8/13/2019 Nursing Review Exam http://slidepdf.com/reader/full/nursing-review-exam 1/225 COMPREHENSIVE NURSING REVIEW by R. C. REÑA | 1 Fundamentals of Nursing Maternity Nursing Pediatric Nursing Community Health Nursing Medical Surgical Nursing Psychiatric Nursing Professional Adjustment Leadership and Management Nursing Research Compiled by: RO!R" C# R!$A 2009 THE EVER POPULAR LAST MINUTE TIPS FOR
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. 'e/els of p"e/ention by 'ea/ell and Cla" emembe" that %"isis is always se%onda"y
+ way bottle system: simply "e%onne%t the t$be& %ontin$o$s b$bble is a sign of leaage& no b$bbling is
obst"$%tion 3in the wate"seal4 and yo$ sho$ld palpate the s$""o$nding a"ea fo" s$b%$taneo$s emphysema
5 Ca"e of %lients with t"a%heostomy and s$%tioning a t"a%heostomy t$be 3ste"ile te%hni6$e4 now the
f$n%tions of the %$ff& obt$"ato" and the tie %a"e of %lients with pooling of se%"etions Post$"al d"ainage: dothis befo"e meals& the positioning depending on the lo%ation of se%"etion& POP,7ICO 3a""angement4 that is
positioning& pe"%$ssing& /ib"ating and %o$ghing et% st$dy s$%tioning
8 !he independent and the dependent /a"iable in "esea"%h
now yo$" PU, and #PP'I,) as well as ,;P,I<,*!#' and *O*=,;P,I<,*!#' also yo$"
>U#*!I!#!I7, and >U#'I!#!I7, designs
9 I7 fl$id toni%ity: )' is hype"toni% while ' is isotoni%
10 Compli%ation of I7 and its inte"/ention s$%h as F'UI) O7,'O#)& P?',@I!IS& I*FI'!#!IO*
SUPPO! by p$tting hands at the ba% of the ne% befo"e t"ying to mo/e the head
1. !$be"%$losis and 'ep"osy& its ea"ly G late sign and symptoms
1 #%$te and Ch"oni% "enal fail$"e Ca$ses 3PostGp"eGint"a4 and hemodialysis
15 #D*& he$mathoid and Ostea"th"itis& @ells Palsy and !"igeminal ne$"algia
18 St$dy "adiation and %hemothe"apy and thei" $s$al side effe%ts 3Sin b$"n& "edness& do not wet "adiation
ma"4 <ammog"aphy& @S,& !S,& ),& P"ostate and Colon %an%e"& Changes that o%%$"s d$"ing elde"ly&
@ladde"& Colon and Ce"/i%al %an%e" )iagnosti% e-aminationGC,#& P"o%tosigmoidos%opy& @iopsy& Pap smea"
1 'a"yngeal %an%e" and t"a%heostomy %a"e 3"efe" to o(ie" fo" t"a%heostomy %a"e4
NP5
1 In yo$" !est 7 st$dy the following: #n-iety and an-iety diso"de"s& !he le/el of an-iety and yo$"an-iolyti%s& S%hi(oph"enia: Pa"anoid type and Catatoni% type and yo$" n$"sing inte"/entions fo" these %lients
P"ess$"ed spee%h& !ho$ght blo%ing& Ho"d salad& pe"se/e"ation et% et% #lte"ation in pe"%eption and tho$ght
lie hall$%ination and del$sion !ypes of del$sions eg "eligio$s and pe"se%$to"y #%ti/ities and diet as well as
n$"sing diagnosis fo" a %lient with <ania& )ep"essed and #l(heime"KsG)ementia patient
. ,ating diso"de"s and the t"eatments of %hoi%e 3@eha/io" the"apy fo" #no"e-ia& Psy%hothe"apy fo" the
Pe"sonality )iso"de"s& Cogniti/e the"apy fo" dep"ession 4 #lways answe" LS!#A HI!? !?, C'I,*!Lespe%ially if the 6$estion is abo$t an-iety diso"de"s and pani% atta%s #lways %hoose an option that will
en%o$"age /e"bali(ation of feelings& ne/e" answe" an option with the wo"d H?A
St$dy yo$" %o$nte" t"ansfe"en%e and yo$" t"ansfe"en%e& Dla$%oma& Cata"a%t and %"$t%hG%ane waling !he
p"in%iples of body me%hani%s& %"anial ne"/e f$n%tioning and how to assess them as well as thei" dist$"ban%es
espe%ially @ells and !"igeminal *e$"algia <enie"es disease& )eli"$m& )ementia& C7#GSt"oe
desensiti(ation Cogniti/e the"apy is the PSAC?O!?,#PA of %hoi%e fo" dep"ession St$dy the"ape$ti%
milie$ = gene"al pt management& en/i"onmental manip$lation& $ses demo%"ati% leade"ship to test new patte"ns
of beha/io" Comm$nity meeting is the hea"t of milie$ the"apy Pha"ma%othe"apy: )"$g %lassifi%ation and
side effe%ts of #*!IPSAC?O!IC& #*;IO'A!ICS& #*!I<#*IC 3!eg"et"ol& 'ithi$m& )epaene4
8 !"ansfe" of %lients f"om @,) to C?#I as well as <O7I*D C'I,*! UP I* @,) 3,#) OJI,4
S$ppo"ting the %lient in: SUPI*, 3eg p"e/ent ne% hype"e-tension by p$tting pillow4& FOH',S
3p"e/ent poste"io" %$"/at$"e of the spine4& )OS#' ,CU<@,*! 3p"e/ent hype"e-tension of the nee4#*) SI),'AI*D position 3P"e/ent late"al fle-ion of the ste"no%leidomastoid4
9 ,6$ipments fo" immobility : !"o%hante" "ollGsandbags = p"e/ent e-te"nal "otation of the hips Pillow to
s$ppo"t ba%& head& a"ms and sho$lde"s Footboa"d to p"e/ent footd"op !"ape(e ba" to mo/e the %lient $p in
bed nee gat%h o" pillow = to slightly fle- the %lients nee
10 I*!O)UC, C?#*D, D#)U#''A = St$dy methods of implementing %hange s$%h as FOC,
1 #%%ept the fa%t that yo$ %an ne/e" now e/e"ything !he"efo"e& on%e yo$ see an $nfamilia" 6$estion that
was ne/e" been ta$ght& $se yo$" test taing st"ategies
2 If yo$ a"e in !est I& II& III& and I7 and yo$ a"e being ased to p"io"iti(e& Use #@C fi"st and then <aslows
?ie"a"%hy of needs
+ !he $se of yo$" n$"sing p"o%ess is he"alded by the wo"d: L!he *$"se Ho$ld o" !he n$"ses initial a%tionL
emembe" to #ssess fi"st befo"e inte"/ening If the sit$ation and the 6$estion al"eady assessed the patient&
then p"o%eed with the ne-t step
. ,n%i"%le yo$" modifie"s Some people mae mistaes be%a$se of fail$"e to see the wo"d& L,;C,P!L o"
L*O!L o" LI*#PPOPI#!,L& et% !he magi% wo"dsM
Use yo$" 6$estionnai"es as yo$" s%"at%h Ao$ %an w"ite anything on that pape" If yo$ will sip a n$mbe"&
pla%e an aste"is o" en%i"%le the n$mbe"
5 )O *O! US, @'U*! P,*CI' #lways $se a sha"p one and
shade lightly # sha"pened pen%il will gi/e a
/e"y da" shade e/en if yo$ will shade it lightly Use the sides of the pen%il not the tip Use <O*DO' *U<@, 2 O*'A Some b"ands espe%ially those made in %hina pen%ils a"e s$bstanda"d !he ma%hine will
%he% the lead If yo$ a"e I*CO*SIS!,*! with yo$" shading lie an alte"ing da" and light shades& yo$ will
F#I' the boa"ds be%a$se of te%hni%alities
Ca"e has been taen to %onfi"m the a%%$"a%y of the info"mation p"esented *e/e"theless& it is diffi%$lt to ens$"e that all theinfo"mation p"esented is enti"ely a%%$"ate fo" all %i"%$mstan%es& and the a$tho" %annot a%%ept any "esponsibility fo" any e""o" o"
omission !he a$tho" maes no wa""anty& e-p"essed o" implied& with "espe%t to this wo"& and dis%laims any liability& loss& o" damageas a %onse6$en%e& di"e%tly o" indi"e%tly& of the $se and appli%ation of any of the %ontents of this wo"
efe"en%es:
#dele Pillitte"i <#!,*#' N C?I') ?,#'!? *USI*D: Ca"e of the Childbea"ing N Child"ea"ing Family 200
PRAYERS TO ST. JOSEPH OF CUPERTINO FOR SUCCESS IN EXAMINATIONS
First Pra!r
O D"eat St Boseph of C$pe"tino who while on ea"th did obtain f"om Dod the
g"a%e to be ased at yo$" e-amination only the 6$estions yo$ new& obtain fo"me a lie fa/o$" in the e-aminations fo" whi%h I am now p"epa"ing In "et$"n I
p"omise to mae yo$ nown and %a$se yo$ to be in/oed
!h"o$gh Ch"ist o$" 'o"d
St Boseph of C$pe"tino& P"ay fo" $s
#men
S!"#$% Pra!r
O St Boseph of C$pe"tino who by yo$" p"aye" obtained f"om Dod to be ased atyo$" e-amination& the only p"eposition yo$ new D"ant that I may lie yo$
s$%%eed in the
*$"sing 'i%ens$"e ,-amination
In "et$"n& I p"omise to mae yo$ nown and %a$se yo$ to be in/oedO St Boseph of C$pe"tino p"ay fo" me
O ?oly Dhost enlighten me
O$" 'ady of Dood St$dies p"ay fo" me
Sa%"ed ?ead of Bes$s& Seat of di/ine wisdom& enlighten me
PRAYER TO SAINT JUDE THADDEUS, PATRON OF THE IMPOSSIBLE
<ost ?oly #postle St B$de& faithf$l se"/ant and f"iend of Bes$s& the %h$"%h hono"s and
in/oes yo$ $ni/e"sally as the pat"on of diffi%$lt %ases& of things almost despai"ed of&
p"ay fo" me I am so helpless and alone Inte"%ede to Dod fo" me that ?e b"ings /isible
and speedy help whe"e help is almost despai"ed of
Come to my assistan%e in this g"eat need that I may "e%ei/e the %onsolation and help of
hea/en in all my ne%essities& t"ib$lations and s$ffe"ings pa"ti%$la"ly he"e mae yo$"
"e6$est and that I may p"aise Dod with yo$ and all the saints fo"e/e"
I p"omise& O @lessed St B$de& to be e/e" mindf$l of this g"eat fa/o" g"anted to me byDod and to always hono" yo$ as my spe%ial and powe"f$l pat"on and to g"atef$lly
Options that do not %oin%ide with the g"ammati%al %onfig$"ation of the stem is *O! the %o""e%t answe"
Choi%es that a"e g"ammati%ally in%o""e%t o" %ontain typog"aphi%al e""o"s a"e p"obably not the %o""e%t answe"
,-ample: Hhen planning a %a"e fo" a %lient who is pan%ytopeni%& !he maEo" goal sho$ld be:
CP"e/ent hemo""hage& infe%tion and de%"ease o-ygenation
@ #dministe"ing an o"al i"on p"epa"ation
C P"e/enting Fatig$e and fl$id o/e"load) ,n%o$"aging a %ons$mption of a ne$t"openi% diet
VIII' PRINCIPLE OF UM)RELLA EFFECT
# %hoi%e that is mo"e in%l$si/e is $s$ally the %o""e%t answe"
,-ample: !o /iew a pe"son holisti%ally& the n$"se sho$ld thin of him o" he" as:
# Physi%al being who e-pe"ien%es pathology and so%iologi%al %hanges
@ So%ial being who needs the dynami%s of g"o$p inte"a%tion
C Psy%hologi%al being whose mind infl$en%es his o" he" health stat$s) @iopsy%hoso%ial being who is in %onstant inte"a%tion with the en/i"onment
IX' Pri$"i*+! # A)C, Mas+#-.s Hi!rar"/ a$% N0rsi$ Pr#"!ssHhen 6$estions "e6$i"e p"io"iti(ation& these p"in%iples sho$ld apply eywo"ds that indi%ate the need to p"io"iti(e
in%l$de:
@,S! 7I!#'
,SS,*!I#' PI<#A
FIS! ?ID?,S! PIOI!A
I<<,)I#!, I*I!I#'
<OS! I<PO!#*! *,;!
,-ample: # n$"se is "e/iewing the plan of %a"e fo" a p"egant %lient with a diagnosis of si%le %ell anemia Hhi%h
n$"sing diagnosis& if stated on the plan of %a"e& wo$ld the n$"se sele%t as "e%ei/ing the highest p"io"ityQ
##n-iety
@Ineffe%ti/e %opingC)ist$"bed body image
))efi%ient fl$id /ol$me
,-ample: Hhen %a"ing fo" #ida afte" a %hest s$"ge"y& yo$" p"io"ity wo$ld be to maintain:
# S$pplementa"y o-ygen
@ Chest t$be d"ainage
C @lood "epla%ement
) 7entilation e-%hange
X' Pri$"i*+! # T!++ M! M#r!
In Psy%hiat"i% *$"sing& emembe" to fo%$s on the %lientKs feeling& %on%e"ns& an-ieties and fea"s !his is best
s$mma"i(ed by a "esponse that en%o$"ages the %lientKs /e"bali(ation of feelings
,-ample: # mothe" says to the n$"se& I am af"aid that my %hild might ha/e anothe" sei($"eT Hhi%h "esponse by
the n$"se is most the"ape$ti%Q
# Hhy wo""y abo$t something yo$ %annot %ont"olQT
@ <ost %hild"en will ne/e" e-pe"ien%e a se%ond sei($"eT
C !ell me what f"ightens yo$ the most abo$t sei($"esT
d !he holisti% app"oa%h p"o/ides fo" a the"ape$ti% "elationship& %ontin$ity& and effi%ient n$"sing
%a"e
11 If n$"se administe"s an inEe%tion to a patient who "ef$ses that inEe%tion& she has %ommitted:
a #ssa$lt and batte"y
b *egligen%e
% <alp"a%ti%e
d *one of the abo/e
12 If patient ass the n$"se he" opinion abo$t a pa"ti%$la" physi%ians and the n$"se "eplies that the physi%ianis in%ompetent& the n$"se %o$ld be held liable fo":
a Slande"
b 'ibel
% #ssa$lt
d espondent s$pe"io"
1+ # "egiste"ed n$"se "ea%hes to answe" the telephone on a b$sy pediat"i% $nit& momenta"ily t$"ning away
f"om a + month=old infant she has been weighing !he infant falls off the s%ale& s$ffe"ing a s$ll f"a%t$"e
!he n$"se %o$ld be %ha"ged with:
a )efamation b #ssa$lt
% @atte"y
d <alp"a%ti%e1. Hhi%h of the following is an e-ample of n$"sing malp"a%ti%eQ
a !he n$"se administe"s peni%illin to a patient with a do%$mented histo"y of alle"gy to the d"$g !he
patient e-pe"ien%es an alle"gi% "ea%tion and has %e"eb"al damage "es$lting f"om ano-ia
b !he n$"se applies a hot wate" bottle o" a heating pad to the abdomen of a patient with abdominal
%"amping
% !he n$"se assists a patient o$t of bed with the bed lo%ed in positionW the patient slips and
f"a%t$"es his "ight h$me"$s
d !he n$"se administe"s the w"ong medi%ation to a patient and the patient /omits !his info"mation
is do%$mented and "epo"ted to the physi%ian and the n$"sing s$pe"/iso"
1 Hhi%h of the following signs and symptoms wo$ld the n$"se e-pe%t to find when assessing an #sian
patient fo" postope"ati/e pain following abdominal s$"ge"yQ
a )e%"eased blood p"ess$"e and hea"t "ate and shallow "espi"ations b >$iet %"ying
% Immobility& diapho"esis& and a/oidan%e of deep b"eathing o" %o$ghing
d Changing position e/e"y 2 ho$"s15 # patient is admitted to the hospital with %omplaints of na$sea& /omiting& dia""hea& and se/e"e abdominal
pain Hhi%h of the following wo$ld immediately ale"t the n$"se that the patient has bleeding f"om the DI
t"a%tQ
a Complete blood %o$nt
b D$aia% test
% 7ital signs
d #bdominal gi"th
18 !he %o""e%t se6$en%e fo" assessing the abdomen is:
a !ympani% pe"%$ssion& meas$"ement of abdominal gi"th& and inspe%tion
b #ssessment fo" distention& tende"ness& and dis%olo"ation a"o$nd the $mbili%$s
% Pe"%$ssions& palpation& and a$s%$ltation
d #$s%$ltation& pe"%$ssion& and palpation
1 ?igh=pit%hed g$"gles head o/e" the "ight lowe" 6$ad"ant a"e:
a # sign of in%"eased bowel motility
b # sign of de%"eased bowel motility
% *o"mal bowel so$nds
d # sign of abdominal %"amping
19 # patient abo$t to $nde"go abdominal inspe%tion is best pla%ed in whi%h of the following positionsQa P"one
b !"endelenb$"g
% S$pine
d Side=lying
20 Fo" a "e%tal e-amination& the patient %an be di"e%ted to ass$me whi%h of the following positionsQ
a Den$pe%te"ol
b Sims
% ?o"i(ontal "e%$mbent
d #ll of the abo/e
21 )$"ing a ombe"g test& the n$"se ass the patient to ass$me whi%h positionQ
22 If a patientKs blood p"ess$"e is 10G95& his p$lse p"ess$"e is:
a .
b 95
% 10
d 2.5
2+ # patient is ept off food and fl$ids fo" 10 ho$"s befo"e s$"ge"y ?is o"al tempe"at$"e at am is 99 F+88 C !his tempe"at$"e "eading p"obably indi%ates:
a Infe%tion
b ?ypothe"mia
% #n-iety
d )ehyd"ation
2. Hhi%h of the following pa"amete"s sho$ld be %he%ed when assessing "espi"ationsQ
a ate
b hythm
% Symmet"yd #ll of the abo/e
2 # +=yea" old patientKs /ital signs at am a"e a-illa"y tempe"at$"e 995 F +85 CW p$lse "ate& W
"espi"ato"y "ate& +0 Hhi%h findings sho$ld be "epo"tedQa espi"ato"y "ate only
b !empe"at$"e only
% P$lse "ate and tempe"at$"e
d !empe"at$"e and "espi"ato"y "ate
25 #ll of the following %an %a$se ta%hy%a"dia e-%ept:
a Fe/e"
b ,-e"%ise
% Sympatheti% ne"/o$s system stim$lation
d Pa"asympatheti% ne"/o$s system stim$lation
28 Palpating the mid%la/i%$la" line is the %o""e%t te%hni6$e fo" assessing
a @aseline /ital signs
b Systoli% blood p"ess$"e% espi"ato"y "ate
d #pi%al p$lse
2 !he absen%e of whi%h p$lse may not be a signifi%ant finding when a patient is admitted to the hospitalQa #pi%al
b adial
% Pedal
d Femo"al
29 Hhi%h of the following patients is at g"eatest "is fo" de/eloping p"ess$"e $l%e"sQ
a #n ale"t& %h"oni% a"th"iti% patient t"eated with ste"oids and aspi"in
b #n =yea" old in%ontinent patient with gast"i% %an%e" who is %onfined to his bed at home
+. Ce"tain s$bstan%es in%"ease the amo$nt of $"ine p"od$%ed !hese in%l$de:
a Caffeine=%ontaining d"ins& s$%h as %offee and %ola
b @eets
% U"ina"y analgesi%sd aolin with pe%tin aope%tate
+ # male patient who had s$"ge"y 2 days ago fo" head and ne% %an%e" is abo$t to mae his fi"st attempt to
amb$late o$tside his "oom !he n$"se notes that he is steady on his feet and that his /ision was $naffe%ted
by the s$"ge"y Hhi%h of the following n$"sing inte"/entions wo$ld be app"op"iateQ
a ,n%o$"age the patient to wal in the hall alone
b )is%o$"age the patient f"om waling in the hall fo" a few mo"e days
% #%%ompany the patient fo" his wal
d Cons$it a physi%al the"apist befo"e allowing the patient to amb$late
+5 # patient has e-a%e"bation of %h"oni% obst"$%ti/e p$lmona"y disease COP) manifested by sho"tness of b"eathW o"thopnea: thi%& tena%io$s se%"etionsW and a d"y ha%ing %o$gh #n app"op"iate n$"sing diagnosis
wo$ld be:
a Ineffe%ti/e ai"way %lea"an%e "elated to thi%& tena%io$s se%"etions b Ineffe%ti/e ai"way %lea"an%e "elated to d"y& ha%ing %o$gh
% Ineffe%ti/e indi/id$al %oping to COP)
d Pain "elated to immobili(ation of affe%ted leg
+8 <"s 'im begins to %"y as the n$"se dis%$sses hai" loss !he best "esponse wo$ld be:
a )onKt wo""y ItKs only tempo"a"yT
b Hhy a"e yo$ %"yingQ I didnKt get to the bad news yetT
% Ao$" hai" is "eally p"ettyT
d I now this will be diffi%$lt fo" yo$& b$t yo$" hai" will g"ow ba% afte" the %ompletion of
%hemothe"aphyT
+ #n additional 7itamin C is "e6$i"ed d$"ing all of the following pe"iods e-%ept:
a Infan%y
b Ao$ng ad$lthood% Childhood
d P"egnan%y
+9 # p"es%"ibed amo$nt of o-ygen s needed fo" a patient with COP) to p"e/ent:
a Ca"dia% a""est "elated to in%"eased pa"tial p"ess$"e of %a"bon dio-ide in a"te"ial blood PaCO2
b Ci"%$lato"y o/e"load d$e to hype"/olemia
% espi"ato"y e-%itement
d Inhibition of the "espi"ato"y hypo-i% stim$l$s
.0 #fte" 1 wee of hospitali(ation& <" D"ay de/elops hypoalemia Hhi%h of the following is the most
signifi%ant symptom of his diso"de"Q
a 'etha"gy b In%"eased p$lse "ate and blood p"ess$"e
% <$s%le weanessd <$s%le i""itability
.1 Hhi%h of the following n$"sing inte"/entions p"omotes patient safetyQ
a #sses the patientKs ability to amb$late and t"ansfe" f"om a bed to a %hai"
b )emonst"ate the signal system to the patient
% Che% to see that the patient is wea"ing his identifi%ation band
d #ll of the abo/e
.2 St$dies ha/e shown that abo$t .0V of patients fall o$t of bed despite the $se of side "ailsW this has led to
whi%h of the following %on%l$sionsQ
a Side "ails a"e ineffe%ti/e
b Side "ails sho$ld not be $sed
% Side "ails a"e a dete""ent that p"e/ent a patient f"om falling o$t of bed
d Side "ails a"e a "eminde" to a patient not to get o$t of bed
.+ ,-amples of patients s$ffe"ing f"om impai"ed awa"eness in%l$de all of the following e-%ept:
a # semi%ons%io$s o" o/e" fatig$ed patient
b # diso"iented o" %onf$sed patient
% # patient who %annot %a"e fo" himself at homed # patient demonst"ating symptoms of d"$gs o" al%ohol withd"awal
.. !he most %ommon inE$"y among elde"ly pe"sons is:
ANSERS a$% RATIONALES #r FUNDAMENTALS OF NURSING PART 2
1 ) ' Hhen a patient de/elops dyspnea and sho"tness of b"eath& the o"thopnei% position en%o$"ages
ma-im$m %hest e-pansion and eeps the abdominal o"gans f"om p"essing against the diaph"agm& th$simp"o/ing /entilation @ed "est and o-ygen by 7ent$"i mas at 2.V wo$ld imp"o/e o-ygenation of the
tiss$es and %ells b$t m$st be o"de"ed by a physi%ian #llowing fo" "est pe"iods de%"eases the possibility of
hypo-ia
2 C ' O"thopnea is diffi%$lty of b"eathing e-%ept in the $p"ight position !a%hypnea is "apid "espi"ation
%ha"a%te"i(ed by 6$i%& shallow b"eaths ,$pnea is no"mal "espi"ation X 6$iet& "hythmi%& and witho$teffo"t
+ C' # platelet %o$nt e/al$ates the n$mbe" of platelets in the %i"%$lating blood /ol$me !he n$"se is
"esponsible fo" gi/ing the patient b"eafast at the s%hed$led time !he physi%ian is "esponsible fo"
inst"$%ting the patient abo$t the test and fo" w"iting the o"de" fo" the test
. )' <ashed potatoes and b"oiled %hi%en a"e low in nat$"al sodi$m %hlo"ide ?am& oli/es& and %hi%en
bo$illon %ontain la"ge amo$nts of sodi$m and a"e %ont"aindi%ated on a low sodi$m diet
D' #ll of the identified n$"sing "esponsibilities a"e pe"tinent when a patient is "e%ei/ing hepa"in !heno"mal a%ti/ated pa"tial th"omboplastin time is 15 to 2 se%onds and the no"mal p"oth"ombin time is 12 to
1 se%ondsW these le/els m$st "emain within two to two and one half the no"mal le/els #ll patients
"e%ei/ing anti%oag$lant the"apy m$st be obse"/ed fo" signs and symptoms of f"an and o%%$lt bleeding
thi"st and %onf$sionW blood p"ess$"e sho$ld be meas$"ed e/e"y . ho$"s and the patient sho$ld be
inst"$%ted to "epo"t p"omptly any bleeding that o%%$"s with tooth b"$shing& bowel mo/ements& $"ination
o" hea/y p"olonged menst"$ation
5 D' !he fo%$s %on%epts that ha/e been a%%epted by all theo"ists as the fo%$s of n$"sing p"a%ti%e f"om the
time of Flo"en%e *ightingale in%l$de the pe"son "e%ei/ing n$"sing %a"e& his en/i"onment& his health on the
health illness %ontin$$m& and the n$"sing a%tions ne%essa"y to meet his needs
8 D' <aslow& who defined a need as a satisfa%tion whose absen%e %a$ses illness& %onside"ed o-ygen to be
the most impo"tant physiologi% needW witho$t it& h$man life %o$ld not e-ist #%%o"ding to this theo"y&othe" physiologi% needs in%l$ding food& wate"& elimination& shelte"& "est and sleep& a%ti/ity and
tempe"at$"e "eg$lation m$st be met befo"e p"o%eeding to the ne-t hie"a"%hi%al le/els on psy%hoso%ial
needs
)' !he b"ain=dead patientKs family needs s$ppo"t and "eass$"an%e in maing a de%ision abo$t o"gan
donation @e%a$se t"ansplants a"e done within ho$"s of death& de%isions abo$t o"gan donation m$st be
made as soon as possible ?owe/e"& the familyKs %on%e"ns m$st be add"essed befo"e membe"s a"e ased
to sign a %onsent fo"m !he body of an o"gan dono" is a/ailable fo" b$"ial
9 C' #ltho$gh a new head n$"se sho$ld initially spend time obse"/ing the $nit fo" its st"engths and
weaness& she sho$ld tae a%tion if a p"oblem th"eatens patient safety In this %ase& the s$pe"/iso" is the
"eso$"%e pe"son to app"oa%h
10 D' St$dies ha/e shown that patients and n$"ses both "espond well to p"ima"y n$"sing %a"e $nits Patients
feel less an-io$s and isolated and mo"e se%$"e be%a$se they a"e allowed to pa"ti%ipate in planning thei"
own %a"e *$"ses feel pe"sonal satisfa%tion& m$%h of it "elated to positi/e feedba% f"om the patients!hey also seem to gain a g"eate" sense of a%hie/ement and esp"it de %o"ps
11 A' #ssa$lt is the $nE$stifiable attempt o" th"eat to to$%h o" inE$"e anothe" pe"son @atte"y is the $nlawf$l
to$%hing of anothe" pe"son o" the %a""ying o$t of th"eatened physi%al ha"m !h$s& any a%t that a n$"se
pe"fo"ms on the patient against his will is %onside"ed assa$lt and batte"y
12 A' O"al %omm$ni%ation that inE$"es an indi/id$alKs "ep$tation is %onside"ed slande" H"itten
%omm$ni%ation that does the same is %onside"ed libel
1+ D' <alp"a%ti%e is defined as inE$"io$s o" $np"ofessional a%tions that ha"m anothe" It in/ol/es
p"ofessional mis%ond$%t& s$%h as omission o" %ommission of an a%t that a "easonable and p"$dent n$"se
wo$ld o" wo$ld not do In this e-ample& the standa"d of %a"e was b"ea%hedW a +=month=old infant sho$ld
ne/e" be left $nattended on a s%ale1. A' !he th"ee elements ne%essa"y to establish a n$"sing malp"a%ti%e a"e n$"sing e""o" administe"ing
peni%illin to a patient with a do%$mented alle"gy to the d"$g& inE$"y %e"eb"al damage& and p"o-imal
%a$se administe"ing the peni%illin %a$sed the %e"eb"al damage #pplying a hot wate" bottle o" heating
pad to a patient witho$t a physi%ianKs o"de" does not in%l$de the th"ee "e6$i"ed %omponents #ssisting a patient o$t of bed with the bed lo%ed in position is the %o""e%t n$"sing p"a%ti%eW the"efo"e& the f"a%t$"e
was not the "es$lt of malp"a%ti%e #dministe"ing an in%o""e%t medi%ation is a n$"sing e""o"W howe/e"& if
s$%h a%tion "es$lted in a se"io$s illness o" %h"oni% p"oblem& the n$"se %o$ld be s$ed fo" malp"a%ti%e
1 C' #n #sian patient is liely to hide his pain Conse6$ently& the n$"se m$st obse"/e fo" obEe%ti/e signs In
an abdominal s$"ge"y patient& these might in%l$de immobility& diapho"esis& and a/oidan%e of deep
b"eathing o" %o$ghing& as well as in%"eased hea"t "ate& shallow "espi"ations stemming f"om pain $pon
mo/ing the diaph"agm and "espi"ato"y m$s%les& and g$a"ding o" "igidity of the abdominal wall S$%h a
patient is $nliely to display emotion& s$%h as %"ying
15 )' !o assess fo" DI t"a%t bleeding when f"an blood is absent& the n$"se has two options: She %an test fo"
o%%$lt blood in /omit$s& if p"esent& o" in stool X th"o$gh g$aia% ?emo%%$lt test # %omplete blood %o$nt
does not p"o/ide immediate "es$lts and does not always immediately "efle%t blood loss Changes in /italsigns may be %a$se by fa%to"s othe" than blood loss #bdominal gi"th is $n"elated to blood loss
18 D' @e%a$se pe"%$ssion and palpation %an affe%t bowel motility and th$s bowel so$nds& they sho$ld followa$s%$ltation in abdominal assessment !ympani% pe"%$ssion& meas$"ement of abdominal gi"th& and
inspe%tion a"e methods of assessing the abdomen #ssessing fo" distention& tende"ness and dis%olo"ation
a"o$nd the $mbili%$s %an indi%ate /a"io$s bowel="elated %onditions& s$%h as %hole%ystitis& appendi%itis
and pe"itonitis
1 C' ?ype"a%ti/e so$nds indi%ate in%"eased bowel motilityW two o" th"ee so$nds pe" min$te indi%ate
de%"eased bowel motility #bdominal %"amping with hype"a%ti/e& high pit%hed tinling bowel so$nds %an
indi%ate a bowel obst"$%tion
19 C' !he s$pine position also %alled the do"sal position& in whi%h the patient lies on his ba% with his fa%e
$pwa"d& allows fo" easy a%%ess to the abdomen In the p"one position& the patient lies on his abdomen with
his fa%e t$"ned to the side In the !"endelenb$"g position& the head of the bed is tilted downwa"d to +0 to
.0 deg"ees so that the $ppe" body is lowe" than the legs In the late"al position& the patient lies on his side
20 D' #ll of these positions a"e app"op"iate fo" a "e%tal e-amination In the gen$pe%to"al nee=%hest position& the patient neels and "ests his %hest on the table& fo"ming a 90 deg"ee angle between the to"so
and $ppe" legs In SimsK position& the patient lies on his left side with the left a"m behind the body and his
"ight leg fle-ed In the ho"i(ontal "e%$mbent position& the patient lies on his ba% with legs e-tended and
hips "otated o$twa"d
21 )' )$"ing a ombe"g test& whi%h e/al$ates fo" senso"y o" %e"ebella" ata-ia& the patient m$st stand with
feet togethe" and a"ms "esting at the sidesYfi"st with eyes open& then with eyes %losed !he need to mo/e
the feet apa"t to maintain this stan%e is an abno"mal finding
22 A' !he p$lse p"ess$"e is the diffe"en%e between the systoli% and diastoli% blood p"ess$"e "eadings X in this
%ase& .
2+ D' # slightly ele/ated tempe"at$"e in the immediate p"eope"ati/e o" post ope"ati/e pe"iod may "es$lt f"om
the la% of fl$ids befo"e s$"ge"y "athe" than f"om infe%tion #n-iety will not %a$se an ele/ated
tempe"at$"e ?ypothe"mia is an abno"mally low body tempe"at$"e
2. D' !he 6$ality and effi%ien%y of the "espi"ato"y p"o%ess %an be dete"mined by app"aising the "ate& "hythm&
depth& ease& so$nd& and symmet"y of "espi"ations
2 D' Unde" no"mal %onditions& a healthy ad$lt b"eathes in a smooth $ninte""$pted patte"n 12 to 20 times a
min$te !h$s& a "espi"ato"y "ate of +0 wo$ld be abno"mal # no"mal ad$lt body tempe"at$"e& as meas$"ed
on an o"al the"momete"& "anges between 98R and 100RF +51R and +8RCW an a-illa"y tempe"at$"e is
app"o-imately one deg"ee lowe" and a "e%tal tempe"at$"e& one deg"ee highe" !h$s& an a-illa"y
tempe"at$"e of 995RF +85RC wo$ld be %onside"ed abno"mal !he "esting p$lse "ate in an ad$lt "anges
f"om 50 to 100 beatsGmin$te& so a "ate of is no"mal
25 D' Pa"asympatheti% ne"/o$s system stim$lation of the hea"t de%"eases the hea"t "ate as well as the fo"%e of
%ont"a%tion& "ate of imp$lse %ond$%tion and blood flow th"o$gh the %o"ona"y /essels Fe/e"& e-e"%ise& and
sympatheti% stim$lation all in%"ease the hea"t "ate
28 D' !he api%al p$lse the p$lse at the ape- of the hea"t is lo%ated on the mid%la/i%$la" line at the fo$"th&
fifth& o" si-th inte"%ostal spa%e @ase line /ital signs in%l$de p$lse "ate& tempe"at$"e& "espi"ato"y "ate& and
blood p"ess$"e @lood p"ess$"e is typi%ally assessed at the ante%$bital fossa& and "espi"ato"y "ate is
assessed best by obse"/ing %hest mo/ement with ea%h inspi"ation and e-pi"ation
2 C' @e%a$se the pedal p$lse %annot be dete%ted in 10V to 20V of the pop$lation& its absen%e is not
ne%essa"ily a signifi%ant finding ?owe/e"& the p"esen%e o" absen%e of the pedal p$lse sho$ld be
do%$mented $pon admission so that %hanges %an be identified d$"ing the hospital stay #bsen%e of the
api%al& "adial& o" femo"al p$lse is abno"mal and sho$ld be in/estigated
29 )' P"ess$"e $l%e"s a"e most liely to de/elop in patients with impai"ed mental stat$s& mobility& a%ti/ity
le/el& n$t"ition& %i"%$lation and bladde" o" bowel %ont"ol #ge is also a fa%to" !h$s& the =yea" old
in%ontinent patient who has impai"ed n$t"ition f"om gast"i% %an%e" and is %onfined to bed is at g"eate"
"is+0 A' #de6$ate hyd"ation thins and loosens p$lmona"y se%"etions and also helps to "epla%e fl$ids lost f"om
ele/ated tempe"at$"e& diapho"esis& dehyd"ation and dyspnea ?igh= h$midity ai" and %hest physiothe"apy
help li6$efy and mobili(e se%"etions
+1 A' Ch"oni% al%oholism %ommonly "es$lts in thiamine defi%ien%y and othe" symptoms of maln$t"ition
+2 C' # patient with dysphagia diffi%$lty swallowing "e6$i"es assistan%e with feeding Feeding himself is a
++ A' # $"ine o$tp$t of less than +0mlGho$" indi%ates hypo/olemia o" olig$"ia& whi%h is "elated to idney
f$n%tion and inade6$ate fl$id intae
+. A' Fl$ids %ontaining %affeine ha/e a di$"eti% effe%t @eets and $"ina"y analgesi%s& s$%h as py"idi$m& %an
%olo" $"ine "ed aope%tate is an anti dia""heal medi%ation
+ C' # hospitali(ed s$"gi%al patient lea/ing his "oom fo" the fi"st time fea"s "eEe%tion and othe"s sta"ing at
him& so he sho$ld not wal alone #%%ompanying him will offe" mo"al s$ppo"t& enabling him to fa%e the"est of the wo"ld Patients sho$ld begin amb$lation as soon as possible afte" s$"ge"y to de%"ease
%ompli%ations and to "egain st"ength and %onfiden%e Haiting to %ons$lt a physi%al the"apist is$nne%essa"y
+5 A' !hi%& tena%io$s se%"etions& a d"y& ha%ing %o$gh& o"thopnea& and sho"tness of b"eath a"e signs of
ineffe%ti/e ai"way %lea"an%e Ineffe%ti/e ai"way %lea"an%e "elated to d"y& ha%ing %o$gh is in%o""e%t
be%a$se the %o$gh is not the "eason fo" the ineffe%ti/e ai"way %lea"an%e Ineffe%ti/e indi/id$al %oping
"elated to COP) is w"ong be%a$se the etiology fo" a n$"sing diagnosis sho$ld not be a medi%al diagnosisCOP) and be%a$se no data indi%ate that the patient is %oping ineffe%ti/ely Pain "elated to
immobili(ation of affe%ted leg wo$ld be an app"op"iate n$"sing diagnosis fo" a patient with a leg f"a%t$"e
+8 D' I now this will be diffi%$ltT a%nowledges the p"oblem and s$ggests a "esol$tion to it )onKt
wo""yT offe"s some "elief b$t doesnKt "e%ogni(e the patientKs feelings I didnKt get to the bad news
yetT wo$ld be inapp"op"iate at any time Ao$" hai" is "eally p"ettyT offe"s no %onsolation o" alte"nati/es
to the patient
+ )' #dditional 7itamin C is needed in g"owth pe"iods& s$%h as infan%y and %hildhood& and d$"ing p"egnan%y to s$pply demands fo" fetal g"owth and mate"nal tiss$es Othe" %onditions "e6$i"ing e-t"a
/itamin C in%l$de wo$nd healing& fe/e"& infe%tion and st"ess
+9 D' )eli/e"y of mo"e than 2 lite"s of o-ygen pe" min$te to a patient with %h"oni% obst"$%ti/e p$lmona"y
disease COP)& who is $s$ally in a state of %ompensated "espi"ato"y a%idosis "etaining %a"bon dio-ide
CO2& %an inhibit the hypo-i% stim$l$s fo" "espi"ation #n in%"eased pa"tial p"ess$"e of %a"bon dio-ide
in a"te"ial blood P#CO2 wo$ld not initially "es$lt in %a"dia% a""est Ci"%$lato"y o/e"load and "espi"ato"y
e-%itement ha/e no "ele/an%e to the 6$estion
.0 C' P"esenting symptoms of hypoalemia a se"$m potassi$m le/el below + m,6Glite" in%l$de m$s%le
weaness& %h"oni% fatig$e& and %a"dia% dys"hythmias !he %ombined effe%ts of inade6$ate food intae and
p"olonged dia""hea %an deplete the potassi$m sto"es of a patient with DI p"oblems
.1 D' #ssisting a patient with amb$lation and t"ansfe" f"om a bed to a %hai" allows the n$"se to e/al$ate the
patientKs ability to %a""y o$t these f$n%tions safely )emonst"ating the signal system and p"o/iding an
oppo"t$nity fo" a "et$"n demonst"ation ens$"es that the patient nows how to ope"ate the e6$ipment and
en%o$"ages him to %all fo" assistan%e when needed Che%ing the patientKs identifi%ation band /e"ifies the patientKs identity and p"e/ents identifi%ation mistaes in d"$g administ"ation
.2 D' Sin%e abo$t .0V of patients fall o$t of bed despite the $se of side "ails& side "ails %annot be said to
p"e/ent fallsW howe/e"& they do se"/e as a "eminde" that the patient sho$ld not get o$t of bed !he othe"
answe"s a"e in%o""e%t inte"p"etations of the statisti%al data
.+ C' # patient who %annot %a"e fo" himself at home does not ne%essa"ily ha/e impai"ed awa"enessW he may
simply ha/e some deg"ee of immobility
.. D' ?ip f"a%t$"e& the most %ommon inE$"y among elde"ly pe"sons& $s$ally "es$lts f"om osteopo"osis !he
othe" answe"s a"e diseases that %an o%%$" in the elde"ly f"om physiologi% %hanges
. A' Sleep dist$"ban%es& inability to %on%ent"ate and de%"eased appetite a"e symptoms of dep"ession& themost %ommon psy%hogeni% diso"de" among elde"ly pe"sons Othe" symptoms in%l$de diminished
memo"y& apathy& disinte"est in appea"an%e& withd"awal& and i""itability )ep"ession typi%ally begins
befo"e the onset of old age and $s$ally is %a$sed by psy%hoso%ial& geneti%& o" bio%hemi%al fa%to"s
.5 D' #ging de%"eases elasti%ity of the blood /essels& whi%h leads to in%"eased pe"iphe"al "esistan%e and
de%"eased blood flow !hese %hanges& in t$"n& in%"ease the wo" load of the left /ent"i%le
.8 D' #l(heime"Ws disease& sometimes nown as senile dementia of the Alzheimer’s type or primary
degenerative dementia& is an insidio$sW p"og"essi/e& i""e/e"sible& and degene"ati/e disease of the b"ain
whose etiology is still $nnown Parkinson’s disease is a ne$"ologi% diso"de" %a$sed by lesions in the
e-t"apy"amidial system and manifested by t"emo"s& m$s%le "igidity& hypoinesis& dysphagia& and
dysphonia Multiple sclerosis, a p"og"essi/e& degene"ati/e disease in/ol/ing demyelination of the ne"/e
fibe"s& $s$ally begins in yo$ng ad$lthood and is ma"ed by pe"iods of "emission and e-a%e"bation
Amyotrophic lateral sclerosis& a disease ma"ed by p"og"essi/e degene"ation of the ne$"ons& e/ent$ally"es$lts in at"ophy of all the m$s%lesW in%l$ding those ne%essa"y fo" "espi"ation
. C' !he n$"se is legally "esponsible fo" labeling the %o"pse when death o%%$"s in the hospital She may be
in/ol/ed in obtaining %onsent fo" an a$topsy o" notifying the %o"one" o" medi%al e-amine" of a patientKs
deathW howe/e"& she is not legally "esponsible fo" pe"fo"ming these f$n%tions !he attending physi%ian
may need info"mation f"om the n$"se to %omplete the death %e"tifi%ate& b$t he is "esponsible fo" iss$ing it
.9 )' !he n$"se m$st pla%e a pillow $nde" the de%"eased pe"sonKs head and sho$lde"s to p"e/ent blood f"om
settling in the fa%e and dis%olo"ing it She is "e6$i"ed to bathe only soiled a"eas of the body sin%e the
ANSERS a$% RATIONALES #r FUNDAMENTALS OF NURSING PART 3
1 D In the %i"%$la" %hain of infe%tion& pathogens m$st be able to lea/e thei" "ese"/oi" and be t"ansmitted to
a s$s%eptible host th"o$gh a po"tal of ent"y& s$%h as b"oen sin
2 C espi"ato"y isolation& lie st"i%t isolation& "e6$i"es that the doo" to the doo" patientKs "oom "emain
%losed ?owe/e"& the patientKs "oom sho$ld be well /entilated& so opening the window o" t$"ning on the
/ent"i%$la" is desi"able !he n$"se does not need to wea" glo/es fo" "espi"ato"y isolation& b$t good hand
washing is impo"tant fo" all types of isolation+ A 'e$openia is a de%"eased n$mbe" of le$o%ytes white blood %ells& whi%h a"e impo"tant in "esisting
infe%tion *one of the othe" sit$ations wo$ld p$t the patient at "is fo" %ont"a%ting an infe%tionW taing
b"oad=spe%t"$m antibioti%s might a%t$ally "ed$%e the infe%tion "is
. A Soaps and dete"gents a"e $sed to help "emo/e ba%te"ia be%a$se of thei" ability to lowe" the s$"fa%e
tension of wate" and a%t as em$lsifying agents ?ot wate" may lead to sin i""itation o" b$"ns
A )epending on the deg"ee of e-pos$"e to pathogens& hand washing may last f"om 10 se%onds to .
min$tes #fte" "o$tine patient %onta%t& hand washing fo" +0 se%onds effe%ti/ely minimi(es the "is of
pathogen t"ansmission
5 ) !he $"ina"y system is no"mally f"ee of mi%"oo"ganisms e-%ept at the $"ina"y meat$s #ny p"o%ed$"e
that in/ol/es ente"ing this system m$st $se s$"gi%ally asepti% meas$"es to maintain a ba%te"ia=f"ee state
8 C #ll in/asi/e p"o%ed$"es& in%l$ding s$"ge"y& %athete" inse"tion& and administ"ation of pa"ente"al the"apy&
"e6$i"e ste"ile te%hni6$e to maintain a ste"ile en/i"onment #ll e6$ipment m$st be ste"ile& and the n$"seand the physi%ian m$st wea" ste"ile glo/es and maintain s$"gi%al asepsis In the ope"ating "oom& the n$"se
and physi%ian a"e "e6$i"ed to wea" ste"ile gowns& glo/es& mass& hai" %o/e"s& and shoe %o/e"s fo" all
in/asi/e p"o%ed$"es St"i%t isolation "e6$i"es the $se of %lean glo/es& mass& gowns and e6$ipment to
p"e/ent the t"ansmission of highly %omm$ni%able diseases by %onta%t o" by ai"bo"ne "o$tes !e"minal
disinfe%tion is the disinfe%tion of all %ontaminated s$pplies and e6$ipment afte" a patient has been
dis%ha"ged to p"epa"e them fo" "e$se by anothe" patient !he p$"pose of p"ote%ti/e "e/e"se isolation is to p"e/ent a pe"son with se"io$sly impai"ed "esistan%e f"om %oming into %onta%t who potentially pathogeni%
o"ganisms
C !he edges of a ste"ile field a"e %onside"ed %ontaminated Hhen ste"ile items a"e allowed to %ome in
%onta%t with the edges of the field& the ste"ile items also be%ome %ontaminated
9 ) ?ai" on o" within body a"eas& s$%h as the nose& t"aps and holds pa"ti%les that %ontain mi%"oo"ganisms
Aawning and hi%%$pping do not p"e/ent mi%"oo"ganisms f"om ente"ing o" lea/ing the body apid eyemo/ement ma"s the stage of sleep d$"ing whi%h d"eaming o%%$"s
10 D !he inside of the glo/e is always %onside"ed to be %lean& b$t not ste"ile
11 A !he ba% of the gown is %onside"ed %lean& the f"ont is %ontaminated So& afte" "emo/ing glo/es and
washing hands& the n$"se sho$ld $ntie the ba% of the gownW slowly mo/e ba%wa"d away f"om the gown&
holding the inside of the gown and eeping the edges off the floo"W t$"n and fold the gown inside o$tW
dis%a"d it in a %ontaminated linen %ontaine"W then wash he" hands again
12 ) #%%o"ding to the Cente"s fo" )isease Cont"ol C)C& blood=to=blood %onta%t o%%$"s most %ommonly
when a health %a"e wo"e" attempts to %ap a $sed needle !he"efo"e& $sed needles sho$ld ne/e" be
"e%appedW instead they sho$ld be inse"ted in a spe%ially designed p$n%t$"e "esistant& labeled %ontaine"
Hea"ing glo/es is not always ne%essa"y when administe"ing an I< inEe%tion ,nte"i% p"e%a$tions p"e/ent
the t"ansfe" of pathogens /ia fe%es
1+ A *$"ses and othe" health %a"e p"ofessionals p"e/io$sly belie/ed that massaging a "eddened a"ea with
lotion wo$ld p"omote /eno$s "et$"n and "ed$%e edema to the a"ea ?owe/e"& "esea"%h has shown that
massage only in%"eases the lielihood of %ell$la" is%hemia and ne%"osis to the a"ea
1. ) @efo"e a blood t"ansf$sion is pe"fo"med& the blood of the dono" and "e%ipient m$st be %he%ed fo"
%ompatibility !his is done by blood typing a test that dete"mines a pe"sonKs blood type and %"oss=
mat%hing a p"o%ed$"e that dete"mines the %ompatibility of the dono"Ks and "e%ipientKs blood afte" the
blood types has been mat%hed If the blood spe%imens a"e in%ompatible& hemolysis and antigen=antibody
1 A Platelets a"e dis=shaped %ells that a"e essential fo" blood %oag$lation # platelet %o$nt dete"mines the
n$mbe" of th"ombo%ytes in blood a/ailable fo" p"omoting hemostasis and assisting with blood
%oag$lation afte" inE$"y It also is $sed to e/al$ate the patientKs potential fo" bleedingW howe/e"& this is not
its p"ima"y p$"pose !he no"mal %o$nt "anges f"om 10&000 to +0&000Gmm + # %o$nt of 100&000Gmm+ o"
less indi%ates a potential fo" bleedingW %o$nt of less than 20&000Gmm + is asso%iated with spontaneo$s
bleeding
15 D 'e$o%ytosis is any t"ansient in%"ease in the n$mbe" of white blood %ells le$o%ytes in the blood
*o"mal H@C %o$nts "ange f"om &000 to 100&000Gmm+
!h$s& a %o$nt of 2&000Gmm+
indi%atesle$o%ytosis
18 A Fatig$e& m$s%le %"amping& and m$s%le weanesses a"e symptoms of hypoalemia an inade6$ate
potassi$m le/el& whi%h is a potential side effe%t of di$"eti% the"apy !he physi%ian $s$ally o"de"s
s$pplemental potassi$m to p"e/ent hypoalemia in patients "e%ei/ing di$"eti%s #no"e-ia is anothe"
symptom of hypoalemia )ysphagia means diffi%$lty swallowing
1 A P"egnan%y o" s$spe%ted p"egnan%y is the only %ont"aindi%ation fo" a %hest ;="ay ?owe/e"& if a %hest
;="ay is ne%essa"y& the patient %an wea" a lead ap"on to p"ote%t the pel/i% "egion f"om "adiation Bewel"y&
metalli% obEe%ts& and b$ttons wo$ld inte"fe"e with the ;="ay and th$s sho$ld not be wo"n abo/e the waist
# signed %onsent is not "e6$i"ed be%a$se a %hest ;="ay is not an in/asi/e e-amination ,ating& d"ining
and medi%ations a"e allowed be%a$se the ;="ay is of the %hest& not the abdominal "egion
19 A Obtaining a sp$t$m spe%imen ea"ly in this mo"ning ens$"es an ade6$ate s$pply of ba%te"ia fo"
%$lt$"ing and de%"eases the "is of %ontamination f"om food o" medi%ation20 A Initial sensiti/ity to peni%illin is %ommonly manifested by a sin "ash& e/en in indi/id$als who ha/e
not been alle"gi% to it p"e/io$sly @e%a$se of the dange" of anaphyla%ti% sho%& he n$"se sho$ld withhold
the d"$g and notify the physi%ian& who may %hoose to s$bstit$te anothe" d"$g #dministe"ing an
antihistamine is a dependent n$"sing inte"/ention that "e6$i"es a w"itten physi%ianKs o"de" #ltho$gh
applying %o"n sta"%h to the "ash may "elie/e dis%omfo"t& it is not the n$"seKs top p"io"ity in s$%h a
potentially life=th"eatening sit$ation
21 D !he J=t"a% method is an I< inEe%tion te%hni6$e in whi%h the patientKs sin is p$lled in s$%h a way
that the needle t"a% is sealed off afte" the inEe%tion !his p"o%ed$"e seals medi%ation deep into the
m$s%le& the"eby minimi(ing sin staining and i""itation $bbing the inEe%tion site is %ont"aindi%ated
be%a$se it may %a$se the medi%ation to e-t"a/asate into the sin
22 D !he /ast$s late"alis& a long& thi% m$s%le that e-tends the f$ll length of the thigh& is /iewed by many
%lini%ians as the site of %hoi%e fo" I< inEe%tions be%a$se it has "elati/ely few maEo" ne"/es and blood/essels !he middle thi"d of the m$s%le is "e%ommended as the inEe%tion site !he patient %an be in a
s$pine o" sitting position fo" an inEe%tion into this site
2+ A !he mid=deltoid inEe%tion site %an a%%ommodate only 1 ml o" less of medi%ation be%a$se of its si(e and
lo%ation on the deltoid m$s%le of the a"m& %lose to the b"a%hial a"te"y and "adial ne"/e
2. D # 2D& GT needle is the "e%ommended si(e fo" ins$lin inEe%tion be%a$se ins$lin is administe"ed by
the s$b%$taneo$s "o$te #n 1D& 1 [T needle is $s$ally $sed fo" I< inEe%tions in %hild"en& typi%ally in
the /ast$s late"alis # 22D& 1 [T needle is $s$ally $sed fo" ad$lt I< inEe%tions& whi%h a"e typi%ally
administe"ed in the /ast$s late"alis o" /ent"ogl$teal site
2 D @e%a$se an int"ade"mal inEe%tion does not penet"ate deeply into the sin& a small=bo"e 2D needle is
"e%ommended !his type of inEe%tion is $sed p"ima"ily to administe" antigens to e/al$ate "ea%tions fo"
alle"gy o" sensiti/ity st$dies # 20D needle is $s$ally $sed fo" I< inEe%tions of oil=based medi%ationsW a
22D needle fo" I< inEe%tionsW and a 2D needle& fo" I< inEe%tionsW and a 2D needle& fo" s$b%$taneo$s
ins$lin inEe%tions
25 A Pa"ente"al peni%illin %an be administe"ed I< o" added to a sol$tion and gi/en I7 It %annot be
administe"ed s$b%$taneo$sly o" int"ade"mally
28 D g" 10 - 50mgGg" 1 500 mg
2 C 100mlG50 min ; 1 gttG 1 ml 2 gttGmin$te
29 A ?emoglobin$"ia& the abno"mal p"esen%e of hemoglobin in the $"ine& indi%ates a hemolyti% "ea%tion
in%ompatibility of the dono"Ks and "e%ipientKs blood In this "ea%tion& antibodies in the "e%ipientKs plasma
%ombine "apidly with dono" @CKsW the %ells a"e hemoly(ed in eithe" %i"%$lato"y o" "eti%$loendothelial
system ?emolysis o%%$"s mo"e "apidly in #@O in%ompatibilities than in h in%ompatibilities Chest pain
and $"ti%a"ia may be symptoms of impending anaphyla-is )istended ne% /eins a"e an indi%ation of
hype"/olemia+0 C In "eal fail$"e& the idney loses thei" ability to effe%ti/ely eliminate wastes and fl$ids @e%a$se of this&
limiting the patientKs intae of o"al and I7 fl$ids may be ne%essa"y Fe/e"& %h"oni% obst"$%ti/e
p$lmona"y disease& and dehyd"ation a"e %onditions fo" whi%h fl$ids sho$ld be en%o$"aged
+1 D Phlebitis& the inflammation of a /ein& %an be %a$sed by %hemi%al i""itants I7 sol$tions o"
medi%ations& me%hani%al i""itants the needle o" %athete" $sed d$"ing /enip$n%t$"e o" %ann$lation& o" a
lo%ali(ed alle"gi% "ea%tion to the needle o" %athete" Signs and symptoms of phlebitis in%l$de pain o"
dis%omfo"t& edema and heat at the I7 inse"tion site& and a "ed st"ea going $p the a"m o" leg f"om theI7 inse"tion site
+2 D et$"n demonst"ation p"o/ides the most %e"tain e/iden%e fo" e/al$ating the effe%ti/eness of patient
tea%hing
++ D Caps$les& ente"i%=%oated tablets& and most e-tended d$"ation o" s$stained "elease p"od$%ts sho$ld not
be dissol/ed fo" $se in a gast"ostomy t$be !hey a"e pha"ma%e$ti%ally man$fa%t$"ed in these fo"ms fo"
/alid "easons& and alte"ing them dest"oys thei" p$"pose !he n$"se sho$ld see an alte"nate physi%ianKs
o"de" when an o"de"ed medi%ation is inapp"op"iate fo" deli/e"y by t$be
+. D # d"$g=alle"gy is an ad/e"se "ea%tion "es$lting f"om an imm$nologi% "esponse following a p"e/io$s
sensiti(ing e-pos$"e to the d"$g !he "ea%tion %an "ange f"om a "ash o" hi/es to anaphyla%ti% sho%Tolerance to a d"$g means that the patient e-pe"ien%es a de%"easing physiologi% "esponse to "epeated
administ"ation of the d"$g in the same dosage Idiosyncrasy is an indi/id$alKs $ni6$e hype"sensiti/ity to a
d"$g& food& o" othe" s$bstan%eW it appea"s to be geneti%ally dete"mined Synergism& is a d"$g inte"a%tion in
whi%h the s$m of the d"$gKs %ombined effe%ts is g"eate" than that of thei" sepa"ate effe%ts
+ D # hemoglobin and hemato%"it %o$nt wo$ld be o"de"ed by the physi%ian if bleeding we"e s$spe%ted
!he othe" answe"s a"e app"op"iate n$"sing inte"/entions fo" a patient who has $nde"gone femo"al
a"te"iog"aphy
+5 A Co$ghing& a p"ote%ti/e "esponse that %lea"s the "espi"ato"y t"a%t of i""itants& $s$ally is in/ol$nta"yW
howe/e" it %an be /ol$nta"y& as when a patient is ta$ght to pe"fo"m %o$ghing e-e"%ises #n antit$ssi/e
d"$g inhibits %o$ghing Splinting the abdomen s$ppo"ts the abdominal m$s%les when a patient %o$ghs
+8 C In an infe%ted patient& shi/e"ing "es$lts f"om the bodyKs attempt to in%"ease heat p"od$%tion and the
p"od$%tion of ne$t"ophils and phago%ytoti% a%tion th"o$gh in%"eased seletal m$s%le tension and%ont"a%tions Initial /aso%onst"i%tion may %a$se sin to feel %old to the to$%h #pplying additional bed
%lothes helps to e6$ali(e the body tempe"at$"e and stop the %hills #ttempts to %ool the body "es$lt in
f$"the" shi/e"ing& in%"eased metabloism& and th$s in%"eased heat p"od$%tion
+ D # %lini%al n$"se spe%ialist m$st ha/e %ompleted a maste"Ks deg"ee in a %lini%al spe%ialty and be a
"egiste"ed p"ofessional n$"se !he *ational 'eag$e of *$"sing a%%"edits ed$%ational p"og"ams in n$"sing
and p"o/ides a testing se"/i%e to e/al$ate st$dent n$"sing %ompeten%e b$t it does not %e"tify n$"ses !he
.+ D <aintaing the d"ainage t$bing and %olle%tion bag le/el with the patientKs bladde" %o$ld "es$lt in "efl$-
of $"ine into the idney I""igating the bladde" with *eospo"in and %lamping the %athete" fo" 1 ho$" e/e"y
. ho$"s m$st be p"es%"ibed by a physi%ian
.. D !he ,'IS# test of /eno$s blood is $sed to assess blood and potential blood dono"s to h$man
imm$nodefi%ien%y /i"$s ?I7 # positi/e ,'IS# test %ombined with /a"io$s signs and symptoms helpsto diagnose a%6$i"ed imm$nodefi%ien%y synd"ome #I)S
. D !a%hypnea an abno"mally "apid "ate of b"eathing wo$ld indi%ate that the patient was still hypo-i%
defi%ient in o-ygen!he pa"tial p"ess$"es of a"te"ial o-ygen and %a"bon dio-ide listed a"e within the
no"mal "ange ,$pnea "efe"s to no"mal "espi"ation
.5 D St$dies ha/e shown that showe"ing with an antisepti% soap befo"e s$"ge"y is the most effe%ti/e method
of "emo/ing mi%"oo"ganisms f"om the sin Sha/ing the site of the intended s$"ge"y might %a$se b"eas in
the sin& the"eby in%"easing the "is of infe%tionW howe/e"& if indi%ated& sha/ing& sho$ld be doneimmediately befo"e s$"ge"y& not the day befo"e # topi%al antisepti% wo$ld not "emo/e mi%"oo"ganisms
and wo$ld be benefi%ial only afte" p"ope" %leaning and "insing !$b bathing might t"ansfe" o"ganisms to
anothe" body site "athe" than "inse them away
.8 C !he leg m$s%les a"e the st"ongest m$s%les in the body and sho$ld bea" the g"eatest st"ess when lifting
<$s%les of the abdomen& ba%& and $ppe" a"ms may be easily inE$"ed
. C !he fa%to"s& nown as 7i"%howKs t"iad& %olle%ti/ely p"edispose a patient to th"omboplebitisW impai"ed
/eno$s "et$"n to the hea"t& blood hype"%oag$lability& and inE$"y to a blood /essel wall In%"eased pa"tialth"omboplastin time indi%ates a p"olonged bleeding time d$"ing fib"in %lot fo"mation& %ommonly the
21 )$"ing whi%h of the following stages of labo" wo$ld the n$"se assess %"owningTQ
a Fi"st stage
b Se%ond stage
% !hi"d stage
d Fo$"th stage
22 @a"bit$"ates a"e $s$ally not gi/en fo" pain "elief d$"ing a%ti/e labo" fo" whi%h of the following "easonsQ
a !he neonatal effe%ts in%l$de hypotonia& hypothe"mia& gene"ali(ed d"owsiness& and "el$%tan%e tofeed fo" the fi"st few days
b !hese d"$gs "eadily %"oss the pla%ental ba""ie"& %a$sing dep"essi/e effe%ts in the newbo"n 2 to +
ho$"s afte" int"am$s%$la" inEe%tion
% !hey "apidly t"ansfe" a%"oss the pla%enta& and la% of an antagonist mae them gene"ally
inapp"op"iate d$"ing labo"
d #d/e"se "ea%tions may in%l$de mate"nal hypotension& alle"gi% o" to-i% "ea%tion o" pa"tial o" total
"espi"ato"y fail$"e
2+ Hhi%h of the following n$"sing inte"/entions wo$ld the n$"se pe"fo"m d$"ing the thi"d stage of labo"Q
a Obtain a $"ine spe%imen and othe" labo"ato"y tests
b #ssess $te"ine %ont"a%tions e/e"y +0 min$tes
% Coa%h fo" effe%ti/e %lient p$shing
d P"omote pa"ent=newbo"n inte"a%tion2. Hhi%h of the following a%tions demonst"ates the n$"seKs $nde"standing abo$t the newbo"nKs
the"mo"eg$lato"y abilityQ
a Pla%ing the newbo"n $nde" a "adiant wa"me"
b S$%tioning with a b$lb sy"inge% Obtaining an #pga" s%o"e
d Inspe%ting the newbo"nKs $mbili%al %o"d
2 Immediately befo"e e-p$lsion& whi%h of the following %a"dinal mo/ements o%%$"Q
a )es%ent
b Fle-ion
% ,-tension
d ,-te"nal "otation
25 @efo"e bi"th& whi%h of the following st"$%t$"es %onne%ts the "ight and left a$"i%les of the hea"tQa Umbili%al /ein
b Fo"amen o/ale
% )$%t$s a"te"ios$s
d )$%t$s /enos$s
28 Hhi%h of the following when p"esent in the $"ine may %a$se a "eddish stain on the diape" of a newbo"nQ
a <$%$s
b U"i% a%id %"ystals
% @ili"$bin
d ,-%ess i"on
2 Hhen assessing the newbo"nKs hea"t "ate& whi%h of the following "anges wo$ld be %onside"ed no"mal ifthe newbo"n we"e sleepingQ
a 0 beats pe" min$te b 100 beats pe" min$te
% 120 beats pe" min$te
d 1.0 beats pe" min$te
29 Hhi%h of the following is t"$e "ega"ding the fontanels of the newbo"nQ
a !he ante"io" is t"iang$la" shapedW the poste"io" is diamond shaped
b !he poste"io" %loses at 1 monthsW the ante"io" %loses at to 12 wees
% !he ante"io" is la"ge in si(e when %ompa"ed to the poste"io" fontanel
d !he ante"io" is b$lgingW the poste"io" appea"s s$nen
+0 Hhi%h of the following g"o$ps of newbo"n "efle-es below a"e p"esent at bi"th and "emain $n%hanged
th"o$gh ad$lthoodQ
a @lin& %o$gh& "ooting& and gag
b @lin& %o$gh& snee(e& gag
% ooting& snee(e& swallowing& and %o$gh
d Stepping& blin& %o$gh& and snee(e
+1 Hhi%h of the following des%"ibes the @abinsi "efle-Q
a !he newbo"nKs toes will hype"e-tend and fan apa"t f"om do"sifle-ion of the big toe when one sideof foot is st"oed $pwa"d f"om the ball of the heel and a%"oss the ball of the foot
b !he newbo"n abd$%ts and fle-es all e-t"emities and may begin to %"y when e-posed to s$dden
mo/ement o" lo$d noise
% !he newbo"n t$"ns the head in the di"e%tion of stim$l$s& opens the mo$th& and begins to s$%
d !he newbo"n will attempt to %"awl fo"wa"d with both a"ms and legs when he is pla%ed on his
abdomen on a flat s$"fa%e
+2 Hhi%h of the following statements best des%"ibes hype"emesis g"a/ida"$mQ
a Se/e"e anemia leading to ele%t"olyte& metaboli%& and n$t"itional imbalan%es in the absen%e of
othe" medi%al p"oblems
b Se/e"e na$sea and /omiting leading to ele%t"olyte& metaboli%& and n$t"itional imbalan%es in the
absen%e of othe" medi%al p"oblems
% 'oss of appetite and %ontin$o$s /omiting that %ommonly "es$lts in dehyd"ation and $ltimatelyde%"easing mate"nal n$t"ients
d Se/e"e na$sea and dia""hea that %an %a$se gast"ointestinal i""itation and possibly inte"nal bleeding
++ Hhi%h of the following wo$ld the n$"se identify as a %lassi% sign of PI?Q
a ,dema of the feet and anles
b ,dema of the hands and fa%e
% Height gain of 1 lbGwee
d ,a"ly mo"ning heada%he
+. In whi%h of the following types of spontaneo$s abo"tions wo$ld the n$"se assess da" b"own /aginal
dis%ha"ge and a negati/e p"egnan%y testsQa !h"eatened
b Imminent
% <issedd In%omplete
+ Hhi%h of the following fa%to"s wo$ld the n$"se s$spe%t as p"edisposing a %lient to pla%enta p"e/iaQ
a <$ltiple gestation
b Ute"ine anomalies
% #bdominal t"a$ma
d enal o" /as%$la" disease
+5 Hhi%h of the following wo$ld the n$"se assess in a %lient e-pe"ien%ing ab"$ptio pla%entaQ
a @"ight "ed& painless /aginal bleeding
b Con%ealed o" e-te"nal da" "ed bleeding
% Palpable fetal o$tline
d Soft and nontende" abdomen
+8 Hhi%h of the following is des%"ibed as p"emat$"e sepa"ation of a no"mally implanted pla%enta d$"ing these%ond half of p"egnan%y& $s$ally with se/e"e hemo""hageQ
a Pla%enta p"e/ia
b ,%topi% p"egnan%y% In%ompetent %e"/i-
d #b"$ptio pla%entae
+ Hhi%h of the following may happen if the $te"$s be%omes o/e"stim$lated by o-yto%in d$"ing the
ind$%tion of labo"Q
a Hea %ont"a%tion p"olonged to mo"e than 80 se%onds
b !etani% %ont"a%tions p"olonged to mo"e than 90 se%onds
% In%"eased pain with b"ight "ed /aginal bleeding
d In%"eased "estlessness and an-iety
+9 Hhen p"epa"ing a %lient fo" %esa"ean deli/e"y& whi%h of the following ey %on%epts sho$ld be %onside"ed
when implementing n$"sing %a"eQ
a Inst"$%t the mothe"Ks s$ppo"t pe"son to "emain in the family lo$nge $ntil afte" the deli/e"y
b #""ange fo" a staff membe" of the anesthesia depa"tment to e-plain what to e-pe%t
postope"ati/ely
% <odify p"eope"ati/e tea%hing to meet the needs of eithe" a planned o" eme"gen%y %esa"ean bi"th
d ,-plain the s$"ge"y& e-pe%ted o$t%ome& and ind of anestheti%s
.0 Hhi%h of the following best des%"ibes p"ete"m labo"Q
a 'abo" that begins afte" 20 wees gestation and befo"e +8 wees gestation
b 'abo" that begins afte" 1 wees gestation and befo"e +8 wees gestation% 'abo" that begins afte" 2. wees gestation and befo"e 2 wees gestation
d 'abo" that begins afte" 2 wees gestation and befo"e .0 wees gestation
.1 Hhen PO< o%%$"s& whi%h of the following p"o/ides e/iden%e of the n$"seKs $nde"standing of the
%lientKs immediate needsQ
a !he %ho"ion and amnion "$pt$"e . ho$"s befo"e the onset of labo"
b PO< "emo/es the fet$s most effe%ti/e defense against infe%tion
% *$"sing %a"e is based on fetal /iability and gestational age
d PO< is asso%iated with malp"esentation and possibly in%ompetent %e"/i-
.2 Hhi%h of the following fa%to"s is the $nde"lying %a$se of dysto%iaQ
.+ Hhen $te"ine "$pt$"e o%%$"s& whi%h of the following wo$ld be the p"io"ityQ
a 'imiting hypo/olemi% sho%
b Obtaining blood spe%imens
% Instit$ting %omplete bed "est
d Inse"ting a $"ina"y %athete"
.. Hhi%h of the following is the n$"seKs initial a%tion when $mbili%al %o"d p"olapse o%%$"sQ
a @egin monito"ing mate"nal /ital signs and F? b Pla%e the %lient in a nee=%hest position in bed
% *otify the physi%ian and p"epa"e the %lient fo" deli/e"y
d #pply a ste"ile wa"m saline d"essing to the e-posed %o"d
. Hhi%h of the following amo$nts of blood loss following bi"th ma"s the %"ite"ion fo" des%"ibing
postpa"t$m hemo""hageQ
a <o"e than 200 ml
b <o"e than +00 ml
% <o"e than .00 ml
d <o"e than 00 ml.5 Hhi%h of the following is the p"ima"y p"edisposing fa%to" "elated to mastitisQ
a ,pidemi% infe%tion f"om noso%omial so$"%es lo%ali(ing in the la%tife"o$s glands and d$%ts
b ,ndemi% infe%tion o%%$""ing "andomly and lo%ali(ing in the pe"igland$la" %onne%ti/e tiss$e% !empo"a"y $"ina"y "etention d$e to de%"eased pe"%eption of the $"ge to a/oid
d @"east inE$"y %a$sed by o/e"distention& stasis& and %"a%ing of the nipples
.8 Hhi%h of the following best des%"ibes th"ombophlebitisQ
a Inflammation and %lot fo"mation that "es$lt when blood %omponents %ombine to fo"m an
agg"egate body
b Inflammation and blood %lots that e/ent$ally be%ome lodged within the p$lmona"y blood /essels
% Inflammation and blood %lots that e/ent$ally be%ome lodged within the femo"al /ein
d Inflammation of the /as%$la" endotheli$m with %lot fo"mation on the /essel wall
. Hhi%h of the following assessment findings wo$ld the n$"se e-pe%t if the %lient de/elops )7!Q
a <id%alf pain& tende"ness and "edness along the /ein
b Chills& fe/e"& malaise& o%%$""ing 2 wees afte" deli/e"y
% <$s%le pain the p"esen%e of ?omans sign& and swelling in the affe%ted limbd Chills& fe/e"& stiffness& and pain o%%$""ing 10 to 1. days afte" deli/e"y
.9 Hhi%h of the following a"e the most %ommonly assessed findings in %ystitisQ
a F"e6$en%y& $"gen%y& dehyd"ation& na$sea& %hills& and flan pain b *o%t$"ia& f"e6$en%y& $"gen%y dys$"ia& hemat$"ia& fe/e" and s$p"ap$bi% pain
% )ehyd"ation& hype"tension& dys$"ia& s$p"ap$bi% pain& %hills& and fe/e"
d ?igh fe/e"& %hills& flan pain na$sea& /omiting& dys$"ia& and f"e6$en%y
0 Hhi%h of the following best "efle%ts the f"e6$en%y of "epo"ted postpa"t$m bl$esTQ
a @etween 10V and .0V of all new mothe"s "epo"t some fo"m of postpa"t$m bl$es
b @etween +0V and 0V of all new mothe"s "epo"t some fo"m of postpa"t$m bl$es
% @etween 0V and 0V of all new mothe"s "epo"t some fo"m of postpa"t$m bl$es
d @etween 2V and 80V of all new mothe"s "epo"t some fo"m of postpa"t$m bl$es
1 Fo" the %lient who is $sing o"al %ont"a%epti/es& the n$"se info"ms the %lient abo$t the need to tae the pill
at the same time ea%h day to a%%omplish whi%h of the followingQ
a )e%"ease the in%iden%e of na$sea
b <aintain ho"monal le/els
% ed$%e side effe%ts
d P"e/ent d"$g inte"a%tions
2 Hhen tea%hing a %lient abo$t %ont"a%eption Hhi%h of the following wo$ld the n$"se in%l$de as the most
8 )$"ing a p"enatal %lass& the n$"se e-plains the "ationale fo" b"eathing te%hni6$es d$"ing p"epa"ation fo"
labo" based on the $nde"standing that b"eathing te%hni6$es a"e most impo"tant in a%hie/ing whi%h of the
followingQ
a ,liminate pain and gi/e the e-pe%tant pa"ents something to do
b ed$%e the "is of fetal dist"ess by in%"easing $te"opla%ental pe"f$sion% Fa%ilitate "ela-ation& possibly "ed$%ing the pe"%eption of pain
d ,liminate pain so that less analgesia and anesthesia a"e needed
#fte" . ho$"s of a%ti/e labo"& the n$"se notes that the %ont"a%tions of a p"imig"a/ida %lient a"e not st"ong
eno$gh to dilate the %e"/i- Hhi%h of the following wo$ld the n$"se anti%ipate doingQ
a Obtaining an o"de" to begin I7 o-yto%in inf$sion
b #dministe"ing a light sedati/e to allow the patient to "est fo" se/e"al ho$"
% P"epa"ing fo" a %esa"ean se%tion fo" fail$"e to p"og"ess
d In%"easing the en%o$"agement to the patient when p$shing begins
9 # m$ltig"a/ida at + weesK gestation is admitted with painless& b"ight "ed bleeding and mild %ont"a%tionse/e"y 8 to 10 min$tes Hhi%h of the following assessments sho$ld be a/oidedQ
a <ate"nal /ital sign
b Fetal hea"t "ate% Cont"a%tion monito"ing
d Ce"/i%al dilation
90 Hhi%h of the following wo$ld be the n$"seKs most app"op"iate "esponse to a %lient who ass why she
m$st ha/e a %esa"ean deli/e"y if she has a %omplete pla%enta p"e/iaQ
a Ao$ will ha/e to as yo$" physi%ian when he "et$"nsT
b Ao$ need a %esa"ean to p"e/ent hemo""hageT
% !he pla%enta is %o/e"ing most of yo$" %e"/i-T
d !he pla%enta is %o/e"ing the opening of the $te"$s and blo%ing yo$" babyT
91 !he n$"se $nde"stands that the fetal head is in whi%h of the following positions with a fa%e p"esentationQ
a Completely fle-ed
b Completely e-tended
% Pa"tially e-tendedd Pa"tially fle-ed
92 Hith a fet$s in the left=ante"io" b"ee%h p"esentation& the n$"se wo$ld e-pe%t the fetal hea"t "ate wo$ld be
most a$dible in whi%h of the following a"easQa #bo/e the mate"nal $mbili%$s and to the "ight of midline
b In the lowe"=left mate"nal abdominal 6$ad"ant
% In the lowe"="ight mate"nal abdominal 6$ad"ant
d #bo/e the mate"nal $mbili%$s and to the left of midline
9+ !he amnioti% fl$id of a %lient has a g"eenish tint !he n$"se inte"p"ets this to be the "es$lt of whi%h of the
followingQ
a 'an$go
b ?yd"amnio
% <e%oni$m
d 7e"ni-
9. # patient is in labo" and has E$st been told she has a b"ee%h p"esentation !he n$"se sho$ld be pa"ti%$la"ly
ale"t fo" whi%h of the followingQ
a >$i%ening
b Ophthalmia neonato"$m
% Pi%a
d P"olapsed $mbili%al %o"d
9 Hhen des%"ibing di(ygoti% twins to a %o$ple& on whi%h of the following wo$ld the n$"se base the
e-planationQa !wo o/a fe"tili(ed by sepa"ate spe"m
b Sha"ing of a %ommon pla%enta
% ,a%h o/a with the same genotype
d Sha"ing of a %ommon %ho"ion
95 Hhi%h of the following "efe"s to the single %ell that "ep"od$%es itself afte" %on%eptionQ
a Ch"omosome
b @lasto%yst
% Jygote
d !"ophoblast
98 In the late 190s& %ons$me"s and health %a"e p"ofessionals began %hallenging the "o$tine $se of analgesi%s
and anestheti%s d$"ing %hildbi"th Hhi%h of the following was an o$tg"owth of this %on%eptQ
9 # %lient has a midpel/i% %ont"a%t$"e f"om a p"e/io$s pel/i% inE$"y d$e to a moto" /ehi%le a%%ident as a
teenage" !he n$"se is awa"e that this %o$ld p"e/ent a fet$s f"om passing th"o$gh o" a"o$nd whi%h
st"$%t$"e d$"ing %hildbi"thQ
a Symphysis p$bis
b Sa%"al p"omonto"y% Is%hial spines
d P$bi% a"%h
99 Hhen tea%hing a g"o$p of adoles%ents abo$t /a"iations in the length of the menst"$al %y%le& the n$"se
$nde"stands that the $nde"lying me%hanism is d$e to /a"iations in whi%h of the following phasesQ
a <enst"$al phase
b P"olife"ati/e phase
% Se%"eto"y phase
d Is%hemi% phase
100 Hhen tea%hing a g"o$p of adoles%ents abo$t male ho"mone p"od$%tion& whi%h of the following wo$ldthe n$"se in%l$de as being p"od$%ed by the 'eydig %ellsQ
1+ C Hith b"east feeding& the fathe"Ks body is not %apable of p"o/iding the mil fo" the newbo"n& whi%h may
inte"fe"e with feeding the newbo"n& p"o/iding fewe" %han%es fo" bonding& o" he may be Eealo$s of the
infantKs demands on his wifeKs time and body @"east feeding is ad/antageo$s be%a$se $te"ine in/ol$tion
o%%$"s mo"e "apidly& th$s minimi(ing blood loss !he p"esen%e of mate"nal antibodies in b"east mil helps
de%"ease the in%iden%e of alle"gies in the newbo"n # g"eate" %han%e fo" e""o" is asso%iated with bottle
feeding *o p"epa"ation is "e6$i"ed fo" b"east feeding
1. A # false=positi/e "ea%tion %an o%%$" if the p"egnan%y test is pe"fo"med less than 10 days afte" an
abo"tion Pe"fo"ming the tests too ea"ly o" too late in the p"egnan%y& sto"ing the $"ine sample too long at"oom tempe"at$"e& o" ha/ing a spontaneo$s o" missed abo"tion impending %an all p"od$%e false=negati/e
"es$lts
1 D !he F? %an be a$s%$ltated with a fetos%ope at abo$t 20 weeKs gestation F? $s$ally is
a$s%$latated at the midline s$p"ap$bi% "egion with )opple" $lt"aso$nd t"ansd$%e" at 10 to 12 weeKs
gestation F?& %annot be hea"d any ea"lie" than 10 weesK gestation
15 C' !o dete"mine the ,)) when the date of the %lientKs '<P is nown $se *agele "$le !o the fi"st day of
the '<P& add 8 days& s$bt"a%t + months& and add 1 yea" if appli%able to a""i/e at the ,)) as follows:
8 12 B$ly min$s + . #p"il !he"efo"e& the %lientKs ,)) is #p"il 12
18 A' Hhen the '<P is $nnown& the gestational age of the fet$s is estimated by $te"ine si(e o" position
f$ndal height !he p"esen%e of the $te"$s in the pel/is indi%ates less than 12 weesK gestation #t
app"o-imately 12 to 1. wees& the f$nd$s is o$t of the pel/is abo/e the symphysis p$bis !he f$nd$s is at
the le/el of the $mbili%$s at app"o-imately 20 weesK gestation and "ea%hes the -iphoid at te"m o" .0wees
1 D )ange" signs that "e6$i"e p"ompt "epo"ting leaing of amnioti% fl$id& /aginal bleeding& bl$""ed /ision&
"apid weight gain& and ele/ated blood p"ess$"e Constipation& b"east tende"ness& and nasal st$ffiness a"e
%ommon dis%omfo"ts asso%iated with p"egnan%y
19 ) # "$bella tite" sho$ld be 1: o" g"eate" !h$"s& a finding of a tite" less than 1: is signifi%ant& indi%ating
that the %lient may not possess imm$nity to "$bella # hemato%"it of ++V a white blood %ell %o$nt of
&000Gmm+& and a 1 ho$" gl$%ose %hallenge test of 110 gGdl a"e with no"mal pa"amete"s
20 D Hith t"$e labo"& %ont"a%tions in%"ease in intensity with waling In addition& t"$e labo" %ont"a%tions
o%%$" at "eg$la" inte"/als& $s$ally sta"ting in the ba% and sweeping a"o$nd to the abdomen !he inte"/al
of t"$e labo" %ont"a%tions g"ad$ally sho"tens
21 ) C"owing& whi%h o%%$"s when the newbo"nKs head o" p"esenting pa"t appea"s at the /aginal opening&
o%%$"s d$"ing the se%ond stage of labo" )$"ing the fi"st stage of labo"& %e"/i%al dilation and effa%ement
o%%$" )$"ing the thi"d stage of labo"& the newbo"n and pla%enta a"e deli/e"ed !he fo$"th stage of labo"
lasts f"om 1 to . ho$"s afte" bi"th& d$"ing whi%h time the mothe" and newbo"n "e%o/e" f"om the physi%al p"o%ess of bi"th and the mothe"Ks o"gans $nde"go the initial "eadE$stment to the nonp"egnant state
22 C @a"bit$"ates a"e "apidly t"ansfe""ed a%"oss the pla%ental ba""ie"& and la% of an antagonist maes them
gene"ally inapp"op"iate d$"ing a%ti/e labo" *eonatal side effe%ts of ba"bit$"ates in%l$de %ent"al ne"/o$s
system dep"ession& p"olonged d"owsiness& delayed establishment of feeding eg d$e to poo" s$%ing
"efle- o" poo" s$%ing p"ess$"e !"an6$ili(e"s a"e asso%iated with neonatal effe%ts s$%h as hypotonia&
hypothe"mia& gene"ali(ed d"owsiness& and "el$%tan%e to feed fo" the fi"st few days *a"%oti% analgesi%
"eadily %"oss the pla%ental ba""ie"& %a$sing dep"essi/e effe%ts in the newbo"n 2 to + ho$"s afte"int"am$s%$la" inEe%tion egional anesthesia is asso%iated with ad/e"se "ea%tions s$%h as mate"nal
29 C !he ante"io" fontanel is la"ge" in si(e than the poste"io" fontanel #dditionally& the ante"io" fontanel&
whi%h is diamond shaped& %loses at 1 months& whe"eas the poste"io" fontanel& whi%h is t"iang$la" shaped&
%loses at to 12 wees *eithe" fontanel sho$ld appea" b$lging& whi%h may indi%ate in%"eased
int"a%"anial p"ess$"e& o" s$nen& whi%h may indi%ate dehyd"ation
+0 ) @lin& %o$gh& snee(e& swallowing and gag "efle-es a"e all p"esent at bi"th and "emain $n%hanged
th"o$gh ad$lthood efle-es s$%h as "ooting and stepping s$bside within the fi"st yea"
+1 A Hith the babinsi "efle-& the newbo"nKs toes hype"e-tend and fan apa"t f"om do"sifle-ion of the big toe
when one side of foot is st"oed $pwa"d fo"m the heel and a%"oss the ball of the foot Hith the sta"tle"efle-& the newbo"n abd$%ts and fle-es all e-t"emities and may begin to %"y when e-posed to s$dden
mo/ement of lo$d noise Hith the "ooting and s$%ing "efle-& the newbo"n t$"ns his head in the di"e%tion
of stim$l$s& opens the mo$th& and begins to s$% when the %hees& lip& o" %o"ne" of mo$th is to$%hed
Hith the %"awl "efle-& the newbo"n will attempt to %"awl fo"wa"d with both a"ms and legs when he is
pla%ed on his abdomen on a flat s$"fa%e
+2 ) !he des%"iption of hype"emesis g"a/ida"$m in%l$des se/e"e na$sea and /omiting& leading to
ele%t"olyte& metaboli%& and n$t"itional imbalan%es in the absen%e of othe" medi%al p"oblems ?ype"emesis
is not a fo"m of anemia 'oss of appetite may o%%$" se%onda"y to the na$sea and /omiting of
hype"emesis& whi%h& if it %ontin$es& %an deplete the n$t"ients t"anspo"ted to the fet$s )ia""hea does not
o%%$" with hype"emesis
++ )' ,dema of the hands and fa%e is a %lassi% sign of PI? <any healthy p"egnant woman e-pe"ien%e foot
and anle edema # weight gain of 2 lb o" mo"e pe" wee indi%ates a p"oblem ,a"ly mo"ning heada%he isnot a %lassi% sign of PI?
+. C' In a missed abo"tion& the"e is ea"ly fetal int"a$te"ine death& and p"od$%ts of %on%eption a"e not
e-pelled !he %e"/i- "emains %losedW the"e may be a da" b"own /aginal dis%ha"ge& negati/e p"egnan%y
test& and %essation of $te"ine g"owth and b"east tende"ness # th"eatened abo"tion is e/iden%ed with
%"amping and /aginal bleeding in ea"ly p"egnan%y& with no %e"/i%al dilation #n in%omplete abo"tion
p"esents with bleeding& %"amping& and %e"/i%al dilation #n in%omplete abo"tion in/ol/es only e-p$lsion
of pa"t of the p"od$%ts of %on%eption and bleeding o%%$"s with %e"/i%al dilation
+ A' <$ltiple gestation is one of the p"edisposing fa%to"s that may %a$se pla%enta p"e/ia Ute"ine anomalies
abdominal t"a$ma& and "enal o" /as%$la" disease may p"edispose a %lient to ab"$ptio pla%entae
+5 )' # %lient with ab"$ptio pla%entae may e-hibit %on%ealed o" da" "ed bleeding& possibly "epo"ting s$dden
intense lo%ali(ed $te"ine pain !he $te"$s is typi%ally fi"m to boa"dlie& and the fetal p"esenting pa"t may
be engaged @"ight "ed& painless /aginal bleeding& a palpable fetal o$tline and a soft nontende" abdomena"e manifestations of pla%enta p"e/ia
+8 D' #b"$ptio pla%entae is des%"ibed as p"emat$"e sepa"ation of a no"mally implanted pla%enta d$"ing the
se%ond half of p"egnan%y& $s$ally with se/e"e hemo""hage Pla%enta p"e/ia "efe"s to implantation of the
pla%enta in the lowe" $te"ine segment& %a$sing painless bleeding in the thi"d t"imeste" of p"egnan%y
,%topi% p"egnan%y "efe"s to the implantation of the p"od$%ts of %on%eption in a site othe" than the
endomet"i$m In%ompetent %e"/i- is a %ond$%tion %ha"a%te"i(ed by painf$l dilation of the %e"/i%al os
witho$t $te"ine %ont"a%tions
+ )' ?ype"stim$lation of the $te"$s s$%h as with o-yto%in d$"ing the ind$%tion of labo" may "es$lt in tetani%
%ont"a%tions p"olonged to mo"e than 90se%onds& whi%h %o$ld lead to s$%h %ompli%ations as fetal dist"ess&ab"$ptio pla%entae& amnioti% fl$id embolism& la%e"ation of the %e"/i-& and $te"ine "$pt$"e Hea
%ont"a%tions wo$ld not o%%$" Pain& b"ight "ed /aginal bleeding& and in%"eased "estlessness and an-iety a"e
not asso%iated with hype"stim$lation
+9 C' # ey point to %onside" when p"epa"ing the %lient fo" a %esa"ean deli/e"y is to modify the p"eope"ati/e
tea%hing to meet the needs of eithe" a planned o" eme"gen%y %esa"ean bi"th& the depth and b"eadth of
inst"$%tion will depend on %i"%$mstan%es and time a/ailable #llowing the mothe"Ks s$ppo"t pe"son to
"emain with he" as m$%h as possible is an impo"tant %on%ept& altho$gh doing so depends on many
/a"iables #""anging fo" ne%essa"y e-planations by /a"io$s staff membe"s to be in/ol/ed with the %lientKs
%a"e is a n$"sing "esponsibility !he n$"se is "esponsible fo" "einfo"%ing the e-planations abo$t the
s$"ge"y& e-pe%ted o$t%ome& and type of anestheti% to be $sed !he obstet"i%ian is "esponsible fo"
e-plaining abo$t the s$"ge"y and o$t%ome and the anesthesiology staff is "esponsible fo" e-planationsabo$t the type of anesthesia to be $sed
.0 A' P"ete"m labo" is best des%"ibed as labo" that begins afte" 20 weesK gestation and befo"e +8 weesK
gestation !he othe" time pe"iods a"e ina%%$"ate
.1 )' PO< %an p"e%ipitate many potential and a%t$al p"oblemsW one of the most se"io$s is the fet$s loss of
an effe%ti/e defense against infe%tion !his is the %lientKs most immediate need at this time !ypi%ally&
PO< o%%$"s abo$t 1 ho$"& not . ho$"s& befo"e labo" begins Fetal /iability and gestational age a"e less
immediate %onside"ations that affe%t the plan of %a"e <alp"esentation and an in%ompetent %e"/i- may be
%a$ses of PO<
.2 )' )ysto%ia is diffi%$lt& painf$l& p"olonged labo" d$e to me%hani%al fa%to"s in/ol/ing the fet$s
.+ A' Hith $te"ine "$pt$"e& the %lient is at "is fo" hypo/olemi% sho% !he"efo"e& the p"io"ity is to p"e/ent
and limit hypo/olemi% sho% Immediate steps sho$ld in%l$de gi/ing o-ygen& "epla%ing lost fl$ids&
p"o/iding d"$g the"apy as needed& e/al$ating fetal "esponses and p"epa"ing fo" s$"ge"y Obtaining blood
spe%imens& instit$ting %omplete bed "est& and inse"ting a $"ina"y %athete" a"e ne%essa"y in p"epa"ation fo"
s$"ge"y to "emedy the "$pt$"e
.. )' !he immediate p"io"ity is to minimi(e p"ess$"e on the %o"d !h$s the n$"seKs initial a%tion in/ol/es
pla%ing the %lient on bed "est and then pla%ing the %lient in a nee=%hest position o" lowe"ing the head of
the bed& and ele/ating the mate"nal hips on a pillow to minimi(e the p"ess$"e on the %o"d <onito"ingmate"nal /ital signs and F?& notifying the physi%ian and p"epa"ing the %lient fo" deli/e"y& and w"apping
the %o"d with ste"ile saline soaed wa"m ga$(e a"e impo"tant @$t these a%tions ha/e no effe%t on
minimi(ing the p"ess$"e on the %o"d
. D' Postpa"t$m hemo""hage is defined as blood loss of mo"e than 00 ml following bi"th #ny amo$nt less
than this not %onside"ed postpa"t$m hemo""hage
.5 D' Hith mastitis& inE$"y to the b"east& s$%h as o/e"distention& stasis& and %"a%ing of the nipples& is the
p"ima"y p"edisposing fa%to" ,pidemi% and endemi% infe%tions a"e p"obable so$"%es of infe%tion fo"
mastitis !empo"a"y $"ina"y "etention d$e to de%"eased pe"%eption of the $"ge to /oid is a %ont"ib$to"y
fa%to" to the de/elopment of $"ina"y t"a%t infe%tion& not mastitis
.8 D' !h"ombophlebitis "efe"s to an inflammation of the /as%$la" endotheli$m with %lot fo"mation on the
wall of the /essel @lood %omponents %ombining to fo"m an agg"egate body des%"ibe a th"omb$s o"
th"ombosis Clots lodging in the p$lmona"y /as%$lat$"e "efe"s to p$lmona"y embolismW in the femo"al/ein& femo"al th"ombophlebitis
. C' Classi% symptoms of )7! in%l$de m$s%le pain& the p"esen%e of ?omans sign& and swelling of the
affe%ted limb <id%alf pain& tende"ness& and "edness& along the /ein "efle%t s$pe"fi%ial th"ombophlebitis
stiffness and pain o%%$""ing 10 to 1. days afte" deli/e"y s$ggest femo"al th"ombophlebitis
.9 )' <anifestations of %ystitis in%l$de& f"e6$en%y& $"gen%y& dys$"ia& hemat$"ia no%t$"ia& fe/e"& and
s$p"ap$bi% pain )ehyd"ation& hype"tension& and %hills a"e not typi%ally asso%iated with %ystitis ?igh
fe/e" %hills& flan pain& na$sea& /omiting& dys$"ia& and f"e6$en%y a"e asso%iated with p/eloneph"itis
0 C' #%%o"ding to statisti%al "epo"ts& between 0V and 0V of all new mothe"s "epo"t some fo"m of
postpa"t$m bl$es !he "anges of 10V to .0V& +0V to 0V& and 2V to 80V a"e in%o""e%t
1 ) eg$la" timely ingestion of o"al %ont"a%epti/es is ne%essa"y to maintain ho"monal le/els of the d"$gs to
s$pp"ess the a%tion of the hypothalam$s and ante"io" pit$ita"y leading to inapp"op"iate se%"etion of FS?
and '? !he"efo"e& folli%les do not mat$"e& o/$lation is inhibited& and p"egnan%y is p"e/ented !he
est"ogen %ontent of the o"al site %ont"a%epti/e may %a$se the na$sea& "ega"dless of when the pill is taenSide effe%ts and d"$g inte"a%tions may o%%$" with o"al %ont"a%epti/es "ega"dless of the time the pill is
taen
2 C Condoms& when $sed %o""e%tly and %onsistently& a"e the most effe%ti/e %ont"a%epti/e method o" ba""ie"
against ba%te"ial and /i"al se-$ally t"ansmitted infe%tions #ltho$gh spe"mi%ides ill spe"m& they do not
p"o/ide "eliable p"ote%tion against the sp"ead of se-$ally t"ansmitted infe%tions& espe%ially int"a%ell$la"
o"ganisms s$%h as ?I7 Inse"tion and "emo/al of the diaph"agm along with the $se of the spe"mi%ides
may %a$se /aginal i""itations& whi%h %o$ld pla%e the %lient at "is fo" infe%tion t"ansmission <aleste"ili(ation eliminates spe"mato(oa f"om the eEa%$late& b$t it does not eliminate ba%te"ial andGo" /i"al
mi%"oo"ganisms that %an %a$se se-$ally t"ansmitted infe%tions
+ A !he diaph"agm m$st be fitted indi/id$ally to ens$"e effe%ti/eness @e%a$se of the %hanges to the
"ep"od$%ti/e st"$%t$"es d$"ing p"egnan%y and following deli/e"y& the diaph"agm m$st be "efitted& $s$ally
at the 5 weesK e-amination following %hildbi"th o" afte" a weight loss of 1 lbs o" mo"e In addition& fo"
ma-im$m effe%ti/eness& spe"mi%idal Eelly sho$ld be pla%ed in the dome and a"o$nd the "im ?owe/e"&
spe"mi%idal Eelly sho$ld not be inse"ted into the /agina $ntil in/ol$tion is %ompleted at app"o-imately 5
wees Use of a female %ondom p"ote%ts the "ep"od$%ti/e system f"om the int"od$%tion of semen o"
spe"mi%ides into the /agina and may be $sed afte" %hildbi"th O"al %ont"a%epti/es may be sta"ted within
the fi"st postpa"t$m wee to ens$"e s$pp"ession of o/$lation Fo" the %o$ple who has dete"mined the
femaleKs fe"tile pe"iod& $sing the "hythm method& a/oidan%e of inte"%o$"se d$"ing this pe"iod& is safe andeffe%ti/e
. C #n IU) may in%"ease the "is of pel/i% inflammato"y disease& espe%ially in women with mo"e than one
se-$al pa"tne"& be%a$se of the in%"eased "is of se-$ally t"ansmitted infe%tions #n UI) sho$ld not be
$sed if the woman has an a%ti/e o" %h"oni% pel/i% infe%tion& postpa"t$m infe%tion& endomet"ial
hype"plasia o" %a"%inoma& o" $te"ine abno"malities #ge is not a fa%to" in dete"mining the "iss asso%iated
with IU) $se <ost IU) $se"s a"e o/e" the age of +0 #ltho$gh the"e is a slightly highe" "is fo"
infe"tility in women who ha/e ne/e" been p"egnant& the IU) is an a%%eptable option as long as the "is= benefit "atio is dis%$ssed IU)s may be inse"ted immediately afte" deli/e"y& b$t this is not "e%ommended
be%a$se of the in%"eased "is and "ate of e-p$lsion at this time
C )$"ing the thi"d t"imeste"& the enla"ging $te"$s pla%es p"ess$"e on the intestines !his %o$pled with the
effe%t of ho"mones on smooth m$s%le "ela-ation %a$ses de%"eased intestinal motility pe"istalsis
In%"easing fibe" in the diet will help fe%al matte" pass mo"e 6$i%ly th"o$gh the intestinal t"a%t& th$s
fo" feeding *a"%oti%s administe"ed p"io" to b"east feeding a"e passed th"o$gh the b"east mil to the
infant& %a$sing e-%essi/e sleepiness *ipple so"eness is not se/e"e eno$gh to wa""ant na"%oti% analgesia
#ll postpa"t$m %lients& espe%ially la%tating mothe"s& sho$ld wea" a s$ppo"ti/e b"assie"e with wide %otton
st"aps !his does not& howe/e"& p"e/ent o" "ed$%e nipple so"eness Soaps a"e d"ying to the sin of the
nipples and sho$ld not be $sed on the b"easts of la%tating mothe"s )"y nipple sin p"edisposes to %"a%s
and fiss$"es& whi%h %an be%ome so"e and painf$l
55 D' # wea& th"eady p$lse ele/ated to 100 @P< may indi%ate impending hemo""hagi% sho% #n in%"eased
p$lse is a %ompensato"y me%hanism of the body in "esponse to de%"eased fl$id /ol$me !h$s& the n$"sesho$ld %he% the amo$nt of lo%hia p"esent !empe"at$"es $p to 100.F in the fi"st 2. ho$"s afte" bi"th a"e
"elated to the dehyd"ating effe%ts of labo" and a"e %onside"ed no"mal #ltho$gh "e%he%ing the blood
p"ess$"e may be a %o""e%t %hoi%e of a%tion& it is not the fi"st a%tion that sho$ld be implemented in light of
the othe" data !he data indi%ate a potential impending hemo""hage #ssessing the $te"$s fo" fi"mness and
position in "elation to the $mbili%$s and midline is impo"tant& b$t the n$"se sho$ld %he% the e-tent of
/aginal bleeding fi"st !hen it wo$ld be app"op"iate to %he% the $te"$s& whi%h may be a possible %a$se of
the hemo""hage
58 D' #ny b"ight "ed /aginal dis%ha"ge wo$ld be %onside"ed abno"mal& b$t espe%ially days afte" deli/e"y&
when the lo%hia is typi%ally pin to b"ownish 'o%hia "$b"a& a da" "ed dis%ha"ge& is p"esent fo" 2 to +days afte" deli/e"y @"ight "ed /aginal bleeding at this time s$ggests late postpa"t$m hemo""hage& whi%h
o%%$"s afte" the fi"st 2. ho$"s following deli/e"y and is gene"ally %a$sed by "etained pla%ental f"agments
o" bleeding diso"de"s 'o%hia "$b"a is the no"mal da" "ed dis%ha"ge o%%$""ing in the fi"st 2 to + days afte"deli/e"y& %ontaining epithelial %ells& e"yth"o%yes& le$o%ytes and de%id$a 'o%hia se"osa is a pin to
b"ownish se"osang$ineo$s dis%ha"ge o%%$""ing f"om + to 10 days afte" deli/e"y that %ontains de%id$a&
e"yth"o%ytes& le$o%ytes& %e"/i%al m$%$s& and mi%"oo"ganisms 'o%hia alba is an almost %olo"less to
yellowish dis%ha"ge o%%$""ing f"om 10 days to + wees afte" deli/e"y and %ontaining le$o%ytes& de%id$a&
epithelial %ells& fat& %e"/i%al m$%$s& %holeste"ol %"ystals& and ba%te"ia
5 A' !he data s$ggests an infe%tion of the endomet"ial lining of the $te"$s !he lo%hia may be de%"eased o"
%opio$s& da" b"own in appea"an%e& and fo$l smelling& p"o/iding f$"the" e/iden%e of a possible infe%tion
#ll the %lientKs data indi%ate a $te"ine p"oblem& not a b"east p"oblem !ypi%ally& t"ansient fe/e"& $s$ally
101]F& may be p"esent with b"east engo"gement Symptoms of mastitis in%l$de infl$en(a=lie
manifestations 'o%ali(ed infe%tion of an episiotomy o" C=se%tion in%ision "a"ely %a$ses systemi%
symptoms& and $te"ine in/ol$tion wo$ld not be affe%ted !he %lient data do not in%l$de dys$"ia&
59 C' @e%a$se of ea"ly postpa"t$m dis%ha"ge and limited time fo" tea%hing& the n$"seKs p"io"ity is to fa%ilitate
the safe and effe%ti/e %a"e of the %lient and newbo"n #ltho$gh p"omoting %omfo"t and "esto"ation of
health& e-plo"ing the familyKs emotional stat$s& and tea%hing abo$t family planning a"e impo"tant in
postpa"t$mGnewbo"n n$"sing %a"e& they a"e not the p"io"ity fo%$s in the limited time p"esented by ea"ly
post=pa"t$m dis%ha"ge
80 C' ?eat loss by "adiation o%%$"s when the infantKs %"ib is pla%ed too nea" %old walls o" windows !h$s
pla%ing the newbo"nKs %"ib %lose to the /iewing window wo$ld be least effe%ti/e @ody heat is lost
th"o$gh e/apo"ation d$"ing bathing Pla%ing the infant $nde" the "adiant wa"me" afte" bathing will assist
the infant to be "ewa"med Co/e"ing the s%ale with a wa"med blanet p"io" to weighing p"e/ents heat loss
th"o$gh %ond$%tion # nit %ap p"e/ents heat loss f"om the head a la"ge head& a la"ge body s$"fa%e a"ea of
the newbo"nKs body81 )' # f"a%t$"ed %la/i%le wo$ld p"e/ent the no"mal <o"o "esponse of symmet"i%al se6$ential e-tension and
abd$%tion of the a"ms followed by fle-ion and add$%tion In talipes e6$ino/a"$s %l$bfoot the foot is
t$"ned medially& and in planta" fle-ion& with the heel ele/ated !he feet a"e not in/ol/ed with the <o"o
"efle- ?ypothy"oiddism has no effe%t on the p"imiti/e "efle-es #bsen%e of the <o"o" "efle- is the most
signifi%ant single indi%ato" of %ent"al ne"/o$s system stat$s& b$t it is not a sign of in%"eased int"a%"anial
p"ess$"e
82 )' ?emo""hage is a potential "is following any s$"gi%al p"o%ed$"e #ltho$gh the infant has been gi/en
/itamin to fa%ilitate %lotting& the p"ophyla%ti% dose is often not s$ffi%ient to p"e/ent bleeding #ltho$ghinfe%tion is a possibility& signs will not appea" within . ho$"s afte" the s$"gi%al p"o%ed$"e !he p"ima"y
dis%omfo"t of %i"%$m%ision o%%$"s d$"ing the s$"gi%al p"o%ed$"e& not afte"wa"d #ltho$gh feedings a"e
withheld p"io" to the %i"%$m%ision& the %han%es of dehyd"ation a"e minimal
8+ )' !he p"esen%e of e-%essi/e est"ogen and p"ogeste"one in the mate"nal=fetal blood followed by p"omptwithd"awal at bi"th p"e%ipitates b"east engo"gement& whi%h will spontaneo$sly "esol/e in . to days afte"
bi"th !he t"a$ma of the bi"th p"o%ess does not %a$se inflammation of the newbo"nKs b"east tiss$e
*ewbo"ns do not ha/e b"east malignan%y !his "eply by the n$"se wo$ld %a$se the mothe" to ha/e $nd$e
an-iety @"east tiss$e does not hype"t"ophy in the fet$s o" newbo"ns
8. D' !he fi"st 1 min$tes to 1 ho$" afte" bi"th is the fi"st pe"iod of "ea%ti/ity in/ol/ing "espi"ato"y and
%i"%$lato"y adaptation to e-t"a$te"ine life !he data gi/en "efle%t the no"mal %hanges d$"ing this time
pe"iod !he infantKs assessment data "efle%t no"mal adaptation !h$s& the physi%ian does not need to be
notified and o-ygen is not needed !he data do not indi%ate the p"esen%e of %hoing& gagging o" %o$ghing&
whi%h a"e signs of e-%essi/e se%"etions S$%tioning is not ne%essa"y
8 )' #ppli%ation of 80V isop"opyl al%ohol to the %o"d minimi(es mi%"oo"ganisms ge"mi%idal and
p"omotes d"ying !he %o"d sho$ld be ept d"y $ntil it falls off and the st$mp has healed #ntibioti%
ointment sho$ld only be $sed to t"eat an infe%tion& not as a p"ophyla-is Infants sho$ld not be s$bme"ged
in a t$b of wate" $ntil the %o"d falls off and the st$mp has %ompletely healed
85 )' !o dete"mine the amo$nt of fo"m$la needed& do the following mathemati%al %al%$lation + g - 120
%alGg pe" day +50 %alo"iesGday feeding 6 . ho$"s 5 feedings pe" day 50 %alo"ies pe" feeding: 50%alo"ies pe" feedingW 50 %alo"ies pe" feeding with fo"m$la 20 %alGo( + o$n%es pe" feeding @ased on the
%al%$lation 2& . o" 5 o$n%es a"e in%o""e%t
88 A' Int"a$te"ine ano-ia may %a$se "ela-ation of the anal sphin%te" and emptying of me%oni$m into the
amnioti% fl$id #t bi"th some of the me%oni$m fl$id may be aspi"ated& %a$sing me%hani%al obst"$%tion o"
%hemi%al pne$monitis !he infant is not at in%"eased "is fo" gast"ointestinal p"oblems ,/en tho$gh the
sin is stained with me%oni$m& it is noninfe%tio$s ste"ile and noni""itating !he postte"m me%oni$m=
stained infant is not at additional "is fo" bowel o" $"ina"y p"oblems
8 C' !he n$"se sho$ld $se a nonelasti%& fle-ible& pape" meas$"ing tape& pla%ing the (e"o point on the
s$pe"io" bo"de" of the symphysis p$bis and st"et%hing the tape a%"oss the abdomen at the midline to the
top of the f$nd$s !he -iphoid and $mbili%$s a"e not app"op"iate landma"s to $se when meas$"ing the
height of the f$nd$s <%)onaldKs meas$"ement
89 )' Homen hospitali(ed with se/e"e p"ee%lampsia need de%"eased C*S stim$lation to p"e/ent a sei($"eSei($"e p"e%a$tions p"o/ide en/i"onmental safety sho$ld a sei($"e o%%$" @e%a$se of edema& daily weight
is impo"tant b$t not the p"io"ity P"e%lampsia %a$ses /asospasm and the"efo"e %an "ed$%e $te"o=pla%ental
pe"f$sion !he %lient sho$ld be pla%ed on he" left side to ma-imi(e blood flow& "ed$%e blood p"ess$"e&
and p"omote di$"esis Inte"/entions to "ed$%e st"ess and an-iety a"e /e"y impo"tant to fa%ilitate %oping
and a sense of %ont"ol& b$t sei($"e p"e%a$tions a"e the p"io"ity
0 C' Cessation of the lo%hial dis%ha"ge signifies healing of the endomet"i$m is of hemo""hage and
infe%tion a"e minimal + wees afte" a no"mal /aginal deli/e"y !elling the %lient anytime is inapp"op"iate be%a$se this "esponse does not p"o/ide the %lient with the spe%ifi% info"mation she is "e6$esting Choi%e
of a %ont"a%epti/e method is impo"tant& b$t not the spe%ifi% %"ite"ia fo" safe "es$mption of se-$al a%ti/ity
C$lt$"ally& the 5=weesK e-amination has been $sed as the time f"ame fo" "es$ming se-$al a%ti/ity& b$t it
may be "es$med ea"lie"
1 C !he middle thi"d of the /ast$s late"alis is the p"efe""ed inEe%tion site fo" /itamin administ"ation be%a$se it is f"ee of blood /essels and ne"/es and is la"ge eno$gh to abso"b the medi%ation !he deltoid
m$s%le of a newbo"n is not la"ge eno$gh fo" a newbo"n I< inEe%tion InEe%tions into this m$s%le in a small
%hild might %a$se damage to the "adial ne"/e !he ante"io" femo"is m$s%le is the ne-t safest m$s%le to $se
in a newbo"n b$t is not the safest @e%a$se of the p"o-imity of the s%iati% ne"/e& the gl$te$s ma-im$s
m$s%le sho$ld not be $ntil the %hild has been waling 2 yea"s
2 D @a"tholinKs glands a"e the glands on eithe" side of the /aginal o"ifi%e !he %lito"is is female e"e%tile
tiss$e fo$nd in the pe"ineal a"ea abo/e the $"eth"a !he pa"otid glands a"e open into the mo$th SeneKs
glands open into the poste"io" wall of the female $"ina"y meat$s
+ D !he fetal gonad m$st se%"ete est"ogen fo" the emb"yo to diffe"entiate as a female #n in%"ease in
mate"nal est"ogen se%"etion does not effe%t diffe"entiation of the emb"yo& and mate"nal est"ogen se%"etion
o%%$"s in e/e"y p"egnan%y <ate"nal and"ogen se%"etion "emains the same as befo"e p"egnan%y and does
not effe%t diffe"entiation Se%"etion of and"ogen by the fetal gonad wo$ld p"od$%e a male fet$s
. A Using bi%a"bonate wo$ld in%"ease the amo$nt of sodi$m ingested& whi%h %an %a$se %ompli%ations
,ating low=sodi$m %"a%e"s wo$ld be app"op"iate Sin%e li6$ids %an in%"ease na$sea a/oiding them in the
mo"ning ho$"s when na$sea is $s$ally the st"ongest is app"op"iate ,ating si- small meals a day wo$ld
eep the stoma%h f$ll& whi%h often de%"ease na$sea
) @allottement indi%ates passi/e mo/ement of the $nengaged fet$s @allottement is not a %ont"a%tion
Fetal i%ing felt by the %lient "ep"esents 6$i%ening ,nla"gement and softening of the $te"$s is nown as
Pisa%eKs sign
5 ) Chadwi%Ks sign "efe"s to the p$"ple=bl$e tinge of the %e"/i- @"a-ton ?i%s %ont"a%tions a"e painless
%ont"a%tions beginning a"o$nd the .th month DoodellKs sign indi%ates softening of the %e"/i- Fle-ibility
of the $te"$s against the %e"/i- is nown as <%)onaldKs sign
8 C @"eathing te%hni6$es %an "aise the pain th"eshold and "ed$%e the pe"%eption of pain !hey also p"omote"ela-ation @"eathing te%hni6$es do not eliminate pain& b$t they %an "ed$%e it Positioning& not b"eathing&
in%"eases $te"opla%ental pe"f$sion
A !he %lientKs labo" is hypotoni% !he n$"se sho$ld %all the physi%al and obtain an o"de" fo" an inf$sion
of o-yto%in& whi%h will assist the $te"$s to %onta%t mo"e fo"%ef$lly in an attempt to dilate the %e"/i-#dministe"ing light sedati/e wo$ld be done fo" hype"toni% $te"ine %ont"a%tions P"epa"ing fo" %esa"ean
se%tion is $nne%essa"y at this time O-yto%in wo$ld in%"ease the $te"ine %ont"a%tions and hopef$lly
p"og"ess labo" befo"e a %esa"ean wo$ld be ne%essa"y It is too ea"ly to anti%ipate %lient p$shing with
9 D !he signs indi%ate pla%enta p"e/ia and /aginal e-am to dete"mine %e"/i%al dilation wo$ld not be done
be%a$se it %o$ld %a$se hemo""hage #ssessing mate"nal /ital signs %an help dete"mine mate"nal
physiologi% stat$s Fetal hea"t "ate is impo"tant to assess fetal well=being and sho$ld be done <onito"ing
the %ont"a%tions will help e/al$ate the p"og"ess of labo"
90 D # %omplete pla%enta p"e/ia o%%$"s when the pla%enta %o/e"s the opening of the $te"$s& th$s blo%ing
the passageway fo" the baby !his "esponse e-plains what a %omplete p"e/ia is and the "eason the baby
%annot %ome o$t e-%ept by %esa"ean deli/e"y !elling the %lient to as the physi%ian is a poo" "esponse
and wo$ld in%"ease the patientKs an-iety #ltho$gh a %esa"ean wo$ld help to p"e/ent hemo""hage& thestatement does not e-plain why the hemo""hage %o$ld o%%$" Hith a %omplete p"e/ia& the pla%enta is
%o/e"ing all the %e"/i-& not E$st most of it
91 ) Hith a fa%e p"esentation& the head is %ompletely e-tended Hith a /e"te- p"esentation& the head is
%ompletely o" pa"tially fle-ed Hith a b"ow fo"ehead p"esentation& the head wo$ld be pa"tially e-tended
92 D Hith this p"esentation& the fetal $ppe" to"so and ba% fa%e the left $ppe" mate"nal abdominal wall !he
fetal hea"t "ate wo$ld be most a$dible abo/e the mate"nal $mbili%$s and to the left of the middle !he
othe" positions wo$ld be in%o""e%t
9+ C' !he g"eenish tint is d$e to the p"esen%e of me%oni$m 'an$go is the soft& downy hai" on the sho$lde"s
and ba% of the fet$s ?yd"amnios "ep"esents e-%essi/e amnioti% fl$id 7e"ni- is the white& %heesy
s$bstan%e %o/e"ing the fet$s
9. D' In a b"ee%h position& be%a$se of the spa%e between the p"esenting pa"t and the %e"/i-& p"olapse of the
$mbili%al %o"d is %ommon >$i%ening is the womanKs fi"st pe"%eption of fetal mo/ement Ophthalmianeonato"$m $s$ally "es$lts f"om mate"nal gono""hea and is %onE$n%ti/itis Pi%a "efe"s to the o"al intae of
nonfood s$bstan%es
9 A' )i(ygoti% f"ate"nal twins in/ol/e two o/a fe"tili(ed by sepa"ate spe"m <ono(ygoti% identi%al twins
in/ol/e a %ommon pla%enta& same genotype& and %ommon %ho"ion
95 C' !he (ygote is the single %ell that "ep"od$%es itself afte" %on%eption !he %h"omosome is the mate"ial
that maes $p the %ell and is gained f"om ea%h pa"ent @lasto%yst and t"ophoblast a"e late" te"ms fo" the
emb"yo afte" (ygote
98 D' P"epa"ed %hildbi"th was the di"e%t "es$lt of the 190Ks %hallenging of the "o$tine $se of analgesi% and
anestheti%s d$"ing %hildbi"th !he ')P was a m$%h late" %on%ept and was not a di"e%t "es$lt of the
%hallenging of "o$tine $se of analgesi%s and anestheti%s d$"ing %hildbi"th oles fo" n$"se midwi/es and
%lini%al n$"se spe%ialists did not de/elop f"om this %hallenge
9 C' !he is%hial spines a"e lo%ated in the mid=pel/i% "egion and %o$ld be na""owed d$e to the p"e/io$s
pel/i% inE$"y !he symphysis p$bis& sa%"al p"omonto"y& and p$bi% a"%h a"e not pa"t of the mid=pel/is
99 )' 7a"iations in the length of the menst"$al %y%le a"e d$e to /a"iations in the p"olife"ati/e phase !he
menst"$al& se%"eto"y and is%hemi% phases do not %ont"ib$te to this /a"iation
100 ) !estoste"one is p"od$%ed by the 'eyding %ells in the seminife"o$s t$b$les Folli%le=stim$lating
ho"mone and le$tein(ing ho"mone a"e "eleased by the ante"io" pit$ita"y gland !he hypothalam$s is
+ @e"nadetteKs do%to" told he" she had a positi/e Chadwi%Ks sign She ass yo$ what this means& and yo$
tell he" that:
a ?e" abdomen is soft and tende"
b ?e" $te"$s has tipped fo"wa"d
% Ce"/i%al m$%$s is %lea" and sti%y
d ?e" /agina has da"ened in %olo"
+5 @e"nadette o/e"hea"d he" do%to" say that ins$lin is not as effe%ti/e d$"ing p"egnan%y as $s$al !hat madehe" wo""y that she is de/eloping diabetes& lie he" a$nt ?ow wo$ld yo$ e-plain how de%"eased ins$lin
effe%ti/eness safeg$a"ds the fet$sQ
a )e%"eased effe%ti/eness p"e/ents the fet$s f"om being hypogly%emi%
b If ins$lin is ineffe%ti/e it %annot %"oss the pla%enta and ha"m the fet$s
% !he lessened a%tion p"e/ents the fet$s f"om gaining too m$%h weight
d !he mothe"& not the fet$s& is g$a"ded by this de%"eased ins$lin a%tion
+8 i(a C$a feels well She ass yo$ why she needs to %ome fo" p"enatal %a"e !he best "eason fo" he" to
1 Hhile pe"fo"ming physi%al assessment of a 12 month=old& the n$"se notes that the infantKs ante"io"fontanelle is still slightly open Hhi%h of the following is the n$"seKs most app"op"iate a%tionQ
a *otify the physi%ian immediately be%a$se the"e is a p"oblem
b Pe"fo"m an intensi/e ne$"ologi% e-amination% Pe"fo"m an intensi/e de/elopmental e-amination
d )o nothing be%a$se this is a no"mal finding fo" the age
2 Hhen tea%hing a mothe" abo$t int"od$%ing solid foods to he" %hild& whi%h of the following indi%ates the
ea"liest age at whi%h this sho$ld be doneQ
a 1 month
b 2 months
% + months
d . months
+ !he infant of a s$bstan%e=ab$sing mothe" is at "is fo" de/eloping a sense of whi%h of the followingQ
a <ist"$st
b Shame
% D$ilt
d Infe"io"ity
. Hhi%h of the following toys sho$ld the n$"se "e%ommend fo" a =month=oldQ
a # big "ed balloon
b # teddy bea" with b$tton eyes
% # p$sh=p$ll wooden t"$%
d # %olo"f$l b$sy bo- !he mothe" of a 2=month=old is %on%e"ned that she may be spoiling he" baby by pi%ing he" $p when she
%"ies Hhi%h of the following wo$ld be the n$"seKs best "esponseQ
a 'et he" %"y fo" a while befo"e pi%ing he" $p& so yo$ donKt spoil he"T
b @abies need to be held and %$ddledW yo$ wonKt spoil he" this wayT
% C"ying at this age means the baby is h$ng"yW gi/e he" a bottleT
d If yo$ lea/e he" alone she will lea"n how to %"y he"self to sleepT
5 Hhen assessing an 1=month=old& the n$"se notes a %ha"a%te"isti% p"ot"$ding abdomen Hhi%h of the
following wo$ld e-plain the "ationale fo" this findingQ
29 Hhi%h of the following info"mation& when /oi%ed by the mothe"& wo$ld indi%ate to the n$"se that she
$nde"stands home %a"e inst"$%tions following the administ"ation of a diphthe"ia& tetan$s& and pe"t$ssis
inEe%tionQ
a <eas$"es to "ed$%e fe/e"
b *eed fo" dieta"y "est"i%tions% easons fo" s$bse6$ent "ash
d <eas$"es to %ont"ol s$bse6$ent dia""hea
+0 Hhi%h of the following a%tions by a %omm$nity health n$"se is most app"op"iate when noting m$ltiple
b"$ises and b$"ns on the poste"io" t"$n of an 1=month=old %hild d$"ing a home /isitQ
a epo"t the %hildKs %ondition to P"ote%ti/e Se"/i%es immediately
b S%hed$le a follow=$p /isit to %he% fo" mo"e b"$ises
% *otify the %hildKs physi%ian immediately
d )on nothing be%a$se this is a no"mal finding in a toddle"
+1 Hhi%h of the following is being $sed when the mothe" of a hospitali(ed %hild %alls the st$dent n$"se andstates& Ao$ idiot& yo$ ha/e no idea how to %a"e fo" my si% %hildTQ
a )ispla%ement
b P"oEe%tion% ep"ession
d Psy%hosis
+2 Hhi%h of the following sho$ld the n$"se e-pe%t to note as a f"e6$ent %ompli%ation fo" a %hild with
%ongenital hea"t diseaseQ
a S$s%eptibility to "espi"ato"y infe%tion
b @leeding tenden%ies
% F"e6$ent /omiting and dia""hea
d Sei($"e diso"de"
++ Hhi%h of the following wo$ld the n$"se do fi"st fo" a +=yea"=old boy who a""i/es in the eme"gen%y "oom
with a tempe"at$"e of 10 deg"ees& inspi"ato"y st"ido"& and "estlessness& who is lea"ning fo"wa"d and
d"oolingQ
a #$s%$ltate his l$ngs and pla%e him in a mist tent b ?a/e him lie down and "est afte" en%o$"aging fl$ids
% ,-amine his th"oat and pe"fo"m a th"oat %$lt$"e
d *otify the physi%ian immediately and p"epa"e fo" int$bation+. Hhi%h of the following wo$ld the n$"se need to eep in mind as a p"edisposing fa%to" when fo"m$lating a
tea%hing plan fo" %hild with a $"ina"y t"a%t infe%tionQ
a # sho"te" $"eth"a in females
b F"e6$ent emptying of the bladde"
% In%"eased fl$id intae
d Ingestion of a%idi% E$i%es
+ Hhi%h of the following sho$ld the n$"se do fi"st fo" a 1=yea"=old boy with a f$ll leg %ast who is
s%"eaming in $n"elenting pain and e-hibiting "ight foot pallo" signifying %ompa"tment synd"omeQ
a <edi%ate him with a%etaminophen
b *otify the physi%ian immediately
% elease the t"a%tion
d <onito" him e/e"y min$tes
+5 #t whi%h of the following ages wo$ld the n$"se e-pe%t to administe" the /a"i%ella (oste" /a%%ine to %hildQ
a #t bi"th
b 2 months
% 5 months
d 12 months
+8 Hhen dis%$ssing no"mal infant g"owth and de/elopment with pa"ents& whi%h of the following toys wo$ldthe n$"se s$ggest as most app"op"iate fo" an =month=oldQ
a P$sh=p$ll toys
b attle
% 'a"ge blo%s
d <obile
+ Hhi%h of the following aspe%ts of psy%hoso%ial de/elopment is ne%essa"y fo" the n$"se to eep in mind
when p"o/iding %a"e fo" the p"es%hool %hildQ
a !he %hild %an $se %omple- "easoning to thin o$t sit$ations
b Fea" of body m$tilation is a %ommon p"es%hool fea"
% !he %hild engages in %ompetiti/e types of play
d Immediate g"atifi%ation is ne%essa"y to de/elop initiati/e
+9 Hhi%h of the following is %ha"a%te"isti% of a p"es%hoole" with mid mental "eta"dationQ
1 D' !he ante"io" fontanelle typi%ally %loses anywhe"e between 12 to 1 months of age !h$s& assessing the
ante"io" fontanelle as still being slightly open is a no"mal finding "e6$i"ing no f$"the" a%tion @e%a$se it is
no"mal finding fo" this age& notifying he physi%ian o" pe"fo"ming additional e-aminations a"e
inapp"op"iate2 D' Solid foods a"e not "e%ommended befo"e age . to 5 months be%a$se of the s$%ing "efle- and the
immat$"ity of the gast"ointestinal t"a%t and imm$ne system !he"efo"e& the ea"liest age at whi%h to
int"od$%e foods is . months #ny time ea"lie" wo$ld be inapp"op"iate
+ A' #%%o"ding to ,"ison& infants need to ha/e thei" needs met %onsistently and effe%ti/ely to de/elop a
sense of t"$st #n infant whose needs a"e %onsistently $nmet o" who e-pe"ien%es signifi%ant delays in
ha/ing them met& s$%h as in the %ase of the infant of a s$bstan%e=ab$sing mothe"& will de/elop a sense of
$n%e"tainty& leading to mist"$st of %a"egi/e"s and the en/i"onment !oddle"s de/elop a sense of shame
when thei" a$tonomy needs a"e not met %onsistently P"es%hoole"s de/elop a sense of g$ilt when thei"
sense of initiati/e is thwa"ted S%hoolage"s de/elop a sense of infe"io"ity when they do not de/elop a
sense of ind$st"y
. D' # b$sy bo- fa%ilitates the fine moto" de/elopment that o%%$"s between . and 5 months @alloons a"e
%ont"aindi%ated be%a$se small %hild"en may aspi"ate balloons @e%a$se the b$tton eyes of a teddy bea"may deta%h and be aspi"ated& this toy is $nsafe fo" %hild"en yo$nge" than + yea"s # =month=old is too
yo$ng to $se a p$sh=p$ll toy
)' Infants need to ha/e thei" se%$"ity needs met by being held and %$ddled #t 2 months of age& they a"e
$nable to mae the %onne%tion between %"ying and attention !his asso%iation does not o%%$" $ntil late
infan%y o" ea"ly toddle"hood 'etting the infant %"y fo" a time befo"e pi%ing $p the infant o" lea/ing the
infant alone to %"y he"self to sleep inte"fe"es with meeting the infantKs need fo" se%$"ity at this /e"y yo$ng
age Infants %"y fo" many "easons #ss$ming that the %hild s h$ng"y may %a$se o/e"feeding p"oblems
s$%h as obesity
5 )' Unde"de/eloped abdominal m$s%$lat$"e gi/es the toddle" a %ha"a%te"isti%ally p"ot"$ding abdomen
be%a$se the leg m$s%les m$st bea" the weight of the "elati/ely la"ge t"$n !oddle" g"owth patte"ns o%%$"
in a steplie& not linea" patte"n8 )' #%%o"ding to ,"ison& toddle"s e-pe"ien%e a sense of shame when they a"e not allowed to de/elop
app"op"iate independen%e and a$tonomy Infants de/elop mist"$st when thei" needs a"e not %onsistentlyg"atified P"es%hoole"s de/elop g$ilt when thei" initiati/e needs a"e not met while s%hoolage"s de/elop a
sense of infe"io"ity when thei" ind$st"y needs a"e not met
C' Ao$ng toddle"s a"e still senso"imoto" lea"ne"s and they enEoy the e-pe"ien%e of feeling diffe"ent
te-t$"es !h$s& finge" paints wo$ld be an app"op"iate toy %hoi%e <$ltiple=pie%e toys& s$%h as p$((le& a"e
too diffi%$lt to manip$late and may be ha(a"do$s if the pie%es a"e small eno$gh to be aspi"ated <iniat$"e
%a"s also ha/e a high potential fo" aspi"ation Comi% boos a"e on too high a le/el fo" toddle"s #ltho$gh
they may enEoy looing at some of the pi%t$"es& toddle"s a"e mo"e liely to "ip a %omi% boo apa"t
9 D' !he %hild m$st be able to sate the need to go to the bath"oom to initiate toilet t"aining Us$ally& a %hild
needs to be d"y fo" only 2 ho$"s& not . ho$"s !he %hild also m$st be able to sit& wal& and s6$at # new
sibling wo$ld most liely hinde" toilet t"aining
10 A' !oddle"s be%ome pi%y eate"s& e-pe"ien%ing food Eags and eating la"ge amo$nts one day and /e"y little
the ne-t # toddle"Ks food gags e-p"ess a p"efe"en%e fo" the "it$alism of eating one type of food fo"
se/e"al days at a time !oddle"s typi%ally enEoy so%iali(ation and limiting othe"s at meal time !oddle"s p"efe" to feed themsel/es and th$s a"e too yo$ng to ha/e table manne"s # toddle"Ks appetite and need fo"
%alo"ies& p"otein& and fl$id de%"ease d$e to the d"amati% slowing of g"owth "ate
11 D' P"es%hoole"s %ommonly ha/e fea"s of the da"& being left alone espe%ially at bedtime& and ghosts&
whi%h may affe%t the %hildKs going to bed at night >$iet play and time with pa"ents is a positi/e bedtime
"o$tine that p"o/ides se%$"ity and also "eadies the %hild fo" sleep !he %hild sho$ld sleep in his own bed
!elling the %hild abo$t lo%ing him in his "oom will /iewed by the %hild as a th"eat #dditionally& a
lo%ed doo" is f"ightening and potentially ha(a"do$s 7igo"o$s a%ti/ity at bedtime sti"s $p the %hild and
maes mo"e diffi%$lt to fall asleep
12 )' )"ess=$p %lothes enhan%e imaginati/e play and imagination& allowing p"es%hoole"s to engage in "i%h
fantasy play @$ilding blo%s and wooden p$((les a"e app"op"iate fo" en%o$"aging fine moto"
de/elopment @ig wheels and t"i%y%les en%o$"age g"oss moto" de/elopment
1+ D' !he s%hool=aged %hild is in the stage of %on%"ete ope"ations& ma"ed by ind$%ti/e "easoning& logi%alope"ations& and "e/e"sible %on%"ete tho$ght !he ability to %onside" the f$t$"e "e6$i"es fo"mal tho$ght
ope"ations& whi%h a"e not de/eloped $ntil adoles%en%e Colle%ting baseball %a"ds and ma"bles& o"de"ing
dolls by si(e& and simple p"oblem=sol/ing options a"e e-amples of the %on%"ete ope"ational thining of the
s%hoolage"
1. C' ea%tion fo"mation is the s%hoolage"Ks typi%al defensi/e "esponse when hospitali(ed In "ea%tion
fo"mation& e-p"ession of $na%%eptable tho$ghts o" beha/io"s is p"e/ented o" o/e""idden by the
e-agge"ated e-p"ession of opposite tho$ghts o" types of beha/io"s eg"ession is seen in toddle"s and p"esh%oole"s when they "et"eat o" "et$"n to an ea"lie" le/el of de/elopment ep"ession "efe"s to the
in/ol$nta"y blo%ing of $npleasant feelings and e-pe"ien%es f"om oneKs awa"eness ationali(ation is the
attempt to mae e-%$ses to E$stify $na%%eptable feelings o" beha/io"s
1 C' !he s%hoolage"Ks %ogniti/e le/el is s$ffi%iently de/eloped to enable good $nde"standing of and
adhe"en%e to "$les !h$s& s%hoolage"s sho$ld be able to $nde"stand the potential dange"s a"o$nd themHith g"owth %omes g"eate" f"eedom and %hild"en be%ome mo"e ad/ent$"o$s and da"ing !he s%hool=aged
%hild is also still p"one to a%%idents and home ha(a"ds& espe%ially be%a$se of in%"eased moto" abilities and
independen%e Pl$s the home ha(a"ds diffe" f"om othe" age g"o$ps !hese ha(a"ds& whi%h a"e potentially
lethal b$t tempting& may in%l$de fi"ea"ms& al%ohol& and medi%ations S%hool=age %hild"en begin to
inte"nali(e thei" own %ont"ols and need less o$tside di"e%tion Pl$s the %hild is away f"om home mo"e
often Some pa"ental o" %a"egi/e" assistan%e is still needed to answe" 6$estions and p"o/ide g$idan%e fo"de%isions and "esponsibilities
15 C' !he most signifi%ant sill lea"ned d$"ing the s%hool=age pe"iod is "eading )$"ing this time the %hild
de/elops fo"mal ad$lt a"ti%$lation patte"ns and lea"ns that wo"ds %an be a""anged in st"$%t$"e Colle%ti/e&
o"de"ing& and so"ting& altho$gh impo"tant& a"e not most signifi%ant sills lea"ned
18 C' @ased on the "e%ommendations of the #me"i%an #%ademy of Family Physi%ians and the #me"i%an
#%ademy of Pediat"i%s& the << /a%%ine sho$ld be gi/en at the age of 10 if the %hild did not "e%ei/e it between the ages of . to 5 yea"s as "e%ommended Imm$ni(ation fo" diphthe"ia and tetan$s is "e6$i"ed at
age 1+
1 D' #%%o"ding to ,"ison& "ole diff$sion de/elops when the adoles%ent does not de/elop a sense of identity
and a sense o" whe"e he fits in !oddle"s de/elop a sense of shame when they do not a%hie/e a$tonomy
P"es%hoole"s de/elop a sense of g$ilt when they do not de/elop a sense of initiati/e S%hool=age %hild"en
de/elop a sense of infe"io"ity when they do not de/elop a sense of ind$st"y
19 A' <ena"%he "efe"s to the onset of the fi"st menst"$ation o" menst"$al pe"iod and "efe"s only to the fi"st
%y%le Ute"ine g"owth and b"oadening of the pel/i% gi"dle o%%$"s befo"e mena"%he
20 A' Stating that this is p"obably the only %on%e"n the adoles%ent has and telling the pa"ents not to wo""y
abo$t it o" the time he" spends on it sh$ts off f$"the" in/estigation and is liely to mae the adoles%ent and
his pa"ents feel defensi/e !he statement abo$t pee" a%%eptan%e and time spent in f"ont of the mi""o" fo"
the de/elopment of self image p"o/ides info"mation abo$t the adoles%entKs needs to the pa"ents and may
help to gain t"$st with the adoles%ent #sing the adoles%ent how he feels abo$t the a%ne will en%o$"age
the adoles%ent to sha"e his feelings )is%$ssing the %leansing method shows inte"est and %on%e"n fo" the
adoles%ent and also %an help to identify any patient=tea%hing needs fo" the adoles%ent "ega"ding %leansing
21 )' P"es%hoole"s sho$ld be de/elopmentally in%apable of demonst"ating e-pli%it se-$al beha/io" If a %hild
does so& the %hild has been e-posed to s$%h beha/io"& and se-$al ab$se sho$ld be s$spe%ted ,-pli%it
se-$al beha/io" d$"ing doll play is not a %ha"a%te"isti% of p"es%hool de/elopment no" symptomati% of
de/elopmental delay Hhethe" o" no" the %hild nows how to play with dolls is i""ele/ant
22 A' !he pa"ents need mo"e tea%hing if they state that they will eep the %hild home $ntil the phobia
s$bsides )oing so "einfo"%es the %hildKs feelings of wo"thlessness and dependen%y !he %hild sho$ld
attend s%hool e/en d$"ing "esol$tion of the p"oblem #llowing the %hild to /e"bali(e helps the %hild to
/entilate feelings and may help to $n%o/e" %a$ses and sol$tions Collabo"ation with the tea%he"s and
%o$nselo"s at s%hool may lead to $n%o/e"ing the %a$se of the phobia and to the de/elopment of sol$tions
!he %hild sho$ld pa"ti%ipate and play an a%ti/e "ole in de/eloping possible sol$tions
2+ C' !he adoles%ent who be%omes p"egnant typi%ally denies the p"egnan%y ea"ly on ,a"ly "e%ognition by a
pa"ent o" health %a"e p"o/ide" may be %"$%ial to timely initiation of p"enatal %a"e !he in%iden%e ofadoles%ent p"egnan%y has de%lined sin%e 1991& yet mo"bidity "emains high <ost teenage p"egnan%ies a"e
$nplanned and o%%$" o$t of wedlo% !he p"egnant adoles%ent is at high "is fo" physi%al %ompli%ations
in%l$ding p"emat$"e labo" and low=bi"th=weight infants& high neonatal mo"tality& i"on defi%ien%y anemia&
p"olonged labo"& and fetopel/i% disp"opo"tion as well as n$me"o$s psy%hologi%al %"ises
2. )' @e%a$se of the st"$%t$"al defe%t& %hild"en with %left palate may ha/e ineffe%ti/e f$n%tioning of thei"
,$sta%hian t$bes %"eating f"e6$ent bo$ts of otitis media <ost %hild"en with %left palate "emain well=
no$"ished and maintain ade6$ate n$t"ition th"o$gh the $se of p"ope" feeding te%hni6$es Food pa"ti%les do
not pass th"o$gh the %left and into the ,$sta%hian t$bes !he"e is no asso%iation between %left palate and
%ongenial ea" defo"mities
2 D' # +=month=old infant sho$ld be able to lift the head and %hest when p"one !he <o"o "efle- typi%ally
diminishes o" s$bsides by + months !he pa"a%h$te "efle- appea"s at 9 months olling f"om f"ont to ba%
$s$ally is a%%omplished at abo$t months25 D' # %hildKs bi"th weight $s$ally t"iples by 12 months and do$bles by . months *o spe%ifi% bi"th weight
pa"amete"s a"e established fo" 8 o" 9 months
28 C' !oddle"s engaging in pa"allel play will play nea" ea%h othe"& b$t not with ea%h othe" !h$s& when two
toddle"s sit nea" ea%h othe" b$t play with sepa"ate dolls& they a"e e-hibiting pa"allel play Sha"ing %"ayons&
playing a boa"d game with a n$"se& o" sha"ing dolls with two diffe"ent n$"ses a"e all e-amples of
%oope"ati/e play
2 A' #%$te lympho%yti% le$emia #'' %a$ses le$openia& "es$lting in imm$nos$pp"ession and in%"easing
the "is of infe%tion& a leading %a$se of death in %hild"en with #'' !he"efo"e& the initial p"io"ity n$"sing
inte"/ention wo$ld be to instit$te infe%tion %ont"ol p"e%a$tions to de%"ease the "is of infe%tion I"on="i%h
foods help with anemia& b$t dieta"y i"on is not an initial inte"/ention !he p"ognosis of #'' $s$ally is
good ?owe/e"& late" on& the n$"se may need to assist the %hild and family with %oping sin%e death and
dying may still be an iss$e in need of dis%$ssion InEe%tions sho$ld be dis%o$"aged& owing to in%"eased"is f"om bleeding d$e to th"ombo%ytopenia
29 A' !he pe"t$sis %omponent may "es$lt in fe/e" and the tetan$s %omponent may "es$lt in inEe%tion
so"eness !he"efo"e& the mothe"Ks /e"bali(ation of info"mation abo$t meas$"es to "ed$%e fe/e" indi%ates
$nde"standing *o dieta"y "est"i%tions a"e ne%essa"y afte" this inEe%tion is gi/en # s$bse6$ent "ash is
mo"e liely to be seen to 10 days afte" "e%ei/ing the << /a%%ine& not the diphthe"ia& pe"t$ssis& and
tetan$s /a%%ine )ia""hea is not asso%iated with this /a%%ine
+0 A' <$ltiple b"$ises and b$"ns on a toddle" a"e signs %hild ab$se !he"efo"e& the n$"se is "esponsible fo"
"epo"ting the %ase to P"ote%ti/e Se"/i%es immediately to p"ote%t the %hild f"om f$"the" ha"m S%hed$ling a
follow=$p /isit is inapp"op"iate be%a$se additional ha"m may %ome to the %hild if the n$"se waits fo"
f$"the" assessment data #ltho$gh the n$"se sho$ld notify the physi%ian& the goal is to initiate meas$"es to
p"ote%t the %hildKs safety *otifying the physi%ian immediately does not initiate the "emo/al of the %hild
f"om ha"m no" does it absol/e the n$"se f"om "esponsibility <$ltiple b"$ises and b$"ns a"e not no"maltoddle" inE$"ies
+1 )' !he mothe" is $sing p"oEe%tion& the defense me%hanism $sed when a pe"son att"ib$tes his o" he" own
$ndesi"able t"aits to anothe" )ispla%ement is the t"ansfe" of emotion onto an $n"elated obEe%t& s$%h as
when the mothe" wo$ld i% a %hai" o" bang the doo" sh$t ep"ession is the s$bme"ging of painf$l ideas
into the $n%ons%io$s Psy%hosis is a state of being o$t of to$%h with "eality
+2 A' Child"en with %ongenital hea"t disease a"e mo"e p"one to "espi"ato"y infe%tions @leeding tenden%ies&
f"e6$ent /omiting& and dia""hea and sei($"e diso"de"s a"e not asso%iated with %ongenital hea"t disease
++ D' !he %hild is e-hibiting %lassi% signs of epiglottitis& always a pediat"i% eme"gen%y !he physi%ian m$st
be notified immediately and the n$"se m$st be p"epa"ed fo" an eme"gen%y int$bation o" t"a%heostomy
F$"the" assessment with a$s%$ltating l$ngs and pla%ing the %hild in a mist tent wastes /al$able time !he
sit$ation is a possible life=th"eatening eme"gen%y ?a/ing the %hild lie down wo$ld %a$se additional
dist"ess and may "es$lt in "espi"ato"y a""est !h"oat e-amination may "es$lt in la"yngospasm that %o$ld be
fatal
+. A' In females& the $"eth"a is sho"te" than in males !his de%"eases the distan%e fo" o"ganisms to t"a/el&
the"eby in%"easing the %han%e of the %hild de/eloping a $"ina"y t"a%t infe%tion F"e6$ent emptying of the
bladde" wo$ld help to de%"ease $"ina"y t"a%t infe%tions by a/oiding sphin%te" st"ess In%"eased fl$id intae
enables the bladde" to be %lea"ed mo"e f"e6$ently& th$s helping to p"e/ent $"ina"y t"a%t infe%tions !he
intae of a%idi% E$i%es helps to eep the $"ine p? a%idi% and th$s de%"ease the %han%e of flo"a
+ )' Compa"tment synd"ome is an eme"gent sit$ation and the physi%ian needs to be notified immediately so
that inte"/entions %an be initiated to "elie/e the in%"easing p"ess$"e and "esto"e %i"%$lation
#%etaminophen !ylenol will be ineffe%ti/e sin%e the pain is "elated to the in%"easing p"ess$"e and tiss$e
is%hemia !he %ast& not t"a%tion& is being $sed in this sit$ation fo" immobili(ation& so "eleasing the t"a%tion
wo$ld be inapp"op"iate In this sit$ation& spe%ifi% a%tion not %ontin$ed monito"ing is indi%ated
+5 D' !he /a"i%ella (oste" /a%%ine 7J7 is a li/e /a%%ine gi/en afte" age 12 months !he fi"st dose of
hepatitis @ /a%%ine is gi/en at bi"th to 2 months& then at 1 to . months& and then again at 5 to 1 months
)taP is "o$tinely gi/en at 2& .& 5& and 1 to 1 months and a booste" at . to 5 yea"s+8 C' @e%a$se the =month=old is "efining his g"oss moto" sills& being able to sit $ns$ppo"ted and also
imp"o/ing his fine moto" sills& p"obably %apable of maing hand=to=hand t"ansfe"s& la"ge blo%s wo$ld
be the most app"op"iate toy sele%tion P$sh=p$ll toys wo$ld be mo"e app"op"iate fo" the 10 to 12=month=
old as he o" she begins to %"$ise the en/i"onment attles and mobiles a"e mo"e app"op"iate fo" infants in
the 1 to + month age "ange <obiles pose a dange" to olde" infants be%a$se of possible st"ang$lation
+ )' )$"ing the p"es%hool pe"iod& the %hild has maste"ed a sense of a$tonomy and goes on to maste" a sense
of initiati/e )$"ing this pe"iod& the %hild %ommonly e-pe"ien%es mo"e fea"s than at any othe" time One
%ommon fea" is fea" of the body m$tilation& espe%ially asso%iated with painf$l e-pe"ien%es !he p"es%hool
%hild $ses simple& not %omple-& "easoning& engages in asso%iati/e& not %ompetiti/e& play inte"a%ti/e and
%oope"ati/e play with sha"ing& and is able to tole"ate longe" pe"iods of delayed g"atifi%ation
+9 A' <ild mental "eta"dation "efe"s to de/elopment disability in/ol/ing an I> 0 to 80 !ypi%ally& the %hild
is not noted as being "eta"ded& b$t e-hibits slowness in pe"fo"ming tass& s$%h as self=feeding& waling&and taing 'ittle o" no spee%h& ma"ed moto" delays& and gait disabilities wo$ld be seen in mo"e se/e"e
fo"ms mental "eta"dation
.0 ) )own synd"ome is %ha"a%te"i(ed by the following a t"ans/e"se palma" %"ease simian %"ease&
palate& e-%ess and la- sin& wide spa%ing and planta" %"ease between the se%ond and big toes&
hype"e-tensible and la- Eoints& la"ge p"ot"$ding tong$e& and m$s%le weaness
.1 A' @e%a$se of the defe%t& the %hild will be $nable to f"om the mo$th ade6$ately a"o$nd nipple& the"eby
"e6$i"ing spe%ial de/i%es to allow fo" feeding and s$%ing g"atifi%ation espi"ato"y stat$s may be
%omp"omised if the %hild is fed imp"ope"ly o" d$"ing postope"ati/e pe"iod& 'o%omotion wo$ld be a
p"oblem fo" the olde" infant be%a$se of the $se of "est"aints DI f$n%tioning is not %omp"omised in the
%hild with a %left lip
.2 )' Postope"ati/ely %hild"en with %left palate sho$ld be pla%ed on thei" abdomens to fa%ilitate d"ainage Ifthe %hild is pla%ed in the s$pine position& he o" she may aspi"ate Using an infant seat does not fa%ilitate
d"ainage Side=lying does not fa%ilitate d"ainage as well as the p"one position
.+ C' P"oEe%tile /omiting is a ey symptom of pylo"i% stenosis eg$"gitation is seen mo"e %ommonly with
D, Steato""hea o%%$"s in malabso"ption diso"de"s s$%h as %elia% disease C$""ant EellyT stools a"e
%ha"a%te"isti% of int$ss$s%eption
.. D' D, is the ba%flow of gast"i% %ontents into the esophag$s "es$lting f"om "ela-ation o" in%ompeten%e
of the lowe" esophageal %a"dia% sphin%te" *o alte"ation in the o"al m$%o$s memb"anes o%%$"s with this
. A' !hi%ened feedings a"e $sed with D, to stop the /omiting !he"efo"e& the n$"se wo$ld monito" the
%hildKs /omiting to e/al$ate the effe%ti/eness of $sing the thi%ened feedings *o "elationship e-ists
between feedings and %ha"a%te"isti%s of stools and $te"ine If feedings a"e ineffe%ti/e& this sho$ld be noted
befo"e the"e is any %hange in the %hildKs weight
.5 C' Child"en with %elia% disease %annot tole"ate o" digest gl$ten !he"efo"e& be%a$se of its gl$ten %ontent&
wheat and wheat=%ontaining p"od$%ts m$st be a/oided i%e& mil& and %hi%en do not %ontain gl$ten and
need not be a/oided
.8 C' ,pisodes of %elia% %"ises a"e p"e%ipitated by infe%tions& ingestion of gl$ten& p"olonged fasting& o"
e-pos$"e to anti%holine"gi% d"$gs Celia% %"isis is typi%ally %ha"a%te"i(ed by se/e"e wate"y dia""hea
espi"ato"y dist"ess is $nliely in a "o$tine $ppe" "espi"ato"y infe%tion I""itability& "athe" than letha"gy& is
mo"e liely @e%a$se of the fl$id loss asso%iated with the se/e"e wate"y dia""hea& the %hildKs weight is
mo"e liely to be de%"eased
. A' Fo" the %hild with ?i"s%hsp"$ng disease& fe/e" and e-plosi/e dia""hea indi%ate ente"o%olitis& a life=
th"eatening sit$ation !he"efo"e& the physi%ian sho$ld be notified immediately Dene"ally& be%a$se of the
intestinal obst"$%tion and inade6$ate p"op$lsi/e intestinal mo/ement& antidia""heals a"e not $sed to t"eat?i"s%hsp"$ng disease !he %hild is a%$tely ill and "e6$i"es inte"/ention& with monito"ing mo"e f"e6$ently
than e/e"y +0 min$tes ?i"s%hsp"$ng disease typi%ally p"esents with %h"oni% %onstipation
.9 A Fail$"e to pass me%oni$m within the fi"st 2. ho$"s afte" bi"th may be an indi%ation of ?i"s%hsp"$ng
disease& a %ongenital anomaly "es$lting in me%hani%al obst"$%tion d$e to inade6$ate motility in an
intestinal segment Fail$"e to pass me%oni$m is not asso%iated with %elia% disease& int$ss$s%eption& o"
abdominal wall defe%t
0 C @e%a$se int$ss$s%eption is not belie/ed to ha/e a familial tenden%y& obtaining a family histo"y wo$ld
p"o/ide the least amo$nt of info"mation Stool inspe%tion& pain patte"n& and abdominal palpation wo$ld
"e/eal possible indi%ato"s of int$ss$s%eption C$""ent& Eelly=lie stools %ontaining blood and m$%$s a"e an
15 #mong the following signs and symptoms& whi%h wo$ld most liely be p"esent in a %lient with mit"al
g$"gitationQ
a #lte"ed le/el of %ons%io$sness
b ,-%eptional )yspnea
% In%"ease %"eatine phospholinase %on%ent"ation
d Chest pain
18 "is with a histo"y of %h"oni% infe%tion of the $"ina"y system %omplains of $"ina"y f"e6$en%y and b$"ning
sensation !o fig$"e o$t whethe" the %$""ent p"oblem is in "enal o"igin& the n$"se sho$ld assess whethe" the%lient has dis%omfo"t o" pain in theM
a U"ina"y meat$s
b Pain in the 'abi$m
% S$p"ap$bi% a"ea
d ight o" left %osto/e"teb"al angle
1 *$"se Pe""y is e/al$ating the "enal f$n%tion of a male %lient #fte" do%$menting $"ine /ol$me and
%ha"a%te"isti%s& *$"se Pe""y assesses whi%h signs as the best indi%ato" of "enal f$n%tion
a @lood p"ess$"e
b Cons%io$sness% )istension of the bladde"
d P$lse "ate
19 Bohn s$ddenly e-pe"ien%es a sei($"e& and *$"se Dina noti%e that Bohn e-hibits $n%ont"ollable Ee"ingmo/ements *$"se Dina do%$ments that Bohn e-pe"ien%ed whi%h type of sei($"eQ
a !oni% sei($"e
b #bsen%e sei($"e
% <yo%loni% sei($"e
d Cloni% sei($"e
20 Smoing %essation is %"iti%al st"ategy fo" the %lient with @$"ghe"Ks disease& *$"se Basmin anti%ipates that the
male %lient will go home with a p"es%"iption fo" whi%h medi%ationQ
a Pa"a%etamol
b Ib$p"ofen
% *it"ogly%e"in
d *i%otine *i%ot"ol
21 *$"se 'illy has been assigned to a %lient with ayna$dKs disease *$"se 'illy "eali(es that the etiology of thedisease is $nnown b$t it is %ha"a%te"i(ed by:
a ,pisodi% /asospasti% diso"de" of %apilla"ies
b ,pisodi% /asospasti% diso"de" of small /eins% ,pisodi% /asospasti% diso"de" of the ao"ta
d ,pisodi% /asospasti% diso"de" of the small a"te"ies
22 *$"se Bamie sho$ld e-plain to male %lient with diabetes that self=monito"ing of blood gl$%ose is p"efe""ed to
$"ine gl$%ose testing be%a$seM
a <o"e a%%$"ate
b Can be done by the %lient
% It is easy to pe"fo"m
d It is not infl$en%ed by d"$gs
2+ Bessie weighed 210 po$nds on admission to the hospital #fte" 2 days of di$"eti% the"apy& Bessie weighs 20
po$nds !he n$"se %o$ld estimate the amo$nt of fl$id Bessie has lostM
a 0+ '
b 1 '
% 20 '
d + '
2. *$"se )onna is awa"e that the shift of body fl$ids asso%iated with Int"a/eno$s administ"ation of alb$min
o%%$"s in the p"o%ess of:
a Osmosis
b )iff$sion% #%ti/e t"anspo"t
d Filt"ation
2 <y"na a 2 yea" old %lient with a f"a%t$"ed left tibia has a long leg %ast and she is $sing %"$t%hes to amb$late
*$"se Boy assesses fo" whi%h sign and symptom that indi%ates %ompli%ation asso%iated with %"$t%h walingQ
a 'eft leg dis%omfo"t
b Hea bi%eps b"a%hii
% !"i%eps m$s%le spasm
d Fo"ea"m weaness
25 Hhi%h of the following statements sho$ld the n$"se tea%h the ne$t"openi% %lient and his family to a/oidQ
a emo/e the ai"way only when %lient is f$lly %ons%io$s
b #ssess fo" hypo/entilation by a$s%$ltating the l$ngs
% Position %lient late"ally with the ne% e-tended
d <aintain h$midified o-ygen /ia nasal %an$la
29 Deo"ge who has $nde"gone tho"a%i% s$"ge"y has %hest t$be %onne%ted to a wate"=seal d"ainage system atta%hed
to s$%tion P"esen%e of e-%essi/e b$bbling is identified in wate"=seal %hambe"& the n$"se sho$ldM
a St"ipT the %hest t$be %athete"
b Che% the system fo" ai" leas% e%ogni(e the system is f$n%tioning %o""e%tly
d )e%"ease the amo$nt of s$%tion p"ess$"e
+0 # %lient who has been diagnosed of hype"tension is being ta$ght to "est"i%t intae of sodi$m !he n$"se wo$ldnow that the tea%hings a"e effe%ti/e if the %lient states thatM
a I %an eat %ele"y sti%s and %a""ots
b I %an eat b"oiled s%allops
% I %an eat sh"edded wheat %e"eal
d I %an eat spaghetti on "ye b"ead
+1 # male %lient with a histo"y of %i""hosis and al%oholism is admitted with se/e"e dyspnea "es$lted to as%ites
!he n$"se sho$ld be awa"e that the as%ites is most liely the "es$lt of in%"easedM
a P"ess$"e in the po"tal /ein
b P"od$%tion of se"$m alb$min
% Se%"etion of bile salts
d Inte"stitial osmoti% p"ess$"e
+2 # newly admitted %lient is diagnosed with ?odginKs disease $nde"goes an e-%isional %e"/i%al lymph node biopsy $nde" lo%al anesthesia Hhat does the n$"se assess fi"st afte" the p"o%ed$"eQ
a 7ital signs
b In%ision site% #i"way
d 'e/el of %ons%io$sness
++ # %lient has 1V blood loss Hhi%h of the following n$"sing assessment findings indi%ates hypo/olemi%
sho%Q
a Systoli% blood p"ess$"e less than 90mm ?g
b P$pils $ne6$ally dilated
% espi"ato"y "ate of . b"eathGmin
d P$lse "ate less than 50bpm
+. *$"se '$%y is planning to gi/e p"e ope"ati/e tea%hing to a %lient who will be $nde"going "hinoplasty Hhi%h
of the following sho$ld be in%l$dedQ
a es$lts of the s$"ge"y will be immediately noti%eable postope"ati/ely
b *o"mal saline nose d"ops will need to be administe"ed p"eope"ati/ely
% #fte" s$"ge"y& nasal pa%ing will be in pla%e to 10 days
d #spi"in %ontaining medi%ations sho$ld not be taen 1. days befo"e s$"ge"y
+ Pa$l is admitted to the hospital d$e to metaboli% a%idosis %a$sed by )iabeti% etoa%idosis )# !he n$"se
p"epa"es whi%h of the following medi%ations as an initial t"eatment fo" this p"oblemQ
a eg$la" ins$lin
b Potassi$m% Sodi$m bi%a"bonate
d Cal%i$m gl$%onate
+5 )" <a"6$e( tells a %lient that an in%"ease intae of foods that a"e "i%h in 7itamin , and beta=%a"otene a"e
impo"tant fo" healthie" sin !he n$"se tea%hes the %lient that e-%ellent food so$"%es of both of these
s$bstan%es a"e:
a Fish and f"$it Eam
b O"anges and g"apef"$it
% Ca""ots and potatoes
d Spina%h and mangoes
+8 # %lient has Dast"oesophageal efl$- )isease D,) !he n$"se sho$ld tea%h the %lient that afte" e/e"y
1+ A )$"ing !otal Pa"ente"al *$t"ition !P* administ"ation& the %lient sho$ld be monito"ed "eg$la"ly fo"
hype"gly%emia
1. D Ba$ndi%e may be p"esent in a%$te pan%"eatitis owing to obst"$%tion of the bilia"y d$%t
1 A !etany may o%%$" afte" thy"oide%tomy if the pa"athy"oid glands a"e a%%identally inE$"ed o" "emo/ed
15 D !ypi%al signs of hypothy"oidism in%l$des weight gain& fatig$e& de%"eased ene"gy& apathy& b"ittle nails& d"y
sin& %old intole"an%e& %onstipation and n$mbness
18 ) #fte" a pel/i% s$"ge"y& the"e is an in%"eased %han%e of th"ombophlebitits owing to the pel/i% manip$lation
that %an inte"fe"e with %i"%$lation and p"omote /eno$s stasis1 D Fo" the safety of all pe"sonnel& if the defib"illato" paddles a"e being dis%ha"ged& all pe"sonnel m$st stand
ba% and be %lea" of all the %onta%t with the %lient o" the %lientKs bed
19 D ?a"d %andy will "elie/e thi"st and in%"ease %a"bohyd"ates b$t does not s$pply e-t"a fl$id
20 C Infe%tion is "esponsible fo" one thi"d of the t"a$mati% o" s$"gi%ally ind$%ed death of %lients with "enal
fail$"e as well as medi%al ind$%ed a%$te "enal fail$"e #F
21 C !he"e is no "espi"ato"y mo/ement in stage . of anesthesia& p"io" to this stage& "espi"ation is dep"essed b$t
p"esent
22 ) Comp"ession of the l$ng by fl$id that a%%$m$lates at the base of the l$ngs "ed$%es e-pansion and ai"
e-%hange2+ C #ssessment of a %lient with ?odginKs disease most often "e/eals enla"ged& painless lymph node& fe/e"&
malaise and night sweats
2. A F"a%t$"ed pain is gene"ally des%"ibed as sha"p& %ontin$o$s& and in%"easing in f"e6$en%y2 D Signs and symptoms of infe%tion $nde" a %asted a"ea in%l$de odo" o" p$"$lent d"ainage and the p"esen%e of
hot spotT whi%h a"e a"eas on the %ast that a"e wa"me" than the othe"s
25 ) Otos%opi% e-amnation in a %lient with mastoiditis "e/eals a d$ll& "ed& thi% and immobile tymphani%
memb"ane with o" witho$t pe"fo"ation
28 D 'oss of gast"i% fl$id /ia nasogast"i% s$%tion o" /omiting %a$ses metaboli% alalosis be%a$se of the loss of
hyd"o%hlo"i% a%id whi%h is a potent a%id in the body
2 A !he ad$lt with no"mal %e"eb"ospinal fl$id has no "ed blood %ells
29 D <eas$"ing the $"ine o$tp$t to dete%t e-%ess amo$nt and %he%ing the spe%ifi% g"a/ity of $"ine samples to
dete"mine $"ine %on%ent"ation a"e app"op"iate meas$"es to dete"mine the onset of diabetes insipid$s
+0 ) !he n$"se sho$ld fo%$s mo"e on de/eloping less st"essf$l ways of a%%omplishing "o$tine tas
+1 C #$tot"ansf$sion is a%%eptable fo" the %lient who is in dange" of %a"dia% a""est
+2 D !he %lient with th"omboembolism does not ha/e %oolness++ A Positioning the %lient on one side with head fle-ed fo"wa"d allows the tong$e to fall fo"wa"d and fa%ilitates
d"ainage se%"etions the"efo"e p"e/ents aspi"ation
+. C *$"sing %a"e afte" bone biopsy in%l$des %lose monito"ing of the p$n%t$"ed site fo" bleeding& swelling andhematoma fo"mation
+ D Haling and swimming a"e /e"y helpf$l in st"engthening ba% m$s%les fo" the %lient s$ffe"ing f"om lowe"
ba% pain
+5 C S$dden& se/e"e abdominal pain is the most indi%ati/e sign of pe"fo"ation Hhen pe"fo"ation of an $l%e"
o%%$"s& the n$"se maybe $nable to hea" bowel so$nds at all
+8 A #fte" s$"ge"y to %o""e%t a deta%hed "etina& p"e/ention of in%"eased int"ao%$la" p"ess$"e is the p"io"ity goal
+ A <ioti% agent %onst"i%ts the p$pil and %ont"a%ts %ilia"y m$s%le !hese effe%ts widen the filt"ation angle and
pe"mit in%"eased o$t flow of a6$eo$s h$mo"
+9 D It is a p"io"ity to hype"o-ygenate the %lient befo"e and afte" s$%tioning to p"e/ent hypo-ia and to maintain
%e"eb"al pe"f$sion
.0 D #bdominal b"eathing imp"o/es l$ngs e-pansion
.1 C # Client with b$"ns is /e"y sensiti/e to tempe"at$"e %hanges be%a$se heat is loss in the b$"n a"eas
.2 A !he g"aft %o/e"s the ne"/e endings& whi%h "ed$%es pain and p"o/ides f"amewo" fo" g"an$lation
.+ ) <eat p"o/ides p"oteins and the f"$it p"oteins /itamin C that both p"omote wo$nd healing
.. C !his is p"ima"ily %a$sed by the t"a$ma of intestinal manip$lation and the dep"essi/e effe%ts anestheti%s and
analgesi%s
. D Constipation& dia""hea& andGo" %onstipation alte"nating with dia""hea a"e the most %ommon symptoms of
%olo"e%tal %an%e".5 ) Hith in%"eased int"aabdominal p"ess$"e& the abdominal wall will be%ome tende" and "igid
.8 A P"ess$"e applied in the p$n%t$"e site indi%ates that a bilia"y /essel was p$n%t$"e whi%h is a %ommon
%ompli%ation afte" li/e" biopsy
. ) ?epatitis # is p"ima"ily sp"ead /ia fe%al=o"al "o$te Sewage poll$ted wate" may ha"bo" the /i"$s
.9 ) #mylase %on%ent"ation is high in the pan%"eas and is ele/ated in the se"$m when the pan%"eas be%omes
a%$tely inflamed and also it disting$ishes pan%"eatitis f"om othe" a%$te abdominal p"oblems
0 A Sodi$m& whi%h is %on%e"ned with the "eg$lation of e-t"a%ell$la" fl$id /ol$me& it is lost with /omiting
Chlo"ide& whi%h balan%es %ations in the e-t"a%ell$la" %ompa"tments& is also lost with /omiting& be%a$se
sodi$m and %hlo"ide a"e pa"allel ele%t"olytes& hyponat"emia will a%%ompany
12 A #n in%"eased in ')' %holeste"ol %on%ent"ation has been do%$mented at "is fa%to" fo" the de/elopment of
athe"os%le"osis ')' %holeste"ol is not b"oen down into the li/e" b$t is deposited into the wall of the blood
/essels
1+ D !he"e is a potential alte"ation in "enal pe"f$sion manifested by de%"eased $"ine o$tp$t !he alte"ed "enal
pe"f$sion may be "elated to "enal a"te"y embolism& p"olonged hypotension& o" p"olonged ao"ti% %"oss=
%lamping d$"ing the s$"ge"y
1. A Dood so$"%e of /itamin @12 a"e dai"y p"od$%ts and meats
1 C #plasti% anemia de%"eases the bone ma""ow p"od$%tion of @CKs& white blood %ells& and platelets !he%lient is at "is fo" b"$ising and bleeding tenden%ies
15 )' #n ele%ti/e p"o%ed$"e is s%hed$led in ad/an%e so that all p"epa"ations %an be %ompleted ahead of time !he
/ital signs a"e the final %he% that m$st be %ompleted befo"e the %lient lea/es the "oom so that %ontin$ity of
%a"e and assessment is p"o/ided fo"
18 A !he pea in%iden%e of #%$te 'ympho%yti% 'e$emia #'' is . yea"s of age It is $n%ommon afte" 1
yea"s of age
1 D #%$te 'ympho%yti% 'e$emia #'' does not %a$se gast"i% distention It does in/ade the %ent"al ne"/o$s
system& and %lients e-pe"ien%e heada%hes and /omiting f"om meningeal i""itation
19 ) )isseminated Int"a/as%$la" Coag$lation )IC has not been fo$nd to "espond to o"al anti%oag$lants s$%h asCo$madin
20 A U"ine o$tp$t p"o/ides the most sensiti/e indi%ation of the %lientKs "esponse to the"apy fo" hypo/olemi%
sho% U"ine o$tp$t sho$ld be %onsistently g"eate" than +0 to + m'Gh"21 C ,a"ly wa"ning signs of la"yngeal %an%e" %an /a"y depending on t$mo" lo%ation ?oa"seness lasting 2 wees
sho$ld be e/al$ated be%a$se it is one of the most %ommon wa"ning signs
22 C Ste"oids de%"ease the bodyKs imm$ne "esponse th$s de%"easing the p"od$%tion of antibodies that atta% the
a%etyl%holine "e%epto"s at the ne$"om$s%$la" E$n%tion
2+ C !he osmoti% di$"eti% mannitol is %ont"aindi%ated in the p"esen%e of inade6$ate "enal f$n%tion o" hea"t
fail$"e be%a$se it in%"eases the int"a/as%$la" /ol$me that m$st be filte"ed and e-%"eted by the idney
2. A !hese de/i%es a"e mo"e a%%$"ate be%a$se they a"e easily to $sed and ha/e imp"o/ed adhe"en%e in ins$lin
"egimens by yo$ng people be%a$se the medi%ation %an be administe"ed dis%"eetly
2 C )amage to blood /essels may de%"ease the %i"%$lato"y pe"f$sion of the toes& this wo$ld indi%ate the la% of
blood s$pply to the e-t"emity
25 D' ,le/ation will help %ont"ol the edema that $s$ally o%%$"s
28 )' U"i% a%id has a low sol$bility& it tends to p"e%ipitate and fo"m deposits at /a"io$s sites whe"e blood flow isleast a%ti/e& in%l$ding %a"tilagino$s tiss$e s$%h as the ea"s
2 ) !he palms sho$ld bea" the %lientKs weight to a/oid damage to the ne"/es in the a-illa
29 A #%ti/e e-e"%ises& alte"nating e-tension& fle-ion& abd$%tion& and add$%tion& mobili(e e-$dates in the Eoints"elie/es stiffness and pain
+0 C' #lte"ation in sensation and %i"%$lation indi%ates damage to the spinal %o"d& if these o%%$"s notify physi%ian
immediately
+1 A In the di$"eti% phase fl$id "etained d$"ing the olig$"i% phase is e-%"eted and may "ea%h + to lite"s daily&
hypo/olemia may o%%$" and fl$ids sho$ld be "epla%ed
+2 C !he %onstit$ents of CSF a"e simila" to those of blood plasma #n e-amination fo" gl$%ose %ontent is done
to dete"mine whethe" a body fl$id is a m$%$s o" a CSF # CSF no"mally %ontains gl$%ose
++ ) !"a$ma is one of the p"ima"y %a$se of b"ain damage and sei($"e a%ti/ity in ad$lts Othe" %ommon %a$ses of
sei($"e a%ti/ity in ad$lts in%l$de neoplasms& withd"awal f"om d"$gs and al%ohol& and /as%$la" disease
+. A It is %"$%ial to monito" the p$pil si(e and papilla"y "esponse to indi%ate %hanges a"o$nd the %"anial ne"/es
+ C !he n$"se most positi/e app"oa%h is to en%o$"age the %lient with m$ltiple s%le"osis to stay a%ti/e& $se st"ess
"ed$%tion te%hni6$es and a/oid fatig$e be%a$se it is impo"tant to s$ppo"t the imm$ne system while "emaining
a%ti/e
+5 D estlessness is an ea"ly indi%ato" of hypo-ia !he n$"se sho$ld s$spe%t hypo-ia in $n%ons%io$s %lient who
s$ddenly be%omes "estless
+8 ) In spinal sho%& the bladde" be%omes %ompletely atoni% and will %ontin$e to fill $nless the %lient is
%athete"i(ed
+ A P"og"ession stage is the %hange of t$mo" f"om the p"eneoplasti% state o" low deg"ee of malignan%y to a fastg"owing t$mo" that %annot be "e/e"sed
+9 D Intensity is the maEo" indi%ati/e of se/e"ity of pain and it is impo"tant fo" the e/al$ation of the t"eatment
.0 )' !he $se of f"ag"ant soap is /e"y d"ying to sin hen%e %a$sing the p"$"it$s
.1 C' #t"opine s$lfate is %ont"aindi%ated with gla$%oma patients be%a$se it in%"eases int"ao%$la" p"ess$"e
.2 A # 58 yea" old %lient is g"eate" "is be%a$se the olde" ad$lt %lient is mo"e liely to ha/e a less=effe%ti/e
imm$ne system
.+ ) !he last a"ea to "et$"n sensation is in the pe"ineal a"ea& and the n$"se in %ha"ge sho$ld monito" the %lient fo"
distended bladde"
.. D Dl$%o%o"ti%oids play no signifi%ant "ole in disease t"eatment
. D !"a%heostomy t$be has se/e"al potential %ompli%ations in%l$ding bleeding& infe%tion and la"yngeal ne"/e
15 # +9 yea" old mothe" with obsessi/e=%omp$lsi/e diso"de" has be%ome immobili(ed by he" elabo"ate hand
washing and waling "it$als *$"se !"ish "e%ogni(es that the basis of OC diso"de" is often:
a P"oblems with being too %ons%ientio$s
b P"oblems with ange" and "emo"se
% Feelings of g$ilt and inade6$a%yd Feeling of $nwo"thiness and hopelessness
18 <a"io is %omplaining to othe" %lients abo$t not being allowed by staff to eep food in his "oom Hhi%h of
the following inte"/entions wo$ld be most app"op"iateQ
a #llowing a sna% to be ept in his "oom
b ep"imanding the %lient
% Igno"ing the %lients beha/io"
d Setting limits on the beha/io"
1 Conney with bo"de"line pe"sonality diso"de" who is to be dis%ha"ge soon th"eatens to do somethingT to
he"self if dis%ha"ged Hhi%h of the following a%tions by the n$"se wo$ld be most impo"tantQa #s a family membe" to stay with the %lient at home tempo"a"ily
b )is%$ss the meaning of the %lientKs statement with he"
% e6$est an immediate e-tension fo" the %lientd Igno"e the %lients statement be%a$se itKs a sign of manip$lation
19 Boey a %lient with antiso%ial pe"sonality diso"de" bel%hes lo$dly # staff membe" ass Boey& )o yo$
now why people find yo$ "ep$lsi/eQT this statement most liely wo$ld eli%it whi%h of the following %lient
"ea%tionQ
a )epensi/eness
b ,mba""assment
% Shame
d emo"sef$lness
20 Hhi%h of the following app"oa%hes wo$ld be most app"op"iate to $se with a %lient s$ffe"ing f"om
na"%issisti% pe"sonality diso"de" when dis%"epan%ies e-ist between what the %lient states and what a%t$ally
e-istQ
a ationali(ation b S$ppo"ti/e %onf"ontation
% 'imit setting
d Consisten%y21 Cely is e-pe"ien%ing al%ohol withd"awal e-hibits t"emo"s& diapho"esis and hype"a%ti/ity @lood p"ess$"e
is 190G8 mmhg and p$lse is 92 bpm Hhi%h of the medi%ations wo$ld the n$"se e-pe%t to administe"Q
a *alo-one *a"%an
b @en(l"opine Cogentin
% 'o"a(epam #ti/an
d ?alope"idol ?aldol
22 Hhi%h of the following foods wo$ld the n$"se !"ish eliminate f"om the diet of a %lient in al%ohol
withd"awalQ
a <il
b O"ange B$i%e
% Soda
d eg$la" Coffee
2+ Hhi%h of the following wo$ld *$"se ?a(el e-pe%t to assess fo" a %lient who is e-hibiting late signs of
he"oin withd"awalQ
a Aawning N diapho"esis
b estlessness N I""itability
% Constipation N steato""hea
d 7omiting and )ia""hea2. !o establish open and t"$sting "elationship with a female %lient who has been hospitali(ed with se/e"e
an-iety& the n$"se in %ha"ge sho$ldQ
a ,n%o$"age the staff to ha/e f"e6$ent inte"a%tion with the %lient
b Sha"e an a%ti/ity with the %lient
% Di/e %lient feedba% abo$t beha/io"
d espe%t %lientKs need fo" pe"sonal spa%e
2 *$"se <onette "e%ogni(es that the fo%$s of en/i"onmental <I'I,U the"apy is to:
a <anip$late the en/i"onment to b"ing abo$t positi/e %hanges in beha/io"
b #llow the %lientKs f"eedom to dete"mine whethe" o" not they will be in/ol/ed in a%ti/ities
% ole play life e/ents to meet indi/id$al needs
d Use nat$"al "emedies "athe" than d"$gs to %ont"ol beha/io"
25 *$"se !"ish wo$ld e-pe%t a %hild with a diagnosis of "ea%ti/e atta%hment diso"de" to:
d !he %lient maintains %onta%t with a %"isis %o$nselo"
.9 *$"se !ina is %a"ing fo" a %lient with dep"ession who has not "esponded to antidep"essant medi%ation !hen$"se anti%ipates that what t"eatment p"o%ed$"e may be p"es%"ibedQ
a *e$"olepti% medi%ation
b Sho"t te"m se%l$sion
% Psy%hos$"ge"y
d ,le%t"o%on/$lsi/e the"apy
0 <a"io is admitted to the eme"gen%y "oom with d"$g=in%l$ded an-iety "elated to o/e" ingestion of
p"es%"ibed antipsy%hoti% medi%ation !he most impo"tant pie%e of info"mation the n$"se in %ha"ge sho$ld
obtain initially is the:
a 'ength of time on the med b *ame of the ingested medi%ation N the amo$nt ingested
% eason fo" the s$i%ide attempt
d *ame of the nea"est "elati/e N thei" phone n$mbe"
ANSERS a$% RATIONALES #r PS(CHIATRIC NURSING Part 1
1 C !otal abstinen%e is the only effe%ti/e t"eatment fo" al%oholism
2 A ?all$%inations a"e /is$al& a$dito"y& g$stato"y& ta%tile o" olfa%to"y pe"%eptions that ha/e no basis in "eality
+ D !he *$"se has a "esponsibility to obse"/e %ontin$o$sly the a%$tely s$i%idal %lient !he *$"se sho$ld wat%h
fo" %l$es& s$%h as %omm$ni%ating s$i%idal tho$ghts& and messagesW hoa"ding medi%ations and taling abo$t
death
. )' ,stablishing a %onsistent eating plan and monito"ing %lientKs weight a"e impo"tant to this diso"de"
C #pp"op"iate n$"sing inte"/entions fo" an an-iety atta% in%l$de $sing sho"t senten%es& staying with the %lient&
de%"easing stim$li& "emaining %alm and medi%ating as needed
5 ) )el$sion of g"ande$" is a false belief that one is highly famo$s and impo"tant
8 D Indi/id$al with dependent pe"sonality diso"de" typi%ally shows inde%isi/eness s$bmissi/eness and %linging
beha/io" so that othe"s will mae de%isions with them
A Clients with s%hi(otypal pe"sonality diso"de" e-pe"ien%e e-%essi/e so%ial an-iety that %an lead to pa"anoid
tho$ghts
9 ) @$limia diso"de" gene"ally is a maladapti/e %oping "esponse to st"ess and $nde"lying iss$es !he %lientsho$ld identify an-iety %a$sing sit$ation that stim$late the b$limi% beha/io" and then lea"n new ways of
%oping with the an-iety
10 A #n ad$lt age +1 to . gene"ates new le/el of awa"eness
11 A *e$"om$s%$la" @lo%e"& s$%h as SUCCI*A'C?O'I*, #ne%tine p"od$%es "espi"ato"y dep"ession
be%a$se it inhibits %ont"a%tions of "espi"ato"y m$s%les
12 C Hith dep"ession& the"e is little o" no emotional in/ol/ement the"efo"e little alte"ation in affe%t
1+ D !hese %lients often hide food o" fo"%e /omitingW the"efo"e they m$st be %a"ef$lly monito"ed
1. A !hese %lients ha/e se/e"ely depleted le/els of sodi$m and potassi$m be%a$se of thei" sta"/ation diet and
ene"gy e-pendit$"e& these ele%t"olytes a"e ne%essa"y fo" %a"dia% f$n%tioning
1 ) 'imiting $nne%essa"y inte"a%tion will de%"ease stim$lation and agitation
15 C it$alisti% beha/io" seen in this diso"de" is aimed at %ont"olling g$ilt and inade6$a%y by maintaining an
absol$te set patte"n of beha/io"
18 D !he n$"se needs to set limits in the %lientKs manip$lati/e beha/io" to help the %lient %ont"ol dysf$n%tional beha/io" # %onsistent app"oa%h by the staff is ne%essa"y to de%"ease manip$lation
1 ) #ny s$i%idal statement m$st be assessed by the n$"se !he n$"se sho$ld dis%$ss the %lientKs statement with
he" to dete"mine its meaning in te"ms of s$i%ide
19 A Hhen the staff membe" as the %lient if he wonde"s why othe"s find him "ep$lsi/e& the %lient is liely to
feel defensi/e be%a$se the 6$estion is belittling !he nat$"al tenden%y is to %o$nte"atta% the th"eat to self
image
20 ) !he n$"se wo$ld spe%ifi%ally $se s$ppo"ti/e %onf"ontation with the %lient to point o$t dis%"epan%ies
between what the %lient states and what a%t$ally e-ists to in%"ease "esponsibility fo" self
21 C !he n$"se wo$ld most liely administe" ben(odia(epine& s$%h as lo"a(epan ati/an to the %lient who ise-pe"ien%ing symptom: !he %lientKs e-pe"ien%es symptoms of withd"awal be%a$se of the "ebo$nd
phenomenon when the sedation of the C*S f"om al%ohol begins to de%"ease
22 D eg$la" %offee %ontains %affeine whi%h a%ts as psy%homoto" stim$lants and leads to feelings of an-iety andagitation Se"/ing %offee top the %lient may add to t"emo"s o" waef$lness
2+ D 7omiting and dia""hea a"e $s$ally the late signs of he"oin withd"awal& along with m$s%le spasm& fe/e"&
na$sea& "epetiti/e& abdominal %"amps and ba%a%he
2. D <o/ing to a %lientKs pe"sonal spa%e in%"eases the feeling of th"eat& whi%h in%"eases an-iety
2 A ,n/i"onmental <I'I,U the"apy aims at ha/ing e/e"ything in the %lientKs s$""o$nding a"ea towa"d
helping the %lient
25 C Child"en who ha/e e-pe"ien%ed atta%hment diffi%$lties with p"ima"y %a"egi/e" a"e not able to t"$st othe"s
and the"efo"e "elate s$pe"fi%ially
28 A Child"en ha/e diffi%$lty /e"bally e-p"essing thei" feelings& a%ting o$t beha/io"& s$%h as tempe" tant"$ms&
may indi%ate $nde"lying dep"ession
2 D !he a$tisti% %hild "epeat so$nds o" wo"ds spoen by othe"s
29 D !he %lient statement is an e-ample of the $se of denial& a defense that blo%s p"oblem by $n%ons%io$s"ef$sing to admit they e-ist
+0 A )is%$ssion of the fea"ed obEe%t t"igge"s an emotional "esponse to the obEe%t
+1 ) !he n$"se p"esen%e may p"o/ide the %lient with s$ppo"t N feeling of %ont"ol+2 D ,-pe"ien%ing the a%t$al t"a$ma in d"eams o" flashba% is the maEo" symptom that disting$ishes post
d !he %lient is able to mo/e all e-t"emities o%%asionally
1 *$"se ?a(el in/ites new %lientKs pa"ents to attend the psy%ho ed$%ational p"og"am fo" families of the
%h"oni%ally mentally ill !he p"og"am wo$ld be most liely to help the family with whi%h of the following
iss$esQ
a )e/eloping a s$ppo"t netwo" with othe" families
b Feeling mo"e g$ilty abo$t the %lientKs illness
% e%ogni(ing the %lientKs weanessd <anaging thei" finan%ial %on%e"n and p"oblems
15 Hhen planning %a"e fo" )o"y with s%hi(otypal pe"sonality diso"de"& whi%h of the following wo$ld help the
%lient be%ome in/ol/ed with othe"sQ
a #ttending an a%ti/ity with the n$"se
b 'eading a sing a long in the afte"noon
% Pa"ti%ipating solely in g"o$p a%ti/ities
d @eing in/ol/ed with p"ima"ily one to one a%ti/ities
18 Hhi%h statement abo$t an indi/id$al with a pe"sonality diso"de" is t"$eQ
a Psy%hoti% beha/io" is %ommon d$"ing a%$te episodes b P"ognosis fo" "e%o/e"y is good with the"ape$ti% inte"/ention
% !he indi/id$al typi%ally "emains in the mainst"eam of so%iety& altho$gh he has p"oblems in so%ial and
o%%$pational "olesd !he indi/id$al $s$ally sees t"eatment willingly fo" symptoms that a"e pe"sonally dist"essf$l
1 *$"se Bohn is taling with a %lient who has been diagnosed with antiso%ial pe"sonality abo$t how to so%iali(e
d$"ing a%ti/ities witho$t being sed$%ti/e *$"se Bohn wo$ld fo%$s the dis%$ssion on whi%h of the following
a"easQ
a )is%$ssing his "elationship with his mothe"
b #sing him to e-plain "easons fo" his sed$%ti/e beha/io"
% S$ggesting to apologi(e to othe"s fo" his beha/io"
d ,-plaining the negati/e "ea%tions of othe"s towa"d his beha/io"
19 !ina with a hist"ioni% pe"sonality diso"de" is melod"amati% and "esponds to othe"s and sit$ations in an
e-agge"ated manne" *$"se !"ish wo$ld "e%ommend whi%h of the following a%ti/ities fo" !inaQ
a @aing %lass
b ole playing% S%"ap boo maing
d <$si% g"o$p
20 Boy has ente"ed the %hemi%al dependen%y $nit fo" t"eatment of al%ohol dependen%y Hhi%h of the following%lientKs possession will the n$"se most liely pla%e in a lo%ed a"eaQ
a !oothpaste
b Shampoo
% #ntisepti% wash
d <oist$"i(e"
21 Hhi%h of the following assessment wo$ld p"o/ide the best info"mation abo$t the %lientKs physiologi% "esponse
and the effe%ti/eness of the medi%ation p"es%"ibed spe%ifi%ally fo" al%ohol withd"awalQ
a Sleeping patte"n
b <ental ale"tness
% *$t"itional stat$s
d 7ital signs
22 #fte" administe"ing nalo-one *a"%an& an opioid antagonist& *$"se onald sho$ld monito" the female %lient
%a"ef$lly fo" whi%h of the followingQ
a espi"ato"y dep"ession
b ,pilepsy
% idney fail$"e
d Ce"eb"al edema
2+ Hhi%h of the following wo$ld n$"se onald $se as the best meas$"e to dete"mine a %lientKs p"og"ess in"ehabilitationQ
a !he way he gets along with his pa"ents
b !he n$mbe" of d"$g=f"ee days he has
% !he inds of f"iends he maes
d !he amo$nt of "esponsibility his Eob entails
2. # female %lient is b"o$ght by amb$lan%e to the hospital eme"gen%y "oom afte" taing an o/e"dose of
ba"bit$"ates is %omatose *$"se !"ish wo$ld be espe%ially ale"t fo" whi%h of the followingQ
1 C Hhen the n$"se and %lient ag"ee to wo" togethe"& a %ont"a%t sho$ld be established& the length of
the "elationship sho$ld be dis%$ssed in te"ms of its $ltimate te"mination
2 ) !he n$"se sho$ld initiate b"ief& f"e6$ent %onta%ts th"o$gho$t the day to let the %lient now that he
is impo"tant to the n$"se !his will positi/ely affe%t the %lientKs self=esteem
+ D !he %lient with dep"ession is p"eo%%$pied& has de%"eased ene"gy& and is $nable to mae
de%isions !he n$"se p"esents the sit$ation& ItKs time fo" a showe"T& and assists the %lient with pe"sonal
hygiene to p"ese"/e his dignity and self=esteem
. C Foods high in ty"amine& those that a"e fe"mented& pi%led& aged& o" smoed m$st be a/oided
be%a$se when they a"e ingested in %ombination with <#OIs a hype"tensi/e %"isis will o%%$" A #nti%holine"gi% effe%ts& whi%h "es$lt f"om blo%age of the pa"asympatheti% %"aniosa%"al
ne"/o$s system in%l$ding $"ine "etention& bl$""ed /ision& d"y mo$th N %onstipation
5 ) )ysthymia is a less se/e"e& %h"oni% dep"ession diagnosed when a %lient has had a dep"essed
mood fo" mo"e days than not o/e" a pe"iod of at least 2 yea"s Client with dysthymi% diso"de" benefit f"om
psy%hothe"ape$ti% app"oa%hes that assist the %lient in "e/e"sing the negati/e self image& negati/e feelings
abo$t the f$t$"e
8 D Flight of ideas is spee%h patte"n of "apid t"ansition f"om topi% to topi%& often witho$t finishing
) !he %lient with mania is /e"y a%ti/e N needs to ha/e this ene"gy %hanneled in a %onst"$%ti/e tas
s$%h as %leaning o" tidying the "oom
9 C # %"$%ial fa%to" is dete"mining the lethality of a method is the amo$nt of time that o%%$"s
between initiating the method N the deli/e"y of the lethal impa%t of the method
10 D !he statement I donKt thin abo$t illing myself as m$%h as I $sed toT Indi%ates a lessening of
s$i%idal ideation and imp"o/ement in the %lientKs %ondition
11 A Using e-e"%ise bi%y%le is app"op"iate fo" the %lient who be%omes /e"y an-io$s when tho$ghts of
s$i%idal o%%$"12 C !he d"$g of %hoi%e fo" a %lient e-pe"ien%ing e-t"a py"amidal side effe%ts f"om halope"idol
?aldol is ben(t"opine mesylate %ogentin be%a$se of its anti %holine"gi% p"ope"ties
1+ D #llowing the %lient to be the fi"st to open the %a"t N tae a t"ay p"esents the %lient with the
"eality that the n$"ses a"e not to$%hing the food N t"ay& the"eby dispelling the del$sion
1. ) #ltho$gh all the a%tions indi%ate imp"o/ement& the ability to initiate simple a%ti/ities witho$t
di"e%tions indi%ates the most imp"o/ement in the %atatoni% beha/io"s
1 A Psy%hoed$%ational g"o$ps fo" families de/elop a s$ppo"t netwo" !hey p"o/ide ed$%ation abo$t
the bio%hemi%al etiology of psy%hiat"i% disease to "ed$%e& not in%"ease family g$ilt
15 C #ttending a%ti/ity with the n$"se assists the %lient to be%ome in/ol/ed with othe"s slowly !he
%lient with s%hi(otypal pe"sonality diso"de" needs s$ppo"t& indness N gentle s$ggestion to imp"o/e so%ial
sills N inte"pe"sonal "elationship
18 C #n indi/id$al with pe"sonality diso"de" $s$ally is not hospitali(ed $nless a %oe-isting #-is I
psy%hiat"i% diso"de" is p"esent Dene"ally& these indi/id$als mae ma"ginal adE$stments and "emain in so%iety&
altho$gh they typi%ally e-pe"ien%e "elationship and o%%$pational p"oblems "elated to thei" infle-ible
beha/io"s Pe"sonality diso"de"s a"e %h"oni% lifelong patte"ns of beha/io"W a%$te episodes do not o%%$"Psy%hoti% beha/io" is $s$ally not %ommon& altho$gh it %an o%%$" in eithe" s%hi(otypal pe"sonality diso"de" o"
bo"de"line pe"sonality diso"de" @e%a$se these diso"de"s a"e end$"ing and e/asi/e and the indi/id$al is
infle-ible& p"ognosis fo" "e%o/e"y is $nfa/o"able Dene"ally& the indi/id$al does not see t"eatment be%a$se he
does not pe"%ei/e p"oblems with his own beha/io" )ist"ess %an o%%$" based on othe" peopleKs "ea%tion to theindi/id$alKs beha/io"
1 D !he n$"se wo$ld e-plain the negati/e "ea%tions of othe"s towa"ds the %lientKs beha/io"s to mae
the %lients awa"e of the impa%t of his sed$%ti/e beha/io"s on othe"s
19 ) !he n$"se wo$ld $se "ole=playing to tea%h the %lient app"op"iate "esponses to othe"s and in/a"io$s sit$ations !his %lient d"amati(es e/ents& d"awn attention to self& and is $nawa"e of and does not deal
with feelings !he n$"se wo"s to help the %lient %la"ify t"$e feelings N lea"n to e-p"ess them app"op"iately
20 C #ntisepti% mo$thwash often %ontains al%ohol N sho$ld be ept in lo%ed a"ea& $nless labeling
%lea"ly indi%ates that the p"od$%t does not %ontain al%ohol
21 D <onito"ing of /ital signs p"o/ides the best info"mation abo$t the %lientKs o/e"all physiologi%
stat$s d$"ing al%ohol withd"awal N the physiologi% "esponse to the medi%ation $sed
22 A #fte" administe"ing nalo-one *a"%an the n$"se sho$ld monito" the %lientKs "espi"ato"y stat$s
%a"ef$lly& be%a$se the d"$g is sho"t a%ting N "espi"ato"y dep"ession may "e%$" afte" its effe%ts wea" off
2+ ) !he best meas$"e to dete"mine a %lientKs p"og"ess in "ehabilitation is the n$mbe" of d"$g= f"ee
days he has !he longe" the %lient is f"ee of d"$gs& the bette" the p"ognosis is
2. D @a"bit$"ates a"e C*S dep"essantsW the n$"se wo$ld be espe%ially ale"t fo" the possibility of
"espi"ato"y fail$"e espi"ato"y fail$"e is the most liely %a$se of death f"om ba"bit$"ate o/e" dose2 ) !he feeling of b$gs %"awling $nde" the sin is te"med as fo"mi%ation& and is asso%iated with
%o%aine $se
25 D !he n$"se wo$ld p"epa"e to administe" an antipsy%hoti% medi%ation s$%h as ?aldol to a %lient
e-pe"ien%ing amphetamine psy%hosis to de%"ease agitation N psy%hoti% symptoms& in%l$ding del$sions&
hall$%inations N %ogniti/e impai"ment
28 C #n a%id en/i"onment aids in the e-%"etion of PCP !he n$"se will definitely gi/e the %lient with
PCP into-i%ation %"anbe""y E$i%e to a%idify the $"ine to a ph of N a%%ele"ate e-%"etion
2 A !he n$"se wo$ld fa%ilitate p"og"essi/e "e/iew of the a%%ident and its %onse6$en%e to help the
%lient integ"ate feelings N memo"ies and to begin the g"ie/ing p"o%ess
29 ) !he n$"se inst"$%ts the n$"sing assistant to in/ite the %lient to l$n%h N a%%ompany him to the
dinning "oom to de%"ease manip$lation& se%onda"y gain& dependen%y and "einfo"%ement of negati/e beha/io"
while maintaining the %lientKs wo"th
+0 C !his p"o/ides s$ppo"t $ntil the indi/id$als %oping me%hanisms and pe"sonal s$ppo"t systems %an
be immobili(ed
+1 C esol/ing a loss is a slow& painf$l& %ontin$o$s p"o%ess $ntil a mental image of the dead pe"son&
almost de/oid of negati/e o" $ndesi"able feat$"es eme"ges
+2 A # mode"ate le/el of %ogniti/e impai"ment d$e to dementia is %ha"a%te"i(ed by in%"easing
dependen%e on en/i"onment N so%ial st"$%t$"e and by in%"easing psy%hologi% "igidity with a%%ent$ated
d Insight the"apy to dete"mine the o"igin of the an-iety and fea"
12 Hhen n$"se ?a(el %onside"s a %lientKs pla%ement on the %ontin$$m of an-iety& a ey in dete"mining thedeg"ee of an-iety being e-pe"ien%ed is the %lientKs:
a Pe"%ept$al field
b )el$sional system
% <emo"y state
d C"eati/ity le/el
1+ In the diagnosis of a possible pe"/asi/e de/elopmental a$tisti% diso"de" !he n$"se wo$ld find it most $n$s$al
d !he mani% phase of bipola" illness as a mood stabili(e" 18 Hhi%h medi%ation %an %ont"ol the e-t"a py"amidal effe%ts asso%iated with antipsy%hoti% agentsQ
a Clo"a(epate !"an-ene
b #mantadine Symmet"el% )o-epin Sine6$an
d Pe"phena(ine !"ilafon
1 Hhi%h of the following statements sho$ld be in%l$ded when tea%hing %lients abo$t monoamine o-idase
inhibito" <#OI antidep"essantsQ
a )onKt tae aspi"in o" nonste"oidal anti=inflammato"y d"$gs *S#I)s
b ?a/e blood le/els s%"eened weely fo" le$%openia
% #/oid st"en$o$s a%ti/ity be%a$se of the %a"dia% effe%ts of the d"$g
d )onKt tae p"es%"ibed o" o/e" the %o$nte" medi%ations witho$t %ons$lting the physi%ian
19 "is pe"iodi%ally has a%$te pani% atta%s !hese atta%s a"e $np"edi%table and ha/e no appa"ent asso%iation
with a spe%ifi% obEe%t o" sit$ation )$"ing an a%$te pani% atta%& "is may e-pe"ien%e:
a ?eightened %on%ent"ation
b )e%"eased pe"%ept$al field% )e%"eased %a"dia% "ate
d )e%"eased "espi"ato"y "ate
20 Initial inte"/entions fo" <a"%o with a%$te an-iety in%l$de all e-%ept whi%h of the followingQa !o$%hing the %lient in an attempt to %omfo"t him
b #pp"oa%hing the %lient in %alm& %onfident manne"
% ,n%o$"aging the %lient to /e"bali(e feelings and %on%e"ns
d P"o/iding the %lient with a safe& 6$iet and p"i/ate pla%e
21 *$"se Bessie is assessing a %lient s$ffe"ing f"om st"ess and an-iety # %ommon physiologi%al "esponse to st"ess
and an-iety is:
a Uti%a"ia
b 7e"tigo
% Sedation
d )ia""hea
22 Hhen pe"fo"ming a physi%al e-amination on a female an-io$s %lient& n$"se *elli wo$ld e-pe%t to find whi%h
of the following effe%ts p"od$%ed by the pa"asympatheti% systemQ
a <$s%le tension
b ?ype"a%ti/e bowel so$nds
% )e%"eased $"ine o$tp$t
d Constipation
2+ Hhi%h of the following d"$gs ha/e been nown to be effe%ti/e in t"eating obsessi/e=%omp$lsi/e diso"de"
OC)Qa )i/alp"oe- depaote and 'ithi$m lithobid
b Chlo"dia(epo-ide 'ib"i$m and dia(epam /ali$m
% Fl$/o-amine '$/o- and %lomip"amine anaf"anil
d @en(t"opine Cogentin and diphenhyd"amine benad"yl
2. !ony with ago"aphobia has been symptom=f"ee fo" . months Classi% signs and symptoms of phobia in%l$de:
a Se/e"e an-iety and fea"
b Hithd"awal and fail$"e to disting$ish "eality f"om fantasy
% )ep"ession and weight loss
d Insomnia and inability to %on%ent"ate
2 Hhi%h n$"sing a%tion is most app"op"iate when t"ying to diff$se a %lientKs impending /iolent beha/io"Q
a Pla%e the %lient in se%l$sion
b 'ea/ing the %lient alone $ntil he %an tal abo$t his feelings
% In/ol/ing the %lient in a 6$iet a%ti/ity to di/e"t attention
d ?elping the %lient identify and e-p"ess feelings of an-iety and ange"
25 osana is in the se%ond stage of #l(heime"Ks disease who appea"s to be in pain Hhi%h 6$estion by *$"se
Benny wo$ld best eli%it info"mation abo$t the painQ
a Hhe"e is yo$" pain lo%atedQT
b )o yo$ h$"tQ pa$se )o yo$ h$"tQT
% Can yo$ des%"ibe yo$" painQT
d Hhe"e do yo$ h$"tQT28 *$"sing p"epa"ation fo" a %lient $nde"going ele%t"o%on/$lsi/e the"apy ,C! "esemble those $sed fo":
a Dene"al anesthesia
b Ca"dia% st"ess testing
% *e$"ologi% e-amination
d Physi%al the"apy
2 Bose who is "e%ei/ing monoamine o-idase inhibito" antidep"essant sho$ld a/oid ty"amine& a %ompo$nd fo$nd
in whi%h of the following foodsQ
a Figs and %"eam %heese
b F"$its and yellow /egetables% #ged %heese and Chianti wine
d D"een leafy /egetables
29 ,"linda& age & with maEo" dep"ession $nde"goes a si-th ele%t"o%on/$lsi/e the"apy ,C! t"eatmentHhen assessing the %lient immediately afte" ,C!& the n$"se e-pe%ts to find:
a Pe"manent sho"t=te"m memo"y loss and hype"tension
b Pe"manent long=te"m memo"y loss and hypomania
% !"ansito"y sho"t=te"m memo"y loss and pe"manent long=te"m memo"y loss
d !"ansito"y sho"t and long te"m memo"y loss and %onf$sion
+0 @a"ba"a with bipola" diso"de" is being t"eated with lithi$m fo" the fi"st time *$"se Clint sho$ld obse"/e the
%lient fo" whi%h %ommon ad/e"se effe%t of lithi$mQ
a Poly$"ia
b Sei($"es
% Constipation
d Se-$al dysf$n%tion
+1 *$"se F"ed is assessing a %lient who has E$st been admitted to the , depa"tment Hhi%h signs wo$ld s$ggestan o/e"dose of an antian-iety agentQ
a S$spi%io$sness& dilated p$pils and in%omplete @P
b #gitation& hype"a%ti/ity and g"andiose ideation% Combati/eness& sweating and %onf$sion
d ,motional lability& e$pho"ia and impai"ed memo"y
+2 )is%ha"ge inst"$%tions fo" a male %lient "e%ei/ing t"i%y%li% antidep"essants in%l$de whi%h of the following
info"mationQ
a est"i%t fl$ids and sodi$m intae
b )onKt %ons$me al%ohol
% )is%ontin$e if d"y mo$th and bl$""ed /ision o%%$"
d est"i%t fl$id and sodi$m intae
++ Impo"tant tea%hing fo" women in thei" %hildbea"ing yea"s who a"e "e%ei/ing antipsy%hoti% medi%ations
in%l$des whi%h of the followingQ
a In%"eased in%iden%e of dysmeno""hea while taing the d"$g
b O%%$""en%e of in%omplete libido d$e to medi%ation ad/e"se effe%ts
% Contin$ing p"e/io$s $se of %ont"a%eption d$"ing pe"iods of ameno""hea
d Inst"$%tion that ameno""hea is i""e/e"sible
+. # %lient "ef$ses to "emain on psy%hot"opi% medi%ations afte" dis%ha"ge f"om an inpatient psy%hiat"i% $nit
Hhi%h info"mation sho$ld the %omm$nity health n$"se assess fi"st d$"ing the initial follow=$p with this
%lientQ
a In%ome le/el and li/ing a""angements b In/ol/ement of family and s$ppo"t systems
% eason fo" inpatient admission
d eason fo" "ef$sal to tae medi%ations
+ !he n$"se $nde"stands that the the"ape$ti% effe%ts of typi%al antipsy%hoti% medi%ations a"e asso%iated with
whi%h ne$"ot"ansmitte" %hangeQ
a )e%"eased dopamine le/el
b In%"eased a%etyl%holine le/el
% Stabili(ation of se"otonin
d Stim$lation of D#@#
+5 Hhi%h of the following best e-plains why t"i%y%li% antidep"essants a"e $sed with %a$tion in elde"ly patientsQ
+8 # %lient with dep"essi/e symptoms is gi/en p"es%"ibed medi%ations and tals with his the"apist abo$t his
belief that he is wo"thless and $nable to %ope with life Psy%hiat"i% %a"e in this t"eatment plan is based on
whi%h f"amewo"Q
a @eha/io"al f"amewo"
b Cogniti/e f"amewo"
% Inte"pe"sonal f"amewo" d Psy%hodynami% f"amewo"
+ # n$"se who e-plains that a %lientKs psy%hoti% beha/io" is $n%ons%io$sly moti/ated $nde"stands that the
%lientKs diso"de"ed beha/io" a"ises f"om whi%h of the followingQ
a #bno"mal thining
b #lte"ed ne$"ot"ansmitte"s
% Inte"nal needs
d esponse to stim$li
+9 # %lient with dep"ession has been hospitali(ed fo" t"eatment afte" taing a lea/e of absen%e f"om wo" !he
%lientKs employe" e-pe%ts the %lient to "et$"n to wo" following inpatient t"eatment !he %lient tells the n$"se&IKm no good IKm a fail$"eT #%%o"ding to %ogniti/e theo"y& these statements "efle%t:
a 'ea"ned beha/io"
b P$niti/e s$pe"ego and de%"eased self=esteem% Fa$lty tho$ght p"o%esses that go/e"n beha/io"
d ,/iden%e of diffi%$lt "elationships in the wo" en/i"onment
.0 !he n$"se des%"ibes a %lient as an-io$s Hhi%h of the following statement abo$t an-iety is t"$eQ
a #n-iety is $s$ally pathologi%al
b #n-iety is di"e%tly obse"/able
% #n-iety is $s$ally ha"mf$l
d #n-iety is a "esponse to a th"eat
.1 # %lient with a phobi% diso"de" is t"eated by systemati% desensiti(ation !he n$"se $nde"stands that this
app"oa%h will do whi%h of the followingQ
a ?elp the %lient e-e%$te a%tions that a"e fea"ed
b ?elp the %lient de/elop insight into i""ational fea"s
% ?elp the %lient s$bstit$tes one fea" fo" anothe" d ?elp the %lient de%"ease an-iety
.2 Hhi%h %lient o$t%ome wo$ld best indi%ate s$%%essf$l t"eatment fo" a %lient with an antiso%ial pe"sonality
diso"de"Qa !he %lient e-hibits %ha"ming beha/io" when a"o$nd a$tho"ity fig$"es
b !he %lient has de%"eased episodes of imp$lsi/e beha/io"s
% !he %lient maes statements of self=satisfa%tion
d !he %lientKs statements indi%ate no "emo"se fo" beha/io"s
.+ !he n$"se is %a"ing fo" a %lient with an a$toimm$ne diso"de" at a medi%al %lini%& whe"e alte"nati/e medi%ine is
$sed as an adE$n%t to t"aditional the"apies Hhi%h info"mation sho$ld the n$"se tea%h the %lient to help foste" a
sense of %ont"ol o/e" his symptomsQ
a Pathophysiology of disease p"o%ess
b P"in%iples of good n$t"ition
% Side effe%ts of medi%ations
d St"ess management te%hni6$es
.. Hhi%h of the following is the most disting$ishing feat$"e of a %lient with an antiso%ial pe"sonality diso"de"Q
a #ttention to detail and o"de"
b @i(a""e manne"isms and tho$ghts
% S$bmissi/e and dependent beha/io"
d )is"ega"d fo" so%ial and legal no"ms
. Hhi%h n$"sing diagnosis is most app"op"iate fo" a %lient with ano"e-ia ne"/osa who e-p"esses feelings of g$ilt
abo$t not meeting family e-pe%tationsQa #n-iety
b )ist$"bed body image
% )efensi/e %oping
d Powe"lessness
.5 # n$"se is e/al$ating the"apy with the family of a %lient with ano"e-ia ne"/osa Hhi%h of the following wo$ld
indi%ate that the the"apy was s$%%essf$lQ
a !he pa"ents "einfo"%ed in%"eased de%ision maing by the %lient
b !he pa"ents %lea"ly /e"bali(e thei" e-pe%tations fo" the %lient
% !he %lient /e"bali(es that family meals a"e now enEoyable
d !he %lient tells he" pa"ents abo$t feelings of low=self esteem
.8 # %lient with dysthymi% diso"de" "epo"ts to a n$"se that his life is hopeless and will ne/e" imp"o/e in the
f$t$"e ?ow %an the n$"se best "espond $sing a %ogniti/e app"oa%hQ
A Pe"sonal inte"nal st"ength and s$ppo"ti/e indi/id$als a"e %"iti%al fa%to"s that %an be employed to assist
the indi/id$al to %ope with a %"isis
9 D C"isis inte"/ention g"o$p helps %lient "eestablish psy%hologi% e6$ilib"i$m by assisting them to e-plo"e
new alte"nati/es fo" %oping It %onside"s "ealisti% sit$ations $sing "ational and fle-ible p"oblem sol/ing
methods
10 C !his wo$ld do%$ment that the %lient feels %omfo"table eno$gh to dis%$ss the p"oblems that ha/e
moti/ated the beha/io"
11 C !he most s$%%essf$l the"apy fo" people with phobias in/ol/es beha/io" modifi%ation te%hni6$es $singdesensiti(ation
12 A Pe"%ept$al field is a ey indi%ato" of an-iety le/el be%a$se the pe"%ept$al fields na""ow as an-iety
in%"eases
1+ D One of the symptoms of a$tisti% %hild displays a la% of "esponsi/eness to othe"s !he"e is little o" no
e-tension to the e-te"nal en/i"onment
1. ) Somati% del$sions fo%$s on bodily f$n%tions o" systems and %ommonly in%l$de del$sion abo$t fo$l
odo" emissions& inse%t manifestations& inte"nal pa"asites and misshapen pa"ts
1 D # %lient with bo"de"line pe"sonality displays a pe"/asi/e patte"n of $np"edi%table beha/io"& mood and
self image Inte"pe"sonal "elationships may be intense and $nstable and beha/io" may be inapp"op"iate and
imp$lsi/e
15 A P"op"anolol is a potent beta ad"ene"gi% blo%e" and p"od$%ing a sedating effe%t& the"efo"e it is $sed to
t"eat antipsy%hoti% ind$%ed aathisia and an-iety
18 ) #mantadine is an anti%holine"gi% d"$g $sed to "eli/e d"$g=ind$%ed e-t"a py"amidal ad/e"se effe%ts
s$%h as m$s%le weaness& in/ol$nta"y m$s%le mo/ements& pse$dopa"insonism and ta" di/e dysinesia
1 C <#OI antidep"essants when %ombined with a n$mbe" of d"$gs %an %a$se life=th"eatening hype"tensi/e
%"isis ItKs impe"ati/e that a %lient %he%s with his physi%ian and pha"ma%ist befo"e taing any othe"
medi%ations
19 ) Pani% is the most se/e"e le/el of an-iety )$"ing pani% atta%& the %lient e-pe"ien%es a de%"ease in the
pe"%ept$al field& be%oming mo"e fo%$sed on self& less awa"e of s$""o$ndings and $nable to p"o%ess
info"mation f"om the en/i"onment !he de%"eased pe"%ept$al field %ont"ib$tes to impai"ed attention and
inability to %on%ent"ate
20 A !he eme"gen%y n$"se m$st establish "appo"t and t"$st with the an-io$s %lient befo"e $sing the"ape$ti%
to$%h !o$%hing an an-io$s %lient may a%t$ally in%"ease an-iety21 D )ia""hea is a %ommon physiologi%al "esponse to st"ess and an-iety
22 ) !he pa"asympatheti% ne"/o$s system wo$ld p"od$%e in%omplete DI motility "es$lting in hype"a%ti/e
bowel so$nds& possibly leading to dia""hea
2+ C !he antidep"essants fl$/o-amine and %lomip"amine ha/e been effe%ti/e in the t"eatment of OC)
2. A Phobias %a$se se/e"e an-iety s$%h as pani% atta% that is o$t of p"opo"tion to the th"eat of the fea"ed
obEe%t o" sit$ation Physi%al signs and symptoms of phobias in%l$de p"of$se sweating& poo" moto" %ont"ol&
ta%hy%a"dia and ele/ated @P
2 D In many instan%es& the n$"se %an diff$se impending /iolen%e by helping the %lient identify and e-p"ess
feelings of ange" and an-iety S$%h statement as Hhat happened to get yo$ this ang"yQT may help the %lient
/e"bali(es feelings "athe" than a%t on them
25 ) Hhen speaing to a %lient with #l(heime"Ks disease& the n$"se sho$ld $se %lose=ended 6$estions
!hose that the %lient %an answe" with yesT o" noT whene/e" possible and a/oid 6$estions that "e6$i"e the%lient to mae %hoi%es epeating the 6$estion aids %omp"ehension
28 A !he n$"se sho$ld p"epa"e a %lient fo" ,C! in a manne" simila" to that fo" gene"al anesthesia
2 C #ged %heese and Chianti wine %ontain high %on%ent"ations of ty"amine
29 D ,C! %ommonly %a$ses t"ansito"y sho"t and long te"m memo"y loss and %onf$sion& espe%ially in
ge"iat"i% %lients It "a"ely "es$lts in pe"manent sho"t and long te"m memo"y loss
+0 A Poly$"ia %ommonly o%%$"s ea"ly in the t"eatment with lithi$m and %o$ld "es$lt in fl$id /ol$me defi%it
+1 D Signs of an-iety agent o/e"dose in%l$de emotional lability& e$pho"ia and impai"ed memo"y
+2 ) )"ining al%ohol %an potentiate the sedating a%tion of t"i%y%li% antidep"essants )"y mo$th and bl$""ed
/ision a"e no"mal ad/e"se effe%ts of t"i%y%li% antidep"essants
++ C Homen may e-pe"ien%e ameno""hea& whi%h is "e/e"sible& while taing antipsy%hoti%s #meno""hea
doesnKt indi%ate %essation of o/$lation th$s& the %lient %an still be p"egnant+. D !he fi"st a"e fo" assessment wo$ld be the %lientKs "eason fo" "ef$sing medi%ation !he %lient may not
$nde"stand the p$"pose fo" the medi%ation& may be e-pe"ien%ing dist"essing side effe%ts& o" may be %on%e"ned
abo$t the %ost of medi%ine In any %ase& the n$"se %annot p"o/ide app"op"iate inte"/ention befo"e assessing the
%lientKs p"oblem with the medi%ation !he patientKs in%ome le/el& li/ing a""angements& and in/ol/ement of
family and s$ppo"t systems a"e "ele/ant iss$es following dete"mination of the %lientKs "eason fo" "ef$sing
medi%ation !he n$"se p"o/iding follow=$p %a"e wo$ld ha/e a%%ess to the %lientKs medi%al "e%o"d and sho$ld
+ A ,-%ess dopamine is tho$ght to be the %hemi%al %a$se fo" psy%hoti% thining !he typi%al antipsy%hoti%s
a%t to blo% dopamine "e%epto"s and the"efo"e de%"ease the amo$nt of ne$"ot"ansmitte" at the synapses !he
typi%al antipsy%hoti%s do not in%"ease a%etyl%holine& stabili(e se"otonin& stim$late D#@#
+5 ) !he !C#s affe%t no"epineph"ine as well as othe" ne$"ot"ansmitte"s& and th$s ha/e signifi%ant
%a"dio/as%$la" side effe%ts !he"efo"e& they a"e $sed with %a$tion in elde"ly %lients who may ha/e in%"eased
"is fa%to"s fo" %a"dia% p"oblems be%a$se of thei" age and othe" medi%al %onditions !he "emaining side
effe%ts wo$ld apply to any %lient taing a !C# and a"e not pa"ti%$la" to an elde"ly pe"son
+8 ) Cogniti/e thining the"apy fo%$ses on the %lientKs mispe"%eptions abo$t self& othe"s and the wo"ld thatimpa%t f$n%tioning and %ont"ib$te to symptoms Using medi%ations to alte" ne$"ot"ansmitte" a%ti/ity is a
psy%hobiologi% app"oa%h to t"eatment !he othe" answe" %hoi%es a"e f"amewo"s fo" %a"e& b$t hey a"e not
appli%able to this sit$ation
+ C !he %on%ept that beha/io" is moti/ated and has meaning %omes f"om the psy%hodynami% f"amewo"
#%%o"ding to this pe"spe%ti/e& beha/io" a"ises f"om inte"nal wishes o" needs <$%h of what moti/ates beha/io" %omes f"om the $n%ons%io$s !he "emaining "esponses do not add"ess the inte"nal fo"%es tho$ght to
moti/ate beha/io"
+9 C !he %lient is demonst"ating fa$lty tho$ght p"o%esses that a"e negati/e and that go/e"n his beha/io" in
his wo" sit$ation X iss$es that a"e typi%ally e-amined $sing a %ogniti/e theo"y app"oa%h Iss$es in/ol/ing
lea"ned beha/io" a"e best e-plo"ed th"o$gh beha/io" theo"y& not %ogniti/e theo"y Iss$es in/ol/ing ego
de/elopment a"e the fo%$s of psy%hoanalyti% theo"y Option . is in%o""e%t be%a$se the"e is no e/iden%e in this
sit$ation that the %lient has %onfli%t$al "elationships in the wo" en/i"onment.0 D #n-iety is a "esponse to a th"eat a"ising f"om inte"nal o" e-te"nal stim$li
.1 A Systemati% desensiti(ation is a beha/io"al the"apy te%hni6$e that helps %lients with i""ational fea"s and
a/oidan%e beha/io" to fa%e the thing they fea"& witho$t e-pe"ien%ing an-iety !he"e is no attempt to p"omote
insight with this p"o%ed$"e& and the %lient will not be ta$ght to s$bstit$te one fea" fo" anothe" #ltho$gh the
%lientKs an-iety may de%"ease with s$%%essf$l %onf"ontation of i""ational fea"s& the p$"pose of the p"o%ed$"e is
spe%ifi%ally "elated to pe"fo"ming a%ti/ities that typi%ally a"e a/oided as pa"t of the phobi% "esponse
.2 ) # %lient with antiso%ial pe"sonality diso"de" typi%ally has f"e6$ent episodes of a%ting imp$lsi/ely with
poo" ability to delay self=g"atifi%ation !he"efo"e& de%"eased f"e6$en%y of imp$lsi/e beha/io"s wo$ld be
e/iden%e of imp"o/ement Cha"ming beha/io" when a"o$nd a$tho"ity fig$"es and statements indi%ating no
"emo"se a"e e-amples of symptoms typi%al of someone with this diso"de" and wo$ld not indi%ate s$%%essf$l
t"eatment Self=satisfa%tion wo$ld be /iewed as a positi/e %hange if the %lient e-p"esses low self=esteemW
howe/e" this is not a %ha"a%te"isti% of a %lient with antiso%ial pe"sonality diso"de"
.+ D In a$toimm$ne diso"de"s& st"ess and the "esponse to st"ess %an e-a%e"bate symptoms St"ess
management te%hni6$es %an help the %lient "ed$%e the psy%hologi%al "esponse to st"ess& whi%h in t$"n willhelp "ed$%e the physiologi% st"ess "esponse !his will affo"d the %lient an in%"eased sense of %ont"ol o/e" his
symptoms !he n$"se %an add"ess the "emaining answe" %hoi%es in he" tea%hing abo$t the %lientKs disease and
t"eatmentW howe/e"& nowledge alone will not help the %lient to manage his st"ess effe%ti/ely eno$gh to
%ont"ol symptoms
.. D )is"ega"d fo" established "$les of so%iety is the most %ommon %ha"a%te"isti% of a %lient with antiso%ial
pe"sonality diso"de" #ttention to detail and o"de" is %ha"a%te"isti% of someone with obsessi/e %omp$lsi/e
diso"de" @i(a""e manne"isms and tho$ghts a"e %ha"a%te"isti%s of a %lient with s%hi(oid o" s%hi(otypal diso"de"S$bmissi/e and dependent beha/io"s a"e %ha"a%te"isti% of someone with a dependent pe"sonality
. D !he %lient with ano"e-ia typi%ally feels powe"less& with a sense of ha/ing little %ont"ol o/e" any aspe%t
of life besides eating beha/io" Often& pa"ental e-pe%tations and standa"ds a"e 6$ite high and lead to the
%lientsK sense of g$ilt o/e" not meas$"ing $p
.5 A One of the %o"e iss$es %on%e"ning the family of a %lient with ano"e-ia is %ont"ol !he familyKs
a%%eptan%e of the %lientKs ability to mae independent de%isions is ey to s$%%essf$l family inte"/ention
#ltho$gh the "emaining options may o%%$" d$"ing the p"o%ess of the"apy& they wo$ld not ne%essa"ily indi%ate
a s$%%essf$l o$t%omeW the %ent"al family iss$es of dependen%e and independen%e a"e not add"esses on these
"esponses
.8 ) Use of %ogniti/e te%hni6$es allows the n$"se to help the %lient "e%ogni(e that this negati/e beliefs may
be disto"tions and that& by %hanging his thining& he %an adopt mo"e positi/e beliefs that a"e "ealisti% and
hopef$l #g"eeing with the %lientKs feelings and p"esenting a %hee"f$l attit$de a"e not %onsistent with a
%ogniti/e app"oa%h and wo$ld not be helpf$l in this sit$ation )enying the %lientKs feelings is belittling and
may %on/ey that the n$"se does not $nde"stand the depth of the %lientKs dist"ess. A' #"t the"apy p"o/ides a nonth"eatening /ehi%le fo" the e-p"ession of feelings& and $se of a small g"o$p
will help the %lient be%ome %omfo"table with pee"s in a g"o$p setting @asetball is a %ompetiti/e game that
"e6$i"es ene"gyW the %lient with maEo" dep"ession is not liely to pa"ti%ipate in this a%ti/ity e%ommending
that the %lient "ead a self=help boo may in%"ease& not de%"ease his isolation Hat%hing mo/ie with a pee"g"o$p does not g$a"antee that inte"a%tion will o%%$"W the"efo"e& the %lient may "emain isolated
.9 C' )ay t"eatment p"og"ams p"o/ide %lients with %h"oni%& pe"sistent mental illness t"aining in so%ial sills&
s$%h as meeting and g"eeting people& asing 6$estions o" di"e%tions& pla%ing an o"de" in a "esta$"ant& taingt$"ns in a g"o$p setting a%ti/ity #ltho$gh management of hall$%inations and medi%ation tea%hing may also be
pa"t of the p"og"am offe"ed in a day t"eatment& the n$"se is "efe""ing the %lient in this sit$ation be%a$se of his
#nswe": # !he %o$nt"y of o"igin has simila" p"epa"ation fo" a n$"se and has laws allowing Filipino n$"ses to
p"a%ti%e in thei" %o$nt"y
#%%o"ding to the Philippine *$"ses #%t of 2002& fo"eign n$"ses wanting to p"a%ti%e in the Philippines m$st show
p"oof that hisGhe" %o$nt"y of o"igin meets the two essential %onditions: a the "e6$i"ements fo" "egist"ation
between the two %o$nt"ies a"e s$bstantially the sameW and b the %o$nt"y of o"igin of the fo"eign n$"se has laws
allowing the Filipino n$"se to p"a%ti%e in hisGhe" %o$nt"y E$st lie its own %iti(ens
+ *$"ses p"a%ti%ing the p"ofession in the Philippines and a"e employed in go/e"nment hospitals a"e "e6$i"ed to
pay ta-es s$%h as:
# @oth in%ome ta- and p"ofessional ta-
@ In%ome ta- only sin%e they a"e e-empt f"om paying p"ofessional ta-
C P"ofessional ta- whi%h is paid by all n$"ses employed in both go/e"nment and p"i/ate hospitals
) In%ome ta- whi%h paid e/e"y <a"%h 1 and p"ofessional ta- whi%h is paid e/e"y Ban$a"y +1
#nswe": @ In%ome ta- only sin%e they a"e e-empt f"om paying p"ofessional ta-
#%%o"ding to the <agna Ca"ta fo" P$bli% ?ealth Ho"e"s& go/e"nment n$"ses a"e e-empted f"om paying
p"ofessional ta- ?en%e& as an employee in the go/e"nment& sGhe will pay only the in%ome ta-
. #%%o"ding to # 918+ Philippine *$"sing #%t of 2002& a g"ad$ate n$"se who wants to tae m$st li%ens$"e
e-amination m$st %omply with the following 6$alifi%ations:# #t least 21 yea"s old& g"ad$ate of @S* f"om a "e%ogni(ed s%hool& and of good mo"al %ha"a%te"
@ #t least 1 yea"s old& g"ad$ate of @S* f"om a "e%ogni(ed s%hool and of good mo"al %ha"a%te"
C #t least 1 yea"s old& p"o/ided that when sGhe passes the boa"d e-ams& sGhe m$st be at least 21 yea"s oldW @S*
g"ad$ate of a "e%ogni(ed s%hool& and of good mo"al %ha"a%te"
) Filipino %iti(en o" a %iti(en of a %o$nt"y whe"e we ha/e "e%ip"o%ityW g"ad$ate of @S* f"om a "e%ogni(ed s%hool
and of good mo"al %ha"a%te"
#nswe": ) Filipino %iti(en o" a %iti(en of a %o$nt"y whe"e we ha/e "e%ip"o%ityW g"ad$ate of @S* f"om a
"e%ogni(ed s%hool and of good mo"al %ha"a%te"
# 918+ se%tion 1+ states that the 6$alifi%ations to tae the boa"d e-ams a"e: Filipino %iti(en o" %iti(en of a%o$nt"y whe"e the Philippines has "e%ip"o%ityW of good mo"al %ha"a%te" and g"ad$ate of @S* f"om a "e%ogni(ed
s%hool of n$"sing !he"e is no e-pli%it p"o/ision abo$t the age "e6$i"ement in # 918+ $nlie in #815. oldlaw
Hhi%h of the following is !U, abo$t membe"ship to the Philippine *$"ses #sso%iation P*#Q
# <embe"ship to P*# is mandato"y and is stip$lated in the Philippine *$"sing #%t of 2002
@ <embe"ship to P*# is %omp$lso"y fo" newly "egiste"ed n$"ses wanting to ente" the p"a%ti%e of n$"sing in the
%o$nt"y
C <embe"ship to P*# is /ol$nta"y and is en%o$"aged by the PC Code of ,thi%s fo" *$"ses
) <embe"ship to P*# is "e6$i"ed by go/e"nment hospitals p"io" to employment
#nswe": C <embe"ship to P*# is /ol$nta"y and is en%o$"aged by the PC Code of ,thi%s fo" *$"ses
<embe"ship to any o"gani(ation& in%l$ding the P*#& is only /ol$nta"y and this "ight to Eoin any o"gani(ation is
g$a"anteed in the 198 %onstit$tion of the Philippines ?owe/e"& the PC Code of ,thi%s states that one of the
ethi%al obligations of the p"ofessional n$"se towa"ds the p"ofession is to be an a%ti/e membe" of the a%%"edited
p"ofessional o"gani(ation
5 Hhen the li%ense of the n$"se is "e/oed& it means that the n$"se:
# Is no longe" allowed to p"a%ti%e the p"ofession fo" the "est of he" life
@ Hill ne/e" ha/e he"Ghis li%ense "e=iss$ed sin%e it has been "e/oed
C <ay apply fo" "e=iss$an%e of hisGhe" li%ense based on %e"tain %onditions stip$lated in # 918+
) Hill "emain $nable to p"a%ti%e p"ofessional n$"sing
#nswe": C <ay apply fo" "e=iss$an%e of hisGhe" li%ense based on %e"tain %onditions stip$lated in # 918+
# 918+ se% 2. states that fo" e6$ity and E$sti%e& a "e/oed li%ense maybe "e=iss$ed p"o/ided that the following
%onditions a"e met: a the %a$se fo" "e/o%ation of li%ense has al"eady been %o""e%ted o" "emo/edW and& b at least
fo$" yea"s has elapsed sin%e the li%ense has been "e/oed
8 #%%o"ding to the %$""ent n$"sing law& the minim$m ed$%ational 6$alifi%ation fo" a fa%$lty membe" of a %ollege
of n$"sing is:
# Only a <aste" of #"ts in *$"sing is a%%eptable
@ <aste"s deg"ee in *$"sing o" in the "elated fields
C #t least a do%to"ate in n$"sing
) #t least 1 $nits in the <aste" of #"ts in *$"sing P"og"am
#nswe": @ <aste"s deg"ee in *$"sing o" in the "elated fields
#%%o"ding to # 918+ se% 28& the ed$%ational 6$alifi%ation of a fa%$lty membe" tea%hing in a %ollege of n$"sing
m$st be maste"s deg"ee whi%h maybe in n$"sing o" "elated fields lie ed$%ation& allied health p"ofessions&
psy%hology
!he ed$%ational 6$alifi%ation of a n$"se to be%ome a s$pe"/iso" in a hospital is:
# @S* with at least 9 $nits of post g"ad$ate st$dies in n$"sing administ"ation
@ <aste" of #"ts in *$"sing maEo" in administ"ation
C #t least 2 yea"s e-pe"ien%e as a headn$"se
) #t least 1 $nits of post g"ad$ate st$dies in n$"sing administ"ation
#nswe": # @S* with at least 9 $nits of post g"ad$ate st$dies in n$"sing administ"ation
#%%o"ding to # 918+ se% 29& the ed$%ational 6$alifi%ation to be a s$pe"/iso" in a hospital is at least 9 $nits of
postg"ad$ate st$dies in n$"sing administ"ation # maste"s deg"ee in n$"sing is "e6$i"ed fo" the %hief n$"se of a
se%onda"y o" te"tia"y hospital
9 !he @oa"d of *$"sing has 6$asi=E$di%ial powe" #n e-ample of this powe" is:# !he @oa"d %an iss$e "$les and "eg$lations that will go/e"n the p"a%ti%e of n$"sing
@ !he @oa"d %an in/estigate /iolations of the n$"sing law and %ode of ethi%s
C !he @oa"d %an /isit a s%hool applying fo" a pe"mit in %ollabo"ation with C?,)
) !he @oa"d p"epa"es the boa"d e-aminations
#nswe": @ !he @oa"d %an in/estigate /iolations of the n$"sing law and %ode of ethi%s>$asi=E$di%ial powe" means that the @oa"d of *$"sing has the a$tho"ity to in/estigate /iolations of the n$"sing
law and %an iss$e s$mmons& s$bpoena o" s$bpoena d$%es te%$m as needed
10 Hhen a n$"se %a$ses an inE$"y to the patient and the inE$"y %a$sed be%omes the p"oof of the negligent a%t& the
p"esen%e of the inE$"y is said to e-emplify the p"in%iple of:
# Fo"%e maEe$"e
@ espondeat s$pe"io" C es ipsa lo6$it$"
) ?oldo/e" do%t"ine
#nswe": C es ipsa lo6$it$"
es ipsa lo6$it$" lite"ally means the thing speas fo" itself !his means in ope"ational te"ms that the inE$"y %a$sed
is the p"oof that the"e was a negligent a%t
11 ,ns$"ing that the"e is an info"med %onsent on the pa"t of the patient befo"e a s$"ge"y is done& ill$st"ates the
bioethi%al p"in%iple of:
# @enefi%en%e@ #$tonomy
C !"$th tellingG/e"a%ity
) *on=malefi%en%e
#nswe": @ #$tonomy
Info"med %onsent means that the patient f$lly $nde"stands what will be the s$"ge"y to be done& the "iss in/ol/ed
and the alte"nati/e sol$tions so that when sGhe gi/e %onsent it is done with f$ll nowledge and is gi/en f"eely !he
a%tion of allowing the patient to de%ide whethe" a s$"ge"y is to be done o" not e-emplifies the bioethi%al p"in%iple
Co$nt"y %l$b management style p$ts %on%e"n fo" the staff as n$mbe" one p"io"ity at the e-pense of the deli/e"y of
se"/i%es ?eGshe "$ns the depa"tment E$st lie a %o$nt"y %l$b whe"e e/e"y one is happy in%l$ding the manage"
2 ?e" fo"me" manage" demonst"ated passion fo" se"/ing he" staff "athe" than being se"/ed She taes time to
listen& p"efe"s to be a tea%he" fi"st befo"e being a leade"& whi%h is %ha"a%te"isti% of
# !"ansfo"mational leade"
@ !"ansa%tional leade"
C Se"/ant leade"
) Cha"ismati% leade"
#nswe": C Se"/ant leade" Se"/ant leade"s a"e open=minded& listen deeply& t"y to f$lly $nde"stand othe"s and not being E$dgmental
+ On the othe" hand& <s Cast"o noti%es that the Chief *$"se ,-e%$ti/e has %ha"ismati% leade"ship style Hhi%hof the following beha/io"s best des%"ibes this styleQ
# Possesses inspi"ational 6$ality that maes followe"s gets att"a%ted of him and "ega"ds him with "e/e"en%e
@ #%ts as he does be%a$se he e-pe%ts that his beha/io" will yield positi/e "es$lts
C Uses /isioning as the %o"e of his leade"ship
) <at%hes his leade"ship style to the sit$ation at hand
#nswe": # Possesses inspi"ational 6$ality that maes followe"s gets att"a%ted of him and "ega"ds him with
"e/e"en%e
Cha"ismati% leade"s mae the followe"s feel at ease in thei" p"esen%e !hey feel that they a"e in good hands
whene/e" the leade" is a"o$nd
. Hhi%h of the following %on%l$sions of <s Cast"o abo$t leade"ship %ha"a%te"isti%s is !U,Q# !he"e is a high %o""elation between the %omm$ni%ation sills of a leade" and the ability to get the Eob done
@ # manage" is effe%ti/e when he has the ability to plan well
C #ssessment of pe"sonal t"aits is a "eliable tool fo" p"edi%ting a manage"Ks potential) !he"e is good e/iden%e that %e"tain pe"sonal 6$alities fa/o" s$%%ess in manage"ial "ole
#nswe": C #ssessment of pe"sonal t"aits is a "eliable tool fo" p"edi%ting a manage"Ks potential
It is not %on%l$si/e that %e"tain 6$alities of a pe"son wo$ld mae him be%ome a good manage" It %an only p"edi%t
a manage"Ks potential of be%oming a good one
She "eads abo$t Path Doal theo"y Hhi%h of the following beha/io"s is manifested by the leade" who $ses this
theo"yQ
# e%ogni(es staff fo" going beyond e-pe%tations by gi/ing them %itations
@ Challenges the staff to tae indi/id$al a%%o$ntability fo" thei" own p"a%ti%e
C #dmonishes staff fo" being lagga"ds
) eminds staff abo$t the san%tions fo" non pe"fo"man%e
#nswe": # e%ogni(es staff fo" going beyond e-pe%tations by gi/ing them %itations
Path Doal theo"y a%%o"ding to ?o$se and asso%iates "ewa"ds good pe"fo"man%e so that othe"s wo$ld do the same
5 One leade"ship theo"y states that leade"s a"e bo"n and not made&T whi%h "efe"s to whi%h of the following
theo"iesQ# !"ait
@ Cha"ismati%
C D"eat <an
) Sit$ational
#nswe": C D"eat <an
'eade"s be%ome leade"s be%a$se of thei" bi"th "ight !his is also %alled Deneti% theo"y o" the #"istotelian theo"y
8 She %ame a%"oss a theo"y whi%h states that the leade"ship style is effe%ti/e dependent on the sit$ation Hhi%h of
the following styles best fits a sit$ation when the followe"s a"e self=di"e%ted& e-pe"ts and a"emat$"ed indi/id$alsQ
'aisse( fai"e leade"ship is p"efe""ed when the followe"s now what to do and a"e e-pe"ts in the field !his
leade"ship style is "elationship=o"iented "athe" than tas=%ente"ed
She s$"fs the inte"net fo" mo"e info"mation abo$t leade"ship styles She "eads abo$t sha"ed leade"ship as a p"a%ti%e in some magnet hospitals Hhi%h of the following des%"ibes this style of leade"shipQ
# 'eade"ship beha/io" is gene"ally dete"mined by the "elationship between the leade"Ks pe"sonality and the
spe%ifi% sit$ation
@ 'eade"s belie/e that people a"e basi%ally good and need not be %losely %ont"olled
C 'eade"s "ely hea/ily on /isioning and inspi"e membe"s to a%hie/e "es$lts
) 'eade"ship is sha"ed at the point of %a"e
#nswe": ) 'eade"ship is sha"ed at the point of %a"e
Sha"ed go/e"nan%e allows the staff n$"ses to ha/e the a$tho"ity& "esponsibility and a%%o$ntability fo" thei" own p"a%ti%e
9 <s Cast"o lea"ns that some leade"s a"e t"ansa%tional leade"s Hhi%h of the following does *O! %ha"a%te"i(e at"ansa%tional leade"Q
# Fo%$ses on management tass
@ Is a %a"etae"
C Uses t"ade=offs to meet goals
) Inspi"es othe"s with /ision
#nswe": ) Inspi"es othe"s with /ision
Inspi"es othe"s with a /ision is %ha"a%te"isti% of a t"ansfo"mational leade" ?e is fo%$sed mo"e on the day=to=day
ope"ations of the depa"tmentG$nit
10 She finds o$t that some manage"s ha/e bene/olent=a$tho"itati/e style of management Hhi%h of the following
beha/io"s will she e-hibit most lielyQ# ?a/e %ondes%ending t"$st and %onfiden%e in thei" s$bo"dinates
@ Di/es e%onomi% o" ego awa"ds
C Comm$ni%ates downwa"d to the staff ) #llows de%ision maing among s$bo"dinates
#nswe": # ?a/e %ondes%ending t"$st and %onfiden%e in thei" s$bo"dinates
@ene/olent=a$tho"itati/e manage"s p"etentio$sly show thei" t"$st and %onfiden%e to thei" followe"s
11 ?a""y is a Unit <anage" I the <edi%al Unit ?e is not satisfied with the way things a"e going in his $nit
Patient satisfa%tion "ate is 50V fo" two %onse%$ti/e months and staff mo"ale is at its lowest ?e de%ides to plan
and initiate %hanges that will p$sh fo" a t$"na"o$nd in the %ondition of the $nit Hhi%h of the following a%tions is
a p"io"ity fo" ?a""yQ
# Call fo" a staff meeting and tae this $p in the agenda
@ See help f"om he" manage"
C )e/elop a st"ategi% a%tion on how to deal with these %on%e"ns
) Igno"e the iss$es sin%e these will be "esol/ed nat$"ally
#nswe": # Call fo" a staff meeting and tae this $p in the agenda
!his will allow fo" the pa"ti%ipation of e/e"y staff in the $nit If they %ont"ib$te to the sol$tions of the p"oblem&
they will own the sol$tionsW hen%e the %han%e fo" %omplian%e wo$ld be g"eate"
12 She nows that the"e a"e e-te"nal fo"%es that infl$en%e %hanges in his $nit Hhi%h of the following is *O! an
e-te"nal fo"%eQ
# <emo f"om the C,O to %$t down on ele%t"i%al %ons$mption
@ )emands of the labo" se%to" to in%"ease wages
C 'ow mo"ale of staff in he" $nit
) ,-a%ting "eg$lato"y and a%%"editation standa"ds
#nswe": C 'ow mo"ale of staff in he" $nit
'ow mo"ale of staff is an inte"nal fa%to" that affe%ts only the $nit #ll the "est of the options emanate f"om the top
C <edi%ations and t"eatments "e6$i"ed fo" all patients
) Patients who need the most %a"e
#nswe": ) Patients who need the most %a"e
In setting p"io"ities fo" a g"o$p of patients& those who need the most %a"e sho$ld be n$mbe"=one p"io"ity to ens$"e
that thei" %"iti%al needs a"e met ade6$ately !he needs of othe" patients who need less %a"e %a be attended to late"
o" e/en delegated to assisti/e pe"sonnel a%%o"ding to "$les on delegation
20 She is hopef$l that he" $nit will mae a big t$"na"o$nd in the s$%%eeding months Hhi%h of the following
a%tions of ?a""y demonst"ates that he has "ea%hed the thi"d stage of %hangeQ
# Honde"s why things a"e not what it $sed to be
@ Finds sol$tions to the p"oblems
C Integ"ate the sol$tions to his day=to=day a%ti/ities
) Sele%ts the best %hange st"ategy
#nswe": C Integ"ate the sol$tions to his day=to=day a%ti/ities
Integ"ate the sol$tions to his day=to=day a%ti/ities is a e-pe%ted to happen d$"ing the thi"d stage of %hange whenthe %hange agent in%o"po"ate the sele%ted sol$tions to his system and begins to %"eate a %hange
21 B$li$s is a newly=appointed n$"se manage" of !he Dood Shephe"d <edi%al Cente"& a te"tia"y hospital lo%atedwithin the hea"t of the met"opolis ?e thins of s%hed$ling planning wo"shop with his staff in o"de" to ens$"e an
effe%ti/e and effi%ient management of the depa"tment Sho$ld he de%ide to %ond$%t a st"ategi% planning wo"shop&
whi%h of the following is *O! a %ha"a%te"isti% of this a%ti/ityQ
# 'ong=te"m goal=setting
@ ,-tends to += yea"s in the f$t$"e
C Fo%$ses on "o$tine tass
) )ete"mines di"e%tions of the o"gani(ation
#nswe": C Fo%$ses on "o$tine tass
St"ategi% planning in/ol/es options #& @ and ) e-%ept C whi%h is att"ib$ted to ope"ational planning
22 Hhi%h of the following statements "efe" to the /ision of the hospitalQ
# !he Dood Shephe"d <edi%al Cente" is a t"endsette" in te"tia"y health %a"e in the Philippines in the ne-t fi/eyea"s
@ !he offi%e"s and staff of !he Dood Shephe"d <edi%al Cente" belie/e in the $ni6$e nat$"e of the h$man pe"son
C #ll the n$"ses shall $nde"go %ontin$ing %ompeten%y t"aining p"og"am) !he Dood Shephe"d <edi%al Cente" aims to p"o/ide a patient=%ente"ed %a"e in a total healing en/i"onment
#nswe": # !he Dood Shephe"d <edi%al Cente" is a t"endsette" in te"tia"y health %a"e in the Philippines in the
ne-t fi/e yea"s
# /ision "efe"s to what the instit$tion wants to be%ome within a pa"ti%$la" pe"iod of time
2+ !he statement& !he Dood Shephe"d <edi%al Cente" aims to p"o/ide patient=%ente"ed %a"e in a total healing
en/i"onmentT "efe"s to whi%h of the followingQ
# 7ision
@ Doal
C Philosophy
) <ission
#nswe": @ Doal
2. B$li$s plans to "e/isit the o"gani(ational %ha"t of the depa"tment ?e plans to %"eate a new position of a Patient
,d$%ato" who has a %oo"dinating "elationship with the head n$"se in the $nit Hhi%h of the following will liely
depi%t this o"gani(ational "elationshipQ
# @o-
@ Solid line
C @"oen line) )otted line
#nswe": C @"oen line
!his is a staff "elationship hen%e it is depi%ted by a b"oen line in the o"gani(ational st"$%t$"e
2 ?e liewise st"esses the need fo" all the employees to follow o"de"s and inst"$%tions f"om him and not f"om
anyone else Hhi%h of the following p"in%iples does he "efe" toQ
!he p"in%iple of $nity of %ommand means that employees sho$ld "e%ei/e o"de"s %oming f"om only one manage"
and not f"om two manage"s !his a/e"ts the possibility of sowing %onf$sion among the membe"s of the
o"gani(ation
25 B$li$s o"ients his staff on the patte"ns of "epo"ting "elationship th"o$gho$t the o"gani(ation Hhi%h of the
following p"in%iples "efe" to thisQ
# Span of %ont"ol
@ ?ie"a"%hy
C ,sp"it dK %o"ps
) Unity of di"e%tion
#nswe": @ ?ie"a"%hy
?ie"a"%hy "efe"s to the patte"n of "epo"ting o" the fo"mal line of a$tho"ity in an o"gani(ational st"$%t$"e
28 ?e emphasi(es to the team that they need to p$t thei" effo"ts togethe" towa"ds the attainment of the goals of
the p"og"am Hhi%h of the following p"in%iples "efe"s to thisQ# Span of %ont"ol
@ Unity of di"e%tion
C Unity of %ommand
) Command "esponsibility
#nswe": @ Unity of di"e%tion
Unity of di"e%tion means ha/ing one goal o" one obEe%ti/e fo" the team to p$"s$eW hen%e all membe"s of the
o"gani(ation sho$ld p$t thei" effo"ts togethe" towa"ds the attainment of thei" %ommon goal o" obEe%ti/e
2 B$li$s st"esses the impo"tan%e of p"omoting ^esp"it d %o"psK among the membe"s of the $nit Hhi%h of the
following "ema"s of the staff indi%ates that they $nde"stand what he pointed o$tQ
# 'etKs wo" togethe" in ha"monyW we need to be s$ppo"ti/e of one anothe"T@ In o"de" that we a%hie/e the same "es$ltsW we m$st all follow the di"e%ti/es of B$li$s and not f"om othe"
manage"sT
C He will ens$"e that all the "eso$"%es we need a"e a/ailable when neededT) He need to p$t o$" effo"ts togethe" in o"de" to "aise the ba" of e-%ellen%e in the %a"e we p"o/ide to all o$"
patientsT
#nswe": # 'etKs wo" togethe" in ha"monyW we need to be s$ppo"ti/e of one anothe"T
!he p"in%iple of ^esp"it dK %o"psK "efe"s to p"omoting ha"mony in the wo"pla%e& whi%h is essential in maintaining
a %limate %ond$%i/e to wo"
29 ?e dis%$sses the goal of the depa"tment Hhi%h of the following statements is a goalQ
# In%"ease the patient satisfa%tion "ate
@ ,liminate the in%iden%e of delayed administ"ation of medi%ations
C ,stablish "appo"t with patients
) ed$%e "esponse time to two min$tes
#nswe": # In%"ease the patient satisfa%tion "ate
Doal is a desi"ed "es$lt towa"ds whi%h effo"ts a"e di"e%ted Options #@& C and ) a"e all obEe%ti/es whi%h a"e
aimed at spe%ifi% end
+0 ?e wants to infl$en%e the %$stoma"y way of thining and beha/ing that is sha"ed by the membe"s of thedepa"tment Hhi%h of the following te"ms "efe" to thisQ
# O"gani(ational %ha"t
@ C$lt$"al netwo"
C O"gani(ational st"$%t$"e
) O"gani(ational %$lt$"e
#nswe": ) O"gani(ational %$lt$"e
#n o"gani(ational %$lt$"e "efe"s to the way the membe"s of the o"gani(ation thin togethe" and do things a"o$nd
them togethe" ItKs thei" way of life in that o"gani(ation
+1 ?e asse"ts the impo"tan%e of p"omoting a positi/e o"gani(ational %$lt$"e in thei" $nit Hhi%h of the following
beha/io"s indi%ate that this is attained by the g"o$pQ
@ P"o/ide a pai" of hands to othe" $nits as needed
C Co/e" all time pe"iods ade6$ately
) #llow fo" g"owth and de/elopment of n$"sing staff
#nswe": @ P"o/ide a pai" of hands to othe" $nits as needed
P"o/iding a pai" of hands fo" othe" $nits is not a p$"pose in doing an effe%ti/e staffing p"o%ess !his is a f$n%tionof a staffing %oo"dinato" at a %ent"ali(ed model
+ Hhi%h of the following g$idelines sho$ld be least %onside"ed in fo"m$lating obEe%ti/es fo" n$"sing %a"eQ
# H"itten n$"sing %a"e plan
@ ?olisti% app"oa%h
C P"es%"ibed standa"ds
) Staff p"efe"en%es
#nswe": ) Staff p"efe"en%esStaff p"efe"en%es sho$ld be the least p"io"ity in fo"m$lating obEe%ti/es of n$"sing %a"e Indi/id$al p"efe"en%es
sho$ld be s$bo"dinate to the inte"est of the patients
+9 Stephanie %onside"s shifting to t"ansfo"mational leade"ship Hhi%h of the following statements best des%"ibes
this type of leade"shipQ
# Uses /isioning as the essen%e of leade"ship
@ Se"/es the followe"s "athe" than being se"/edC <aintains f$ll t"$st and %onfiden%e in the s$bo"dinates
) Possesses innate %ha"isma that maes othe"s feel good in his p"esen%e
#nswe": # Uses /isioning as the essen%e of leade"ship
!"ansfo"mational leade"ship "elies hea/ily on /isioning as the %o"e of leade"ship
.0 #s a manage"& she fo%$ses he" ene"gy on both the 6$ality of se"/i%es "ende"ed to the patients as well as the
welfa"e of the staff of he" $nit Hhi%h of the following management styles does she adoptQ# Co$nt"y %l$b management
@ O"gani(ation man management
C !eam management
) #$tho"ity=obedien%e management
#nswe": C !eam management
!eam management has a high %on%e"n fo" se"/i%es and high %on%e"n fo" staff
.1 athe"ine is a yo$ng Unit <anage" of the Pediat"i% Ha"d <ost of he" staff n$"ses a"e senio" to he"& /e"y
a"ti%$late& %onfident and sometimes agg"essi/e athe"ine feels $n%omfo"table belie/ing that she is the s%apegoat
of e/e"ything that goes w"ong in he" depa"tment Hhi%h of the following is the best a%tion that she m$st taeQ
# Identify the so$"%e of the %onfli%t and $nde"stand the points of f"i%tion@ )is"ega"d what she feels and %ontin$e to wo" independently
C See help f"om the )i"e%to" of *$"sing
) >$it he" Eob and loo fo" anothe" employment
#nswe": # Identify the so$"%e of the %onfli%t and $nde"stand the points of f"i%tion
!his in/ol/es a p"oblem sol/ing app"oa%h& whi%h add"esses the "oot %a$se of the p"oblem
.2 #s a yo$ng manage"& she nows that %onfli%t o%%$"s in any o"gani(ation Hhi%h of the following statements
"ega"ding %onfli%t is *O! t"$eQ
# Can be dest"$%ti/e if the le/el is too high
@ Is not benefi%ialW hen%e it sho$ld be p"e/ented at all times
C <ay "es$lt in poo" pe"fo"man%e) <ay %"eate leade"s
#nswe": @ Is not benefi%ialW hen%e it sho$ld be p"e/ented at all times
Confli%ts a"e benefi%ial be%a$se it s$"fa%es o$t iss$es in the open and %an be sol/ed "ight away 'iewise&
membe"s of the team be%ome mo"e %ons%ientio$s with thei" wo" when they a"e awa"e that othe" membe"s of the
.+ athe"ine tells one of the staff& I donKt ha/e time to dis%$ss the matte" with yo$ now See me in my offi%e
late"T when the latte" ass if they %an tal abo$t an iss$e Hhi%h of the following %onfli%t "esol$tion st"ategies did
she $seQ
# Smoothing
@ Comp"omise
C #/oidan%e) est"i%tion
#nswe": C #/oidan%e
!his st"ategy sh$ns dis%$ssing the iss$e head=on and p"efe"s to postpone it to a late" time In effe%t the p"oblem
"emains $nsol/ed and both pa"ties a"e in a lose=lose sit$ation
.. athleen nows that one of he" staff is e-pe"ien%ing b$"no$t Hhi%h of the following is the best thing fo" he"
to doQ
# #d/ise he" staff to go on /a%ation
@ Igno"e he" obse"/ationsW it will be "esol/ed e/en witho$t inte"/ention
C emind he" to show loyalty to the instit$tion
) 'et the staff /entilate he" feelings and as how she %an be of help
#nswe": ) 'et the staff /entilate he" feelings and as how she %an be of helpea%hing o$t and helping the staff is the most effe%ti/e st"ategy in dealing with b$"n o$t nowing that someone
is "eady to help maes the staff feel impo"tantW hen%e he" self=wo"th is enhan%ed
. She nows that pe"fo"man%e app"aisal %onsists of all the following a%ti/ities ,;C,P!:
# Setting spe%ifi% standa"ds and a%ti/ities fo" indi/id$al pe"fo"man%e
@ Using agen%y standa"ds as a g$ide
C )ete"mine a"eas of st"ength and weanesses) Fo%$sing a%ti/ity on the %o""e%tion of identified beha/io"
#nswe": ) Fo%$sing a%ti/ity on the %o""e%tion of identified beha/io"
Pe"fo"man%e app"aisal deal with both positi/e and negati/e pe"fo"man%eW is not meant to be a fa$lt=finding
a%ti/ity
.5 Hhi%h of the following statements is *O! t"$e abo$t pe"fo"man%e app"aisalQ
# Info"ming the staff abo$t the spe%ifi% imp"essions of thei" wo" help imp"o/e thei" pe"fo"man%e
@ # /e"bal app"aisal is an a%%eptable s$bstit$te fo" a w"itten "epo"t
C Patients a"e the best so$"%e of info"mation "ega"ding pe"sonnel app"aisal
) !he o$t%ome of pe"fo"man%e app"aisal "ests p"ima"ily with the staff
#nswe": C Patients a"e the best so$"%e of info"mation "ega"ding pe"sonnel app"aisal
!he patient %an be a so$"%e of info"mation abo$t the pe"fo"man%e of the staff b$t it is ne/e" the best so$"%e
)i"e%tly obse"/ing the staff is the best so$"%e of info"mation fo" pe"sonnel app"aisal
.8 !he"e a"e times when athe"ine e/al$ates he" staff as she maes he" daily "o$nds Hhi%h of the following is
*O! a benefit of %ond$%ting an info"mal app"aisalQ
# !he staff membe" is obse"/ed in nat$"al setting
@ In%idental %onf"ontation and %ollabo"ation is allowed
C !he e/al$ation is fo%$sed on obEe%ti/e data systemati%ally
) !he e/al$ation may p"o/ide /alid info"mation fo" %ompilation of a fo"mal "epo"t
#nswe": C !he e/al$ation is fo%$sed on obEe%ti/e data systemati%ally
Colle%ting obEe%ti/e data systemati%ally %an not be a%hie/ed in an info"mal app"aisal It is fo%$sed on what
a%t$ally happens in the nat$"al wo" setting
. She %ond$%ts a 5=month pe"fo"man%e "e/iew session with a staff membe" Hhi%h of the following a%tions isapp"op"iateQ
# She ass anothe" n$"se to attest the session as a witness
@ She info"ms the staff that she may as anothe" n$"se to "ead the app"aisal befo"e the session is o/e"
C She tells the staff that the session is manage"=%ente"ed) !he session is p"i/ate between the two membe"s
#nswe": ) !he session is p"i/ate between the two membe"s
!he session is p"i/ate between the manage" and the staff and "emains to be so when the two pa"ties do not di/$lge
.9 #le-and"a is tased to o"gani(e the new wing of the hospital She was gi/en the a$tho"ity to do as she
deems fit She is awa"e that the di"e%to" of n$"sing has s$bstantial t"$st and %onfiden%e in he" %apabilities&
%omm$ni%ates th"o$gh downwa"d and $pwa"d %hannels and $s$ally $ses the ideas and opinions of he" staff
Hhi%h of the following is he" style of managementQ
# @ene/olent Xa$tho"itati/e@ Cons$ltati/e
C ,-ploiti/e=a$tho"itati/e) Pa"ti%ipati/e
#nswe": @ Cons$ltati/e
# %ons$ltati/e manage" is almost lie a pa"ti%ipati/e manage" !he pa"ti%ipati/e manage" has %omplete t"$st and
%onfiden%e in the s$bo"dinate& always $ses the opinions and ideas of s$bo"dinates and %omm$ni%ates in all
di"e%tions
2 She de%ides to ill$st"ate the o"gani(ational st"$%t$"e Hhi%h of the following elements is *O! in%l$dedQ
# 'e/el of a$tho"ity
@ 'ines of %omm$ni%ation
C Span of %ont"ol
) Unity of di"e%tion
#nswe": ) Unity of di"e%tion
Unity of di"e%tion is a management p"in%iple& not an element of an o"gani(ational st"$%t$"e
1 She plans of assigning %ompetent people to fill the "oles designed in the hie"a"%hy Hhi%h p"o%ess "efe"s to
thisQ
# Staffing
@ S%hed$ling
C e%"$itment
) Ind$%tion
#nswe": # StaffingStaffing is a management f$n%tion in/ol/ing p$tting the best people to a%%omplish tass and a%ti/ities to attain the
goals of the o"gani(ation
2 She %he%s the do%$menta"y "e6$i"ements fo" the appli%ants fo" staff n$"se position Hhi%h one is *O!
ne%essa"yQ# Ce"tifi%ate of p"e/io$s employment
@ e%o"d of "elated lea"ning e-pe"ien%e ',
C <embe"ship to a%%"edited p"ofessional o"gani(ation
) P"ofessional identifi%ation %a"d
#nswe": @ e%o"d of "elated lea"ning e-pe"ien%e ',e%o"d of ', is not "e6$i"ed fo" employment p$"poses b$t it is "e6$i"ed fo" the n$"seKs li%ens$"e e-amination
+ Hhi%h phase of the employment p"o%ess in%l$des getting on the pay"oll and %ompleting do%$menta"y
"e6$i"ementsQ
# O"ientation
@ Ind$%tion
C Sele%tion
) e%"$itment
#nswe": @ Ind$%tion
!his step in the "e%"$itment p"o%ess gi/es time fo" the staff to s$bmit all the do%$menta"y "e6$i"ements fo"
employment
. She t"ies to design an o"gani(ational st"$%t$"e that allows %omm$ni%ation to flow in all di"e%tions and in/ol/e
wo"e"s in de%ision maing Hhi%h fo"m of o"gani(ational st"$%t$"e is thisQ
)e%ent"ali(ed st"$%t$"es allow the staff to sol/e de%isions by themsel/es& in/ol/e them in de%ision maingW hen%e
they a"e always gi/en oppo"t$nities to inte"a%t with one anothe"
8 #$b"ey thins abo$t p"ima"y n$"sing as a system to deli/e" %a"e Hhi%h of the following a%ti/ities is *O!
done by a p"ima"y n$"seQ
# Collabo"ates with the physi%ian@ P"o/ides %a"e to a g"o$p of patients togethe" with a g"o$p of n$"ses
C P"o/ides %a"e fo" =5 patients d$"ing thei" hospital stay
) Pe"fo"ms %omp"ehensi/e initial assessment
#nswe": @ P"o/ides %a"e to a g"o$p of patients togethe" with a g"o$p of n$"ses!his f$n%tion is done in team n$"sing whe"e the n$"se is a membe" of a team that p"o/ides %a"e fo" a g"o$p of
patients
Hhi%h patte"n of n$"sing %a"e in/ol/es the %a"e gi/en by a g"o$p of pa"ap"ofessional wo"e"s led by a
p"ofessional n$"se who tae %a"e of patients with the same disease %onditions and a"e lo%ated geog"aphi%ally nea"
ea%h othe"Q
# Case method
@ <od$la" n$"sing
C *$"sing %ase management) !eam n$"sing
#nswe": @ <od$la" n$"sing
<od$la" n$"sing is a /a"iant of team n$"sing !he diffe"en%e lies in the fa%t that the membe"s in mod$la" n$"singa"e pa"ap"ofessional wo"e"s
9 St aphael <edi%al Cente" E$st opened its new Pe"fo"man%e Imp"o/ement )epa"tment <s 7alen%ia is
appointed as the >$ality Cont"ol Offi%e" She %ommits he"self to he" new "ole and plans he" st"ategies to "eali(e
the goals and obEe%ti/es of the depa"tment Hhi%h of the following is a p"ima"y tas that they sho$ld pe"fo"m to
ha/e an effe%ti/e %ont"ol systemQ
# <ae an inte"p"etation abo$t st"engths and weanesses
@ Identify the /al$es of the depa"tment
C Identify st"$%t$"e& p"o%ess& o$t%ome standa"ds N %"ite"ia
) <eas$"e a%t$al pe"fo"man%es
#nswe": @ Identify the /al$es of the depa"tment
Identify the /al$es of the depa"tment will set the g$iding p"in%iples within whi%h the depa"tment will ope"ate its
a%ti/ities
50 <s 7alen%ia de/elops the standa"ds to be followed #mong the following standa"ds& whi%h is %onside"ed as a
st"$%t$"e standa"dQ
# !he patients /e"bali(ed satisfa%tion of the n$"sing %a"e "e%ei/ed
@ otation of d$ty will be done e/e"y fo$" wees fo" all patient %a"e pe"sonnel
1. ?e systemati%ally plans his sampling plan Sho$ld he de%ides to in%l$de whoe/e" patients a"e admitted d$"ing
the st$dy he $ses what sampling methodQ
# B$dgment
@ #%%identalC andom
) >$ota
#nswe": @ #%%idental
#%%idental sampling is a non=p"obability sampling method whi%h in%l$des those who a"e at the site d$"ing data%olle%tion
1 ?e finally de%ides to $se E$dgment sampling Hhi%h of the following a%tions of aphael is %o""e%tQ
# Plans to in%l$de whoe/e" is the"e d$"ing his st$dy
@ )ete"mines the diffe"ent nationality of patients f"e6$ently admitted and de%ides to get "ep"esentations samples
f"om ea%h
C #ssigns n$mbe"s fo" ea%h of the patients& pla%e these in a fishbowl and d"aw 10 f"om it
) )e%ides to get 20 samples f"om the admitted patients
#nswe": @ )ete"mines the diffe"ent nationality of patients f"e6$ently admitted and de%ides to get
"ep"esentations samples f"om ea%h
B$dgment sampling in/ol/es in%l$ding samples a%%o"ding to the nowledge of the in/estigato" abo$t the
pa"ti%ipants in the st$dy
15 ?e nows that %e"tain patients who a"e in a spe%iali(ed "esea"%h setting tend to "espond psy%hologi%ally to the
%onditions of the st$dy !his is "efe""ed to as
# @ias
@ ?awtho"ne effe%t
C ?alo effe%t
) ?o"ns effe%t
#nswe": @ ?awtho"ne effe%t
?awtho"ne effe%t is based on the st$dy of ,lton <ayo and %ompany abo$t the effe%t of an inte"/ention done toimp"o/e the wo"ing %onditions of the wo"e"s on thei" p"od$%ti/ity It "es$lted to an in%"eased p"od$%ti/ity b$t
not d$e to the inte"/ention b$t d$e to the psy%hologi%al effe%ts of being obse"/ed !hey pe"fo"med diffe"ently
be%a$se they we"e $nde" obse"/ation
18 Hhi%h of the following items "efe" to the sense of %los$"e that aphael e-pe"ien%es when data %olle%tion
%eases to yield any new info"mationQ
# Sat$"ation
@ P"e%ision
C 'imitation
) ele/an%e
#nswe": # Sat$"ation
Sat$"ation is a%hie/ed when the in/estigato" %an not e-t"a%t new "esponses f"om the info"mants& b$t instead& gets
the same "esponses "epeatedly
1 In 6$alitati/e "esea"%h the a%t$al analysis of data begins with:
# sea"%h fo" themes
@ /alidation of themati% analysis
C wea/e the themati% st"ands togethe"
) 6$asi statisti%s
#nswe": # sea"%h fo" themes
!he in/estigato" sta"ts data analysis by looing fo" themes f"om the /e"batim "esponses of the info"mants
19 aphael is also inte"ested to now the %oping abilities of patients who a"e newly diagnosed to ha/e te"minal
%an%e" Hhi%h of the following types of "esea"%h is app"op"iateQ
!he $ltimate goal of %ond$%ting "esea"%h is to imp"o/e patient %a"e whi%h is a%hie/ed by enhan%ing the p"a%ti%eof n$"ses when they $tili(e "esea"%h "es$lts in thei" p"a%ti%e
.. ega"dless of the signifi%an%e of the st$dy& the feasibility of the st$dy needs to be %onside"ed Hhi%h of the
following is %onside"ed a p"io"ityQ
# #/ailability of "esea"%h s$bEe%ts
@ @$dgeta"y allo%ation
C !ime f"ame
) ,-pe"ien%e of the "esea"%he"
#nswe": # #/ailability of "esea"%h s$bEe%ts
#/ailability is the most impo"tant %"ite"ia to be %onside"ed by the "esea"%he" in dete"mining whethe" the st$dy is
feasible o" not *o matte" how signifi%ant the st$dy may be if the"e a"e no a/ailable s$bEe%tsG"espondents& thest$dy %an not p$sh th"o$gh
.5 #"etha nows that a good "esea"%h p"oblem e-hibits the following %ha"a%te"isti%sW whi%h one is *O!
in%l$dedQ
# Clea"ly identified the /a"iablesGphenomenon $nde" %onside"ation
@ Spe%ifies the pop$lation being st$died
C Implies the feasibility of empi"i%al testing
) Indi%ates the hypothesis to be tested
#nswe": ) Indi%ates the hypothesis to be tested
*ot all st$dies "e6$i"e a hypothesis s$%h as 6$alitati/e st$dies& whi%h does not deal with /a"iables b$t with
phenomenon o" %on%epts
.8 She states the p$"poses of the st$dy Hhi%h of the following des%"ibe the p$"pose of a st$dyQ
1 ,stablishes the gene"al di"e%tion of a st$dy
2 Capt$"es the essen%e of the st$dy
+ Fo"mally a"ti%$lates the goals of the st$dy. Sometimes wo"ded as an intent
# 1& 2& +
@ 2& +& .
C 1& +& .
) 1& 2& +& .
#nswe": ) 1& 2& +& .
!he p$"poses of a "esea"%h st$dy %o/e"s all the options indi%ated
. She opts to $se inte"/iews in data %olle%tion In addition to /alidity& what is the othe" <OS! se"io$s weaness
of this methodQ
# #%%$"a%y
@ Sensiti/ity
C ObEe%ti/ity) eliability
#nswe": # #%%$"a%y
#%%$"a%y and /alidity a"e the most se"io$s weanesses of the self="epo"t data !his is d$e to the fa%t that the"espondents sometimes do not want to tell the t"$th fo" fea" of being "eEe%ted o" in o"de" to please theinte"/iewe"
.9 She plans to s$bEe%t he" inst"$ment to p"etesting Hhi%h of the following is *O! a%hie/ed in doing
p"etestingQ
# )ete"mines how m$%h time it taes to administe" the inst"$ment pa%age
@ Identify pa"ts that a"e diffi%$lt to "ead o" $nde"stand
C )ete"mine the b$dgeta"y allo%ation fo" the st$dy
) )ete"mine if the meas$"es yield data with s$ffi%ient /a"iability
#nswe": C )ete"mine the b$dgeta"y allo%ation fo" the st$dy
)ete"mining b$dgeta"y allo%ation fo" the st$dy is not a p$"pose of doing a p"etesting of the inst"$ments !his is
done at an ea"lie" stage of the design and planning phase
0 She tests the inst"$ment whethe" it loos as tho$gh it is meas$"ing app"op"iate %onst"$%ts Hhi%h of the
following "efe"s to thisQ# Fa%e /alidity
@ Content /alidity
C Const"$%t 7alidity
) C"ite"ion="elated /alidity
#nswe": # Fa%e /alidity
Fa%e /alidity meas$"es whethe" the inst"$ment appea"s to be meas$"ing the app"op"iate %onst"$%t It is the easiest
type of /alidity testing
1 Hhi%h of the following 6$estions wo$ld dete"mine the %onst"$%t /alidity of the inst"$mentQ
# Hhat is this inst"$ment "eally meas$"ingQT
@ ?ow "ep"esentati/e a"e the 6$estions on this test of the $ni/e"se of 6$estions on this topi%QTC )oes the 6$estion ased loos as tho$gh it is meas$"ing the app"op"iate %onst"$%tQT
) )oes the inst"$ment %o""elate highly with an e-te"nal %"ite"ionQ
#nswe": # Hhat is this inst"$ment "eally meas$"ingQT
Const"$%t /alidity aims to /alidate what the inst"$ment is "eally meas$"ing !he mo"e abst"a%t the %on%ept& the
mo"e diffi%$lt to meas$"e the %onst"$%t
2 Hhi%h of the following e-pe"imental "esea"%h designs wo$ld be app"op"iate fo" this st$dy if she wants to find
o$t a %a$se and effe%t "elationship between the st"$%t$"ed dis%ha"ge plan and %omplian%e to home %a"e "egimen
among the s$bEe%tsQ
# !"$e e-pe"iment
@ >$asi e-pe"imentC Post=test only design
) Solomon fo$"=g"o$p
#nswe": C Post=test only design
Post= !est only design is app"op"iate be%a$se it is impossible to meas$"e the %omplian%e to home %a"e "egimen
/a"iable p"io" to the dis%ha"ge of the patient f"om the hospital
+ One hypothesis that she fo"m$lated is Complian%e to home %a"e "egimen is g"eate" among patients who
"e%ei/ed the st"$%t$"ed dis%ha"ge plan than those who "e%ei/ed /e"bal dis%ha"ge inst"$%tionsK Hhi%h is the
independent /a"iable in this st$dyQ
# St"$%t$"ed dis%ha"ge plan
@ Complian%e to home %a"e "egimenC Post=open hea"t s$"ge"y patients) D"eate" %omplian%e
#nswe": # St"$%t$"ed dis%ha"ge plan
St"$%t$"ed dis%ha"ge plan is the inte"/ention o" the ^%a$seK in the st$dy that "es$lts to an ^effe%tK& whi%h is
%omplian%e to home %a"e "egimen o" the dependent /a"iable
. Sit$ation : #lyssa plans to %ond$%t a st$dy abo$t n$"sing p"a%ti%e in the %o$nt"y She de%ides to "ef"esh he"
nowledge abo$t the diffe"ent types of "esea"%h in o"de" to %hoose the most app"op"iate design fo" he" st$dy
She %ame a%"oss s$"/eys& lie the So%ial Heathe" Station and P$lse #sia S$"/ey Hhi%h of the following is
the p$"pose of this ind of "esea"%hQ
# Obtains info"mation "ega"ding the p"e/alen%e& dist"ib$tion and inte""elationships of /a"iables within a
pop$lation at a pa"ti%$la" time
@ Det an a%%$"ate and %omplete data abo$t a phenomenon
C )e/elop a tool fo" data gathe"ing
) Fo"m$late a f"amewo" fo" the st$dy
#nswe": # Obtains info"mation "ega"ding the p"e/alen%e& dist"ib$tion and inte""elationships of /a"iables within
S$"/eys a"e done to gathe" info"mation on peopleKs a%tions& nowledge& intentions& opinions and attit$des
5 She will liely $se self="epo"t method Hhi%h of the following self="epo"t methods is the most "espe%ted
method $sed in s$"/eysQ
# Pe"sonal inte"/iews
@ >$estionnai"es
C !elephone inte"/iews
) ating S%ale
#nswe": # Pe"sonal inte"/iews
Pe"sonal inte"/iews is the best method of %olle%ting s$"/ey data be%a$se the 6$ality of info"mation they yield is
highe" than othe" methods and be%a$se "elati/ely few people "ef$se to be inte"/iewed in pe"son
8 #lyssa "eads abo$t e-plo"ato"y "esea"%h Hhi%h of the following is the p$"pose of doing this type of "esea"%hQ
# Ind$%ti/ely de/elops a theo"y based on obse"/ations abo$t p"o%esses in/ol/ing sele%ted people
@ <aes new nowledge $sef$l and p"a%ti%al
C Identifies the /a"iables in the st$dy
) Finds o$t the %a$se and effe%t "elationship between /a"iables
#nswe": C Identifies the /a"iables in the st$dy,-plo"ato"y "esea"%h is the fi"st le/el of in/estigation and it deals with identifying the /a"iables in the st$dy
She "e/iews 6$alitati/e design of "esea"%h Hhi%h of the following is t"$e abo$t ethnog"aphi% st$dyQ
# )e/elops theo"ies that in%"ease the nowledge abo$t a %e"tain phenomenon
@ Fo%$ses on the meanings of life e-pe"ien%es of people
C )eals with patte"ns and e-pe"ien%es of a defined %$lt$"al g"o$p in a holisti% fashion
) In=depth in/estigation of a single entity
#nswe": C )eals with patte"ns and e-pe"ien%es of a defined %$lt$"al g"o$p in a holisti% fashion
,thnog"aphi% "esea"%h deals with the %$lt$"al patte"ns and beliefs of %e"tain %$lt$"e g"o$ps
9 She nows that the p$"pose of doing ethnog"aphi% st$dy is to:
# Unde"stand the wo"ld/iew of a %$lt$"al g"o$p
@ St$dy the life e-pe"ien%es of peopleC )ete"mine the "elationship between /a"iables
) In/estigate intensi/ely a single entity
#nswe": # Unde"stand the wo"ld/iew of a %$lt$"al g"o$p
!he aim of ethnog"aphe"s is to lea"n f"om the membe"s of a %$lt$"al g"o$p by $nde"standing thei" way of life as
they pe"%ei/e and li/e it
50 #lyssa wants to lea"n mo"e abo$t e-pe"imental design Hhi%h is the p$"pose of this "esea"%hQ
# !est the %a$se and effe%t "elationship among the /a"iable $nde" a %ont"olled sit$ation
@ Identify the /a"iables in the st$dy
C P"edi%ts the f$t$"e based on %$""ent inte"/ention
) )es%"ibe the %ha"a%te"isti%s& opinions& attit$des o" beha/io"s of %e"tain pop$lation abo$t a %$""ent iss$e o"
e/ent
#nswe": # !est the %a$se and effe%t "elationship among the /a"iable $nde" a %ont"olled sit$ation
,-pe"imental "esea"%h is a 'e/el III in/estigation whi%h dete"mines the %a$se and effe%t "elationshi p between/a"iables
51 She nows that the"e a"e th"ee elements of e-pe"imental "esea"%h Hhi%h is *O! in%l$dedQ
# <anip$lation
@ andomi(ationC Cont"ol
) !"ial
#nswe": ) !"ial
!"ial is not an element of e-pe"imental "esea"%h <anip$lation of /a"iables& "andomi(ation and %ont"ol a"e the
) Conta%ts of patients with histo"y of fe/e" and %o$gh
#nswe": # PatientKs "ef$sal to f$lly di/$lge info"mation
PatientKs "ef$sal to di/$lge info"mation is a limitation be%a$se it is beyond the %ont"ol of ?a""y
5 Hhat type of "esea"%h is app"op"iate fo" this st$dyQ
# )es%"ipti/e= %o""elational
@ ,-pe"imentC >$asi=e-pe"iment
) ?isto"i%al
#nswe": # )es%"ipti/e= %o""elational
)es%"ipti/e= %o""elational st$dy is the most app"op"iate fo" this st$dy be%a$se it st$dies the /a"iables that %o$ld bethe ante%edents of the in%"eased in%iden%e of noso%omial infe%tion
59 In the statement& F"e6$ent hand washing of health wo"e"s de%"eases the in%iden%e of noso%omial infe%tions
among post=s$"ge"y patientsT& the dependent /a"iable is
# in%iden%e of noso%omial infe%tions
@ de%"eases
C f"e6$ent hand washing) post=s$"ge"y patients
#nswe": # in%iden%e of noso%omial infe%tions
!he dependent /a"iable is the in%iden%e of noso%omial infe%tion& whi%h is the o$t%ome o" effe%t of the
independent /a"ia ble& f"e6$ent hand washing
80 ?a""y nows that he has to p"ote%t the "ights of h$man "esea"%h s$bEe%ts Hhi%h of the following a%tions of
?a""y ens$"es anonymityQ
# eep the identities of the s$bEe%t se%"et
@ Obtain info"med %onsent
C P"o/ide e6$al t"eatment to all the s$bEe%ts of the st$dy
) elease findings only to the pa"ti%ipants of the st$dy
#nswe": # eep the identities of the s$bEe%t se%"et
eeping the identities of the "esea"%h s$bEe%t se%"et will ens$"e anonymity be%a$se this will hinde" p"o/iding lin
between the info"mation gi/en to whoe/e" is its so$"%e
81 ?e is o"iented to the $se of ele%t"oni% databases fo" n$"sing "esea"%h Hhi%h of the following will she liely
a%%essQ
# <,)'I*,
@ *ational Instit$te of *$"sing esea"%hC #me"i%an Bo$"nal of *$"sing
) Inte"national Co$n%il of *$"ses
#nswe": @ *ational Instit$te of *$"sing esea"%h *ational Instit$te fo" *$"sing esea"%h is a $sef$l so$"%e of info"mation fo" n$"sing "esea"%h !he "est of the
options may be helpf$l b$t *I* is the most $sef$l site fo" n$"ses
82 ?e de/elops methods fo" data gathe"ing Hhi%h of the following %"ite"ia of a good inst"$ment "efe"s to the
ability of the inst"$ment to yield the same "es$lts $pon its "epeated administ"ationQ
# 7alidity
@ Spe%ifi%ity
C Sensiti/ity
) eliability
#nswe": ) eliability
eliability is %onsisten%y of the "esea"%h inst"$ment It "efe"s to the "epeatability of the inst"$ment in e-t"a%ting
the same "esponses $pon its "epeated administ"ation
8+ ?a""y is awa"e of the impo"tan%e of %ont"olling th"eats to inte"nal /alidity fo" e-pe"imental "esea"%h& whi%h
)esign is not a th"eat to inte"nal /alidity of the inst"$ment E$st lie the othe" options
8. ?is %olleag$e ass abo$t the e-te"nal /alidity of the "esea"%h findings Hhi%h of the "esponses of ?a""y is
app"op"iateQ !he "esea"%h findings %an be
# gene"ali(ed to othe" settings o" samples@ shown to "es$lt only f"om the effe%t of the independent /a"iable
C "efle%ted as "es$lts of e-t"aneo$s /a"iables
) f"ee of sele%tion biases
#nswe": # gene"ali(ed to othe" settings o" samples,-te"nal /alidity "efe"s to the gene"ali(ability of "esea"%h findings to othe" settings o" samples !his is an iss$e of
impo"tan%e to e/iden%e=based n$"sing p"a%ti%e
NURSING RESEARCH Part 2
Sit0ati#$ 1 Ao$ a"e fo"t$nate to be %hosen as pa"t
of the "esea"%h team in the hospital # "e/iew of the
2 Bonas who is diagnosed with en%ephalitis is $nde" the t"eatment of <annitol Hhi%h of the following
patient o$t%omes indi%ate to *$"se onald that the t"eatment of <annitol has been effe%ti/e fo" a patient
that has in%"eased int"a%"anial p"ess$"eQ
a In%"eased $"ina"y o$tp$t b )e%"eased
% Slowed papilla"y "esponse
d )e%"eased le/el of %ons%io$sness
+ <a"y ased *$"se <a$"een abo$t the in%$bation pe"iod of "abies Hhi%h statement by the *$"se
<a$"een is app"op"iateQ
a In%$bation pe"iod is 5 months
b In%$bation pe"iod is 1 wee
% In%$bation pe"iod is 1 month
d In%$bation pe"iod /a"ies depending on the site of the bite. Hhi%h of the following sho$ld *$"se Che""y do fi"st in taing %a"e of a male %lient with "abiesQ
a ,n%o$"age the patient to tae a bath
b Co/e" I7 bottle with b"own pape" bag% Pla%e the patient nea" the %omfo"t "oom
d Pla%e the patient nea" the doo"
Hhi%h of the following is the s%"eening test fo" deng$e hemo""hagi% fe/e"Q
a Complete blood %o$nt
b ,'IS#
% $mpel=leeds test
d Sedimentation "ate
5 <" )ela osa is s$spe%ted to ha/e mala"ia afte" a b$siness t"ip in Palawan !he most impo"tant
diagnosti% test in mala"ia is:
a H@C %o$nt
b U"inalysis
% ,'IS#d Pe"iphe"al blood smea"
8 !he *$"se s$pe"/iso" is planning fo" patientKs assignment fo" the #< shift !he n$"se s$pe"/iso"
a/oids assigning whi%h of the following staff membe"s to a %lient with he"pes (oste"Qa *$"se who ne/e" had %hi%en po-
b *$"se who ne/e" had "oseola
% *$"se who ne/e" had ge"man measles
d *$"se who ne/e" had m$mps
Cla"issa is 8 wees p"egnant F$"the" e-amination "e/ealed that she is s$s%eptible to "$bella Hhen
wo$ld be the most app"op"iate fo" he" to "e%ei/e "$bella imm$ni(ationQ
a #t on%e
b )$"ing 2nd t"imeste"
% )$"ing +"d t"imeste"
d #fte" the deli/e"y of the baby
9 # female %hild with "$bella sho$ld be isolated f"om a:
a 21 yea" old male %o$sin li/ing in the same ho$se
b 1 yea" old siste" who "e%ently got ma""ied
% 11 yea" old siste" who had "$beola d$"ing %hildhood
d . yea" old gi"l who li/es ne-t doo"
10 Hhat is the p"ima"y p"e/ention of lep"osyQ
a *$t"ition
b 7itamins% @CD /a%%ination
d )P! /a%%ination
11 # ba%te"ia whi%h %a$ses diphthe"ia is also nown asQ
a #moeba
b Chole"a
% lebs=loeffle" ba%ill$s
d Spi"o%hete
12 *$"se on pe"fo"med manto$- sin test today <onday to a male ad$lt %lient Hhi%h statement by
the %lient indi%ates that he $nde"stood the inst"$%tion wellQ
8 @aby <a"ie was bo"n <ay 2+& 19. *$"se Bohn will e-pe%t finge" th$mb opposition on:
a #p"il 19
b Feb"$a"y 19
% <a"%h 19
d B$ne 19
85 @aby eese is a 12 month old %hild *$"se Oli/e" wo$ld anti%ipate how many teethQ
a 9 b 8
%
d 5
88 Hhi%h of the following is the p"ima"y antidote fo" !ylenol poisoningQ
a *a"%an
b )igo-in
% #%etyl%ysteine
d Fl$ma(enil
8 # male %hild has an intelligen%e 6$otient of app"o-imately .0 Hhi%h ind of en/i"onment andinte"dis%iplina"y p"og"am most liely to benefit this %hild wo$ld be best des%"ibed as:
a ?abit t"aining
b Shelte"ed wo"shop% C$stodial
d ,d$%ational
89 *$"se B$dy is awa"e that following %ondition wo$ld "efle%t p"esen%e of %ongenital DI anomalyQ
a Co"d p"olapse
b Polyhyd"amios
% Pla%enta p"e/ia
d Oligohyd"amios
0 *$"se Ch"istine p"o/ides health tea%hing fo" the pa"ents of a %hild diagnosed with %elia% disease
*$"se Ch"istine tea%hes the pa"ents to in%l$de whi%h of the following food items in the %hildKs diet:
a ye toast
b Oatmeal
% Hhite b"eadd i%e
1 *$"se andy is planning to administe" o"al medi%ation to a + yea" old %hild *$"se andy is awa"e
that the best way to p"o%eed is by:a Ho$ld yo$ lie to d"in yo$" medi%ineQT
b If yo$ tae yo$" medi%ine now& IKll gi/e yo$ lollipopT
% See the othe" boy too his medi%ineQ *ow itKs yo$" t$"nT
d ?e"eKs yo$" medi%ine Ho$ld yo$ lie a mango o" o"ange E$i%eQT
2 #t what age a %hild %an b"$sh he" teeth witho$t helpQ
a 5 yea"s
b 8 yea"s
% yea"s
d yea"s
+ ibi/a"in 7i"a(ole is p"es%"ibed fo" a female hospitali(ed %hild with S7 *$"se B$dy p"epa"e this
medi%ation /ia whi%h "o$teQ
a Int"a /eno$s
b O"al
% O-ygen tent
d S$b%$taneo$s
. !he p"esent %hai"man of the @oa"d of *$"sing in the Philippines is:
a <a"ia Boanna Ce"/antes
b Ca"men%ita #ba6$in% 'eono" ose"o
d P"imiti/a Pa6$i%
!he obligation to maintain effi%ient ethi%al standa"ds in the p"a%ti%e of n$"sing belong to this body:
a @O*
b #*S#P
% P*#
d *
5 # male n$"se was fo$nd g$ilty of negligen%e ?is li%ense was "e/oed e=iss$an%e of "e/oed
C,gg salad on wheat b"ead& %a""ot sti%s& lett$%e salad& "aisin pie
)Po" %hop& %"eamed potatoes& %o"n& and %o%on$t %ae
8 Clients with si%le %ell anemia a"e ta$ght to a/oid a%ti/ities that %a$se hypo-ia and hypo-emia Hhi%h of
the following a%ti/ities wo$ld the n$"se "e%ommendQ
## family /a%ation in the o%y <o$ntains
@Chape"oning the lo%al boys %l$b on a snow=siing t"ip
C!"a/eling by ai"plane fo" b$siness t"ips)# b$s t"ip to the <$se$m of *at$"al ?isto"y
!he n$"se is %ond$%ting an admission assessment of a %lient with /itamin @12 defi%ien%y Hhi%h of thefollowing wo$ld the n$"se in%l$de in the physi%al assessmentQ
#Palpate the spleen
@!ae the blood p"ess$"e
C,-amine the feet fo" pete%hiae
),-amine the tong$e
9 #n #f"i%an #me"i%an female %omes to the o$tpatient %lini% !he physi%ian s$spe%ts /itamin @12
defi%ien%y anemia @e%a$se Ea$ndi%e is often a %lini%al manifestation of this type of anemia& what body pa"t
wo$ld be the best indi%ato"Q
#ConE$n%ti/a of the eye
@Soles of the feet
Coof of the mo$th
)Shins
10 !he n$"se is %ond$%ting a physi%al assessment on a %lient with anemia Hhi%h of the following %lini%al
manifestations wo$ld be most indi%ati/e of the anemiaQ
#@P 1.5G
@espi"ations 2 shallowCHeight gain of 10 po$nds in 5 months
)Pin %omple-ion
11 !he n$"se is tea%hing the %lient with poly%ythemia /e"a abo$t p"e/ention of %ompli%ations of the disease
Hhi%h of the following statements by the %lient indi%ates a need fo" f$"the" tea%hingQ
2+ # %lient with #ddisons disease has been admitted with a histo"y of na$sea and /omiting fo" the past +
days !he %lient is "e%ei/ing I7 gl$%o%o"ti%oids Sol$=<ed"ol Hhi%h of the following inte"/entions wo$ld
the n$"se implementQ
#Dl$%omete" "eadings as o"de"ed@IntaeGo$tp$t meas$"ements
CSodi$m and potassi$m le/els monito"ed
))aily weights
2. # %lient had a total thy"oide%tomy yeste"day !he %lient is %omplaining of tingling a"o$nd the mo$th and
in the finge"s and toes Hhat wo$ld the n$"ses ne-t a%tion beQ
#Obtain a %"ash %a"t
@Che% the %al%i$m le/el
C#ssess the d"essing fo" d"ainage
)#ssess the blood p"ess$"e fo" hype"tension2 # +2=yea"=old mothe" of th"ee is b"o$ght to the %lini% ?e" p$lse is 2& the"e is a weight gain of +0 po$nds
in . months& and the %lient is wea"ing two sweate"s !he %lient is diagnosed with hypothy"oidism Hhi%h of
the following n$"sing diagnoses is of highest p"io"ityQ#Impai"ed physi%al mobility "elated to de%"eased end$"an%e
.. # %lient is admitted to the hospital with a tempe"at$"e of 99RF& %omplaints of blood=tinged hemoptysis&
fatig$e& and night sweats !he %lients symptoms a"e %onsistent with a diagnosis of:
#Pne$monia
@ea%tion to anti/i"al medi%ation
C!$be"%$losis
)S$pe"infe%tion d$e to low C). %o$nt. !he %lient is seen in the %lini% fo" t"eatment of mig"aine heada%hes !he d"$g Imit"e- s$mat"iptan
s$%%inate is p"es%"ibed fo" the %lient Hhi%h of the following in the %lients histo"y sho$ld be "epo"ted to the
do%to"Q
#)iabetes
@P"in(metals angina
CCan%e"
)Cl$ste" heada%hes
.5 !he %lient with s$spe%ted meningitis is admitted to the $nit !he do%to" is pe"fo"ming an assessment to
dete"mine meningeal i""itation and spinal ne"/e "oot inflammation # positi/e e"nigs sign is %ha"ted if then$"se notes:
#Pain on fle-ion of the hip and nee
@*$%hal "igidity on fle-ion of the ne% CPain when the head is t$"ned to the left side
))i((iness when %hanging positions
.8 !he %lient with #l(heime"s disease is being assisted with a%ti/ities of daily li/ing when the n$"se notes
that the %lient $ses he" toothb"$sh to b"$sh he" hai" !he n$"se is awa"e that the %lient is e-hibiting:
##gnosia
@#p"a-ia
C#nomia
)#phasia
. !he %lient with dementia is e-pe"ien%ing %onf$sion late in the afte"noon and befo"e bedtime !he n$"se is
awa"e that the %lient is e-pe"ien%ing what is nown as:
#Ch"oni% fatig$e synd"ome
@*o"mal agingCS$ndowning
))el$sions
.9 !he %lient with %onf$sion says to the n$"se& LI ha/ent had anything to eat all day long Hhen a"e theygoing to b"ing b"eafastQL !he n$"se saw the %lient in the day "oom eating b"eafast with othe" %lients +0
min$tes befo"e this %on/e"sation Hhi%h "esponse wo$ld be best fo" the n$"se to maeQ
#LAo$ now yo$ had b"eafast +0 min$tes agoL
@LI am so so""y that they didnt get yo$ b"eafast Ill "epo"t it to the %ha"ge n$"seL
CLIll get yo$ some E$i%e and toast Ho$ld yo$ lie something elseQL
)LAo$ will ha/e to wait a whileW l$n%h will be he"e in a little whileL
0 !he do%to" has p"es%"ibed ,-elon "i/astigmine fo" the %lient with #l(heime"s disease Hhi%h side effe%t
is most often asso%iated with this d"$gQ
#U"ina"y in%ontinen%e
@?eada%hes
CConf$sion
)*a$sea
1 # %lient is admitted to the labo" and deli/e"y $nit in a%ti/e labo" )$"ing e-amination& the n$"se notes a
pap$la" lesion on the pe"ine$m Hhi%h initial a%tion is most app"op"iateQ
#)o%$ment the finding
@epo"t the finding to the do%to"
CP"epa"e the %lient fo" a C=se%tion
)Contin$e p"ima"y %a"e as p"es%"ibed2 # %lient with a diagnosis of ?P7 is at "is fo" whi%h of the followingQ
#?odgins lymphoma
@Ce"/i%al %an%e"
C<$ltiple myeloma
)O/a"ian %an%e"
+ )$"ing the initial inte"/iew& the %lient "epo"ts that she has a lesion on the pe"ine$m F$"the" in/estigation
"e/eals a small bliste" on the /$l/a that is painf$l to to$%h !he n$"se is awa"e that the most liely so$"%e of
. # %lient /isiting a family planning %lini% is s$spe%ted of ha/ing an S!I !he best diagnosti% test fo"
t"eponema pallid$m is:
#7ene"eal )isease esea"%h 'ab 7)'
@apid plasma "eagin P
CFlo"es%ent t"eponemal antibody F!#
)!haye"=<a"tin %$lt$"e !<C
# 1=yea"=old p"imig"a/ida is admitted with a tentati/e diagnosis of ?,''P synd"ome Hhi%h labo"ato"y
finding is asso%iated with ?,''P synd"omeQ#,le/ated blood gl$%ose
@,le/ated platelet %o$nt
C,le/ated %"eatinine %lea"an%e
),le/ated hepati% en(ymes
5 !he n$"se is assessing the deep tendon "efle-es of a %lient with p"ee%lampsia Hhi%h method is $sed to
eli%it the bi%eps "efle-Q
#!he n$"se pla%es he" th$mb on the m$s%le inset in the ante%$bital spa%e and taps the th$mb b"isly with
the "efle- hamme"
@!he n$"se loosely s$spends the %lients a"m in an open hand while tapping the ba% of the %lients elbowC!he n$"se inst"$%ts the %lient to dangle he" legs as the n$"se st"ies the a"ea below the patella with the
bl$nt side of the "efle- hamme"
)!he n$"se inst"$%ts the %lient to pla%e he" a"ms loosely at he" side as the n$"se st"ies the m$s%le inse"t E$st abo/e the w"ist
8 # p"imig"a/ida with diabetes is admitted to the labo" and deli/e"y $nit at +. wees gestation Hhi%h
5 !he home health n$"se is /isiting an 1=yea"=old with osteogenesis impe"fe%ta Hhi%h info"mation
obtained on the /isit wo$ld %a$se the most %on%e"nQ !he %lient:
#'ies to play football
@)"ins se/e"al %a"bonated d"ins pe" dayC?as two siste"s with si%le %ell t"a%t
)Is taing a%etaminophen to %ont"ol pain
55 !he n$"se wo"ing the o"gan t"ansplant $nit is %a"ing fo" a %lient with a white blood %ell %o$nt of )$"ing
e/ening /isitation& a /isito" b"ings a baset of f"$it Hhat a%tion sho$ld the n$"se taeQ
##llow the %lient to eep the f"$it
@Pla%e the f"$it ne-t to the bed fo" easy a%%ess by the %lient
COffe" to wash the f"$it fo" the %lient
)!ell the family membe"s to tae the f"$it home
58 !he n$"se is %a"ing fo" the %lient following a la"ynge%tomy when s$ddenly the %lient be%omesnon"esponsi/e and pale& with a @P of 90G.0 systoli% !he initial n$"ses a%tion sho$ld be to:
#Pla%e the %lient in !"endelenb$"g position
@In%"ease the inf$sion of )e-t"ose in no"mal salineC#dministe" at"opine int"a/eno$sly
)<o/e the eme"gen%y %a"t to the bedside
5 !he %lient admitted 2 days ea"lie" with a l$ng "ese%tion a%%identally p$lls o$t the %hest t$be Hhi%h a%tion
by the n$"se indi%ates $nde"standing of the management of %hest t$besQ
#O"de" a %hest -="ay
@einse"t the t$be
CCo/e" the inse"tion site with a 7aseline ga$(e
)Call the do%to"
59 # %lient being t"eated with sodi$m wa"fa"in has a P"otime of 120 se%onds Hhi%h inte"/ention wo$ld be
most impo"tant to in%l$de in the n$"sing %a"e planQ
##ssess fo" signs of abno"mal bleeding
@#nti%ipate an in%"ease in the Co$madin dosageCInst"$%t the %lient "ega"ding the d"$g the"apy
)In%"ease the f"e6$en%y of ne$"ologi%al assessments
80 Hhi%h sele%tion wo$ld p"o/ide the most %al%i$m fo" the %lient who is . months p"egnantQ## g"anola ba"
@# b"an m$ffin
C# %$p of yog$"t
)# glass of f"$it E$i%e
81 !he %lient with p"ee%lampsia is admitted to the $nit with an o"de" fo" magnesi$m s$lfate Hhi%h a%tion by
the n$"se indi%ates $nde"standing of the possible side effe%ts of magnesi$m s$lfateQ
#!he n$"se pla%es a sign o/e" the bed not to %he% blood p"ess$"e in the "ight a"m
@!he n$"se pla%es a padded tong$e blade at the bedside
C!he n$"se inse"ts a Foley %athete"
)!he n$"se da"ens the "oom
82 # 5=yea"=old %lient is admitted to the $nit with a hemoglobin of 5gGd' !he physi%ian has w"itten an o"de"
to t"ansf$se 2 $nits of whole blood Hhen dis%$ssing the t"eatment& the %hilds mothe" tells the n$"se that she
does not belie/e in ha/ing blood t"ansf$sions and that she will not allow he" %hild to ha/e the t"eatment
Hhat n$"sing a%tion is most app"op"iateQ
##s the mothe" to lea/e while the blood t"ansf$sion is in p"og"ess
@,n%o$"age the mothe" to "e%onside"
C,-plain the %onse6$en%es witho$t t"eatment
)*otify the physi%ian of the mothe"s "ef$sal8+ # %lient is admitted to the $nit 2 ho$"s afte" an e-plosion %a$ses b$"ns to the fa%e !he n$"se wo$ld be
most %on%e"ned with the %lient de/eloping whi%h of the followingQ
#?ypo/olemia
@'a"yngeal edema
C?ype"nat"emia
)?ype"alemia
8. !he n$"se is e/al$ating n$t"itional o$t%omes fo" an elde"ly %lient with b$limia Hhi%h data best indi%ates
98 !he n$"se is %a"ing fo" a %lient admitted with epiglottis @e%a$se of the possibility of %omplete obst"$%tion
of the ai"way& whi%h of the following sho$ld the n$"se ha/e a/ailableQ
#Int"a/eno$s a%%ess s$pplies
@# t"a%heostomy set
CInt"a/eno$s fl$id administ"ation p$mp
)S$pplemental o-ygen
9 # 2=yea"=old %lient with D"a/es disease is admitted to the $nit Hhat wo$ld the n$"se e-pe%t theadmitting assessment to "e/ealQ
#@"ady%a"dia
@)e%"eased appetite
C,-ophthalmos
)Height gain
99 !he n$"se is p"o/iding dieta"y inst"$%tions to the mothe" of an =yea"=old %hild diagnosed with %elia%
disease Hhi%h of the following foods& if sele%ted by the mothe"& wo$ld indi%ate he" $nde"standing of the
dieta"y inst"$%tionsQ
#?am sandwi%h on whole=wheat toast@Spaghetti and meatballs
C?amb$"ge" with et%h$p
)Cheese omelet100 !he n$"se is %a"ing fo" an 0=yea"=old with %h"oni% b"on%hitis Upon the mo"ning "o$nds& the n$"se finds
an O2 sat of 85V Hhi%h of the following a%tions sho$ld the n$"se tae fi"stQ
#*otify the physi%ian
@e%he% the O2 sat$"ation le/el in 1 min$tes
C#pply o-ygen by mas
)#ssess the %hilds p$lse
101 # g"a/ida III pa"a 0 is admitted to the labo" and deli/e"y $nit !he do%to" pe"fo"ms an amniotomy Hhi%h
obse"/ation wo$ld the n$"se be e-pe%ted to mae afte" the amniotomyQ
#Fetal hea"t tones 150bpm
@# mode"ate amo$nt of st"aw=%olo"ed fl$id
C# small amo$nt of g"eenish fl$id
)# small segment of the $mbili%al %o"d102 !he %lient is admitted to the $nit # /aginal e-am "e/eals that she is 2%m dilated Hhi%h of the following
statements wo$ld the n$"se e-pe%t he" to maeQ
#LHe ha/e a name pi%ed o$t fo" the babyL
@LI need to p$sh when I ha/e a %ont"a%tionL
CLI %ant %on%ent"ate if anyone is to$%hing meL
)LHhen %an I get my epid$"alQL
10+ !he %lient is ha/ing fetal hea"t "ates of 90X110bpm d$"ing the %ont"a%tions !he fi"st a%tion the n$"se
sho$ld tae is:
#eposition the monito"
@!$"n the %lient to he" left side
C#s the %lient to amb$late
)P"epa"e the %lient fo" deli/e"y10. In e/al$ating the effe%ti/eness of I7 Pito%in fo" a %lient with se%onda"y dysto%ia& the n$"se sho$ld e-pe%t:
## painless deli/e"y
@Ce"/i%al effa%ement
CInf"e6$ent %ont"a%tions
)P"og"essi/e %e"/i%al dilation10 # /aginal e-am "e/eals a footling b"ee%h p"esentation !he n$"se sho$ld tae whi%h of the following
a%tions at this timeQ
##nti%ipate the need fo" a Caesa"ean se%tion
@#pply the fetal hea"t monito"
CPla%e the %lient in Den$ Pe%to"al position
)Pe"fo"m an $lt"aso$nd e-am
105 # /aginal e-am "e/eals that the %e"/i- is .%m dilated& with inta%t memb"anes and a fetal hea"t tone "ate of150X180bpm !he n$"se de%ides to apply an e-te"nal fetal monito" !he "ationale fo" this implementation is:
#!he %e"/i- is %losed
@!he memb"anes a"e still inta%t
C!he fetal hea"t tones a"e within no"mal limits
)!he %ont"a%tions a"e intense eno$gh fo" inse"tion of an inte"nal monito"
108 !he following a"e all n$"sing diagnoses app"op"iate fo" a g"a/ida 1 pa"a 0 in labo" Hhi%h one wo$ld be
most app"op"iate fo" the p"imag"a/ida as she %ompletes the ea"ly phase of labo"Q
#Impai"ed gas e-%hange "elated to hype"/entilation
@#lte"ation in pla%ental pe"f$sion "elated to mate"nal position
CImpai"ed physi%al mobility "elated to fetal=monito"ing e6$ipment
)Potential fl$id /ol$me defi%it "elated to de%"eased fl$id intae
10 #s the %lient "ea%hes %m dilation& the n$"se notes late de%ele"ations on the fetal monito" !he F?
baseline is 15X18bpm with /a"iability of 0X2bpm Hhat is the most liely e-planation of this patte"nQ
#!he baby is asleep
@!he $mbili%al %o"d is %omp"essed
C!he"e is a /agal "esponse
)!he"e is $te"opla%ental ins$ffi%ien%y109 !he n$"se notes /a"iable de%ele"ations on the fetal monito" st"ip !he most app"op"iate initial a%tion
wo$ld be to:
#*otify he" do%to"
@Sta"t an I7
Ceposition the %lient
)eadE$st the monito"
110 Hhi%h of the following is a %ha"a%te"isti% of a "eass$"ing fetal hea"t "ate patte"nQ
## fetal hea"t "ate of 180X10bpm
@# baseline /a"iability of 2X+bpmCOmino$s pe"iodi% %hanges
)#%%ele"ation of F? with fetal mo/ements
111 !he "ationale fo" inse"ting a F"en%h %athete" e/e"y ho$" fo" the %lient with epid$"al anesthesia is:#!he bladde" fills mo"e "apidly be%a$se of the medi%ation $sed fo" the epid$"al
@?e" le/el of %ons%io$sness is s$%h that she is in a t"an%elie state
C!he sensation of the bladde" filling is diminished o" lost
)She is emba""assed to as fo" the bedpan that f"e6$ently
112 # %lient in the family planning %lini% ass the n$"se abo$t the most liely time fo" he" to %on%ei/e !he
n$"se e-plains that %on%eption is most liely to o%%$" when:
#,st"ogen le/els a"e low
@'$teni(ing ho"mone is high
C!he endomet"ial lining is thin
)!he p"ogeste"one le/el is low
11+ # %lient tells the n$"se that she plans to $se the "hythm method of bi"th %ont"ol !he n$"se is awa"e that
the s$%%ess of the "hythm method depends on the:##ge of the %lient
@F"e6$en%y of inte"%o$"se
Ceg$la"ity of the menses)ange of the %lients tempe"at$"e
11. # %lient with diabetes ass the n$"se fo" ad/i%e "ega"ding methods of bi"th %ont"ol Hhi%h method of
bi"th %ont"ol is most s$itable fo" the %lient with diabetesQ
#Int"a$te"ine de/i%e
@O"al %ont"a%epti/es
C)iaph"agm
)Cont"a%epti/e sponge
11 !he do%to" s$spe%ts that the %lient has an e%topi% p"egnan%y Hhi%h symptom is %onsistent with a
diagnosis of e%topi% p"egnan%yQ
#Painless /aginal bleeding
@#bdominal %"amping
C!h"obbing pain in the $ppe" 6$ad"ant
)S$dden& stabbing pain in the lowe" 6$ad"ant
115 !he n$"se is tea%hing a p"egnant %lient abo$t n$t"itional needs d$"ing p"egnan%y Hhi%h men$ sele%tion
will best meet the n$t"itional needs of the p"egnant %lientQ
#?amb$"ge" pattie& g"een beans& F"en%h f"ies& and i%ed tea
@oast beef sandwi%h& potato %hips& baed beans& and %ola
C@aed %hi%en& f"$it %$p& potato salad& %oleslaw& yog$"t& and i%ed tea)Fish sandwi%h& gelatin with f"$it& and %offee
118 !he %lient with hype"emesis g"a/ida"$m is at "is fo" de/eloping:
#espi"ato"y alalosis witho$t dehyd"ation
@<etaboli% a%idosis with dehyd"ation
Cespi"ato"y a%idosis witho$t dehyd"ation
)<etaboli% alalosis with dehyd"ation
11 # %lient tells the do%to" that she is abo$t 20 wees p"egnant !he most definiti/e sign of p"egnan%y is:
#,le/ated h$man %ho"ioni% gonadat"opin
@!he p"esen%e of fetal hea"t tones
CUte"ine enla"gement
)@"east enla"gement and tende"ness
119 !he n$"se is %a"ing fo" a neonate whose mothe" is diabeti% !he n$"se will e-pe%t the neonate to be:
120 Hhi%h of the following inst"$%tions sho$ld be in%l$ded in the n$"ses tea%hing "ega"ding o"al
%ont"a%epti/esQ
#Height gain sho$ld be "epo"ted to the physi%ian
@#n alte"nate method of bi"th %ont"ol is needed when taing antibioti%sCIf the %lient misses one o" mo"e pills& two pills sho$ld be taen pe" day fo" 1 wee
)Changes in the menst"$al flow sho$ld be "epo"ted to the physi%ian
121 !he n$"se is dis%$ssing b"eastfeeding with a postpa"t$m %lient @"eastfeeding is %ont"aindi%ated in the
postpa"t$m %lient with:
#)iabetes
@Positi/e ?I7
C?ype"tension
)!hy"oid disease
122 # %lient is admitted to the labo" and deli/e"y $nit %omplaining of /aginal bleeding with /e"y littledis%omfo"t !he n$"ses fi"st a%tion sho$ld be to:
##ssess the fetal hea"t tones
@Che% fo" %e"/i%al dilationCChe% fo" fi"mness of the $te"$s
)Obtain a detailed histo"y
12+ # %lient telephones the eme"gen%y "oom stating that she thins that she is in labo" !he n$"se sho$ld tell
the %lient that labo" has p"obably beg$n when:
#?e" %ont"a%tions a"e 2 min$tes apa"t
@She has ba% pain and a bloody dis%ha"ge
CShe e-pe"ien%es abdominal pain and f"e6$ent $"ination
)?e" %ont"a%tions a"e min$tes apa"t
12. !he n$"se is tea%hing a g"o$p of p"enatal %lients abo$t the effe%ts of %iga"ette smoe on fetal
de/elopment Hhi%h %ha"a%te"isti% is asso%iated with babies bo"n to mothe"s who smoed d$"ing p"egnan%yQ
12 !he physi%ian has o"de"ed an inEe%tion of hoDam fo" the postpa"t$m %lient whose blood type is #negati/e b$t whose baby is O positi/e !o p"o/ide postpa"t$m p"ophyla-is& hoDam sho$ld be administe"ed:
#Hithin 82 ho$"s of deli/e"y
@Hithin 1 wee of deli/e"y
CHithin 2 wees of deli/e"y
)Hithin 1 month of deli/e"y
125 #fte" the physi%ian pe"fo"ms an amniotomy& the n$"ses fi"st a%tion sho$ld be to assess the:
#)eg"ee of %e"/i%al dilation
@Fetal hea"t tones
CClients /ital signs
)Clients le/el of dis%omfo"t
128 # %lient is admitted to the labo" and deli/e"y $nit !he n$"se pe"fo"ms a /aginal e-am and dete"mines that
the %lients %e"/i- is %m dilated with 8V effa%ement @ased on the n$"ses assessment the %lient is in whi%h
phase of labo"Q
##%ti/e
@'atent
C!"ansition
),a"ly
12 # newbo"n with na"%oti% abstinen%e synd"ome is admitted to the n$"se"y *$"sing %a"e of the newbo"nsho$ld in%l$de:
#!ea%hing the mothe" to p"o/ide ta%tile stim$lation
@H"apping the newbo"n sn$gly in a blanet
CPla%ing the newbo"n in the infant seat
)Initiating an ea"ly infant=stim$lation p"og"am
129 # %lient ele%ts to ha/e epid$"al anesthesia to "elie/e the dis%omfo"t of labo" Following the initiation of
epid$"al anesthesia& the n$"se sho$ld gi/e p"io"ity to:
#Che%ing fo" %e"/i%al dilation
@Pla%ing the %lient in a s$pine position
CChe%ing the %lients blood p"ess$"e
)Obtaining a fetal hea"t "ate
1+0 !he n$"se is awa"e that the best way to p"e/ent post= ope"ati/e wo$nd infe%tion in the s$"gi%al %lient is to:
1+ !he n$"se is monito"ing the p"og"ess of a %lient in labo" Hhi%h finding sho$ld be "epo"ted to the
physi%ian immediatelyQ
#!he p"esen%e of s%ant bloody dis%ha"ge
@F"e6$ent $"ination
C!he p"esen%e of g"een=tinged amnioti% fl$id)<ode"ate $te"ine %ont"a%tions
1. !he n$"se is meas$"ing the d$"ation of the %lients %ont"a%tions Hhi%h statement is t"$e "ega"ding the
meas$"ement of the d$"ation of %ont"a%tionsQ
#)$"ation is meas$"ed by timing f"om the beginning of one %ont"a%tion to the beginning of the ne-t
%ont"a%tion
@)$"ation is meas$"ed by timing f"om the end of one %ont"a%tion to the beginning of the ne-t %ont"a%tion
C)$"ation is meas$"ed by timing f"om the beginning of one %ont"a%tion to the end of the same %ont"a%tion
))$"ation is meas$"ed by timing f"om the pea of one %ont"a%tion to the end of the same %ont"a%tion
1 !he physi%ian has o"de"ed an int"a/eno$s inf$sion of Pito%in fo" the ind$%tion of labo" Hhen %a"ing fo"the obstet"i% %lient "e%ei/ing int"a/eno$s Pito%in& the n$"se sho$ld monito" fo":
#<ate"nal hypogly%emia
@Fetal b"ady%a"diaC<ate"nal hype""efle-ia
)Fetal mo/ement
15 # %lient with diabetes /isits the p"enatal %lini% at 2 wees gestation Hhi%h statement is t"$e "ega"ding
ins$lin needs d$"ing p"egnan%yQ
#Ins$lin "e6$i"ements mode"ate as the p"egnan%y p"og"esses
@# de%"eased need fo" ins$lin o%%$"s d$"ing the se%ond t"imeste"
C,le/ations in h$man %ho"ioni% gonadot"ophin de%"ease the need fo" ins$lin
)Fetal de/elopment depends on ade6$ate ins$lin "eg$lation
18 # %lient in the p"enatal %lini% is assessed to ha/e a blood p"ess$"e of 10G95 !he n$"se sho$ld gi/e
p"io"ity to:
#P"o/iding a %alm en/i"onment
@Obtaining a diet histo"yC#dministe"ing an analgesi%
)#ssessing fetal hea"t tones
1 # p"imig"a/ida& age .2& is 5 wees p"egnant @ased on the %lients age& he" infant is at "is fo":#)own synd"ome
@espi"ato"y dist"ess synd"ome
C!$"ne"s synd"ome
)Pathologi%al Ea$ndi%e
19 # %lient with a missed abo"tion at 29 wees gestation is admitted to the hospital !he %lient will most
liely be t"eated with:
#<agnesi$m s$lfate
@Cal%i$m gl$%onate
C)inop"ostone P"ostin ,
)@"omo%"ystine Pa"del
150 # %lient with p"ee%lampsia has been "e%ei/ing an inf$sion %ontaining magnesi$m s$lfate fo" a blood
p"ess$"e that is 150G0W deep tendon "efle-es a"e 1 pl$s& and the $"ina"y o$tp$t fo" the past ho$" is 100m'
!he n$"se sho$ld:
#Contin$e the inf$sion of magnesi$m s$lfate while monito"ing the %lients blood p"ess$"e
@Stop the inf$sion of magnesi$m s$lfate and %onta%t the physi%ian
CSlow the inf$sion "ate and t$"n the %lient on he" left side
)#dministe" %al%i$m gl$%onate I7 p$sh and %ontin$e to monito" the blood p"ess$"e
151 Hhi%h statement made by the n$"se des%"ibes the inhe"itan%e patte"n of a$tosomal "e%essi/e diso"de"sQ##n affe%ted newbo"n has $naffe%ted pa"ents
@#n affe%ted newbo"n has one affe%ted pa"ent
C#ffe%ted pa"ents ha/e a one in fo$" %han%e of passing on the defe%ti/e gene
)#ffe%ted pa"ents ha/e $naffe%ted %hild"en who a"e %a""ie"s
152 # p"egnant %lient& age +2& ass the n$"se why he" do%to" has "e%ommended a se"$m alpha fetop"otein !he
n$"se sho$ld e-plain that the do%to" has "e%ommended the test:
#@e%a$se it is a state law
@!o dete%t %a"dio/as%$la" defe%ts
C@e%a$se of he" age
)!o dete%t ne$"ologi%al defe%ts
15+ # %lient with hypothy"oidism ass the n$"se if she will still need to tae thy"oid medi%ation d$"ing the
p"egnan%y !he n$"ses "esponse is based on the nowledge that:
)'eft o%%ipital t"ans/e"se p"esentation18 !he p"ima"y physiologi%al alte"ation in the de/elopment of asthma is:
#@"on%hiola" inflammation and dyspnea
@?ype"se%"etion of abno"mally /is%o$s m$%$s
CInfe%tio$s p"o%esses %a$sing m$%osal edema
)Spasm of b"on%hiola" smooth m$s%le
189 # %lient with mania is $nable to finish he" dinne" !o help he" maintain s$ffi%ient no$"ishment& the n$"se
sho$ld:
#Se"/e high=%alo"ie foods she %an %a""y with he"
@,n%o$"age he" appetite by sending o$t fo" he" fa/o"ite foods
CSe"/e he" small& att"a%ti/ely a""anged po"tions
)#llow he" in the $nit it%hen fo" e-t"a food whene/e" she pleases
10 !o maintain @"yants t"a%tion& the n$"se m$st mae %e"tain that the %hilds:#?ips a"e "esting on the bed& with the legs s$spended at a "ight angle to the bed
@?ips a"e slightly ele/ated abo/e the bed and the legs a"e s$spended at a "ight angle to the bed
C?ips a"e ele/ated abo/e the le/el of the body on a pillow and the legs a"e s$spended pa"allel to the bed)?ips and legs a"e flat on the bed& with the t"a%tion positioned at the foot of the bed
11 Hhi%h a%tion by the n$"se indi%ates $nde"standing of he"pes (oste"Q
#!he n$"se %o/e"s the lesions with a ste"ile d"essing
@!he n$"se wea"s glo/es when p"o/iding %a"e
C!he n$"se administe"s a p"es%"ibed antibioti%
)!he n$"se administe"s o-ygen
12 !he %lient has an o"de" fo" a t"o$gh to be d"awn on the %lient "e%ei/ing 7an%omy%in !he n$"se is awa"e
that the n$"se sho$ld %onta%t the lab fo" them to %olle%t the blood:
#1 min$tes afte" the inf$sion
@+0 min$tes befo"e the inf$sion
C1 ho$" afte" the inf$sion
)2 ho$"s afte" the inf$sion
1+ !he %lient $sing a diaph"agm sho$ld be inst"$%ted to:
#ef"ain f"om eeping the diaph"agm in longe" than . ho$"s
@eep the diaph"agm in a %ool lo%ation
C?a/e the diaph"agm "esi(ed if she gains po$nds
)?a/e the diaph"agm "esi(ed if she has any s$"ge"y
1. !he n$"se is p"o/iding postpa"t$m tea%hing fo" a mothe" planning to b"eastfeed he" infant Hhi%h of the%lients statements indi%ates the need fo" additional tea%hingQ
#LIm wea"ing a s$ppo"t b"aL
@LIm e-p"essing mil f"om my b"eastL
CLIm d"ining fo$" glasses of fl$id d$"ing a 2.=ho$" pe"iodL
)LHhile Im in the showe"& Ill allow the wate" to "$n o/e" my b"eastsL
1 )amage to the 7II %"anial ne"/e "es$lts in:
#Fa%ial pain
@#bsen%e of ability to smell
C#bsen%e of eye mo/ement
)!innit$s
15 # %lient is "e%ei/ing Py"idi$m phena(opy"idine hyd"o%hlo"ide fo" a $"ina"y t"a%t infe%tion !he %lient
)7is$al dist$"ban%es %an be %o""e%ted with p"es%"iption glasses
209 # %lient on the postpa"t$m $nit has a p"o%toepisiotomy !he n$"se sho$ld anti%ipate administe"ing whi%h
medi%ationQ
#)$l%ola- s$pposito"y
@)o%$sate sodi$m Cola%e
C<ethye"gono/ine maleate <ethe"gine
)@"omo%"iptine s$lfate Pa"lodel
210 # %lient with pan%"eati% %an%e" has an inf$sion of !P* !otal Pa"ente"al *$t"ition !he do%to" haso"de"ed fo" sliding=s%ale ins$lin !he most liely e-planation fo" this o"de" is:
#!otal Pa"ente"al *$t"ition leads to negati/e nit"ogen balan%e and ele/ated gl$%ose le/els
@!otal Pa"ente"al *$t"ition %annot be managed with o"al hypogly%emi%s
C!otal Pa"ente"al *$t"ition is a high=gl$%ose sol$tion that often ele/ates the blood gl$%ose le/els
)!otal Pa"ente"al *$t"ition leads to f$"the" pan%"eati% disease
211 #n adoles%ent p"imig"a/ida who is 10 wees p"egnant attends the antepa"tal %lini% fo" a fi"st %he%=$p !o
de/elop a tea%hing plan& the n$"se sho$ld initially assess:
#!he %lients nowledge of the signs of p"ete"m labo"
@!he %lients feelings abo$t the p"egnan%yCHhethe" the %lient was $sing a method of bi"th %ont"ol
)!he %lients tho$ght abo$t f$t$"e %hild"en
212 #n obstet"i% %lient is admitted with dehyd"ation Hhi%h I7 fl$id wo$ld be most app"op"iate fo" the %lientQ#. no"mal saline
@)e-t"ose 1V in wate"
C'a%tated inge"s
))e-t"ose V in . no"mal saline
21+ !he physi%ian has o"de"ed a thy"oid s%an to %onfi"m the diagnosis @efo"e the p"o%ed$"e& the n$"se
sho$ld:
##ssess the %lient fo" alle"gies
@@ol$s the %lient with I7 fl$id
C!ell the %lient he will be asleep
)Inse"t a $"ina"y %athete"
21. !he physi%ian has o"de"ed an inEe%tion of hoDam fo" a %lient with blood type # negati/e !he n$"se
$nde"stands that hoDam is gi/en to:#P"o/ide imm$nity against h isoen(ymes
@P"e/ent the fo"mation of h antibodies
C,liminate %i"%$lating h antibodies)Con/e"t the h fa%to" f"om negati/e to positi/e
21 !he n$"se is %a"ing fo" a %lient admitted to the eme"gen%y "oom afte" a fall ;="ays "e/eal that the %lient
has se/e"al f"a%t$"ed bones in the foot Hhi%h t"eatment sho$ld the n$"se anti%ipate fo" the f"a%t$"ed footQ
##ppli%ation of a sho"t in%l$si/e spi%a %ast
@Stabili(ation with a plaste"=of=Pa"is %ast
CS$"ge"y with i"s%hne" wi"e implantation
)# ga$(e d"essing only
215 # %lient with bladde" %an%e" is being t"eated with i"idi$m seed implants !he n$"ses dis%ha"ge tea%hing
sho$ld in%l$de telling the %lient to:
#St"ain his $"ine
@In%"ease his fl$id intae
Cepo"t $"ina"y f"e6$en%y
)#/oid p"olonged sitting
218 Following a hea"t t"ansplant& a %lient is sta"ted on medi%ation to p"e/ent o"gan "eEe%tion Hhi%h %atego"y
of medi%ation p"e/ents the fo"mation of antibodies against the new o"ganQ
##nti/i"als
@#ntibioti%s
CImm$nos$pp"essants)#nalgesi%s
21 !he n$"se is p"epa"ing a %lient fo" %ata"a%t s$"ge"y !he n$"se is awa"e that the p"o%ed$"e will $se:
#<yd"iati%s to fa%ilitate "emo/al
@<ioti% medi%ations s$%h as !imopti%
C# lase" to smooth and "eshape the lens
)Sili%one oil inEe%tions into the eyeball
219 # %lient with #l(heime"s disease is awaiting pla%ement in a silled n$"sing fa%ility Hhi%h long=te"m
plans wo$ld be most the"ape$ti% fo" the %lientQ
#Pla%ing mi""o"s in se/e"al lo%ations in the home
@Pla%ing a pi%t$"e of he"self in he" bed"oom
CPla%ing simple signs to indi%ate the lo%ation of the bed"oom& bath"oom& and so on
220 # %lient with an abdominal %hole%yste%tomy "et$"ns f"om s$"ge"y with a Ba%son=P"att d"ain !he %hief
p$"pose of the Ba%son=P"att d"ain is to:
#P"e/ent the need fo" d"essing %hanges
@ed$%e edema at the in%ision
CP"o/ide fo" wo$nd d"ainage
)eep the %ommon bile d$%t open
221 !he n$"se is pe"fo"ming an initial assessment of a newbo"n Ca$%asian male deli/e"ed at +2 wees
gestation !he n$"se %an e-pe%t to find the p"esen%e of:#<ongolian spots
@S%"otal "$gae
C?ead lag
)7e"ni- %aseosa
222 !he n$"se is %a"ing fo" a %lient admitted with m$ltiple t"a$ma F"a%t$"es in%l$de the pel/is& fem$"& and
$lna Hhi%h finding sho$ld be "epo"ted to the physi%ian immediatelyQ
#?emat$"ia
@<$s%le spasms
C)i((iness)*a$sea
22+ # %lient is b"o$ght to the eme"gen%y "oom by the poli%e ?e is %ombati/e and yells& LI ha/e to get o$t of
he"e !hey a"e t"ying to ill meL Hhi%h assessment is most liely %o""e%t in "elation to this statementQ#!he %lient is e-pe"ien%ing an a$dito"y hall$%ination
@!he %lient is ha/ing a del$sion of g"ande$"
C!he %lient is e-pe"ien%ing pa"anoid del$sions
)!he %lient is into-i%ated
22. !he n$"se is p"epa"ing to s$%tion the %lient with a t"a%heotomy !he n$"se notes a p"e/io$sly $sed bottle
of no"mal saline on the %lients bedside table !he"e is no label to indi%ate the date o" time of initial $se !he
n$"se sho$ld:
#'ip the bottle and $se a pa% of ste"ile .-. fo" the d"essing
@Obtain a new bottle and label it with the date and time of fi"st $se
C#s the wa"d se%"eta"y when the sol$tion was "e6$ested
)'abel the e-isting bottle with the %$""ent date and time
22 #n infants #pga" s%o"e is 9 at min$tes !he n$"se is awa"e that the most liely %a$se fo" the ded$%tionof one point is:
#!he baby is %old
@!he baby is e-pe"ien%ing b"ady%a"diaC!he babys hands and feet a"e bl$e
)!he baby is letha"gi%
225 !he p"ima"y "eason fo" "apid %ontin$o$s "ewa"ming of the a"ea affe%ted by f"ostbite is to:
#'essen the amo$nt of %ell$la" damage
@P"e/ent the fo"mation of bliste"s
CP"omote mo/ement
)P"e/ent pain and dis%omfo"t
228 # %lient "e%ently sta"ted on hemodialysis wants to now how the dialysis will tae the pla%e of his
idneys !he n$"ses "esponse is based on the nowledge that hemodialysis wo"s by:
#Passing wate" th"o$gh a dialy(ing memb"ane
@,liminating plasma p"oteins f"om the blood
C'owe"ing the p? by "emo/ing non/olatile a%ids
)Filte"ing waste th"o$gh a dialy(ing memb"ane
22 )$"ing a home /isit& a %lient with #I)S tells the n$"se that he has been e-posed to measles Hhi%h a%tion
by the n$"se is most app"op"iateQ
##dministe" an antibioti%
@Conta%t the physi%ian fo" an o"de" fo" imm$ne glob$lin
C#dministe" an anti/i"al)!ell the %lient that he sho$ld "emain in isolation fo" 2 wees
229 # %lient hospitali(ed with <S# methi%illin="esistant staph a$"e$s is pla%ed on %onta%t p"e%a$tions
Hhi%h statement is t"$e "ega"ding p"e%a$tions fo" infe%tions sp"ead by %onta%tQ
#!he %lient sho$ld be pla%ed in a "oom with negati/e p"ess$"e
@Infe%tion "e6$i"es %lose %onta%tW the"efo"e& the doo" may "emain open
C!"ansmission is highly liely& so the %lient sho$ld wea" a mas at all times
)Infe%tion "e6$i"es sin=to=sin %onta%t and is p"e/ented by hand washing& glo/es& and a gown
2+0 # %lient who is admitted with an abo/e=the=nee amp$tation tells the n$"se that his foot h$"ts and it%hes
Hhi%h "esponse by the n$"se indi%ates $nde"standing of phantom limb painQ
#L!he pain will go away in a few daysL
@L!he pain is d$e to pe"iphe"al ne"/o$s system inte""$ptions I will get yo$ some pain medi%ationL
CL!he pain is psy%hologi%al be%a$se yo$" foot is no longe" the"eL
A$s-!rs a$% Rati#$a+!s #r C#6*r!/!$si8! E<a6i$ati#$ Part 2
1 #nswe" ) is %o""e%t It is impo"tant to assess the e-t"emities fo" blood /essel o%%l$sion in the %lient with si%le
%ell anemia be%a$se a %hange in %apilla"y "efill wo$ld indi%ate a %hange in %i"%$lation @ody tempe"at$"e&motion& and sensation wo$ld not gi/e info"mation "ega"ding pe"iphe"al %i"%$lationW the"efo"e& answe"s #& @&
and C a"e in%o""e%t
2 #nswe" ) is %o""e%t Pla%ing the %lient in semi=Fowle"Ks position p"o/ides the best o-ygenation fo" this %lient
Fle-ion of the hips and nees& whi%h in%l$des the nee=%hest position& impedes %i"%$lation and is not %o""e%t positioning fo" this %lient !he"efo"e& answe"s #& @& and C a"e in%o""e%t
+ #nswe" @ is %o""e%t It is impo"tant to eep the %lient in si%le %ell %"isis hyd"ated to p"e/ent f$"the" si%ling of
the blood #nswe" # is in%o""e%t be%a$se a me%hani%al %$ff pla%es too m$%h p"ess$"e on the a"m #nswe" C is
in%o""e%t be%a$se "aising the nee gat%h impedes %i"%$lation #nswe" ) is in%o""e%t be%a$se !ylenol is too
mild an analgesi% fo" the %lient in %"isis
. #nswe" C is %o""e%t ?yd"ation is impo"tant in the %lient with si%le %ell disease to p"e/ent th"omb$s
fo"mation Popsi%les& gelatin& E$i%e& and p$dding ha/e high fl$id %ontent !he foods in answe"s #& @& and ) do
not aid in hyd"ation and a"e& the"efo"e& in%o""e%t
#nswe" C is %o""e%t !he most p"ominent %lini%al manifestation of si%le %ell %"isis is pain ?owe/e"& the p$lse
is in%o""e%t be%a$se altho$gh a wa"m en/i"onment "ed$%es pain and minimi(es si%ling& it wo$ld not be a
p"io"ity #nswe" @ is in%o""e%t be%a$se altho$gh hyd"ation is impo"tant& it wo$ld not "e6$i"e a bol$s #nswe") is in%o""e%t be%a$se )eme"ol is a%idifying to the blood and in%"eases si%ling
5 #nswe" C is %o""e%t ,gg yols& wheat b"ead& %a""ots& "aisins& and g"een& leafy /egetables a"e all high in i"on&whi%h is an impo"tant mine"al fo" this %lient oast beef& %abbage& and po" %hops a"e also high in i"on& b$t the
side dishes a%%ompanying these %hoi%es a"e notW the"efo"e& answe"s #& @& and ) a"e in%o""e%t
8 #nswe" ) is %o""e%t !aing a t"ip to the m$se$m is the only answe" that does not pose a th"eat # family
/a%ation in the o%y <o$ntains at high altit$des& %old tempe"at$"es& and ai"plane t"a/el %an %a$se si%lingepisodes and sho$ld be a/oidedW the"efo"e& answe"s #& @& and C a"e in%o""e%t
#nswe" ) is %o""e%t !he tong$e is smooth and beefy "ed in the %lient with /itamin @12 defi%ien%y& so
e-amining the tong$e sho$ld be in%l$ded in the physi%al assessment @leeding& splenomegaly& and blood
p"ess$"e %hanges do not o%%$"& maing answe"s #& @& and C in%o""e%t
9 #nswe" C is %o""e%t !he o"al m$%osa and ha"d palate "oof of the mo$th a"e the best indi%ato"s of Ea$ndi%e in
da"=sinned pe"sons !he %onE$n%ti/a %an ha/e no"mal deposits of fat& whi%h gi/e a yellowish h$eW th$s&answe" # is in%o""e%t !he soles of the feet %an be yellow if they a"e %allo$sed& maing answe" @ in%o""e%tW the
shins wo$ld be an a"ea of da"e" pigment& so answe" ) is in%o""e%t
10 #nswe" @ is %o""e%t Hhen the"e a"e fewe" "ed blood %ells& the"e is less hemoglobin and less o-ygen
!he"efo"e& the %lient is often sho"t of b"eath& as indi%ated in answe" @ !he %lient with anemia is often pale in
%olo"& has weight loss& and may be hypotensi/e #nswe"s #& C& and ) a"e within no"mal and& the"efo"e& a"e
in%o""e%t
11 #nswe" # is %o""e%t !he %lient with poly%ythemia /e"a is at "is fo" th"omb$s fo"mation ?yd"ating the
%lient with at least +' of fl$id pe" day is impo"tant in p"e/enting %lot fo"mation& so the statement to d"in lessthan 00m' is in%o""e%t #nswe"s @& C& and ) a"e in%o""e%t be%a$se they all %ont"ib$te to the p"e/ention of
%ompli%ations S$ppo"t hose p"omotes /eno$s "et$"n& the ele%t"i% "a(o" p"e/ents bleeding d$e to inE$"y& and a
diet low in i"on is essential to p"e/enting f$"the" "ed %ell fo"mation
12 #nswe" C is %o""e%t adiation t"eatment fo" othe" types of %an%e" %an "es$lt in le$emia Some hobbies ando%%$pations in/ol/ing %hemi%als a"e lined to le$emia& b$t not the ones in these answe"sW the"efo"e& answe"s
# and @ a"e in%o""e%t #nswe" ) is in%o""e%t be%a$se the in%iden%e of le$emia is highe" in twins than in
siblings
1+ #nswe" ) is %o""e%t Pete%hiae a"e not $s$ally /is$ali(ed on da" sin !he soles of the feet and palms of the
hand p"o/ide a lighte" s$"fa%e fo" assessing the %lient fo" peti%hiae #nswe"s #& @& and C a"e in%o""e%t be%a$se
the sin might be too da" to mae an assessment
1. #nswe" @ is %o""e%t !he %lient with le$emia is at "is fo" infe%tion and has often had "e%$""ent "espi"ato"y
infe%tions d$"ing the p"e/io$s 5 months Insomnolen%e& weight loss& and a de%"ease in ale"tness also o%%$" in
le$emia& b$t bleeding tenden%ies and infe%tions a"e the p"ima"y %lini%al manifestationsW the"efo"e& answe"s #&
C& and ) a"e in%o""e%t
1 #nswe" @ is %o""e%t !he %lient with a%$te le$emia has bleeding tenden%ies d$e to de%"eased platelet %o$nts&
and any inE$"y wo$ld e-a%e"bate the p"oblem !he %lient wo$ld "e6$i"e %lose monito"ing fo" hemo""hage&
whi%h is of highe" p"io"ity than the diagnoses in answe"s #& C& and )& whi%h a"e in%o""e%t
15 #nswe" # is %o""e%t adiation the"apy often %a$ses ste"ility in male %lients and wo$ld be of p"ima"yimpo"tan%e to this %lient !he psy%hoso%ial needs of the %lient a"e impo"tant to add"ess in light of the age and
life %hoi%es ?odginKs disease& howe/e"& has a good p"ognosis when diagnosed ea"ly #nswe"s @& C& and )
a"e in%o""e%t be%a$se they a"e of lesse" p"io"ity
18 #nswe" # is %o""e%t Clients with a$toimm$ne th"ombo%ytopeni% p$"p$"a #!P ha/e low platelet %o$nts&
maing answe" # the %o""e%t answe" Hhite %ell %o$nts& potassi$m le/els& and P!! a"e not affe%ted in #!PW
1 #nswe" # is %o""e%t !he no"mal platelet %o$nt is 120&000X.00&000 @leeding o%%$"s in %lients with low
platelets !he p"io"ity is to p"e/ent and minimi(e bleeding O-ygenation in answe" C is impo"tant& b$t platelets
do not %a""y o-ygen #nswe"s @ and ) a"e of lesse" p"io"ity and a"e in%o""e%t in this instan%e
19 #nswe" C is %o""e%t ,le/ating the head of the bed +0R a/oids p"ess$"e on the sella t$"%i%a and alle/iates
heada%hes #nswe"s #& @& and ) a"e in%o""e%t be%a$se !"endelenb$"g& 7alsal/a mane$/e"& and %o$ghing all
in%"ease the int"a%"anial p"ess$"e20 #nswe" @ is %o""e%t !he la"ge amo$nt of fl$id loss %an %a$se fl$id and ele%t"olyte imbalan%e that sho$ld be
%o""e%ted !he loss of ele%t"olytes wo$ld be "efle%ted in the /ital signs <eas$"ing the $"ina"y o$tp$t isimpo"tant& b$t the stem al"eady says that the %lient has poly$"ia& so answe" # is in%o""e%t ,n%o$"aging fl$id
intae will not %o""e%t the p"oblem& maing answe" C in%o""e%t #nswe" ) is in%o""e%t be%a$se weighing the
%lient is not ne%essa"y at this time
21 #nswe" C is %o""e%t !he %lient sho$ld be positioned $p"ight and leaning fo"wa"d& to p"e/ent aspi"ation of
blood #nswe"s #& @& and ) a"e in%o""e%t be%a$se di"e%t p"ess$"e to the nose stops the bleeding& and i%e pa%s
sho$ld be applied di"e%tly to the nose as well If a pa% is ne%essa"y& the na"es a"e loosely pa%ed
22 #nswe" # is %o""e%t @lood p"ess$"e is the best indi%ato" of %a"dio/as%$la" %ollapse in the %lient who has had
an ad"enal gland "emo/ed !he "emaining gland might ha/e been s$pp"essed d$e to the t$mo" a%ti/ity
!empe"at$"e wo$ld be an indi%ato" of infe%tion& de%"eased o$tp$t wo$ld be a %lini%al manifestation b$t wo$ld
tae longe" to o%%$" than blood p"ess$"e %hanges& and spe%ifi% g"a/ity %hanges o%%$" with othe" diso"de"sW
the"efo"e& answe"s @& C& and ) a"e in%o""e%t
2+ #nswe" # is %o""e%t I7 gl$%o%o"ti%oids "aise the gl$%ose le/els and often "e6$i"e %o/e"age with ins$lin#nswe" @ is not ne%essa"y at this time& sodi$m and potassi$m le/els wo$ld be monito"ed when the %lient is
"e%ei/ing mine"al %o"ti%oids& and daily weights is $nne%essa"yW the"efo"e& answe"s @& C& and ) a"e in%o""e%t
2. #nswe" @ is %o""e%t !he pa"athy"oid glands a"e "esponsible fo" %al%i$m p"od$%tion and %an be damaged
d$"ing a thy"oide%tomy !he tingling is d$e to low %al%i$m le/els !he %"ash %a"t wo$ld be needed in"espi"ato"y dist"ess b$t wo$ld not be the ne-t a%tion to taeW th$s& answe" # is in%o""e%t ?ype"tension o%%$"s
in thy"oid sto"m and the d"ainage wo$ld o%%$" in hemo""hage& so answe"s C and ) a"e in%o""e%t
2 #nswe" ) is %o""e%t !he de%"ease in p$lse %an affe%t the %a"dia% o$tp$t and lead to sho%& whi%h wo$ld tae
p"e%eden%e o/e" the othe" %hoi%esW the"efo"e& answe"s #& @& and C a"e in%o""e%t
25 #nswe" # is %o""e%t !he %lient taing antilipidemi%s sho$ld be en%o$"aged to "epo"t m$s%le weaness
be%a$se this is a sign of "habdomyositis !he medi%ation taes effe%t within 1 month of beginning the"apy& so
answe" @ is in%o""e%t !he medi%ation sho$ld be taen with wate" be%a$se f"$it E$i%e& pa"ti%$la"ly g"apef"$it&
%an de%"ease the effe%ti/eness& maing answe" C in%o""e%t 'i/e" f$n%tion st$dies sho$ld be %he%ed befo"e beginning the medi%ation& not afte" the fa%t& maing answe" ) in%o""e%t
28 #nswe" @ is %o""e%t ?ype"stat is gi/en I7 p$sh fo" hype"tensi/e %"ises& b$t it often %a$ses hype"gly%emia
!he gl$%ose le/el will d"op "apidly when stopped #nswe" # is in%o""e%t be%a$se the hype"stat is gi/en by I7
p$sh !he %lient sho$ld be pla%ed in do"sal "e%$mbent position& not a !"endelenb$"g position& as stated in
answe" C #nswe" ) is in%o""e%t be%a$se the medi%ation does not ha/e to be %o/e"ed with foil
2 #nswe" C is %o""e%t # hea"t "ate of 50 in the baby sho$ld be "epo"ted immediately !he dose sho$ld be held
if the hea"t "ate is below 100bpm !he blood gl$%ose& blood p"ess$"e& and "espi"ations a"e within no"mal limitsW
th$s answe"s #& @& and ) a"e in%o""e%t
29 #nswe" C is %o""e%t *it"ogly%e"ine sho$ld be ept in a b"own bottle o" e/en a spe%ial ai"= and wate"=tight&
solid o" plated sil/e" o" gold %ontaine" be%a$se of its instability and tenden%y to be%ome less potent whene-posed to ai"& light& o" wate" !he s$pply sho$ld be "eplenished e/e"y 5 months& not + months& and one tablet
sho$ld be taen e/e"y min$tes $ntil pain s$bsides& so answe"s # and @ a"e in%o""e%t If the pain does nots$bside& the %lient sho$ld "epo"t to the eme"gen%y "oom !he medi%ation sho$ld be taen s$bling$ally and
sho$ld not be %"$shed& as stated in answe" )
+0 #nswe" C is %o""e%t !$"ey %ontains the least amo$nt of fats and %holeste"ol 'i/e"& eggs& beef& %"eam
sa$%es& sh"imp& %heese& and %ho%olate sho$ld be a/oided by the %lientW th$s& answe"s #& @& and ) a"e in%o""e%t
!he %lient sho$ld bae meat "athe" than f"ying to a/oid adding fat to the meat d$"ing %ooing
+1 #nswe" @ is %o""e%t !he E$g$la" /eins in the ne% sho$ld be assessed fo" distension !he othe" pa"ts of the
body will be edemato$s in "ight=sided %ongesti/e hea"t fail$"e& not left=sidedW th$s& answe"s #& C& and ) a"e
in%o""e%t
+2 #nswe" # is %o""e%t !he phlebostati% a-is is lo%ated at the fifth inte"%ostals spa%e mida-illa"y line and is the
%o""e%t pla%ement of the manomete" !he P<I o" point of ma-imal imp$lse is lo%ated at the fifth inte"%ostals
spa%e mid%la/i%$la" line& so answe" @ is in%o""e%t ,"bKs point is the point at whi%h yo$ %an hea" the /al/es
%lose sim$ltaneo$sly& maing answe" C in%o""e%t !he !ail of Spen%e the $ppe" o$te" 6$ad"ant is the a"ea
whe"e most b"east %an%e"s a"e lo%ated and has nothing to do with pla%ement of a manomete"W th$s& answe" ) is
in%o""e%t
++ #nswe" @ is %o""e%t Jest"il is an #C, inhibito" and is f"e6$ently gi/en with a di$"eti% s$%h as 'asi- fo"
hype"tension #nswe"s #& C& and ) a"e in%o""e%t be%a$se the o"de" is a%%$"ate !he"e is no need to 6$estion theo"de"& administe" the medi%ation sepa"ately& o" %onta%t the pha"ma%y
+. #nswe" @ is %o""e%t !he best indi%ato" of pe"iphe"al edema is meas$"ing the e-t"emity # pape" tape
meas$"e sho$ld be $sed "athe" than one of plasti% o" %loth& and the a"ea sho$ld be ma"ed with a pen& p"o/iding
the most obEe%ti/e assessment #nswe" # is in%o""e%t be%a$se weighing the %lient will not indi%ate pe"iphe"al
edema #nswe" C is in%o""e%t be%a$se %he%ing the intae and o$tp$t will not indi%ate pe"iphe"al edema
#nswe" ) is in%o""e%t be%a$se %he%ing fo" pitting edema is less "eliable than meas$"ing with a pape" tape
meas$"e
+ #nswe" ) is %o""e%t Clients with "adi$m implants sho$ld ha/e %lose %onta%t limited to +0 min$tes pe" /isit
!he gene"al "$le is limiting time spent e-posed to "adi$m& p$tting distan%e between people and the "adi$m
so$"%e& and $sing lead to shield against the "adi$m !ea%hing the family membe" these p"in%iples is e-t"emely
impo"tant #nswe"s #& @& and C a"e not empatheti% and do not add"ess the 6$estionW the"efo"e& they a"e
in%o""e%t
+5 #nswe" @ is %o""e%t !he %lient with a fa%ial st"oe will ha/e diffi%$lty swallowing and %hewing& and thefoods in answe" @ p"o/ide the least amo$nt of %hewing !he foods in answe"s #& C& and ) wo$ld "e6$i"e mo"e
%hewing and& th$s& a"e in%o""e%t
+8 #nswe" # is %o""e%t *o/alog ins$lin onsets /e"y 6$i%ly& so food sho$ld be a/ailable within 10X1 min$tes
of taing the ins$lin #nswe" @ does not add"ess a pa"ti%$la" type of ins$lin& so it is in%o""e%t *P? ins$lin
peas in X12 ho$"s& so a sna% sho$ld be eaten at the e-pe%ted pea time It may not be + pm as stated in
answe" C #nswe" ) is in%o""e%t be%a$se the"e is no need to sa/e the desse"t $ntil bedtime
+ #nswe" @ is %o""e%t !he $mbili%al %o"d needs time to d"y and fall off befo"e p$tting the infant in the t$b
#ltho$gh answe"s #& C& and ) might be impo"tant& they a"e not the p"ima"y answe" to the 6$estion
+9 #nswe" ) is %o""e%t 'e$%o/o"in is the antidote fo" <ethot"e-ate and !"imet"e-ate whi%h a"e foli% a%idantagonists 'e$%o/o"in is a foli% a%id de"i/ati/e #nswe"s #& @& and C a"e in%o""e%t be%a$se 'e$%o/o"in does
not t"eat i"on defi%ien%y& in%"ease ne$t"ophils& o" ha/e a syne"gisti% effe%t
.0 #nswe" # is %o""e%t !he ?emophil$s infl$en(a /a%%ine is gi/en at . months with the polio /a%%ine#nswe"s @& C& and ) a"e in%o""e%t be%a$se these /a%%ines a"e gi/en late" in life
.1 #nswe" @ is %o""e%t P"oton p$mp inhibito"s s$%h as *e-i$m and P"otoni- sho$ld be taen with meals& fo"
optimal effe%t ?istamine=blo%ing agents s$%h as Janta% sho$ld be taen +0 min$tes befo"e meals& so answe"
# is in%o""e%t !agamet %an be taen in a single dose at bedtime& maing answe" C in%o""e%t #nswe" ) does
not t"eat the p"oblem ade6$ately and& the"efo"e& is in%o""e%t
.2 #nswe" # is %o""e%t If the %lient is a th"eat to the staff and to othe" %lients the n$"se sho$ld %all fo" help and
p"epa"e to administe" a medi%ation s$%h as ?aldol to sedate him #nswe" @ is in%o""e%t be%a$se simply telling
the %lient to %alm down will not wo" #nswe" C is in%o""e%t be%a$se telling the %lient that if he %ontin$es he
will be p$nished is a th"eat and may f$"the" ange" him #nswe" ) is in%o""e%t be%a$se if the %lient is left alone
he might ha"m himself
.+ #nswe" # is %o""e%t If the f$nd$s of the %lient is displa%ed to the side& this might indi%ate a f$ll bladde" !he
ne-t a%tion by the n$"se sho$ld be to %he% fo" bladde" distention and %athete"i(e& if ne%essa"y !he answe"s in@& C& and ) a"e a%tions that "elate to postpa"tal hemo""hage
.. #nswe" C is %o""e%t # low=g"ade tempe"at$"e& blood=tinged sp$t$m& fatig$e& and night sweats a"e symptoms
%onsistent with t$be"%$losis If the answe" in # had said pne$mo%ystis pne$monia& answe" # wo$ld ha/e been%onsistent with the symptoms gi/en in the stem& b$t E$st saying pne$monia isnKt spe%ifi% eno$gh to diagnose
the p"oblem #nswe"s @ and ) a"e not di"e%tly "elated to the stem
. #nswe" @ is %o""e%t If the %lient has a histo"y of P"in(metalKs angina& he sho$ld not be p"es%"ibed t"iptan
p"epa"ations be%a$se they %a$se /aso%onst"i%tion and %o"ona"y spasms !he"e is no %ont"aindi%ation fo" taing
t"iptan d"$gs in %lients with diabetes& %an%e"& o" %l$ste" heada%hes maing answe"s #& C& and ) in%o""e%t
.5 #nswe" # is %o""e%t e"nigKs sign is positi/e if pain o%%$"s on fle-ion of the hip and nee !he @"$d(insi
"efle- is positi/e if pain o%%$"s on fle-ion of the head and ne% onto the %hest so answe" @ is in%o""e%t
#nswe"s C and ) might be p"esent b$t a"e not "elated to e"nigKs sign
.8 #nswe" @ is %o""e%t #p"a-ia is the inability to $se obEe%ts app"op"iately #gnosia is loss of senso"y
%omp"ehension& anomia is the inability to find wo"ds& and aphasia is the inability to spea o" $nde"stand so
answe"s #& C& and ) a"e in%o""e%t
. #nswe" C is %o""e%t In%"eased %onf$sion at night is nown as Ls$ndowningL synd"ome !his in%"eased
%onf$sion o%%$"s when the s$n begins to set and %ontin$es d$"ing the night #nswe" # is in%o""e%t be%a$se
fatig$e is not ne%essa"ily p"esent In%"eased %onf$sion at night is not pa"t of no"mal agingW the"efo"e& answe" @
is in%o""e%t # del$sion is a fi"m& fi-ed beliefW the"efo"e& answe" ) is in%o""e%t
.9 #nswe" C is %o""e%t !he %lient who is %onf$sed might fo"get that he ate ea"lie" )onKt a"g$e with the %lient
Simply get him something to eat that will satisfy him $ntil l$n%h #nswe"s # and ) a"e in%o""e%t be%a$se the
n$"se is dismissing the %lient #nswe" @ is /alidating the del$sion0 #nswe" ) is %o""e%t *a$sea and gast"ointestinal $pset a"e /e"y %ommon in %lients taing
a%etyl%holineste"ase inhibito"s s$%h as ,-elon Othe" side effe%ts in%l$de li/e" to-i%ity& di((iness& $nsteadiness&
and %l$msiness !he %lient might al"eady be e-pe"ien%ing $"ina"y in%ontinen%e o" heada%hes& b$t they a"e not
ne%essa"ily asso%iatedW and the %lient with #l(heime"Ks disease is al"eady %onf$sed !he"efo"e& answe"s #& @&
and C a"e in%o""e%t
1 #nswe" @ is %o""e%t #ny lesion sho$ld be "epo"ted to the do%to" !his %an indi%ate a he"pes lesion Clients
with open lesions "elated to he"pes a"e deli/e"ed by Cesa"ean se%tion be%a$se the"e is a possibility of
t"ansmission of the infe%tion to the fet$s with di"e%t %onta%t to lesions It is not eno$gh to do%$ment the
finding& so answe" # is in%o""e%t !he physi%ian m$st mae the de%ision to pe"fo"m a C=se%tion& maing
answe" C in%o""e%t It is not eno$gh to %ontin$e p"ima"y %a"e& so answe" ) is in%o""e%t
2 #nswe" @ is %o""e%t !he %lient with ?P7 is at highe" "is fo" %e"/i%al and /aginal %an%e" "elated to this S!I
She is not at highe" "is fo" the othe" %an%e"s mentioned in answe"s #& C& and )& so those a"e in%o""e%t
+ #nswe" @ is %o""e%t # lesion that is painf$l is most liely a he"peti% lesion # %han%"e lesion asso%iated with
syphilis is not painf$l& so answe" # is in%o""e%t Condylomata lesions a"e painless wa"ts& so answe" ) is
in%o""e%t In answe" C& gono""hea does not p"esent as a lesion& b$t is e-hibited by a yellow dis%ha"ge
. #nswe" C is %o""e%t Flo"es%ent t"eponemal antibody F!# is the test fo" t"eponema pallid$m 7)' and
P a"e s%"eening tests done fo" syphilis& so answe"s # and @ a"e in%o""e%t !he !haye"=<a"tin %$lt$"e is done
fo" gono""hea& so answe" ) is in%o""e%t
#nswe" ) is %o""e%t !he %"ite"ia fo" ?,''P is hemolysis& ele/ated li/e" en(ymes& and low platelet %o$nt In
answe" #& an ele/ated blood gl$%ose le/el is not asso%iated with ?,''P Platelets a"e de%"eased& not ele/ated&in ?,''P synd"ome as stated in answe" @ !he %"eatinine le/els a"e ele/ated in "enal disease and a"e not
asso%iated with ?,''P synd"ome so answe" C is in%o""e%t
5 #nswe" # is %o""e%t #nswe" @ eli%its the t"i%eps "efle-& so it is in%o""e%t #nswe" C eli%its the patella "efle-&
maing it in%o""e%t #nswe" ) eli%its the "adial ne"/e& so it is in%o""e%t
8 #nswe" @ is %o""e%t @"ethine is $sed %a$tio$sly be%a$se it "aises the blood gl$%ose le/els #nswe"s #& C&
and ) a"e all medi%ations that a"e %ommonly $sed in the diabeti% %lient& so they a"e in%o""e%t
#nswe" C is %o""e%t Hhen the 'GS "atio "ea%hes 2:1& the l$ngs a"e %onside"ed to be mat$"e !he infant will
most liely be small fo" gestational age and will not be at "is fo" bi"th t"a$ma& so answe" ) is in%o""e%t !he
'GS "atio does not indi%ate %ongenital anomalies& as stated in answe" #& and the infant is not at "is fo"int"a$te"ine g"owth "eta"dation& maing answe" @ in%o""e%t
9 #nswe" C is %o""e%t Bitte"iness is a sign of sei($"e in the neonate C"ying& waef$lness& and yawning a"e
e-pe%ted in the newbo"n& so answe"s #& @& and ) a"e in%o""e%t50 #nswe" @ is %o""e%t !he %lient is e-pe%ted to be%ome sleepy& ha/e hot flashes& and be letha"gi% #
de%"easing $"ina"y o$tp$t& absen%e of the nee=Ee" "efle-& and de%"eased "espi"ations indi%ate to-i%ity& so
answe"s #& C& and ) a"e in%o""e%t
51 #nswe" ) is %o""e%t If the %lient e-pe"ien%es hypotension afte" an inEe%tion of epid$"al anestheti%& the n$"se
sho$ld t$"n he" to the left side& apply o-ygen by mas& and speed the I7 inf$sion If the blood p"ess$"e does
not "et$"n to no"mal& the physi%ian sho$ld be %onta%ted ,pineph"ine sho$ld be ept fo" eme"gen%y
administ"ation #nswe" # is in%o""e%t be%a$se pla%ing the %lient in !"endelenb$"g position head down will
allow the anesthesia to mo/e $p abo/e the "espi"ato"y %ente"& the"eby de%"easing the diaph"agmKs ability to
mo/e $p and down and /entilate the %lient In answe" @& the I7 "ate sho$ld be in%"eased& not de%"eased In
answe" C& the o-ygen sho$ld be applied by mas& not %ann$la
52 #nswe" # is %o""e%t Can%e" of the pan%"eas f"e6$ently leads to se/e"e na$sea and /omiting and alte"ed
n$t"ition !he othe" p"oblems a"e of lesse" %on%e"nW th$s& answe"s @& C& and ) a"e in%o""e%t5+ #nswe" C is %o""e%t <eas$"ing with a pape" tape meas$"e and ma"ing the a"ea that is meas$"ed is the most
obEe%ti/e method of estimating as%ites Inspe%ting and %he%ing fo" fl$id wa/es a"e mo"e s$bEe%ti/e& so
answe"s # and @ a"e in%o""e%t Palpation of the li/e" will not tell the amo$nt of as%itesW th$s& answe" ) isin%o""e%t
5. #nswe" @ is %o""e%t !he /ital signs indi%ate hypo/olemi% sho% !hey do not indi%ate %e"eb"al tiss$e
pe"f$sion& ai"way %lea"an%e& o" senso"y pe"%eption alte"ations& so answe"s #& C& and ) a"e in%o""e%t
5 #nswe" # is %o""e%t !he %lient with osteogenesis impe"fe%ta is at "is fo" pathologi%al f"a%t$"es and is liely
to e-pe"ien%e these f"a%t$"es if he pa"ti%ipates in %onta%t spo"ts !he %lient might e-pe"ien%e symptoms of
hypo-ia if he be%omes dehyd"ated o" deo-ygenatedW e-t"eme e-e"%ise& espe%ially in wa"m weathe"& %an
e-a%e"bate the %ondition #nswe"s @& C& and ) a"e not fa%to"s fo" %on%e"n
55 #nswe" ) is %o""e%t !he %lient with ne$t"openia sho$ld not ha/e f"esh f"$it be%a$se it sho$ld be peeled
andGo" %ooed befo"e eating ?e sho$ld also not eat foods g"own on o" in the g"o$nd o" eat f"om the salad ba"
!he n$"se sho$ld "emo/e potted o" %$t flowe"s f"om the "oom as well #ny so$"%e of ba%te"ia sho$ld be
eliminated& if possible #nswe"s #& @& and C will not help p"e/ent ba%te"ial in/asions
58 #nswe" @ is %o""e%t In %lients who ha/e not had s$"ge"y to the fa%e o" ne%& the answe" wo$ld be answe" #W
howe/e"& in this sit$ation& this %o$ld f$"the" inte"fe"e with the ai"way In%"easing the inf$sion and pla%ing the
%lient in s$pine position wo$ld be bette" #nswe"s C is in%o""e%t be%a$se it is not ne%essa"y at this time and
%o$ld %a$se hyponat"emia and f$"the" hypotension #nswe" ) is not ne%essa"y at this time
5 #nswe" C is %o""e%t If the %lient p$lls the %hest t$be o$t of the %hest& the n$"seKs fi"st a%tion sho$ld be to
%o/e" the inse"tion site with an o%%l$si/e d"essing #fte"wa"d& the n$"se sho$ld %all the do%to"& who will o"de"
a %hest -="ay and possibly "einse"t the t$be #nswe"s #& @& and ) a"e not the fi"st a%tion to be taen59 #nswe" # is %o""e%t !he no"mal P"otime is 12X20 se%onds # P"otime of 120 se%onds indi%ates an
e-t"emely p"olonged P"otime and %an "es$lt in a spontaneo$s bleeding episode #nswe"s @& C& and ) may be
needed at a late" time b$t a"e not the most impo"tant a%tions to tae fi"st
80 #nswe" C is %o""e%t !he food with the most %al%i$m is the yog$"t #nswe"s #& @& and ) a"e good %hoi%es&
b$t not as good as the yog$"t& whi%h has app"o-imately .00mg of %al%i$m
81 #nswe" C is %o""e%t !he %lient "e%ei/ing magnesi$m s$lfate sho$ld ha/e a Foley %athete" in pla%e& and
ho$"ly intae and o$tp$t sho$ld be %he%ed !he"e is no need to "ef"ain f"om %he%ing the blood p"ess$"e in
the "ight a"m # padded tong$e blade sho$ld be ept in the "oom at the bedside& E$st in %ase of a sei($"e& b$t
this is not "elated to the magnesi$m s$lfate inf$sion )a"ening the "oom is $nne%essa"y& so answe"s #& @& and
) a"e in%o""e%t
82 #nswe" ) is %o""e%t If the %lientKs mothe" "ef$ses the blood t"ansf$sion& the do%to" sho$ld be notified
@e%a$se the %lient is a mino"& the %o$"t might o"de" t"eatment #nswe" # is in%o""e%t @e%a$se it is not the
p"ima"y "esponsibility fo" the n$"se to en%o$"age the mothe" to %onsent o" e-plain the %onse6$en%es& so
answe"s @ and C a"e in%o""e%t
8+ #nswe" @ is %o""e%t !he n$"se sho$ld be most %on%e"ned with la"yngeal edema be%a$se of the a"ea of b$"n
!he ne-t p"io"ity sho$ld be answe" #& as well as hyponat"emia and hypoalemia in C and )& b$t these answe"s
a"e not of p"ima"y %on%e"n so a"e in%o""e%t
8. #nswe" ) is %o""e%t !he %lient with ano"e-ia shows the most imp"o/ement by weight gain Sele%ting a
balan%ed diet does little good if the %lient will not eat& so answe" # is in%o""e%t !he hemato%"it might imp"o/e
by se/e"al means& s$%h as blood t"ansf$sion& b$t that does not indi%ate imp"o/ement in the ano"e-i% %onditionWthe"efo"e& answe" @ is in%o""e%t !he tiss$e t$"go" indi%ates fl$id stasis& not imp"o/ement of ano"e-ia& so
answe" C is in%o""e%t
8 #nswe" ) is %o""e%t #t this time& pain beneath the %ast is no"mal !he %lientKs toes sho$ld be wa"m to the
to$%h& and p$lses sho$ld be p"esent Pa"esthesia is not no"mal and might indi%ate %ompa"tment synd"ome
!he"efo"e& #nswe"s #& @& and C a"e in%o""e%t
85 #nswe" @ is %o""e%t It is no"mal fo" the %lient to ha/e a wa"m sensation when dye is inEe%ted #nswe"s #& C&
and ) indi%ate that the n$"se belie/es that the hot feeling is abno"mal& so they a"e in%o""e%t
88 #nswe" ) is %o""e%t It is not ne%essa"y to wea" glo/es to tae the /ital signs of the %lient If the %lient has
a%ti/e infe%tion with methi%illin="esistant staphylo%o%%$s a$"e$s& glo/es sho$ld be wo"n !he health%a"ewo"e"s in answe"s #& @& and C indi%ate nowledge of infe%tion %ont"ol by thei" a%tions
8 #nswe" ) is %o""e%t )$"ing ,C!& the %lient will ha/e a g"and mal sei(e !his indi%ates %ompletion of the
ele%t"o%on/$lsi/e the"apy #nswe"s #& @& and C do not indi%ate that the ,C! has been effe%ti/e& so a"ein%o""e%t
89 #nswe" # is %o""e%t Infe%tion with pinwo"ms begins when the eggs a"e ingested o" inhaled !he eggs hat%h
in the $ppe" intestine and mat$"e in 2X wees !he females then mate and mig"ate o$t the an$s& whe"e they
lay $p to 18&000 eggs !his %a$ses intense it%hing !he mothe" sho$ld be told to $se a flashlight to e-amine the
"e%tal a"ea abo$t 2X+ ho$"s afte" the %hild is asleep Pla%ing %lea" tape on a tong$e blade will allow the eggs to
adhe"e to the tape !he spe%imen sho$ld then be b"o$ght in to be e/al$ated !he"e is no need to s%"ap the sin&
%olle%t a stool spe%imen& o" b"ing a sample of hai"& so answe"s @& C& and ) a"e in%o""e%t
0 #nswe" @ is %o""e%t ,"te"obiasis& o" pinwo"ms& is t"eated with 7e"mo- mebenda(ole o" #ntiminth
py"antel pamoate !he enti"e family sho$ld be t"eated to ens$"e that no eggs "emain @e%a$se a single
t"eatment is $s$ally s$ffi%ient& the"e is $s$ally good %omplian%e !he family sho$ld then be tested again in 2
wees to ens$"e that no eggs "emain #nswe"s #& C& and ) a"e in%o""e%t statements
1 #nswe" # is %o""e%t !he p"egnant n$"se sho$ld not be assigned to any %lient with "adioa%ti/ity p"esent !he%lient "e%ei/ing linea" a%%ele"ato" the"apy t"a/els to the "adi$m depa"tment fo" the"apy !he "adiation stays in
the depa"tment& so the %lient is not "adioa%ti/e !he %lients in answe"s @& C& and ) pose a "is to the p"egnant
n$"se !hese %lients a"e "adioa%ti/e in /e"y small doses& espe%ially $pon "et$"ning f"om the p"o%ed$"es Fo"app"o-imately 82 ho$"s& the %lients sho$ld dispose of $"ine and fe%es in spe%ial %ontaine"s and $se plasti%
spoons and fo"s
2 #nswe" # is %o""e%t !he %lient with C$shingKs disease has ad"eno%o"ti%al hype"se%"etion !his in%"ease in
the le/el of %o"tisone %a$ses the %lient to be imm$ne s$pp"essed In answe" @& the %lient with diabetes poses no
"is to othe" %lients !he %lient in answe" C has an in%"ease in g"owth ho"mone and poses no "is to himself o"
othe"s !he %lient in answe" ) has hype"thy"oidism o" my-edema and poses no "is to othe"s o" himself
+ #nswe" ) is %o""e%t !he n$"se %o$ld be %ha"ged with malp"a%ti%e& whi%h is failing to pe"fo"m& o"
pe"fo"ming an a%t that %a$ses ha"m to the %lient Di/ing the infant an o/e"dose falls into this %atego"y #nswe"s
#& @& and C a"e in%o""e%t be%a$se they apply to othe" w"ongf$l a%ts *egligen%e is failing to pe"fo"m %a"e fo"
the %lientW a to"t is a w"ongf$l a%t %ommitted on the %lient o" thei" belongingsW and assa$lt is a /iolent physi%al
o" /e"bal atta%
. #nswe" ) is %o""e%t !he li%ensed p"a%ti%al n$"se sho$ld not be assigned to begin a blood t"ansf$sion !he
li%ensed p"a%ti%al n$"se %an inse"t a Foley %athete"& dis%ontin$e a nasogast"i% t$be& and %olle%t sp$t$m
spe%imenW the"efo"e& answe"s #& @& and C a"e in%o""e%t
#nswe" @ is %o""e%t !he /ital signs a"e abno"mal and sho$ld be "epo"ted immediately Contin$ing to
monito" the /ital signs %an "es$lt in dete"io"ation of the %lientKs %ondition& maing answe" # in%o""e%t #sing
the %lient how he feels in answe" C will only p"o/ide s$bEe%ti/e data& and the n$"se in answe" ) is not the best
n$"se to assign be%a$se this %lient is $nstable5 #nswe" @ is %o""e%t !he n$"se with + yea"s of e-pe"ien%e in labo" and deli/e"y nows the most abo$t
possible %ompli%ations in/ol/ing p"ee%lampsia !he n$"se in answe" # is a new n$"se to the $nit& and the
n$"ses in answe"s C and ) ha/e no e-pe"ien%e with the postpa"t$m %lient
8 #nswe" @ is %o""e%t !he Boint Commission on #%%"editation of ?ospitals will p"obably be inte"ested in the
p"oblems in answe"s # and C !he fail$"e of the n$"sing assistant to %a"e fo" the %lient with hepatitis might
"es$lt in te"mination& b$t is not of inte"est to the Boint Commission
#nswe" @ is %o""e%t !he ne-t a%tion afte" dis%$ssing the p"oblem with the n$"se is to do%$ment the in%ident
by filing a fo"mal "ep"imand If the beha/io" %ontin$es o" if ha"m has "es$lted to the %lient& the n$"se may be
te"minated and "epo"ted to the @oa"d of *$"sing& b$t these a"e not the fi"st a%tions "e6$ested in the stem # to"t
is a w"ongf$l a%t to the %lient o" his belongings and is not indi%ated in this instan%e !he"efo"e& #nswe"s #& C&
9 #nswe" ) is %o""e%t !he %lient at highest "is fo" %ompli%ations is the %lient with m$ltiple s%le"osis who is
being t"eated with %o"tisone /ia the %ent"al line !he othe"s a"e mo"e stable <S# is methi%illin="esistant
staphylo%o%%$s a$"e$s 7an%omy%in is the d"$g of %hoi%e and is gi/en at s%hed$led times to maintain blood
le/els of the d"$g !he %lients in answe"s #& @& and C a"e mo"e stable and %an be seen late"
90 #nswe" @ is %o""e%t !he p"egnant %lient and the %lient with a b"oen a"m and fa%ial la%e"ations a"e the best
%hoi%es fo" pla%ing in the same "oom !he %lients in answe"s #& C& and ) need to be pla%ed in sepa"ate "ooms
d$e to the se"io$s nat$"es of thei" inE$"ies
91 #nswe" # is %o""e%t @efo"e instilling eyed"ops& the n$"se sho$ld %leanse the a"ea with wate" # 5=yea"=old%hild is not de/elopmentally "eady to instill his own eyed"ops& so answe" @ is in%o""e%t #ltho$gh the mothe"
of the %hild %an instill the eyed"ops& the a"ea m$st be %leansed befo"e administ"ation& maing answe" C
in%o""e%t #ltho$gh the eye might appea" to be %lea"& the n$"se sho$ld instill the eyed"ops& as o"de"ed& so
answe" ) is in%o""e%t
92 #nswe" C is %o""e%t emembe" the #@Cs ai"way& b"eathing& %i"%$lation when answe"ing this 6$estion
#nswe" C is %o""e%t be%a$se a hotdog is the si(e and shape of the %hildKs t"a%hea and poses a "is of aspi"ation
#nswe"s #& @& and C a"e in%o""e%t be%a$se white g"ape E$i%e& a g"illed %heese sandwi%h& and i%e %"eam do not
pose a "is of aspi"ation fo" a %hild
9+ #nswe" C is %o""e%t !he n$"se sho$ld en%o$"age "ooming=in to p"omote pa"ent=%hild atta%hment It is oayfo" the pa"ents to be in the "oom fo" assessment of the %hild #llowing the %hild to ha/e items that a"e familia"
to him is allowed and en%o$"agedW the"efo"e& answe"s # and @ a"e in%o""e%t #nswe" ) is not pa"t of the
n$"seKs "esponsibilities9. #nswe" @ is %o""e%t !he hea"ing aid sho$ld be sto"ed in a wa"m& d"y pla%e It sho$ld be %leaned daily b$t
sho$ld not be moldy& so answe" # is in%o""e%t # toothpi% is inapp"op"iate to $se to %lean the aidW the
toothpi% might b"ea off in the hea"ing aide& maing answe" C in%o""e%t Changing the batte"ies weely& as in
answe" )& is not ne%essa"y
9 #nswe" C is %o""e%t #lways "emembe" yo$" #@Cs ai"way& b"eathing& %i"%$lation when sele%ting an
answe" #ltho$gh answe"s @ and ) might be app"op"iate fo" this %hild& answe" C sho$ld ha/e the highest
p"io"ity #nswe" # does not apply fo" a %hild who has $nde"gone a tonsille%tomy
95 #nswe" # is %o""e%t If the %hild has ba%te"ial pne$monia& a high fe/e" is $s$ally p"esent @a%te"ial
pne$monia $s$ally p"esents with a p"od$%ti/e %o$gh& not a nonp"od$%ti/e %o$gh& maing answe" @ in%o""e%t
hinitis is often seen with /i"al pne$monia& and /omiting and dia""hea a"e $s$ally not seen with pne$monia& so
answe"s C and ) a"e in%o""e%t
98 #nswe" @ is %o""e%t Fo" a %hild with epiglottis and the possibility of %omplete obst"$%tion of the ai"way&eme"gen%y t"a%heostomy e6$ipment sho$ld always be ept at the bedside Int"a/eno$s s$pplies& fl$id& and
o-ygen will not t"eat an obst"$%tionW the"efo"e& answe"s #& C& and ) a"e in%o""e%t
9 #nswe" C is %o""e%t ,-ophthalmos p"ot"$sion of eyeballs often o%%$"s with hype"thy"oidism !he %lientwith hype"thy"oidism will often e-hibit ta%hy%a"dia& in%"eased appetite& and weight lossW the"efo"e& answe"s #&
@& and ) a"e in%o""e%t
99 #nswe" ) is %o""e%t !he %hild with %elia% disease sho$ld be on a gl$ten=f"ee diet #nswe"s #& @& and C all
%ontain gl$ten& while answe" ) gi/es the only %hoi%e of foods that does not %ontain gl$ten
100#nswe" C is %o""e%t emembe" the #@Cs ai"way& b"eathing& %i"%$lation when answe"ing this 6$estion
@efo"e notifying the physi%ian o" assessing the p$lse& o-ygen sho$ld be applied to in%"ease the o-ygen
sat$"ation& so answe"s # and ) a"e in%o""e%t !he no"mal o-ygen sat$"ation fo" a %hild is 92VX100V& maing
answe" @ in%o""e%t
101#nswe" @ is %o""e%t #n amniotomy is an a"tifi%ial "$pt$"e of memb"anes and no"mal amnioti% fl$id is st"aw=
%olo"ed and odo"less Fetal hea"t tones of 150 indi%ate ta%hy%a"dia& and g"eenish fl$id is indi%ati/e of
me%oni$m& so answe"s # and C a"e in%o""e%t If the n$"se notes the $mbili%al %o"d& the %lient is e-pe"ien%ing a
p"olapsed %o"d& so answe" ) is in%o""e%t and wo$ld need to be "epo"ted immediately
102#nswe" ) is %o""e%t )ilation of 2%m ma"s the end of the latent phase of labo" #nswe" # is a /ag$e
answe"& answe" @ indi%ates the end of the fi"st stage of labo"& and answe" C indi%ates the t"ansition phase
10+#nswe" @ is %o""e%t !he no"mal fetal hea"t "ate is 120X150bpmW 100X110bpm is b"ady%a"dia !he fi"st
a%tion wo$ld be to t$"n the %lient to the left side and apply o-ygen #nswe" # is not indi%ated at this time
#nswe" C is not the best a%tion fo" %lients e-pe"ien%ing b"ady%a"dia !he"e is no data to indi%ate the need to
mo/e the %lient to the deli/e"y "oom at this time10.#nswe" ) is %o""e%t !he e-pe%ted effe%t of Pito%in is %e"/i%al dilation Pito%in %a$ses mo"e intense
%ont"a%tions& whi%h %an in%"ease the pain& maing answe" # in%o""e%t Ce"/i%al effa%ement is %a$sed by
p"ess$"e on the p"esenting pa"t& so answe" @ is in%o""e%t #nswe" C is opposite the a%tion of Pito%in
10#nswe" @ is %o""e%t #pplying a fetal hea"t monito" is the %o""e%t a%tion at this time !he"e is no need to
p"epa"e fo" a Caesa"ean se%tion o" to pla%e the %lient in Den$ Pe%to"al position nee=%hest& so answe"s # and
C a"e in%o""e%t #nswe" ) is in%o""e%t be%a$se the"e is no need fo" an $lt"aso$nd based on the finding
105#nswe" @ is %o""e%t !he n$"se de%ides to apply an e-te"nal monito" be%a$se the memb"anes a"e inta%t
#nswe"s #& C& and ) a"e in%o""e%t !he %e"/i- is dilated eno$gh to $se an inte"nal monito"& if ne%essa"y #n
inte"nal monito" %an be applied if the %lient is at 0=station Cont"a%tion intensity has no bea"ing on the
appli%ation of the fetal monito"
108#nswe" ) is %o""e%t Clients admitted in labo" a"e told not to eat d$"ing labo"& to a/oid na$sea and /omiting
I%e %hips may be allowed& b$t this amo$nt of fl$id might not be s$ffi%ient to p"e/ent fl$id /ol$me defi%it In
answe" #& impai"ed gas e-%hange "elated to hype"/entilation wo$ld be indi%ated d$"ing the t"ansition phase
#nswe"s @ and C a"e not %o""e%t in "elation to the stem
10#nswe" ) is %o""e%t !his info"mation indi%ates a late de%ele"ation !his type of de%ele"ation is %a$sed by
$te"opla%ental la% of o-ygen #nswe" # has no "elation to the "eadings& so itKs in%o""e%tW answe" @ "es$lts in a
/a"iable de%ele"ationW and answe" C is indi%ati/e of an ea"ly de%ele"ation
109#nswe" C is %o""e%t !he initial a%tion by the n$"se obse"/ing a late de%ele"ation sho$ld t$"n the %lient to the
sideYp"efe"ably& the left side #dministe"ing o-ygen is also indi%ated #nswe" # might be ne%essa"y b$t not
befo"e t$"ning the %lient to he" side #nswe" @ is not ne%essa"y at this time #nswe" ) is in%o""e%t be%a$sethe"e is no data to indi%ate that the monito" has been applied in%o""e%tly
110#nswe" ) is %o""e%t #%%ele"ations with mo/ement a"e no"mal #nswe"s #& @& and C indi%ate omino$s
findings on the fetal hea"t monito"
111#nswe" C is %o""e%t ,pid$"al anesthesia de%"eases the $"ge to /oid and sensation of a f$ll bladde" # f$ll
bladde" will de%"ease the p"og"ession of labo" #nswe"s #& @& and ) a"e in%o""e%t fo" the stem
112#nswe" @ is %o""e%t '$teni(ing ho"mone "eleased by the pit$ita"y is "esponsible fo" o/$lation #t abo$t day
1.& the %ontin$ed in%"ease in est"ogen stim$lates the "elease of l$teni(ing ho"mone f"om the ante"io" pit$ita"y
!he '? s$"ge is "esponsible fo" o/$lation& o" the "elease of the dominant folli%le in p"epa"ation fo" %on%eption&
whi%h o%%$"s within the ne-t 10X12 ho$"s afte" the '? le/els pea #nswe"s #& C& and ) a"e in%o""e%t be%a$seest"ogen le/els a"e high at the beginning of o/$lation& the endomet"ial lining is thi%& not thin& and the
p"ogeste"one le/els a"e high& not low
11+#nswe" C is %o""e%t !he s$%%ess of the "hythm method of bi"th %ont"ol is dependent on the %lientKs menses being "eg$la" It is not dependent on the age of the %lient& f"e6$en%y of inte"%o$"se& o" "ange of the %lientKs
tempe"at$"eW the"efo"e& answe"s #& @& and ) a"e in%o""e%t
11.#nswe" C is %o""e%t !he best method of bi"th %ont"ol fo" the %lient with diabetes is the diaph"agm #
pe"manent int"a$te"ine de/i%e %an %a$se a %ontin$ing inflammato"y "esponse in diabeti%s that sho$ld be
a/oided& o"al %ont"a%epti/es tend to ele/ate blood gl$%ose le/els& and %ont"a%epti/e sponges a"e not good at
p"e/enting p"egnan%y !he"efo"e& answe"s #& @& and ) a"e in%o""e%t
11#nswe" ) is %o""e%t !he signs of an e%topi% p"egnan%y a"e /ag$e $ntil the fallopian t$be "$pt$"es !he %lient
will %omplain of s$dden& stabbing pain in the lowe" 6$ad"ant that "adiates down the leg o" $p into the %hest
Painless /aginal bleeding is a sign of pla%enta p"e/ia& abdominal %"amping is a sign of labo"& and th"obbing
pain in the $ppe" 6$ad"ant is not a sign of an e%topi% p"egnan%y& maing answe"s #& @& and C in%o""e%t
115#nswe" C is %o""e%t #ll of the %hoi%es a"e tasty& b$t the p"egnant %lient needs a diet that is balan%ed and has
in%"eased amo$nts of %al%i$m #nswe" # is la%ing in f"$its and mil #nswe" @ %ontains the potato %hips&whi%h %ontain a la"ge amo$nt of sodi$m #nswe" C %ontains meat& f"$it& potato salad& and yog$"t& whi%h has
abo$t +50mg of %al%i$m #nswe" ) is not the best diet be%a$se it la%s /egetables and mil p"od$%ts
118#nswe" @ is %o""e%t !he %lient with hype"emesis has pe"sistent na$sea and /omiting Hith /omiting %omesdehyd"ation Hhen the %lient is dehyd"ated& she will ha/e metaboli% a%idosis #nswe"s # and C a"e in%o""e%t
be%a$se they a"e "espi"ato"y dehyd"ation #nswe" ) is in%o""e%t be%a$se the %lient will not be in alalosis with
pe"sistent /omiting
11#nswe" @ is %o""e%t !he most definiti/e diagnosis of p"egnan%y is the p"esen%e of fetal hea"t tones !he
signs in answe"s #& C& and ) a"e s$bEe%ti/e and might be "elated to othe" medi%al %onditions #nswe"s # and C
may be "elated to a hydatidifo"m mole& and answe" ) is often p"esent befo"e menses o" with the $se of o"al
%ont"a%epti/es
119#nswe" C is %o""e%t !he infant of a diabeti% mothe" is $s$ally la"ge fo" gestational age #fte" bi"th& gl$%ose
le/els fall "apidly d$e to the absen%e of gl$%ose f"om the mothe" #nswe" # is in%o""e%t be%a$se the infant will
not be small fo" gestational age #nswe" @ is in%o""e%t be%a$se the infant will not be hype"gly%emi% #nswe" )
is in%o""e%t be%a$se the infant will be la"ge& not small& and will be hypogly%emi%& not hype"gly%emi%
120#nswe" @ is %o""e%t Hhen the %lient is taing o"al %ont"a%epti/es and begins antibioti%s& anothe" method of
bi"th %ont"ol sho$ld be $sed #ntibioti%s de%"ease the effe%ti/eness of o"al %ont"a%epti/es #pp"o-imately X10
po$nds of weight gain is not $n$s$al& so answe" # is in%o""e%t If the %lient misses a bi"th %ont"ol pill& she
sho$ld be inst"$%ted to tae the pill as soon as she "emembe"s the pill #nswe" C is in%o""e%t If she misses
two& she sho$ld tae twoW if she misses mo"e than two& she sho$ld tae the missed pills b$t $se anothe" method
of bi"th %ont"ol fo" the "emainde" of the %y%le #nswe" ) is in%o""e%t be%a$se %hanges in menst"$al flow a"e
e-pe%ted in %lients $sing o"al %ont"a%epti/es Often these %lients ha/e lighte" menses121#nswe" @ is %o""e%t Clients with ?I7 sho$ld not b"eastfeed be%a$se the infe%tion %an be t"ansmitted to the
baby th"o$gh b"east mil !he %lients in answe"s #& C& and )Ythose with diabetes& hype"tension& and thy"oid
diseaseY%an be allowed to b"eastfeed
122#nswe" # is %o""e%t !he symptoms of painless /aginal bleeding a"e %onsistent with pla%enta p"e/ia
#nswe"s @& C& and ) a"e in%o""e%t Ce"/i%al %he% fo" dilation is %ont"aindi%ated be%a$se this %an in%"ease the
bleeding Che%ing fo" fi"mness of the $te"$s %an be done& b$t the fi"st a%tion sho$ld be to %he% the fetal hea"t
tones # detailed histo"y %an be done late"
12+#nswe" ) is %o""e%t !he %lient sho$ld be ad/ised to %ome to the labo" and deli/e"y $nit when the
%ont"a%tions a"e e/e"y min$tes and %onsistent She sho$ld also be told to "epo"t to the hospital if she
e-pe"ien%es "$pt$"e of memb"anes o" e-t"eme bleeding She sho$ld not wait $ntil the %ont"a%tions a"e e/e"y 2
min$tes o" $ntil she has bloody dis%ha"ge& so answe"s # and @ a"e in%o""e%t #nswe" C is a /ag$e answe" and
12.#nswe" # is %o""e%t Infants of mothe"s who smoe a"e often low in bi"th weight Infants who a"e la"ge fo"
gestational age a"e asso%iated with diabeti% mothe"s& so answe" @ is in%o""e%t P"ete"m bi"ths a"e asso%iated
with smoing& b$t not with app"op"iate si(e fo" gestation& maing answe" C in%o""e%t D"owth "eta"dation is
asso%iated with smoing& b$t this does not affe%t the infant lengthW the"efo"e& answe" ) is in%o""e%t
12#nswe" # is %o""e%t !o p"o/ide p"ote%tion against antibody p"od$%tion& hoDam sho$ld be gi/en within 82
ho$"s !he answe"s in @& C& and ) a"e too late to p"o/ide antibody p"ote%tion hoDam %an also be gi/en
d$"ing p"egnan%y
125#nswe" @ is %o""e%t Hhen the memb"anes "$pt$"e& the"e is often a t"ansient d"op in the fetal hea"t tones !hehea"t tones sho$ld "et$"n to baseline 6$i%ly #ny alte"ation in fetal hea"t tones& s$%h as b"ady%a"dia o"
ta%hy%a"dia& sho$ld be "epo"ted #fte" the fetal hea"t tones a"e assessed& the n$"se sho$ld e/al$ate the %e"/i%al
dilation& /ital signs& and le/el of dis%omfo"t& maing answe"s #& C& and ) in%o""e%t
128#nswe" # is %o""e%t !he a%ti/e phase of labo" o%%$"s when the %lient is dilated .X8%m !he latent o" ea"ly
phase of labo" is f"om 1%m to +%m in dilation& so answe"s @ and ) a"e in%o""e%t !he t"ansition phase of labo"
is X10%m in dilation& maing answe" C in%o""e%t
12#nswe" @ is %o""e%t !he infant of an addi%ted mothe" will $nde"go withd"awal Sn$gly w"apping the infant
in a blanet will help p"e/ent the m$s%le i""itability that these babies often e-pe"ien%e !ea%hing the mothe" to
p"o/ide ta%tile stim$lation o" p"o/ide fo" ea"ly infant stim$lation a"e in%o""e%t be%a$se he is i""itable and needs6$iet and little stim$lation at this time& so answe"s # and ) a"e in%o""e%t Pla%ing the infant in an infant seat in
answe" C is in%o""e%t be%a$se this will also %a$se mo/ement that %an in%"ease m$s%le i""itability
129#nswe" C is %o""e%t Following epid$"al anesthesia& the %lient sho$ld be %he%ed fo" hypotension and signsof sho% e/e"y min$tes fo" 1 min$tes !he %lient %an be %he%ed fo" %e"/i%al dilation late" afte" she is
stable !he %lient sho$ld not be positioned s$pine be%a$se the anesthesia %an mo/e abo/e the "espi"ato"y %ente"
and the %lient %an stop b"eathing Fetal hea"t tones sho$ld be assessed afte" the blood p"ess$"e is %he%ed
!he"efo"e& answe"s #& @& and ) a"e in%o""e%t
1+0#nswe" @ is %o""e%t !he best way to p"e/ent post=ope"ati/e wo$nd infe%tion is hand washing Use of
p"es%"ibed antibioti%s will t"eat infe%tion& not p"e/ent infe%tions& maing answe" # in%o""e%t Hea"ing a mas
and asing the %lient to %o/e" he" mo$th a"e good p"a%ti%es b$t will not p"e/ent wo$nd infe%tionsW the"efo"e&
answe"s C and ) a"e in%o""e%t
1+1#nswe" @ is %o""e%t !he %lient with a hip f"a%t$"e will most liely ha/e disalignment #nswe"s #& C& and )
a"e in%o""e%t be%a$se all f"a%t$"es %a$se pain& and %oolness of the e-t"emities and absen%e of p$lses a"e
indi%ati/e of %ompa"tment synd"ome o" pe"iphe"al /as%$la" disease
1+2#nswe" @ is %o""e%t #fte" menopa$se& women la% ho"mones ne%essa"y to abso"b and $tili(e %al%i$m)oing weight=bea"ing e-e"%ises and taing %al%i$m s$pplements %an help to p"e/ent osteopo"osis b$t a"e not
%a$ses& so answe"s # and C a"e in%o""e%t @ody types that f"e6$ently e-pe"ien%e osteopo"osis a"e thin
Ca$%asian females& b$t they a"e not most liely "elated to osteopo"osis& so answe" ) is in%o""e%t1++#nswe" @ is %o""e%t !he infantKs hips sho$ld be off the bed app"o-imately 1R in @"yantKs t"a%tion #nswe"
# is in%o""e%t be%a$se this does not indi%ate that the t"a%tion is wo"ing %o""e%tly& no" does C #nswe" ) is
in%o""e%t be%a$se @"yantKs t"a%tion is a sin t"a%tion& not a seletal t"a%tion
1+.#nswe" # is %o""e%t @alan%ed seletal t"a%tion $ses pins and s%"ews # Steinman pin goes th"o$gh la"ge
bones and is $sed to stabili(e la"ge bones s$%h as the fem$" #nswe" @ is in%o""e%t be%a$se only the affe%ted
leg is in t"a%tion i"s%hne" wi"es a"e $sed to stabili(e small bones s$%h as finge"s and toes& as in answe" C
#nswe" ) is in%o""e%t be%a$se this type of t"a%tion is not $sed fo" f"a%t$"ed hips
1+#nswe" # is %o""e%t @leeding is a %ommon %ompli%ation of o"thopedi% s$"ge"y !he blood=%olle%tion de/i%e
sho$ld be %he%ed f"e6$ently to ens$"e that the %lient is not hemo""haging !he %lientKs pain sho$ld be
assessed& b$t this is not life=th"eatening Hhen the %lient is in less dange"& the n$t"itional stat$s sho$ld be
assessed and an immobili(e" is not $sedW th$s& answe"s @& C& and ) a"e in%o""e%t
1+5#nswe" # is %o""e%t !he %lientKs family membe" sho$ld be ta$ght to fl$sh the t$be afte" ea%h feeding and
%lamp the t$be !he pla%ement sho$ld be %he%ed befo"e feedings& and indigestion %an o%%$" with the P,D
t$be& E$st as it %an o%%$" with any %lient& so answe"s @ and C a"e in%o""e%t <edi%ations %an be o"de"ed fo"
indigestion& b$t it is not a "eason fo" ala"m # pe"%$taneo$s endos%opy gast"ostomy t$be is $sed fo" %lients
who ha/e e-pe"ien%ed diffi%$lty swallowing !he t$be is inse"ted di"e%tly into the stoma%h and does not
"e6$i"e swallowingW the"efo"e& answe" ) is in%o""e%t
1+8#nswe" C is %o""e%t !he %lient with a total nee "epla%ement sho$ld be assessed fo" anemia # hemato%"it of25V is e-t"emely low and might "e6$i"e a blood t"ansf$sion @leeding of 2%m on the d"essing is not e-t"eme
Ci"%le and date and time the bleeding and monito" fo" %hanges in the %lientKs stat$s # low=g"ade tempe"at$"e
is not $n$s$al afte" s$"ge"y ,ns$"e that the %lient is well hyd"ated& and "e%he% the tempe"at$"e in 1 ho$" If
the tempe"at$"e is abo/e 101RF& "epo"t this finding to the do%to" !ylenol will p"obably be o"de"ed 7oiding
afte" s$"ge"y is also not $n%ommon and no need fo" %on%e"nW the"efo"e answe"s #& @& and ) a"e in%o""e%t
1+#nswe" @ is %o""e%t Pl$mbism is lead poisoning One fa%to" asso%iated with the %ons$mption of lead is
eating f"om potte"y made in Cent"al #me"i%a o" <e-i%o that is $nfi"ed !he %hild li/es in a ho$se b$ilt afte"
1985 this is when lead was taen o$t of paint& and the pa"ents mae stained glass as a hobby Stained glass is
p$t togethe" with lead& whi%h %an d"op on the wo" a"ea& whe"e the %hild %an %ons$me the lead beads #nswe"
# is in%o""e%t be%a$se simply t"a/eling o$t of the %o$nt"y does not in%"ease the "is In answe" C& the ho$se
was b$ilt afte" the lead was "emo/ed with the paint #nswe" ) is $n"elated to the stem
1+9#nswe" # is %o""e%t !he e6$ipment that %an help with a%ti/ities of daily li/ing is the high=seat %ommode
!he hip sho$ld be ept highe" than the nee !he "e%line" is good be%a$se it p"e/ents 90R fle-ion b$t not daily
a%ti/ities # !,*S !"ans%$taneo$s ,le%t"i%al *e"/e Stim$lation $nit helps with pain management and an
abd$%tion pillow is $sed to p"e/ent add$%tion of the hip and possibly dislo%ation of the p"osthesisW the"efo"e&
answe"s @& C& and ) a"e in%o""e%t
1.0#nswe" @ is %o""e%t *a"%an is the antidote fo" na"%oti% o/e"dose If hypo-ia o%%$"s& the %lient sho$ld ha/e
o-ygen administe"ed by mas& not %ann$la !he"e is no data to s$ppo"t the administ"ation of blood p"od$%ts o"
%a"dio"es$s%itation& so answe"s #& C& and ) a"e in%o""e%t1.1#nswe" @ is %o""e%t !he 5=yea"=old sho$ld ha/e a "oommate as %lose to the same age as possible& so the 12=
yea"=old is the best mat%h !he 10=yea"=old with sa"%oma has %an%e" and will be t"eated with %hemothe"apy
that maes him imm$ne s$pp"essed& the 5=yea"=old with osteomylitis is infe%ted& and the %lient in answe" # is
too old and is femaleW the"efo"e& answe"s #& C& and ) a"e in%o""e%t
1.2#nswe" @ is %o""e%t Co- II inhibito"s ha/e been asso%iated with hea"t atta%s and st"oes #ny %hanges in
%a"dia% stat$s o" signs of a st"oe sho$ld be "epo"ted immediately& along with any %hanges in bowel o" bladde"
habits be%a$se bleeding has been lined to $se of Co- II inhibito"s !he %lient does not ha/e to tae the
medi%ation with mil& "emain $p"ight& o" allow 5 wees fo" optimal effe%t& so answe"s #& C& and ) a"e
in%o""e%t1.+#nswe" ) is %o""e%t # plaste"=of=Pa"is %ast taes 2. ho$"s to d"y& and the %lient sho$ld not bea" weight fo"
2. ho$"s !he %ast sho$ld be handled with the palms& not the finge"tips& so answe" # is in%o""e%t Petaling a
%ast is %o/e"ing the end of the %ast with %ast batting o" a so%& to p"e/ent sin i""itation and flaing of the sin$nde" the %ast& maing answe" @ in%o""e%t !he %lient sho$ld be told not to d"y the %ast with a hai" d"ye"
be%a$se this %a$ses hot spots and %o$ld b$"n the %lient !his also %a$ses $ne6$al d"yingW th$s& answe" C is
in%o""e%t
1..#nswe" # is %o""e%t !he"e is no "eason that the %lientKs f"iends sho$ld not be allowed to a$tog"aph the %astW
it will not ha"m the %ast in any way& so answe"s @& C& and ) a"e in%o""e%t
1.#nswe" # is %o""e%t !he n$"se is pe"fo"ming the pin %a"e %o""e%tly when she $ses ste"ile glo/es and >=tips
# li%ensed p"a%ti%al n$"se %an pe"fo"m pin %a"e& the"e is no need to %lean the weights& and the n$"se %an help
with opening the pa%ages b$t it isnKt "e6$i"edW the"efo"e& answe"s @& C& and ) a"e in%o""e%t
1.5#nswe" # is %o""e%t # body %ast o" spi%a %ast e-tends f"om the $ppe" abdomen to the nees o" below
@owel so$nds sho$ld be %he%ed to ens$"e that the %lient is not e-pe"ien%ing a pa"alyti% ille$s Che%ing the
blood p"ess$"e is a t"eatment fo" any %lient& offe"ing pain medi%ation is not %alled fo"& and %he%ing fo"
swelling isnKt spe%ifi% to the stem& so answe"s @& C& and ) a"e in%o""e%t1.8#nswe" C is %o""e%t ?alo t"a%tion will be o"de"ed fo" the %lient with a %e"/i%al f"a%t$"e $ssellKs t"a%tion is
$sed fo" bones of the lowe" e-t"emities& as is @$%Ks t"a%tion C"$%hfield tongs a"e $sed while in the hospital
and the %lient is immobileW the"efo"e& answe"s #& @& and ) a"e in%o""e%t1.#nswe" @ is %o""e%t !he %ont"olle" fo" the %ontin$o$s passi/e=motion de/i%e sho$ld be pla%ed away f"om
the %lient <any %lients %omplain of pain while ha/ing t"eatments with the CP<& so they might t$"n off the
ma%hine !he CP< fle-es and e-tends the leg !he %lient is in the bed d$"ing CP< the"apy& so answe" # is
in%o""e%t #nswe" C is in%o""e%t be%a$se %lients will e-pe"ien%e pain with the t"eatment Use of the CP< does
not alle/iate the need fo" physi%al the"apy& as s$ggested in answe" )
1.9#nswe" # is %o""e%t !he %lientKs palms sho$ld "est lightly on the handles !he elbows sho$ld be fle-ed no
mo"e than +0R b$t sho$ld not be e-tended #nswe" @ is in%o""e%t be%a$se 0R is not a "ela-ed angle fo" the
elbows and will not fa%ilitate %o""e%t wale" $se !he %lient sho$ld wal to the middle of the wale"& not to the
f"ont of the wale"& maing answe" C in%o""e%t !he %lient sho$ld be ta$ght not to %a""y the wale" be%a$se this
wo$ld not p"o/ide stabilityW th$s& answe" ) is in%o""e%t
10#nswe" C is %o""e%t !he %lient with a p"olapsed %o"d sho$ld be t"eated by ele/ating the hips and %o/e"ing
the %o"d with a moist& ste"ile saline ga$(e !he n$"se sho$ld $se he" finge"s to p$sh $p on the p"esenting pa"t
$ntil a %esa"ean se%tion %an be pe"fo"med #nswe"s #& @& and ) a"e in%o""e%t !he n$"se sho$ld not attempt to
"epla%e the %o"d& t$"n the %lient on the side& o" %o/e" with a d"y ga$(e
11#nswe" @ is %o""e%t Chest t$bes wo" to "einflate the l$ng and d"ain se"o$s fl$id !he t$be does not e6$ali(e
e-pansion of the l$ngs Pain is asso%iated with %ollapse of the l$ng& and inse"tion of %hest t$bes is painf$l& so
answe"s # and C a"e in%o""e%t #nswe" ) is t"$e& b$t this is not the p"ima"y "ationale fo" pe"fo"ming %hest t$be
inse"tion12#nswe" ) is %o""e%t S$%%ess with b"eastfeeding depends on many fa%to"s& b$t the most dependable "eason
fo" s$%%ess is desi"e and willingness to %ontin$e the b"eastfeeding $ntil the infant and mothe" ha/e time to
adapt !he ed$%ational le/el& the infantKs bi"th weight& and the si(e of the mothe"Ks b"east ha/e nothing to do
with s$%%ess& so answe"s #& @& and C a"e in%o""e%t
1+#nswe" C is %o""e%t D"een=tinged amnioti% fl$id is indi%ati/e of me%oni$m staining !his finding indi%ates
fetal dist"ess !he p"esen%e of s%ant bloody dis%ha"ge is no"mal& as a"e f"e6$ent $"ination and mode"ate $te"ine
%ont"a%tions& maing answe"s #& @& and ) in%o""e%t
1.#nswe" C is %o""e%t )$"ation is meas$"ed f"om the beginning of one %ont"a%tion to the end of the same
%ont"a%tion #nswe" # "efe"s to f"e6$en%y #nswe" @ is in%o""e%t be%a$se we do not meas$"e f"om the end of
one %ont"a%tion to the beginning of the ne-t %ont"a%tion )$"ation is not meas$"ed f"om the pea of the
1#nswe" @ is %o""e%t !he %lient "e%ei/ing Pito%in sho$ld be monito"ed fo" de%ele"ations !he"e is no
asso%iation with Pito%in $se and hypogly%emia& mate"nal hype""efle-ia& o" fetal mo/ementW the"efo"e& answe"s
#& C& and ) a"e in%o""e%t
15#nswe" ) is %o""e%t Fetal de/elopment depends on ade6$ate n$t"ition and ins$lin "eg$lation Ins$lin needs
in%"ease d$"ing the se%ond and thi"d t"imeste"s& ins$lin "e6$i"ements do not mode"ate as the p"egnan%y
p"og"esses& and ele/ated h$man %ho"ioni% gonadot"ophin ele/ates ins$lin needs& not de%"eases themW the"efo"e&
answe"s #& @& and C a"e in%o""e%t
18#nswe" # is %o""e%t # %alm en/i"onment is needed to p"e/ent sei($"e a%ti/ity #ny stim$lation %an p"e%ipitate sei($"es Obtaining a diet histo"y sho$ld be done late"& and administe"ing an analgesi% is not
indi%ated be%a$se the"e is no data in the stem to indi%ate pain !he"efo"e& answe"s @ and C a"e in%o""e%t
#ssessing the fetal hea"t tones is impo"tant& b$t this is not the highest p"io"ity in this sit$ation as stated in
answe" )
1#nswe" # is %o""e%t !he %lient who is age .2 is at "is fo" fetal anomalies s$%h as )own synd"ome and
othe" %h"omosomal abe""ations #nswe"s @& C& and ) a"e in%o""e%t be%a$se the %lient is not at highe" "is fo"
"espi"ato"y dist"ess synd"ome o" pathologi%al Ea$ndi%e& and !$"ne"Ks synd"ome is a geneti% diso"de"
19#nswe" C is %o""e%t !he %lient with a missed abo"tion will ha/e ind$%tion of labo" P"ostin , is a fo"m of
p"ostaglandin $sed to soften the %e"/i- <agnesi$m s$lfate is $sed fo" p"ete"m labo" and p"ee%lampsia& %al%i$mgl$%onate is the antidote fo" magnesi$m s$lfate& and Pa"del is a dopamine "e%epto" stim$lant $sed to t"eat
Pa"insonKs diseaseW the"efo"e& answe"s #& @& and ) a"e in%o""e%t Pa"del was $sed at one time to d"y b"east
mil150#nswe" # is %o""e%t !he %lientKs blood p"ess$"e and $"ina"y o$tp$t a"e within no"mal limits !he only
alte"ation f"om no"mal is the de%"eased deep tendon "efle-es !he n$"se sho$ld %ontin$e to monito" the blood
p"ess$"e and %he% the magnesi$m le/el !he the"ape$ti% le/el is .X95mgGd' #nswe"s @& C& and ) a"e
in%o""e%t !he"e is no need to stop the inf$sion at this time o" slow the "ate Cal%i$m gl$%onate is the antidote
fo" magnesi$m s$lfate& b$t the"e is no data to indi%ate to-i%ity
151#nswe" C is %o""e%t #$tosomal "e%essi/e diso"de"s %an be passed f"om the pa"ents to the infant If both
pa"ents pass the t"ait& the %hild will get two abno"mal genes and the disease "es$lts Pa"ents %an also pass the
t"ait to the infant #nswe" # is in%o""e%t be%a$se& to ha/e an affe%ted newbo"n& the pa"ents m$st be %a""ie"s
#nswe" @ is in%o""e%t be%a$se both pa"ents m$st be %a""ie"s #nswe" ) is in%o""e%t be%a$se the pa"ents might
ha/e affe%ted %hild"en
152#nswe" ) is %o""e%t #lpha fetop"otein is a s%"eening test done to dete%t ne$"al t$be defe%ts s$%h as spina
bifida !he test is not mandato"y& as stated in answe" # It does not indi%ate %a"dio/as%$la" defe%ts& and themothe"Ks age has no bea"ing on the need fo" the test& so answe"s @ and C a"e in%o""e%t
15+#nswe" @ is %o""e%t )$"ing p"egnan%y& the thy"oid gland t"iples in si(e !his maes it mo"e diffi%$lt to
"eg$late thy"oid medi%ation #nswe" # is in%o""e%t be%a$se the"e %o$ld be a need fo" thy"oid medi%ationd$"ing p"egnan%y #nswe" C is in%o""e%t be%a$se the thy"oid f$n%tion does not slow Fetal g"owth is not
a""ested if thy"oid medi%ation is %ontin$ed& so answe" ) is in%o""e%t
15.#nswe" C is %o""e%t Cyanosis of the feet and hands is a%"o%yanosis !his is a no"mal finding 1 min$te afte"
bi"th #n api%al p$lse sho$ld be 120X150& and the baby sho$ld ha/e m$s%le tone& maing answe"s # and @
in%o""e%t Ba$ndi%e immediately afte" bi"th is pathologi%al Ea$ndi%e and is abno"mal& so answe" ) is in%o""e%t
15#nswe" # is %o""e%t Clients with si%le %ell %"ises a"e t"eated with heat& hyd"ation& o-ygen& and pain "elief
Fl$ids a"e in%"eased& not de%"eased @lood t"ansf$sions a"e $s$ally not "e6$i"ed& and the %lient %an be deli/e"ed
/aginallyW th$s& answe"s @& C& and ) a"e in%o""e%t
155#nswe" # is %o""e%t @efo"e $lt"asonog"aphy& the %lient sho$ld be ta$ght to d"in plenty of fl$ids and not
/oid !he %lient may amb$late& an enema is not needed& and the"e is no need to withhold food fo" ho$"s
!he"efo"e& answe"s @& C& and ) a"e in%o""e%t
158#nswe" ) is %o""e%t @y 1 yea" of age& the infant is e-pe%ted to t"iple his bi"th weight #nswe"s #& @& and C
a"e in%o""e%t be%a$se they a"e too low
15#nswe" @ is %o""e%t # nonst"ess test is done to e/al$ate pe"iodi% mo/ement of the fet$s It is not done to
e/al$ate l$ng mat$"ity as in answe" # #n o-yto%in %hallenge test shows the effe%t of %ont"a%tions on fetal
hea"t "ate and a nonst"ess test does not meas$"e ne$"ologi%al well=being of the fet$s& so answe"s C and ) a"e
in%o""e%t
159#nswe" @ is %o""e%t ?ypospadia is a %ondition in whi%h the"e is an opening on the do"sal side of the penis#nswe" # is in%o""e%t be%a$se hypospadia does not %on%e"n the $"eth"al opening #nswe" C is in%o""e%t
be%a$se the si(e of the penis is not affe%ted #nswe" ) is in%o""e%t be%a$se the opening is on the do"sal side&
not the /ent"al side
180#nswe" # is %o""e%t !"ansition is the time d$"ing labo" when the %lient loses %on%ent"ation d$e to intense
%ont"a%tions Potential fo" inE$"y "elated to p"e%ipitate deli/e"y has nothing to do with the dilation of the %e"/i-&
so answe" @ is in%o""e%t !he"e is no data to indi%ate that the %lient has had anesthesia o" fl$id /ol$me defi%it&
maing answe"s C and ) in%o""e%t
181#nswe" C is %o""e%t 7a"i%ella is %hi%en po- !his he"pes /i"$s is t"eated with anti/i"al medi%ations !he
%lient is not t"eated with antibioti%s o" anti%oag$lants as stated in answe"s # and ) !he %lient might ha/e a
fe/e" befo"e the "ash appea"s& b$t when the "ash appea"s& the tempe"at$"e is $s$ally gone& so answe" @ is
182#nswe" @ is %o""e%t Clients with %hest pain %an be t"eated with nit"ogly%e"in& a beta blo%e" s$%h as
p"opanolol& o" 7a"apamil !he"e is no indi%ation fo" an antibioti% s$%h as #mpi%illin& so answe"s #& C& and )
a"e in%o""e%t
18+#nswe" @ is %o""e%t #nti=inflammato"y d"$gs sho$ld be taen with meals to a/oid stoma%h $pset #nswe"s
#& C& and ) a"e in%o""e%t Clients with "he$matoid a"th"itis sho$ld e-e"%ise& b$t not to the point of pain
#lte"nating hot and %old is not ne%essa"y& espe%ially be%a$se wa"m& moist soas a"e mo"e $sef$l in de%"easing
pain Height=bea"ing a%ti/ities s$%h as waling a"e $sef$l b$t is not the best answe" fo" the stem
18.#nswe" ) is %o""e%t <o"phine is %ont"aindi%ated in %lients with gallbladde" disease and pan%"eatitis be%a$semo"phine %a$ses spasms of the Sphente" of Oddi <epe"idine& <ylanta& and Cimetadine a"e o"de"ed fo"
pan%"eatitis& maing answe"s #& @& and C in%o""e%t
18#nswe" @ is %o""e%t ?all$%inogeni% d"$gs %an %a$se hall$%inations Contin$o$s obse"/ation is o"de"ed to
p"e/ent the %lient f"om ha"ming himself d$"ing withd"awal #nswe"s #& C& and ) a"e in%o""e%t be%a$se
hall$%inogeni% d"$gs donKt %"eate both stim$lant and dep"essant effe%ts o" p"od$%e se/e"e "espi"ato"y
dep"ession ?owe/e"& they do p"od$%e psy%hologi%al dependen%e "athe" than physi%al dependen%e
185#nswe" @ is %o""e%t @a"bit$"ates %"eate a sedati/e effe%t Hhen the %lient stops taing ba"bit$"ates& he will
e-pe"ien%e ta%hy%a"dia& dia""hea& and ta%hpnea #nswe" # is in%o""e%t e/en tho$gh dep"ession and s$i%idal
ideation go along with ba"bit$"ate $seW it is not the p"io"ity <$s%le %"amps and abdominal pain a"e /ag$esymptoms that %o$ld be asso%iated with othe" p"oblems !a%hy%a"dia is asso%iated with stopping ba"bit$"ates&
b$t e$pho"ia is not
188#nswe" # is %o""e%t If the fetal hea"t tones a"e hea"d in the "ight $ppe" abdomen& the infant is in a b"ee%h p"esentation If the infant is positioned in the "ight o%%ipital ante"io" p"esentation& the F?!s will be lo%ated in
the "ight lowe" 6$ad"ant& so answe" @ is in%o""e%t If the fet$s is in the sa%"al position& the F?!s will be lo%ated
in the %ente" of the abdomen& so answe" C is in%o""e%t If the F?!s a"e hea"d in the left lowe" abdomen& the
infant is most liely in the left o%%ipital t"ans/e"se position& maing answe" ) in%o""e%t
18#nswe" ) is %o""e%t #sthma is the p"esen%e of b"on%hiola" spasms !his spasm %an be b"o$ght on by
alle"gies o" an-iety #nswe" # is in%o""e%t be%a$se the p"ima"y physiologi%al alte"ation is not inflammation
#nswe" @ is in%o""e%t be%a$se the"e is the p"od$%tion of abno"mally /is%o$s m$%$s& not a p"ima"y alte"ation
#nswe" C is in%o""e%t be%a$se infe%tion is not p"ima"y to asthma
189#nswe" # is %o""e%t !he %lient with mania is seldom sitting long eno$gh to eat and b$"ns many %alo"ies fo"
ene"gy #nswe" @ is in%o""e%t be%a$se the %lient sho$ld be t"eated the same as othe" %lients Small meals a"e
not a %o""e%t option fo" this %lient #llowing he" into the it%hen gi/es he" p"i/ileges that othe" %lients do not
ha/e and sho$ld not be allowed& so answe" ) is in%o""e%t10#nswe" @ is %o""e%t @"yantKs t"a%tion is $sed fo" f"a%t$"ed fem$"s and dislo%ated hips !he hips sho$ld be
ele/ated 1R off the bed #nswe" # is in%o""e%t be%a$se the hips sho$ld not be "esting on the bed #nswe" C is
in%o""e%t be%a$se the hips sho$ld not be abo/e the le/el of the body #nswe" ) is in%o""e%t be%a$se the hipsand legs sho$ld not be flat on the bed
11#nswe" @ is %o""e%t ?e"pes (oste" is shingles Clients with shingles sho$ld be pla%ed in %onta%t p"e%a$tions
Hea"ing glo/es d$"ing %a"e will p"e/ent t"ansmission of the /i"$s Co/e"ing the lesions with a ste"ile ga$(e is
not ne%essa"y& antibioti%s a"e not p"es%"ibed fo" he"pes (oste"& and o-ygen is not ne%essa"y fo" shinglesW
the"efo"e& answe"s #& C& and ) a"e in%o""e%t
12#nswe" @ is %o""e%t # t"o$gh le/el sho$ld be d"awn +0 min$tes befo"e the thi"d o" fo$"th dose !he times in
answe"s #& C& and ) a"e in%o""e%t times to d"aw blood le/els
1+#nswe" @ is %o""e%t !he %lient $sing a diaph"agm sho$ld eep the diaph"agm in a %ool lo%ation #nswe"s #&
C& and ) a"e in%o""e%t She sho$ld "ef"ain f"om lea/ing the diaph"agm in longe" than ho$"s& not . ho$"s She
sho$ld ha/e the diaph"agm "esi(ed when she gains o" loses 10 po$nds o" has abdominal s$"ge"y
1.#nswe" C is %o""e%t <othe"s who plan to b"eastfeed sho$ld d"in plenty of li6$ids& and fo$" glasses is not
eno$gh in a 2.=ho$" pe"iod Hea"ing a s$ppo"t b"a is a good p"a%ti%e fo" the mothe" who is b"eastfeeding as
well as the mothe" who plans to bottle=feed& so answe" # is in%o""e%t ,-p"essing mil f"om the b"east will
stim$late mil p"od$%tion& maing answe" @ in%o""e%t #llowing the wate" to "$n o/e" the b"east will also
fa%ilitate Lletdown&L when the mil begins to be p"od$%edW th$s& answe" ) is in%o""e%t
1#nswe" # is %o""e%t !he fa%ial ne"/e is %"anial ne"/e 7II If damage o%%$"s& the %lient will e-pe"ien%e fa%ial
pain !he a$dito"y ne"/e is "esponsible fo" hea"ing loss and tinnit$s& eye mo/ement is %ont"olled by the
!"o%hea" o" C I7& and the olfa%to"y ne"/e %ont"ols smellW the"efo"e& answe"s @& C& and ) a"e in%o""e%t15#nswe" @ is %o""e%t Clients taing Py"idi$m sho$ld be ta$ght that the medi%ation will t$"n the $"ine o"ange
o" "ed It is not asso%iated with dia""hea& mental %onf$sion& o" %hanges in tasteW the"efo"e& answe"s #& C& and )
a"e in%o""e%t Py"idi$m %an also %a$se a yellowish %olo" to sin and s%le"a if taen in la"ge doses
18#nswe" @ is %o""e%t #%%$tane is %ont"aindi%ated fo" $se by p"egnant %lients be%a$se it %a$ses te"atogeni%
effe%ts Cal%i$m le/els& api%al p$lse& and %"eatinine le/els a"e not ne%essa"yW the"efo"e& answe"s #& C& and )
a"e in%o""e%t
1#nswe" ) is %o""e%t Clients taing #%y%lo/i" sho$ld be en%o$"aged to d"in plenty of fl$ids be%a$se "enal
impai"ment %an o%%$" 'imiting a%ti/ity is not ne%essa"y& no" is eating a high=%a"bohyd"ate diet Use of an
in%enti/e spi"omete" is not spe%ifi% to %lients taing #%y%lo/i"W the"efo"e& answe"s #& @& and C a"e in%o""e%t
19#nswe" # is %o""e%t Clients who a"e p"egnant sho$ld not ha/e an <I be%a$se "adioa%ti/e isotopes a"e
$sed ?owe/e"& %lients with a titani$m hip "epla%ement %an ha/e an <I& so answe" @ is in%o""e%t *o
antibioti%s a"e $sed with this test and the %lient sho$ld "emain still only when inst"$%ted& so answe"s C and )
a"e not spe%ifi% to this test
190#nswe" ) is %o""e%t Clients taing #mphote"i%in @ sho$ld be monito"ed fo" li/e"& "enal& and bone ma""ow
f$n%tion be%a$se this d"$g is to-i% to the idneys and li/e"& and %a$ses bone ma""ow s$pp"ession Ba$ndi%e is a
sign of li/e" to-i%ity and is not spe%ifi% to the $se of #mphote"i%in @ Changes in /ision a"e not "elated& and
na$sea is a side effe%t& not a sign of to-i%ityW no" is $"ina"y f"e6$en%y !h$s& answe"s #& @& and C a"e in%o""e%t
191#nswe" C is %o""e%t !he %lient with %hest pain sho$ld be seen fi"st be%a$se this %o$ld indi%ate a myo%a"dial
infa"%tion !he %lient in answe" # has a blood gl$%ose within no"mal limits !he %lient in answe" @ ismaintained on blood p"ess$"e medi%ation !he %lient in answe" ) is in no dist"ess
192#nswe" @ is %o""e%t Pan%"eati% en(ymes sho$ld be gi/en with meals fo" optimal effe%ts !hese en(ymes
assist the body in digesting needed n$t"ients #nswe"s #& C& and ) a"e in%o""e%t methods of administe"ing
pan%"eati% en(ymes
19+#nswe" C is %o""e%t !he lens allows light to pass th"o$gh the p$pil and fo%$s light on the "etina !he lens
does not stim$late the "etina& assist with eye mo/ement& o" magnify small obEe%ts& so answe"s #& @& and ) a"e
in%o""e%t
19.#nswe" C is %o""e%t <ioti% eyed"ops %onst"i%t the p$pil and allow a6$eo$s h$mo" to d"ain o$t of the Canal
of S%hlemm !hey do not anestheti(e the %o"nea& dilate the p$pil& o" pa"aly(e the m$s%les of the eye& mainganswe"s #& @& and ) in%o""e%t
19#nswe" # is %o""e%t Hhen $sing eyed"ops& allow min$tes between the two medi%ationsW the"efo"e& answe"
@ is in%o""e%t !hese medi%ations %an be $sed by the same %lient b$t it is not ne%essa"y to $se a %y%lopegi%with these medi%ations& maing answe"s C and ) in%o""e%t
195#nswe" @ is %o""e%t Clients with %olo" blindness will most liely ha/e p"oblems disting$ishing /iolets&
bl$es& and g"een !he %olo"s in answe"s #& C& and ) a"e less %ommonly affe%ted
198#nswe" ) is %o""e%t !he %lient with a pa%emae" sho$ld be ta$ght to %o$nt and "e%o"d his p$lse "ate
#nswe"s #& @& and C a"e in%o""e%t #nle edema is a sign of "ight=sided %ongesti/e hea"t fail$"e #ltho$gh this
is not no"mal& it is often p"esent in %lients with hea"t disease If the edema is p"esent in the hands and fa%e& it
sho$ld be "epo"ted Che%ing the blood p"ess$"e daily is not ne%essa"y fo" these %lients !he %lient with a
pa%emae" %an $se a mi%"owa/e o/en& b$t he sho$ld stand abo$t feet f"om the o/en while it is ope"ating
19#nswe" # is %o""e%t Clients who a"e being "et"ained fo" bladde" %ont"ol sho$ld be ta$ght to withhold fl$ids
afte" abo$t 8 pm& o" 1 !he times in answe"s @& C& and ) a"e too ea"ly in the day
199#nswe" ) is %o""e%t C"anbe""y E$i%e is mo"e alaline and& when metaboli(ed by the body& is e-%"eted with
a%idi% $"ine @a%te"ia does not g"ow f"eely in a%idi% $"ine In%"easing intae of meats is not asso%iated with$"ina"y t"a%t infe%tions& so answe" # is in%o""e%t !he %lient does not ha/e to a/oid %it"$s f"$its and pe"i%a"e
sho$ld be done& b$t hyd"ogen pe"o-ide is d"ying& so answe"s @ and C a"e in%o""e%t
200#nswe" C is %o""e%t *P? ins$lin peas in X12 ho$"s& so a sna% sho$ld be offe"ed at that time *P?ins$lin onsets in 90X120 min$tes& so answe" # is in%o""e%t #nswe" @ is $nt"$e be%a$se *P? ins$lin is time
"eleased and does not $s$ally %a$se s$dden hypogly%emia #nswe" ) is in%o""e%t& b$t the %lient sho$ld eat a
bedtime sna%
201#nswe" ) is %o""e%t <ethot"e-ate is a foli% a%id antagonist 'e$%o/o"in is the d"$g gi/en fo" to-i%ity to this
d"$g It is not $sed to t"eat i"on=defi%ien%y anemia& %"eate a syne"gisti% effe%ts& o" in%"ease the n$mbe" of
%i"%$lating ne$t"ophils !he"efo"e& answe"s #& @& and C a"e in%o""e%t
202#nswe" @ is %o""e%t !he %lient who is alle"gi% to dogs& eggs& "abbits& and %hi%en feathe"s is most liely
alle"gi% to the "$bella /a%%ine !he %lient who is alle"gi% to neomy%in is also at "is !he"e is no dange" to the
%lient if he has an o"de" fo" a !@ sin test& ,'IS# test& o" %hest -="ayW th$s& answe"s #& C& and ) a"e in%o""e%t
20+#nswe" @ is %o""e%t Janta% "antidine is a histamine blo%e" that sho$ld be gi/en with meals fo" optimal
effe%t& not befo"e meals ?owe/e"& !agamet %imetidine is a histamine blo%e" that %an be gi/en in one dose at
bedtime *eithe" of these d"$gs sho$ld be gi/en befo"e o" afte" meals& so answe"s # and ) a"e in%o""e%t
20.#nswe" C is %o""e%t !he p"o-imal end of the do$ble=ba""el %olostomy is the end towa"d the small intestines
!his end is on the %lientKs "ight side !he distal end& as in answe"s #& @& and )& is on the %lientKs left side
20#nswe" # is %o""e%t If the n$"se %he%s the f$nd$s and finds it to be displa%ed to the "ight o" left& this is an
indi%ation of a f$ll bladde" !his finding is not asso%iated with hypotension o" %lots& as stated in answe" @
O-yto-i% d"$gs Pito%in a"e d"$gs $sed to %ont"a%t the $te"$s& so answe" C is in%o""e%t It has nothing to do
with displa%ement of the $te"$s #nswe" ) is in%o""e%t be%a$se displa%ement is asso%iated with a f$ll bladde"¬ /aginal bleeding
205#nswe" C is %o""e%t Clients with an inte"nal defib"illato" o" a pa%emae" sho$ld not ha/e an <I be%a$se it
%an %a$se dys"hythmias in the %lient with a pa%emae" If the %lient has a need fo" o-ygen& is %la$st"ophobi%& o"
is deaf& he %an ha/e an <I& b$t p"o/isions s$%h as e-tension t$bes fo" the o-ygen& sedati/es& o" a signal
system sho$ld be made to a%%ommodate these p"oblems !he"efo"e& answe"s #& @& and ) a"e in%o""e%t
208#nswe" C is %o""e%t # 5=month=old is too old fo" the %olo"f$l mobile ?e is too yo$ng to play with the
ele%t"oni% game o" the +0=pie%e Eigsaw p$((le !he best toy fo" this age is the %a"s in a plasti% %ontaine"& so
answe"s #& @& and ) a"e in%o""e%t
20#nswe" C is %o""e%t !he %lient with polio has m$s%le weaness Pe"iods of "est th"o$gho$t the day will
%onse"/e the %lientKs ene"gy # hot bath %an %a$se b$"nsW howe/e"& a wa"m bath wo$ld be helpf$l& so answe" #
is in%o""e%t St"en$o$s e-e"%ises a"e not ad/isable& maing answe" @ in%o""e%t 7is$al dist$"ban%es a"e di"e%tly
asso%iated with polio and %annot be %o""e%ted with glassesW the"efo"e& answe" ) is in%o""e%t
209#nswe" @ is %o""e%t !he %lient with a p"otoepisiotomy will need stool softene"s s$%h as do%$sate sodi$m
S$pposito"ies a"e gi/en only with an o"de" f"om the do%to"& <ethe"gine is a d"$g $sed to %ont"a%t the $te"$s&
and Pa"lodel is an anti=Pa"insonian d"$gW the"efo"e& answe"s #& C& and ) a"e in%o""e%t
210#nswe" C is %o""e%t !otal Pa"ente"al *$t"ition is a high=gl$%ose sol$tion !his the"apy often %a$ses the
gl$%ose le/els to be ele/ated @e%a$se this is a %ommon %ompli%ation& ins$lin might be o"de"ed #nswe"s #& @&
and ) a"e in%o""e%t !P* is $sed to t"eat negati/e nit"ogen balan%eW it will not lead to negati/e nit"ogen
balan%e !otal Pa"ente"al *$t"ition %an be managed with o"al hypogly%emi% d"$gs& b$t it is diffi%$lt to do so
!otal Pa"ente"al *$t"ition will not lead to f$"the" pan%"eati% disease211#nswe" @ is %o""e%t !he %lient who is 10 wees p"egnant sho$ld be assessed to dete"mine how she feels
abo$t the p"egnan%y It is too ea"ly to dis%$ss p"ete"m labo"& too late to dis%$ss whethe" she was $sing a
method of bi"th %ont"ol& and afte" the %lient deli/e"s& a dis%$ssion of f$t$"e %hild"en sho$ld be instit$ted !h$s&
answe"s #& C& and ) a"e in%o""e%t
212#nswe" # is %o""e%t !he best I7 fl$id fo" %o""e%tion of dehyd"ation is no"mal saline be%a$se it is most lie
no"mal se"$m )e-t"ose p$lls fl$id f"om the %ell& la%tated inge"Ks %ontains mo"e ele%t"olytes than the %lientKs
se"$m& and de-t"ose with no"mal saline will also alte" the int"a%ell$la" fl$id !he"efo"e& answe"s @& C& and )
a"e in%o""e%t
21+#nswe" # is %o""e%t # thy"oid s%an $ses a dye& so the %lient sho$ld be assessed fo" alle"gies to iodine !he%lient will not ha/e a bol$s of fl$id& will not be asleep& and will not ha/e a $"ina"y %athete" inse"ted& so answe"s
@& C& and ) a"e in%o""e%t
21.#nswe" @ is %o""e%t hoDam is $sed to p"e/ent fo"mation of h antibodies It does not p"o/ide imm$nity toh isoen(ymes& eliminate %i"%$lating h antibodies& o" %on/e"t the h fa%to" f"om negati/e to positi/eW th$s&
answe"s #& C& and ) a"e in%o""e%t
21#nswe" @ is %o""e%t # %lient with a f"a%t$"ed foot often has a sho"t leg %ast applied to stabili(e the f"a%t$"e
# spi%a %ast is $sed to stabili(e a f"a%t$"ed pel/is o" /e"teb"al f"a%t$"e i"s%hne" wi"es a"e $sed to stabili(e
small bones s$%h as toes and the %lient will most liely ha/e a %ast o" immobili(e"& so answe"s #& C& and ) a"e
in%o""e%t
215#nswe" # is %o""e%t I"idi$m seeds %an be e-pelled d$"ing $"ination& so the %lient sho$ld be ta$ght to st"ain
his $"ine and "epo"t to the do%to" if any of the seeds a"e e-pelled In%"easing fl$ids& "epo"ting $"ina"y
f"e6$en%y& and a/oiding p"olonged sitting a"e not ne%essa"yW the"efo"e& answe"s @& C& and ) a"e in%o""e%t
218#nswe" C is %o""e%t Imm$nos$pp"essants a"e $sed to p"e/ent antibody fo"mation #nti/i"als& antibioti%s&
and analgesi%s a"e not $sed to p"e/ent antibody p"od$%tion& so answe"s #& @& and ) a"e in%o""e%t
21#nswe" # is %o""e%t @efo"e %ata"a%t "emo/al& the %lient will ha/e <yd"iati% d"ops instilled to dilate the p$pil !his will fa%ilitate "emo/al of the lens <ioti%s %onst"i%t the p$pil and a"e not $sed in %ata"a%t %lients #
lase" is not $sed to smooth and "eshape the lensW the diseased lens is "emo/ed Sili%one oil is not inEe%ted in this
%lientW th$s& answe"s @& C& and ) a"e in%o""e%t219#nswe" C is %o""e%t Pla%ing simple signs that indi%ate the lo%ation of "ooms whe"e the %lient sleeps& eats&
and bathes will help the %lient be mo"e independent P"o/iding mi""o"s and pi%t$"es is not "e%ommended with
the %lient who has #l(heime"Ks disease be%a$se mi""o"s and pi%t$"es tend to %a$se agitation& and alte"nating
health%a"e wo"e"s %onf$ses the %lientW the"efo"e& answe"s #& @& and ) a"e in%o""e%t
220#nswe" C is %o""e%t # Ba%son=P"att d"ain is a se"$m=%olle%tion de/i%e %ommonly $sed in abdominal
s$"ge"y # Ba%son=P"att d"ain will not p"e/ent the need fo" d"essing %hanges& "ed$%e edema of the in%ision& o"
eep the %ommon bile d$%t open& so answe"s #& @& and ) a"e in%o""e%t # t=t$be is $sed to eep the %ommon
bile d$%t open
221#nswe" C is %o""e%t !he infant who is +2 wees gestation will not be able to %ont"ol his head& so head lag
will be p"esent <ongolian spots a"e %ommon in #f"i%an #me"i%an infants& not Ca$%asian infantsW the %lient at
+2 wees will ha/e s%"otal "$gae o" "edness b$t will not ha/e /e"ni- %aseosa& the %heesy appea"ing %o/e"ing
fo$nd on most f$ll=te"m infants !he"efo"e& answe"s #& @& and ) a"e in%o""e%t
222#nswe" # is %o""e%t ?emat$"ia in a %lient with a pel/i% f"a%t$"e %an indi%ate t"a$ma to the bladde" o"
impending bleeding diso"de"s It is not $n$s$al fo" the %lient to %omplain of m$s%les spasms with m$ltiple
f"a%t$"es& so answe" @ is in%o""e%t )i((iness %an be asso%iated with blood loss and is nonspe%ifi%& maing
answe" C in%o""e%t *a$sea& as stated in answe" )& is also %ommon in the %lient with m$ltiple t"a$mas
22+#nswe" C is %o""e%t !he %lientKs statement L!hey a"e t"ying to ill meL indi%ates pa"anoid del$sions !he"e
is no data to indi%ate that the %lient is hea"ing /oi%es o" is into-i%ated& so answe"s # and ) a"e in%o""e%t)el$sions of g"ande$" a"e fi-ed beliefs that the %lient is s$pe"io" o" pe"haps a famo$s pe"son& maing answe" @
in%o""e%t
22.#nswe" @ is %o""e%t @e%a$se the n$"se is $nawa"e of when the bottle was opened o" whethe" the saline is
ste"ile& it is safest to obtain a new bottle #nswe"s #& C& and ) a"e not safe p"a%ti%es
22#nswe" C is %o""e%t Infants with an #pga" of 9 at min$tes most liely ha/e a%"yo%yanosis& a no"mal
physiologi% adaptation to bi"th It is not "elated to the infant being %old& e-pe"ien%ing b"ady%a"dia& o" being
letha"gi%W th$s& answe"s #& @& and ) a"e in%o""e%t
225#nswe" # is %o""e%t apid %ontin$o$s "ewa"ming of a f"ostbite p"ima"ily lessens %ell$la" damage It does
not p"e/ent fo"mation of bliste"s It does p"omote mo/ement& b$t this is not the p"ima"y "eason fo" "apid
"ewa"ming It might in%"ease pain fo" a sho"t pe"iod of time as the feeling %omes ba% into the e-t"emityW
228#nswe" ) is %o""e%t ?emodialysis wo"s by $sing a dialy(ing memb"ane to filte" waste that has
a%%$m$lated in the blood It does not pass wate" th"o$gh a dialy(ing memb"ane no" does it eliminate plasma
p"oteins o" lowe" the p?& so answe"s #& @& and C a"e in%o""e%t
22#nswe" @ is %o""e%t !he %lient who is imm$ne=s$pp"essed and is e-posed to measles sho$ld be t"eated with
medi%ations to boost his imm$nity to the /i"$s #n antibioti% o" anti/i"al will not p"ote%t the %lient and it is too
late to pla%e the %lient in isolation& so answe"s #& C& and ) a"e in%o""e%t
229#nswe" ) is %o""e%t !he %lient with <S# sho$ld be pla%ed in isolation Dlo/es& a gown& and a mas
sho$ld be $sed when %a"ing fo" the %lient and hand washing is /e"y impo"tant !he doo" sho$ld "emain %losed& b$t a negati/e=p"ess$"e "oom is not ne%essa"y& so answe"s # and @ a"e in%o""e%t <S# is sp"ead by %onta%t
with blood o" body fl$id o" by to$%hing the sin of the %lient It is %$lt$"ed f"om the nasal passages of the
%lient& so the %lient sho$ld be inst"$%ted to %o/e" his nose and mo$th when he snee(es o" %o$ghs It is not
ne%essa"y fo" the %lient to wea" the mas at all timesW the n$"se sho$ld wea" the mas& so answe" C is in%o""e%t
2+0#nswe" @ is %o""e%t Pain "elated to phantom limb synd"ome is d$e to pe"iphe"al ne"/o$s system
inte""$ption #nswe" # is in%o""e%t be%a$se phantom limb pain %an last se/e"al months o" indefinitely #nswe"
C is in%o""e%t be%a$se it is not psy%hologi%al It is also not d$e to infe%tions& as stated in answe" )
2+1#nswe" # is %o""e%t )$"ing a Hhipple p"o%ed$"e the head of the pan%"eas& whi%h is a pa"t of the stoma%h&
the EeE$n$m& and a po"tion of the stoma%h a"e "emo/ed and "eanastomosed #nswe" @ is in%o""e%t be%a$se the p"o-imal thi"d of the small intestine is not "emo/ed !he enti"e stoma%h is not "emo/ed& as in answe" C& and in
answe" )& the esophag$s is not "emo/ed
2+2#nswe" C is %o""e%t Peppe" is not p"o%essed and %ontains ba%te"ia #nswe"s #& @& and ) a"e in%o""e%t be%a$se f"$its sho$ld be %ooed o" washed and peeled& and salt and et%h$p a"e allowed
2++#nswe" # is %o""e%t Co$madin is an anti%oag$lant One of the tests fo" bleeding time is a P"otime !his test
sho$ld be done monthly ,ating mo"e f"$its and /egetables is not ne%essa"y& and da"=g"een /egetables %ontain
/itamin & whi%h in%"eases %lotting& so answe" @ is in%o""e%t )"ining mo"e li6$ids and a/oiding %"owds is
not ne%essa"y& so answe"s C and ) a"e in%o""e%t
2+.#nswe" # is %o""e%t !he %lient who is ha/ing a %ent"al /eno$s %athete" "emo/ed sho$ld be told to hold his
b"eath and bea" down !his p"e/ents ai" f"om ente"ing the line #nswe"s @& C& and ) will not fa%ilitate
"emo/al
2+#nswe" @ is %o""e%t Clients with a histo"y of st"epto%o%%al infe%tions %o$ld ha/e antibodies that "ende" the
st"eptoinase ineffe%ti/e !he"e is no "eason to assess the %lient fo" alle"gies to pineapples o" bananas& the"e is
no %o""elation to the $se of phenytoin and st"eptoinase& and a histo"y of al%ohol ab$se is also not a fa%to" in
the o"de" fo" st"eptoinaseW the"efo"e& answe"s #& C& and ) a"e in%o""e%t2+5#nswe" @ is %o""e%t !he %lient who is imm$ne=s$pp"essed and has bone ma""ow s$pp"ession sho$ld be
ta$ght not to floss his teeth be%a$se platelets a"e de%"eased Using oils and %"eam=based soaps is allowed& as is
eating salt and $sing an ele%t"i% "a(o"W the"efo"e& answe"s #& C& and ) a"e in%o""e%t2+8#nswe" # is %o""e%t !he best method and safest way to %hange the ties of a t"a%heotomy is to apply the new
ones befo"e "emo/ing the old ones ?a/ing a helpe" is good& b$t the helpe" might not p"e/ent the %lient f"om
%o$ghing o$t the t"a%heotomy #nswe" C is not the best way to p"e/ent the %lient f"om %o$ghing o$t the
t"a%heotomy #sing the do%to" to s$t$"e the t"a%heotomy in pla%e is not app"op"iate
2+#nswe" ) is %o""e%t !he o$tp$t of +00m' is indi%ati/e of hemo""hage and sho$ld be "epo"ted immediately
#nswe" # does nothing to help the %lient <iling the t$be is done only with an o"de" and will not help in this
sit$ation& and slowing the int"a/eno$s inf$sion is not %o""e%tW th$s& answe"s @ and C a"e in%o""e%t
2+9#nswe" # is %o""e%t !he infant with tet"ology of falot has fi/e hea"t defe%ts ?e will be t"eated with digo-in
to slow and st"engthen the hea"t ,pineph"ine& aminophyline& and at"opine will speed the hea"t "ate and a"e not
$sed in this %lientW the"efo"e& answe"s @& C& and ) a"e in%o""e%t
2.0!he %o""e%t answe" is ma"ed by an ; in the diag"am !he !ail of Spen%e is lo%ated in the $ppe" o$te"
6$ad"ant of the b"east
2.1#nswe" # is %o""e%t !he toddle" with a /ent"i%$la" septal defe%t will ti"e easily ?e will not g"ow no"mally
b$t will not need mo"e %alo"ies ?e will be s$s%eptible to ba%te"ial infe%tion& b$t he will be no mo"e s$s%eptible
to /i"al infe%tions than othe" %hild"en !he"efo"e& answe"s @& C& and ) a"e in%o""e%t
2.2#nswe" @ is %o""e%t # nonst"ess test dete"mines pe"iodi% mo/ement of the fet$s It does not dete"mine l$ng
mat$"ity& show %ont"a%tions& o" meas$"e ne$"ologi%al well=being& maing answe"s #& C& and ) in%o""e%t
2.+#nswe" C is %o""e%t !he monito" indi%ates /a"iable de%ele"ations %a$sed by %o"d %omp"ession If Pito%in isinf$sing& the n$"se sho$ld t$"n off the Pito%in Inst"$%ting the %lient to p$sh is in%o""e%t be%a$se p$shing %o$ld
in%"ease the de%ele"ations and be%a$se the %lient is %m dilated& maing answe" # in%o""e%t Pe"fo"ming a
/aginal e-am sho$ld be done afte" t$"ning off the Pito%in& and pla%ing the %lient in a semi=Fowle"Ks position is
not app"op"iate fo" this sit$ationW the"efo"e& answe"s @ and ) a"e in%o""e%t
2..#nswe" C is %o""e%t !he g"aph indi%ates /ent"i%$la" ta%hy%a"dia !he answe"s in #& @& and ) a"e not noted
on the ,CD st"ip
2.#nswe" @ is %o""e%t 'o/eno- inEe%tions sho$ld be gi/en in the abdomen& not in the deltoid m$s%le !he
%lient sho$ld not aspi"ate afte" the inEe%tion o" %lea" the ai" f"om the sy"inge befo"e inEe%tion !he"efo"e&
answe"s #& C& and ) a"e in%o""e%t
2.5#nswe" @ is %o""e%t 7ali$m is not gi/en in the same sy"inge with othe" medi%ations& so answe" # is
in%o""e%t !hese medi%ations %an be gi/en to the same %lient& so answe" ) is in%o""e%t In answe" C& it is not
ne%essa"y to wait to inEe%t the se%ond medi%ation 7ali$m is an antian-iety medi%ation& and Phene"gan is $sed
as an antiemeti%
2.8#nswe" @ is %o""e%t 7oiding e/e"y + ho$"s p"e/ents stagnant $"ine f"om %olle%ting in the bladde"& whe"e
ba%te"ia %an g"ow )o$%hing is not "e%ommended and obtaining a $"inalysis monthly is not ne%essa"y& maing
answe"s # and C in%o""e%t !he %lient sho$ld p"a%ti%e wiping f"om f"ont to ba% afte" /oiding and bowel
mo/ements& so answe" ) is in%o""e%t
2.#nswe" C is %o""e%t Of these %lients& the one who sho$ld be assigned to the %a"e of the n$"sing assistant is
the %lient with dementia Only an * o" the physi%ian %an pla%e the %lient in se%l$sion& so answe" # isin%o""e%t !he n$"se sho$ld empty the Foley %athete" of the p"ee%lampti% %lient be%a$se the %lient is $nstable&
maing answe" @ in%o""e%t # n$"se o" physi%al the"apist sho$ld amb$late the %lient with a f"a%t$"ed hip& so
answe" ) is in%o""e%t
2.9#nswe" # is %o""e%t !he %lient who has "e%ently had a thy"oide%tomy is at "is fo" t"a%heal edema # padded
tong$e blade is $sed fo" sei($"es and not fo" the %lient with t"a%heal edema& so answe" @ is in%o""e%t If the
%lient e-pe"ien%es t"a%heal edema& the endot"a%heal t$be o" ai"way will not %o""e%t the p"oblem& so answe"s C
and ) a"e in%o""e%t
20#nswe" ) is %o""e%t ?istoplasmosis is a f$ng$s %a""ied by bi"ds It is not t"ansmitted to h$mans by %ats&
dogs& o" t$"tles !he"efo"e& answe"s #& @& and C a"e in%o""e%t