paranoid personalities. Clients with
histrionic personality disorder are dramatic, not suspicious
and argumentative. Clients with schizoid personality
disorder are usually detached from other and tend to have
eccentric behavior.
93. Answer: (C) Explain that the drug is less affective if the
client smokes. Olanzapine (Zyprexa) is less effective for
clients who smoke cigarettes. Serotonin syndrome occurs
with clients who take a combination of antidepressant
medications. Olanzapine doesn’t cause euphoria, and
extrapyramidal adverse reactions aren’t a
problem. However, the client should be aware of adverse
effects such as tardive dyskinesia.
94. Answer: (A) Lack of honesty. Clients with antisocial
personality disorder tent to engage in acts of dishonesty,
shown by lying. Clients with schizotypal
personality disorder tend to be superstitious. Clients with
histrionic personality disorders tend to overreact to
frustrations and disappointments, have temper tantrums,
and seek attention.
95. Answer: (A) “I’m not going to look just at the negative
things about myself”. As the clients makes progress on
improving self-esteem, selfblame and negative self
evaluation will decrease. Clients with
dependent personality disorder tend to feel fragile and
inadequate and would be extremely unlikely to discuss
their level of competence and progress. These clients focus
on self and aren’t envious or jealous. Individuals
with dependent personality disorders don’t take over
situations because they see themselves as inept and
inadequate.

96. Answer: (C) Assess for possible physical problems such as

rash. Clients with schizophrenia generally have poor
visceral recognition because they live so fully in their
fantasy world. They need to have as in-depth assessment of
physical complaints that may spill over into their
delusional symptoms. Talking with the client won’t provide
as assessment of his itching, and itching isn’t as adverse
reaction of antipsychotic drugs, calling the physician to get
the client’s medication increased doesn’t address his
physical complaints.

97. Answer: (B) Echopraxia. Echopraxia is the copying of

another’s behaviors and is the result of the loss of ego
boundaries. Modeling is the conscious copying
of someone’s behaviors. Ego-syntonicity refers to behaviors
that correspond with the individual’s sense of self.
Ritualism behaviors are repetitive and compulsive.

98. Answer: (C) Hallucination. Hallucinations are sensory

experiences that are misrepresentations of reality or have
no basis in reality. Delusions are beliefs not based in reality.
Disorganized speech is characterized by jumping from one
topic to the next or using unrelated words. An idea
of reference is a belief that an unrelated situation holds
special meaning for the client.

99. Answer: (C) Regression. Regression, a return to earlier

behavior to reduce anxiety, is the basic defense mechanism
in schizophrenia. Projection is a defense mechanism in
which one blames others and attempts to justify actions;
it’s used primarily by people with paranoid schizophrenia
and delusional disorder. Rationalization is a defense
mechanism used to justify one’s action. Repression is the
basic defense mechanism in the neuroses; it’s an
involuntary exclusion of painful thoughts, feelings, or
experiences from awareness.

100. Answer: (A) Should report feelings of restlessness or

agitation at once. Agitation and restlessness are adverse
effect of haloperidol and can be treated with
antocholinergic drugs. Haloperidol isn’t likely to cause
photosensitivity or control essential hypertension.
Although the client may experience increased
concentration and activity, these effects are due to a
decreased in symptoms, not the drug itself.

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