1. C. Check for any change in responsiveness every two hours until the follow- up visit.

Signs of an
epidural hematoma in children usually do not appear for 24 hours or more hours; a follow-up visit
usually is arranged for one to two days after the injury.

2. A. Arteriolar constriction occurs.The early compensation of shock is cardiovascular and is seen in

changes in pulse, BP, and pulse pressure; blood is shunted to vital centers, particularly heart and brain.

3. A. Allow the client to open canned or pre-packaged food. The client’s comfort, safety, and
nutritional status are the priorities; the client may feel comfortable to eat if the food has been sealed
before reaching the mental health facility.

4. D. “Joining a support group of parents who are coping with this problem can be quite helpful.
Taking with others in similar circumstances provides support and allows for sharing of experiences.

5. B. Observe the dressing at the back of the neck for the presence of blood. Drainage flows by
gravity.

6. C. Prepare her for a pelvic examination. Pelvic examination would reveal dilation and
effacement

7. D. On the right side of the heart. Pulmonic stenosis increases resistance to blood flow, causing
right ventricular hyperthropy; with right ventricular failure there is an increase in pressure on the right
side of the heart.

8. A. Eating patterns are altered. A new dietary regimen, with a balance of foods from the food
pyramid, must be established and continued for weight reduction to occur and be maintained.

9. B. “It is Ok to cry; I’ll just stay with you for now”. This portrays a nonjudgmental attitude that
recognizes the client’s needs.

10. C. Lactated Ringer’s solution. Lactated Ringer’s solution replaces lost sodium and corrects
metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy,
not primary fluid replacement. Dextrose isn’t given to burn patients during the first 24 hours because it
can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the intracellular
space to the plasma, so potassium would be detrimental.

11. C. Twitching and disorientation. Excess extracellular fluid moves into cells (water intoxication);
intracellular fluid excess in sensitive brain cells causes altered mental status; other signs include
anorexia nervosa, nausea, vomiting, twitching, sleepiness, and convulsions.

12. B. Resume the usual diet as soon as desired. As long as the client has no nausea or vomiting,
there are no dietary restriction.

13. B. Shrinkage of the residual limb must be completed. Shrinkage of the residual limb, resulting
from reduction of subcutaneous fat and interstitial fluid, must occur for an adequate fit between the
limb and the prosthesis.
14. A. Change the maternal position. Stimulation of the sympathetic nervous system is an initial
response to mild hypoxia that accompanies partial cord compression (umbilical vein) during
contractions; changing the maternal position can alleviate the compression.

15. A. Perform a finger stick to test the client’s blood glucose level. The client has signs of diabetes,
which may result from steroid therapy, testing the blood glucose level is a method of screening for
diabetes, thus gathering more data.

16. C. Heart block. This is the primary indication for a pacemaker because there is an interfere with
the electrical conduction system of the heart.

17. A. With meals and snacks. Pancreases capsules must be taken with food and snacks because it
acts on the nutrients and readies them for absorption.

18. B. Put a hat on the infant’s head. Oxygen has cooling effect, and the baby

should be kept warm so that metabolic activity and oxygen demands are not increased.

19. C. Wear an Ultra-Filter mask when they are in the client’s room. Tubercle bacilli are transmitted
through air currents; therefore personal protective equipment such as an Ultra-Filter mask is necessary.

20. D. Cerebral cortex compression. Cerebral compression affects pyramidal tracts, resulting in
decorticate rigidity and cranial nerve injury, which cause pupil dilation.

21. A.Mediastinal shift. Mediastinal structures move toward the uninjured lung, reducing
oxygenation and venous return.

22. C. Prevent situations that may stimulate the cervix or uterus. Stimulation of the cervix or uterus
may cause bleeding or hemorrhage and should be avoided.

23. C. Severe shortness of breath. This could indicate a recurrence of the pneumothorax as one side
of the lung is inadequate to meet the oxygen demands of the body.

24. A. Suction equipment. Respiratory complications can occur because of edema of the glottis or
injury to the recurrent laryngeal nerve.

25. A. Strong desire to improve her body image. Clients with anorexia nervosa have a disturbed self
image and always see themselves as fat and needing further reducing.

26. B. Attempting to reduce or limit situations that increase anxiety. Persons with high anxiety levels
develop various behaviors to relieve their anxiety; by reducing anxiety, the need for these obsessive-
compulsive action is reduced.

27. C. Becomes fussy when frustrated and displays a shortened attention span. Shortened attention
span and fussy behavior may indicate a change in intracranial pressure and/or shunt malfunction.

28. B. Maintaining the ordered hydration. Promoting hydration maintains urine production at a
higher rate, which flushes the bladder and prevents urinary stasis and possible infection.
29. C. Taking the client’s pedal pulse in the affected limb. Monitoring a pedal pulse will assess
circulation to the foot.

30. A. “Where are you?”. “Where are you?” is the best question to elicit information about the
client’s orientation to place because it encourages a response that can be assessed.

31. D. Bleeding from the venipuncture site. This indicates a fibrinogenemia; massive clotting in the
area of the separation has resulted in a lowered circulating fibrinogen.

32. D. blowing pattern. Clients should use a blowing pattern to overcome the premature urge to
push.

33. A. Cheeseburger and a malted. Of the selections offered, this is the highest in calories and
protein, which are needed for increased basal metabolic rate and for tissue repair.

34. B. Cyanotic lips and face. Central cyanosis (blue lips and face) indicates lowered oxygenation of
the blood, caused by either decreased lung expansion or right to left shunting of blood.

35. A. Notify the physician of the findings because the level is dangerously high. Levels close to 2
mEq/L are dangerously close to the toxic level; immediate action must be taken.

36. C. Days 15 to 17. Ovulation occurs approximately 14 days before the next menses, about the
16th day in 30 day cycle; the 15th to 17th days would be the

best time to avoid sexual intercourse.

37. C. Assure that informed consent has been obtained from the client. An invasive procedure such
as amniocentesis requires informed consent.

38. D. Prevent development of respiratory distress. Respiratory distress or arrest may occur when
the serum level of magnesium sulfate reaches 12 to 15 mg/dl; deep tendon reflexes disappear when the
serum level is 10 to 12 mg/dl; the drug is withheld in the absence of deep tendon reflexes; the
therapeutic serum level is 5 to 8 mg/dl.

39. A. Obtaining the child’s daily weight. Weight monitoring is the most useful means of assessing
fluid balance and changes in the edematous state; 1 liter of fluid weighs about 2.2 pounds.

40. C. Reduces the inflammatory response of tissues. Corticosteroids act to decrease inflammation
which decreases edema.

41. D. An audible click on hip manipulation. With specific manipulation, an audible click may be
heard of felt as he femoral head slips into the acetabulum.

42. B. Allow the denial but be available to discuss death. This does not remove client’s only way of
coping, and it permits future movement through the grieving process when the client is ready.

43. B. Divide food into four to six meals a day. The volume of food in the stomach should be kept
small to limit pressure on the cardiac sphincter.
44. B. “I feel washed out; there isn’t much left”. The client’s statement infers an emptiness with an
associated loss.

45. A. Vitamin K is not absorbed. Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract
in the absence of bile; bile enters the duodenum via the common bile duct.

46. D. Leg weakness with muscle cramps. Impulse conduction of skeletal muscle is impaired with
decreased potassium levels, muscular weakness and cramps may occur with hypokalemia.

47. D. Simian lines on the hands. This is characteristic finding in newborns with Down syndrome.

48. B. Eyes. Rheumatoid arthritis can cause inflammation of the iris and ciliary body of the eyes
which may lead to blindness.

49. A. Accept the client’s decision without discussion. This is all the nurse can do until trust is
established; facing the client to attend will disrupt the group.

50. D. Provide a simple explanation of the procedure and continue to reassure the client. The nurse
should offer support and use clear, simple terms to allay client’s anxiety.

51. D. If I have difficulty in inserting the irrigating tube into the stoma”. This occurs with stenosis of
the stoma; forcing insertion of the tube could cause injury.

52. C. Blood loss of 850 ml after a vaginal birth. Excessive blood loss predisposes the client to an
increased risk of infection because of decreased maternal resistance; they expected blood loss is 350 to
500 ml.

53. A. Provide frequent saline mouthwashes. This is soothing to the oral mucosa and helps prevent
infection.

54. B. “Society makes people react in old ways”. The client is incapable of accepting responsibility
for self-created problems and blames society for the behavior.

55. A. Taste and smell. Swelling can obstruct nasal breathing, interfering with

the senses of taste and smell.

56. A. Fatigue. Fatigue is a major problem caused by an increase in waste products because of
catabolic processes.

57. A. Offer the client assistance to the bathroom. Statistics indicate that the most frequent cause of
falls by hospitalized clients is getting up or attempting to get up to the bathroom unassisted.

58. D. Turn completely over, sit momentarily without support, reach to be picked up. These abilities
are age-appropriate for the 6 month old child.

59. D. Feed the baby on the unaffected breast first until the affected breast heals. The most
vigorous sucking will occur during the first few minutes of breastfeeding when the infant would be on
the unaffected breast; later suckling is less traumatic.
60. D. Place sterile cotton loosely in the external ear of the client. This would absorb the drainage
without causing further trauma.

61. D. Airing their feelings regarding the transmission of the disease to the child. Discussion with
parents who have children with similar problems helps to reduce some of their discomfort and guilt.

62. A. Suspicious feelings. The nurse must deal with these feelings and establish basic trust to
promote a therapeutic milieu.

63. A. Surgical menopause will occur. When a bilateral oophorectomy is performed, both ovaries
are excised, eliminating ovarian hormones and initiating response.

64. D. Pointing out to the client that death can occur with malnutrition. The client expects the nurse
to focus on eating, but the emphasis should be placed on feelings rather than actions.

65. B. Medication is not adequately effective. The expected effect should be more than a one point
decrease in the pain level.

66. B. Assisting the parents to stimulate their baby through touch, sound, and sight. Stimuli are
provided via all the senses; since the infant’s behavioral development is enhanced through parent-infant
interactions, these interactions should be encouraged.

67. D. Recognize himself as an independent person of worth. Academic deficits, an inability to

function within constraints required of certain settings, and negative peer attitudes often lead to low
self-esteem.

68. B. Monitoring the child’s blood pressure. Because the tumor is of renal origin, the rennin
angiotensin mechanism can be involved, and blood pressure monitoring is important.

69. A. Nursing unit manager. Controlled substance issues for a particular nursing unit are the
responsibility of that unit’s nurse manager.

70. D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side. All
these interventions promote aeration of the re-expanding lung and maintenance of function in the arm
and shoulder on the affected side.

71. A. For people to attain their birthrights of health and longevity. According to Winslow, all public
health efforts are for people to realize their birthrights of health and longevity.

72. C. Swaroop’s index. Swaroop’s index is the percentage of the deaths aged 50 years or older. Its
inverse represents the percentage of untimely deaths (those who died younger than 50 years).

73. D. Public health nursing focuses on preventive, not curative, services.. The catchment area in
PHN consists of a residential community, many of whom

are well individuals who have greater need for preventive rather than curative services.

74. B. Ensure the accessibility and quality of health care. Ensuring the accessibility and quality of
health care is the primary mission of DOH.
75. B. Efficiency. Efficiency is determining whether the goals were attained at the least possible cost.

76. 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.

77. A. Act 3573. Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929,
mandated the reporting of diseases listed in the law to the nearest health station.

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

79. B. It provides an opportunity to do first hand appraisal of the home situation. Choice A is not
correct since a home visit requires that the nurse spend so much time with the family. Choice C is an
advantage of a group conference, while choice D is true of a clinic consultation.

80. B. Should minimize if not totally prevent the spread of infection. Bag technique is performed
before and after handling a client in the home to prevent transmission of infection to and from the
client.

81. A. Recognizes staff for going beyond expectations by giving them citations. Path Goal theory
according to House and associates rewards good performance so that others would do the same.

82. D. Inspires others with vision. Inspires others with a vision is characteristic of a transformational
leader. He is focused more on the day-to-day operations of the department/unit.

83. A. Psychological and sociological needs are emphasized. When the functional method is used,
the psychological and sociological needs of the patients are neglected; the patients are regarded as
‘tasks to be done”

84. B. Preparing a nursing care plan in collaboration with the patient. The best source of information
about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on
his expressed priority needs would ensure meeting his needs effectively.

85. C. Unity of command. The principle of unity of command means that employees should receive
orders coming from only one manager and not from two managers. This averts the possibility of sowing
confusion among the members of the organization.

86. A. Increase the patient satisfaction rate. Goal is a desired result towards which efforts are
directed. Options AB, C and D are all objectives which are aimed at specific end.

87. A. Uses visioning as the essence of leadership. Transformational leadership relies heavily on
visioning as the core of leadership.

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

89. A. Staffing. Staffing is a management function involving putting the best people to accomplish
tasks and activities to attain the goals of the organization.

90. B. Decentralized. Decentralized structures allow the staff to make decisions

on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal
flow.

91. D. end each entry with the nurse’s signature and title. The end of each entry should include the
nurse’s signature and title; the signature holds the nurse accountable for the recorded information.
Erasing errors in documentation on a legal document such as a client’s chart isn’t permitted by law.
Because a client’s medical record is considered a legal document, the nurse should make all entries in
ink. The nurse is accountable for the information recorded and therefore shouldn’t leave any blank lines
in which another health care worker could make additions.

92. A. Allergies and socioeconomic status. General background data consist of such components as
allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine
output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is
present.

93. C. I.V. cannula insertion. Caregivers must use surgical asepsis when performing wound care or
any procedure in which a sterile body cavity is entered or skin integrity is broken. To achieve surgical
asepsis, objects must be rendered or kept free of all pathogens. Inserting an I.V. cannula requires
surgical asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a vein). The
other options are used to ensure medical asepsis or clean technique to prevent the spread of infection.
The GI tract isn’t sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean
technique.

94. B. Pouring solution onto a sterile field cloth. Pouring solution onto a sterile field cloth violates
surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via
capillary action. The other options are practices that help ensure surgical asepsis.

95. C. Impaired gas exchange. The client has a below-normal value for the partial pressure of arterial
oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2),
supporting the nursing diagnosis of Impaired gas exchange. ABG values can’t indicate a diagnosis of Fluid
volume deficit (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing,
diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.

96. A. Stream seeding. Stream seeding is done by putting tilapia fry in streams or other bodies of
water identified as breeding places of the Anopheles mosquito.

97. B. Severe dehydration. The order of priority in the management of severe dehydration is as
follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes,
Oresol/nasogastric tube, Oresol/orem. When the foregoing measures are not possible or effective, tehn
urgent referral to the hospital is done.

98. 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.

99. A. Sugar. R.A. 8976 mandates fortification of rice, wheat flour, sugar and cooking oil with
Vitamin A, iron and/or iodine.
100. A. Palms. The anatomic characteristics of the palms allow a reliable and convenient basis for
examination for pallor.