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NLE...

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The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her selfexamination:
at the end of her menstrual cycle.
on the same day each month.
on the 1st day of the menstrual cycle.
immediately after her menstrual period.
RATIONALE: Premenopausal women should do their self-examination immediately after the menstrual period, when the breasts
are least tender and least lumpy. On the 1st and last days of the cycle, the woman's breasts are still very tender. Postmenopausal
women, because their bodies lack fluctuation of hormone levels, should select one particular day of the month to do breast selfexamination.
The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should
encourage the client to:
avoid focusing on his weight.
increase his activity level.
follow a regular diet.
continue leading a high-stress lifestyle.
RATIONALE: The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a lowcholesterol, low-sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis
The nurse is providing teaching to a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD
has many risk factors. Risk factors that can be controlled or modified include:
gender, obesity, family history, and smoking.
inactivity, stress, gender, and smoking.
obesity, inactivity, diet, and smoking.
stress, family history, and obesity.
RATIONALE: The risk factors for coronary artery disease that can be controlled or modified include obesity, inactivity, diet,
stress, and smoking. Gender and family history are risk factors that can't be controlled.
The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise
the client to:
restrict fluid intake to 1 qt (1,000 ml)/day.
drink liquids only with meals.
not drink liquids 2 hours before meals.
drink liquids only between meals.
The client most at risk for sensory overload is:
A.a 28-year-old pregnant client with complaints of nausea, vomiting, and fatigue.

B. an 80-year-old client in the intensive care unit (ICU).


C. a 4-year-old in a clinic for immunizations.
D. a 72-year-old client having dressings changed by a home care nurse.
RATIONALE: Sensory overload is a condition in which the central nervous system receives much more auditory, visual, or other
environmental stimuli per time frame than can be processed effectively. Because of all the monitors, beeping sounds, lights, and
constant activity, an 80-year-old in the ICU is most at risk for sensory overload. The pregnant client is experiencing symptoms
that aren't environmental stimuli. The other choices deal with less overwhelming stimuli.

RATIONALE: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids
between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk
ingested with meals, and aids in preventing rapid gastric emptying. There's no need to restrict the amount of fluids, just the time
when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of
bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of
performing the examination is to discover:
cancerous lumps.
areas of thickness or fullness.
changes from previous self-examinations.
fibrocystic masses.
RATIONALE: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a
physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or
masses that are fibrocystic as opposed to malignant.
The nurse is giving instructions to a client who is going home with a cast on his leg. Which point is most critical?
Using crutches properly
Exercising joints above and below the cast, as ordered
Avoiding walking on a leg cast without the physician's permission
Reporting signs of impaired circulation
RATIONALE: Although all of these interventions are important, reporting signs of impaired circulation is the most critical.
Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options
reflect more long-term concerns. The client should learn to use his crutches properly to avoid nerve damage. The client may
exercise above and below the cast, as the physician orders. The client should be told not to walk on the cast without the
physician's permission.

The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women
get mammograms:
A.yearly after age 40.
B. after the birth of the first child and every 2 years thereafter.
C. after the first menstrual period and annually thereafter.

D. every 3 years between ages 20 and 40 and annually thereafter.


RATIONALE: The American Cancer Society recommends a mammogram yearly for women over age 40. The other statements
are incorrect. It's recommended that women between ages 20 and 40 have a professional breast examination (not a mammogram)
every 3 years
When caring for a client who's being treated for hyperthyroidism, it's important to:
provide extra blankets and clothing to keep the client warm.
monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
balance the client's periods of activity and rest.
encourage the client to be active to prevent constipation. Dapat B sagot dto.
RATIONALE: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with
hyperthyroidism are hyperactive and complain of feeling very warm. Consequently, it's important to keep the environment cool
and to teach the client how to manage his physical reactions to heat. Clients with hypothyroidism, not hyperthyroidism,
complain of being cold and need warm clothing and blankets to maintain a comfortable temperature. They also receive thyroid
replacement therapy, often feel lethargic and sluggish, and are prone to constipation. Therefore, the nurse should encourage
clients with hypothyroidism to be more active to prevent constipation.
A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These
instructions should include which of the following?
Avoid lifting objects weighing more than 5 lb (2.27 kg).
Lie on your abdomen when in bed.
Keep rooms brightly lit.
Avoid straining during bowel movement or bending at the waist.
RATIONALE: The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase
intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7 kg) not 5 lb. Instruct
the client when lying in bed to lie on either the side or back.Avoid Bright light.
A client receiving hemodialysis treatments has had surgery to form an arteriovenous fistula. Which of the following is most
important for the nurse to be aware of when providing care for this client?
A.Using a stethoscope for auscultating the fistula is contraindicated.
B.The client feels best immediately after the dialysis treatment.
C. Taking a blood pressure reading on the affected arm can cause clotting of the fistula.
D.The client shouldn't feel pain during initiation of dialysis.
RATIONALE: Pressure on the fistula or on the extremity can decrease blood flow and precipitate clotting. Auscultation of a
bruit in the fistula is one way to determine patency. Typically, clients feel fatigued immediately after hemodialysis because of the
rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, the needle
stick is still painful.
A 30-year-old teacher performs breast self-examinations monthly. Which of the following findings should she report promptly?
Areolae that are bilaterally darkened in color
Freely movable masses that become tender before the menstrual period
Multiple tender, round masses in both breasts

A hard, nontender mass in the upper outer quadrant of the left breast
RATIONALE: Hard, nontender masses are associated with cancerous tumors. The upper outer quadrant is the most common site.
Darkened areolae are associated with hormonal changes, such as those caused by pregnancy. Multiple tender, round masses in
both breasts that become tender before a menstrual period indicate fibrocystic breast problems.
Policy and procedure dictates that hand washing is a requirement when caring for clients. Which statement about hand washing
is true?
Frequent hand washing reduces transmission of pathogens from one client to another.
Wearing gloves is a substitute for hand washing.
Bar soap, which is generally available, should be used for hand washing.
Waterless products shouldn't be used in situations where running water is unavailable.
RATIONALE: Whether gloves are worn or not, hand washing is required before and after client contact because thorough hand
washing reduces the risk of cross-contamination. Bar soap shouldn't be used because it's a potential carrier of bacteria. Soap
dispensers are preferable, but they must also be checked for bacteria. When water is unavailable, the nurse should wash using a
liquid hand sanitizer.

The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection?
Presence of an indwelling urinary catheter
Rectal temperature of 100 F (37.8C)
Red, warm, tender incision
White blood cell (WBC) count of 8,000/ml
RATIONALE: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection.
The presence of any invasive device predisposes a client to infection but alone doesn't indicate infection. A rectal temperature of
100 F would be a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges
from 5,000 to 10,000/ml.

The nurse is caring for a client with a fractured hip. The client is combative and confused, and he's trying to get out of bed. The
nurse should:
leave the client and get help.
obtain a physician's order to restrain the client.
read the facility's policy on restraints.
order soft restraints from the storeroom.
RATIONALE: It's mandatory in most settings to have a physician's order before restraining a client. A client should never be left
alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse
should be familiar with the facility's policy.

The nurse is assessing a client for the risk of falls. The nurse should collect:
gait and balance information.

the agency's restraint policy.


the family's psychosocial history.
the client's dietary preferences.
RATIONALE: Assessing the client's gait and balance helps determine the risk of falls. The facility's policy on restraints isn't
relevant to a risk assessment for falls. Assessing the family's psychosocial history and the client's dietary preferences are
important but not as important as gait and balance in relation to the risk of falls.

The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience:
A.nervousness or paresthesia.
B. Throbbing headache or dizziness.
C. drowsiness or blurred vision.
D. Tinnitus or diplopia.
RATIONALE: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. However, the client usually
develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.
The nurse is caring for a client receiving lidocaine I.V. Which factor is most relevant to administration of this medication?
A. Decrease in arterial oxygen saturation when measured with a pulse oximeter
B . Increase in systemic blood pressure
C. Presence of premature ventricular contractions (PVCs) on cardiac monitor
D. Increase in intracranial pressure (ICP)
RATIONALE: Lidocaine drips are commonly used to treat clients whose arrhythmias haven't been controlled with oral medication and who are
having PVCs that are visible on the cardiac monitor. blood pressure, and ICP are important factors but aren't as significant as PVCs in this
situation.
The nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about
which medication?
<Acetaminophen (Tylenol)
<Dopamine (Intropin)
<Tamoxifen (Nolvadex)
<Progesterone (Gesterol 50)
RATIONALE: Tamoxifen is an estrogen-blocker used to treat both premenopausal and postmenopausal breast cancer and to prevent breast cancer
in certain women who are at high risk. Acetaminophen is a nonnarcotic analgesic. Dopamine is a vasoconstrictor used to treat hypotension.
Progesterone is a hormone used to treat amenorrhea or dysfunctional uterine bleeding
The nurse is caring for a client who is taking an anticoagulant. The nurse should teach the client to:
report incidents of diarrhea.
avoid foods high in vitamin K.
use a straight razor when shaving.
take aspirin for pain relief.

RATIONALE: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with
anticoagulation. The client may need to report diarrhea, but this isn't an effect of taking an anticoagulant. An electric razor not a
straight razor should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding, so acetaminophen
should be used for pain relief.
The nurse is delivering the client's 10 a.m. medications. The client is away from his room for a diagnostic study. Which action is
the most appropriate for the nurse to take?
Leave the medications on the client's bedside table.
Ask the client's roommate to keep the medications for the client until he returns.
Lock the medications in the medicine preparation area until the client returns.
Have the client skip that dose of medication.
RATIONALE: Whenever a client isn't immediately available to take the medication, the nurse must put the medicine in a
secured area. The nurse should never leave drugs unattended in a client's room or in the care of a roommate. The nurse also
shouldn't omit doses of medication without an order from the physician.
The nurse is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:
leaving the hair intact.
shaving the area.
clipping the hair in the area.
removing the hair with a depilatory.
RATIONALE: Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions,
and depilatories can irritate the skin.
The nurse is assessing a client for the risk of falls. The nurse should collect:
gait and balance information.
the agency's restraint policy.
the family's psychosocial history.
the client's dietary preferences.
RATIONALE: Assessing the client's gait and balance helps determine the risk of falls. The facility's policy on restraints isn't
relevant to a risk assessment for falls. Assessing the family's psychosocial history and the client's dietary preferences are
important but not as important as gait and balance in relation to the risk of falls.
The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the
care plan?
Turn and reposition the client a minimum of every 8 hours.
Vigorously massage lotion into bony prominences.
Post a turning schedule at the client's bedside.
Slide the client, rather than lift, when turning.RATIONALE: A turning schedule with a signing sheet will help ensure that
the client gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours not every 8 hours for
clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid
vigorous massage, which could damage capillaries. When moving the client, the nurse should lift rather than slide the
client to avoid shearing.

The nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA
is true?
The PCA pump can't infuse narcotics continuously.
Pain relief is initiated by the client as needed.
No complications related to narcotic delivery by the pump exist.
The nurse prescribes the dosage of narcotic for delivery.
RATIONALE: The PCA pump allows for a continuous dose of the narcotic delivery and a demand dose initiated by the client.
PCA also prevents the client from receiving an accidental overdose because of a programmed interval during which the pump
can't be activated (usually 6 to 10 minutes). The client may still experience complications of narcotic delivery. The physician,
rather than the nurse, prescribes the narcotic dose.
The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior.
The client is still conscious. The nurse should first administer:
I.M. or subcutaneous glucagon.
an I.V. bolus of dextrose 50%.
15 to 20 g of a fast-acting carbohydrate such as orange juice.
10 U of fast-acting insulin.
RATIONALE: This client is having a hypoglycemic episode. Because the client is conscious, the nurse should first administer a
fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should
administer either I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a
client who is hypoglycemic; this action will further compromise the client's condition.
The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client
is:
delirium.
depression.
excessive drug use.
Alzheimer's disease.
RATIONALE: Alzheimer's disease is the most common cause of dementia in the elderly. Approximately 10% of people over age
65 have Alzheimer's disease; about 50% of people over age 85 have the disease. Delirium, or acute confusion, is caused by an
underlying disease and isn't itself a cause of dementia. Depression is common in the elderly but, in many cases, manifests itself
in apathy, self-deprecation, or inertia not dementia. Excessive drug use, commonly stemming from the client seeing multiple
physicians who are unaware of drugs that other physicians have prescribed, can cause dementia. Although it's a problem among
the elderly, it isn't as common as Alzheimer's disease.
The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to
help relieve gas. The nurse should teach him that this action:
destroys the odor-proof seal.
won't affect the colostomy system.
is appropriate for relieving the gas in a colostomy system.
destroys the moisture barrier seal.

RATIONALE: Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag and
unclamping it are the only appropriate methods for relieving gas.
When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to:
Initiate a stream of urine.
breathe deeply.
turn to the side.
hold the labia or shaft of penis.
RATIONALE: When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax
the urinary sphincter. Initiating a stream of urine isn't recommended during catheter insertion. Turning to the side or holding the
labia or penis won't ease insertion, and doing so may contaminate the sterile field
The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:
overhydration causes the skin to tent.
dehydration causes the skin to appear edematous and spongy.
inelastic skin turgor is a normal part of aging.
normal skin turgor is moist and boggy.
RATIONALE: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting.
Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.
The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
Coma or seizures.
sunken eyeballs and poor skin turgor.
increased heart rate with hypotension.
thirst or confusion.
RATIONALE: Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Coma,
seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs.
The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the
eyedrop into the:
conjunctival sac.
pupil.
sclera.
vitreous humor.
RATIONALE: The nurse should instill the eyedrop into the conjunctival sac where absorption can best take place. The pupil
permits light to enter the eye. The sclera maintains the eye's shape and size. The vitreous humor maintains the retina's placement
and the shape of the eye.
The nurse is administering eardrops to an adult client. To straighten the ear canal in an adult client before instilling the drops, the
nurse should gently pull the:
auricle down and back.

tragus down and back.


auricle up and back.
tragus up and back.
RATIONALE: To straighten the ear canal in an adult client to instill eardrops, gently pull the auricle up and back. Repositioning
the tragus won't straighten the ear canal. Pull the auricle down and back for a child.
The nurse is teaching a client about using vaginal medications. The nurse should instruct the client to:
use a tampon after insertion to increase medication absorption.
release and pull up on the applicator before removal.
never refrigerate suppositories.
use only a water-soluble lubricant when inserting a suppository.
RATIONALE: The nurse should instruct the client to use only a water-soluble lubricant when inserting a suppository. Tampons
shouldn't be used because the tampon will absorb some medication, making the medication less effective. When removing the
applicator, the client should keep the plunger depressed. Suppositories may be refrigerated to keep their form.
The nurse is administering sublingual nitroglycerin to a client with chest pain. The nurse should place the medication:
in the cheek.
on the tip of the tongue.
under the tongue.
under the lower lid of the eye.
RATIONALE: Sublingual medication should be placed under the tongue. Buccal medication should be placed in the cheek.
Eyedrops should be instilled in the lower lid in the conjunctival sac. Oral medications should be placed on the tongue and
swallowed.
A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. The rationale for using TENS is to:
help relax tense muscles.
prevent stiffness and further loss of mobility.
reduce swelling and inflammation.
block painful stimuli traveling over small nerve fibers.

RATIONALE: The rationale for using TENS for pain relief is to block painful stimuli traveling over small nerve fibers. Massage
is used to relax tense muscles. Range-of-motion exercises are used to prevent stiffness and further loss of mobility. Elevation and
repositioning are used to reduce swelling and inflammation.
A client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale
for holding a cane on the uninvolved side is to:
prevent leaning.
distribute weight away from the involved side.
maintain stride length.

prevent edema.
RATIONALE: Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to
the body prevents leaning. Use of a cane won't maintain stride length or prevent edema.
The nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg
amputation, exercise of the remaining limb:
isn't necessary.
should begin immediately postoperatively.
should begin the day after surgery.
begins at a rehabilitation center.
RATIONALE: Exercise should begin the day after surgery. Exercise is necessary to maintain the muscle tone of the remaining
limb. Immediately after the surgery, the client usually isn't alert enough to participate and may be in too much pain. Exercise
needs to begin before discharge to a rehabilitation center.
The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously
applied topical medications before applying new medications is to:
decrease the possibility of absorption on the nurse's skin.
allow distribution of medication.
prevent soiling of the client's clothes.
avoid administering more than the prescribed dose.
RATIONALE: The nurse should remove previously applied topical medications before applying new medications to prevent
accumulation of medication that exceeds the prescribed dose. Wearing gloves will decrease the possibility of absorption on the
nurse's skin. Spreading topical medications evenly will allow for distribution of medication. Placing a dressing, if allowable,
over the medication will prevent soiling of client's clothes.
A 55-year-old female with autoimmune Addison's disease has been admitted to your nursing unit with dehydration. Your initial assessment
confirms a nursing diagnosis of deficient fluid volume. Which of the following etiologic factors establishes this nursing diagnosis?
Glucocorticoid excess
Mineralocorticoid deficiency
Melanocyte-stimulating hormone excess
Melanocyte-stimulating hormone deficit
RATIONALE: Mineralocorticoid deficiency in Addison's disease causes increased losses of sodium, chloride, water, and potassium in urine,
which leads to a fluid volume deficit. Addison's disease is associated with a glucocorticoid deficit. Melanocyte-stimulating hormone excess
doesn't cause fluid volume deficit. Addison's disease is characterized by a melanocyte-stimulating hormone excess.
A client has severe pruritus from hepatitis B. Which of the following nursing measures would best enhance the client's comfort?
Use hot water to increase vasodilation.
Use cold water to decrease itching sensation.
Give tepid water baths.
Avoid lotions and creams.

RATIONALE: Measures to treat pruritus include tepid sponge baths and the use of emollient creams and lotions. Hot water should be avoided
because capillary dilation may increase pruritus. Warm water is preferred to cold. The use of emollient creams and lotions on dry skin is
recommended.
A 46-year-old male client is admitted to the hospital with a suspected diagnosis of hepatitis B. He is jaundiced and complains of weakness. Which
of the following should the nurse include in the client's care plan?
Rest periods after small, frequent meals
A low-protein diet
Menus selected by the client
Regular exercise
RATIONALE: Rest periods and small, frequent meals are necessary for clients with hepatitis B. A diet high in protein is recommended to enhance
recovery of injured liver cells. The client needs some guidance selecting his food choices. Choices can be made from high-protein foods. Rest,
not exercise, is indicated during the acute phase of the disease.
The nurse is performing an assessment on a client who has developed a paralytic ileus. The client's bowel sounds will be:
hyperactive.
hypoactive.
high-pitched.
blowing.
RATIONALE: If a paralytic ileus occurs, bowel sounds will be hypoactive or absent. Hyperactive bowel sounds may signify
hunger, intestinal obstruction, or diarrhea. High-pitched sounds may signify a dilated bowel. A blowing sound may be a bruit
from a partially obstructed abdominal aorta.
The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein
thrombosis (DVT) by:
encouraging ambulation to prevent pooling of blood.
providing warmth to the extremity.
elevating the extremity to prevent pooling of blood.
forcing blood into the deep venous system
RATIONALE: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing
blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of
the stockings. Antiembolism stockings could possibly provide warmth, but this isn't how they prevent DVT. Elevating the
extremity will decrease edema but won't prevent DVT.
The nurse is caring for a client who's hypoglycemic. This client will have a blood glucose level:
below 70 mg/dl.
between 70 and 120 mg/dl.
between 120 and 180 mg/dl.
above 180 mg/dl.
RATIONALE: A blood glucose level below 70 mg/dl is considered hypoglycemic. A normal blood glucose level is between 70
and 120 mg/dl. Above 120 mg/dl indicates hyperglycemia.

A client has an order for 5,000 U of subcutaneous (S.C.) heparin, every 12 hours. When injecting heparin S.C., the nurse should:
aspirate after the injection.
use the Z-track method.
use a 90-degree angle for insertion.
always use the same injection site.
RATIONALE: When injecting heparin S.C., the nurse shouldn't aspirate. Rather, the nurse should inject at a 90-degree angle and
rotate injection sites. The Z-track method is used for I.M. injections that may irritate.
The nurse is preparing a client for insertion of an I.V. catheter. When selecting a site on the hand or arm for insertion of an I.V.
catheter, the nurse should:
choose a proximal site.
choose a distal site.
have the client hold his arm over his head.
leave the tourniquet on for at least 5 minutes.
RATIONALE: When selecting a site for insertion of an I.V. catheter, the nurse should choose a distal site not a proximal site.
Doing so leaves the upper veins available for subsequent cannulations. Have the client hold his arm in a dependent position to
increase blood flow. Never leave a tourniquet in place longer than 2 minutes.
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast
care?
Cover the cast with a blanket until the cast dries.
Keep your right leg elevated above heart level.
Use a knitting needle to scratch itches inside the cast.
A foul smell from the cast is normal.
RATIONALE: The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while
drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast
because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an
infection.
The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
use commercial preparations to remove corns.
cut toenails by rounding edges.
wash and inspect feet daily.
walk barefoot at least once each day.
RATIONALE: Diabetic clients should wash their feet daily to allow for daily inspection of the feet. The client should wear
nonconstrictive shoes. Corns should be treated by a podiatrist, not with commercial preparations. Nails should be filed straight
across. Clients with diabetes mellitus should never walk barefoot
The nurse is teaching a group of patient-care attendants about infection-control measures. The nurse tells the group that the first
line of intervention for preventing the spread of infection is:
Wearing gloves.

Administering antibiotics
Hand Hygiene
Assigning private rooms for clients
RATIONALE: Hand washing is the first line of intervention for preventing the spread of infection. Antibiotics should be initiated
when an organism is identified. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection
and should be implemented according to standard precautions.
A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the
collection time should:
start with the first voiding.
start after a known voiding.
always be with first morning urine.
always be the evening's last void as the last sample.
RATIONALE: When initiating a 24-hour urine specimen, have the client void, then start the timing. The collection should start
on an empty bladder. The exact time the test starts isn't important, but they're commonly started in the morning.
The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal aging
change is:
cloudy vision.
Decreased reflexes.
Incontinece
tremors.
RATIONALE: Degenerative changes can lead to decreased reflexes, which is a normal result of aging. Cloudy vision,
incontinence, and tremors may be signs and symptoms of underlying pathology.
A client has undergone a left hemicolecty for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia
in this client?
Administering oxygen, coughing, breathing deeply, and maintaining bed rest
Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
Administering pain medications, frequent repositioning, and limiting fluid intake
RATIONALE: Activities that help to prevent the occurrence of postoperative pneumonia are: coughing, breathing deeply,
frequent repositioning, medicating the client for pain, and using an incentive spirometer. Limiting fluids and lying still will
increase the risk of pneumonia.
When developing a care plan for an older adult (age 65 and older), the nurse should consider which challenges faced by clients
in this age group?
Selecting vocation, becoming financially independent, and managing a home
Developing leisure activities, preparing for retirement, and resolving empty-nest crisis
Managing a home, developing leisure activities, and preparing for retirement

Adjusting to retirement, deaths of family members, and decreased physical strength


RATIONALE: Challenges faced in older adulthood (ages 65 and older) include adjusting to retirement, deaths of family
members, and decreased physical strength. Challenges faced in young adulthood (ages 18 to 35) include selecting a vocation,
becoming financially independent, and managing a home. Challenges faced in middle adulthood (ages 35 to 65) include
developing leisure activities, preparing for retirement, and resolving empty-nest crisis.
The nurse is administering I.M. injections to an older client. The nurse should remember that an older client has:
less subcutaneous tissue and muscle mass than a younger client.
more subcutaneous tissue and less muscle mass than a younger client.
less subcutaneous tissue and more muscle mass than a younger client.
more subcutaneous tissue and muscle mass than a younger client.
RATIONALE: When administering I.M. injections, the nurse should remember that an older client has less subcutaneous tissue
and muscle mass than a younger client.
A person's psychosocial needs during the dying process of a relative may include:
flexible visitation, participation in client care, and rest breaks.
flexible visitation, denial of imminent death, and rest breaks.
limited visitation, participation in client care, and rest breaks.
short, frequent, limited periods of visitation; participation in client care; and rest breaks.
RATIONALE: A person's psychosocial needs during the dying process of a relative may include flexible visitation, participation
in client care, and rest breaks. Denial of death may be a response to the situation but isn't classified as a need. Visitation should
accommodate wishes of the family member as long as client care isn't compromised.
A 42-year-old male complains of extreme fatigue and weakness after his 1st week of radiation therapy. Which of the following
responses by the nurse would best reassure him?
"These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and X-ray
studies."
"These symptoms are part of your disease and can't be helped."
"Don't be concerned about these symptoms. Everybody feels this way after having radiation therapy."
"This is a good sign. It means that only the cancer cells are dying."
RATIONALE: Fatigue and weakness result from radiation treatment and usually don't represent deterioration or disease
progression. The symptoms associated with radiation therapy usually decrease after therapy ends. The symptoms may concern
the client and shouldn't be belittled. Radiation destroys both cancerous and normal cells.
A female client experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and
situational low self-esteem.Which of the following actions would best indicate that the client is meeting the goal of improved
body image and self-esteem?
The client requests that her family bring her makeup and wig.
The client begins to discuss the future with her family.
The client reports less disruption from pain and discomfort.
The client cries openly when discussing her disease.

RATIONALE: Requesting her wig and makeup indicates that the client with alopecia is becoming interested in looking her best
and that her body image and self-esteem may be improving. The other options may indicate that other nursing goals are being
met, but they don't assess improved body image and self-esteem.
An 18-year-old male has suffered a C5 spinal cord contusion that has resulted in quadriplegia. His mother is crying in the
waiting room 2 days after the injury has occurred. When you sit down to talk to her, she asks whether her son will ever play
football again. Which of the following responses would be best?
Reassure her that given time and motivation, he will return to normal function.
Advise her that it isn't in his best interest for her to be so upset, and explain the importance of moral support.
Reflect on how she's feeling, and encourage her to express other fears that she has about his injury.
Explain that you aren't sure, but you will call the physician to talk to her right away.
RATIONALE: Listening and encouraging her to express her feelings will be most therapeutic and will allow the nurse to gather
more data about the mother's understanding of the injury. Telling her that her son will return to normal functioning is false
reassurance; in many cases, spinal cord contusion results in permanent loss of function. The mother needs to be allowed to voice
her concerns rather than being burdened right now about giving moral support. The physician won't be able to answer her
question either; definitive prognosis isn't possible so soon after a spinal cord contusion.
A client is in the first postoperative day after a total laryngectomy and radical neck dissection. Which of the following is a
priority goal?
Communicate by use of esophageal speech.
Improve body image and self-esteem.
Attain optimal levels of nutrition.
Maintain a patent airway.
RATIONALE: Although all of these options are appropriate postoperative goals, maintaining a patent airway takes priority,
especially on the first postoperative day. A laryngectomy tube is most likely to be in place, and suctioning is commonly needed
to clear secretions. Edema and hematoma formation at the surgical site also can increase the risk of a blocked airway.
Communicating by use of esophageal speech and attaining optimal level of nutrition are important but wouldn't take priority on
the first postoperative day. Improving body image is a long-term goal.
The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is
nonmodifiable?
A.Poor control of blood glucose levels
B.Inappropriate foot care
C.Current or recent foot trauma
D.Advance Age
RATIONALE: Nonmodifiable risk factors are ones that aren't in the client's ability to change. Therefore, advanced age is the
correct answer. The other choices are factors over which the client can exert some control

A client undergoes a rhinoplasty to repair a nasal fracture in which displacement has caused an airway obstruction.
Postoperatively, the client swallows frequently and requires frequent changes of the mustache dressing, which is soiled with
bright red blood. Which is the best action for the nurse to take?
Offer the client an ice pack to decrease edema and control bleeding.

Offer the client a cold drink to soothe the throat.


Explain to the client that a tube was in the throat for the anesthetic.
Check the pharynx with a penlight for bleeding, and notify the physician.
RATIONALE: Repeated swallowing after a rhinoplasty is a sign of postnasal bleeding; the physician should be notified. Neither
an ice pack nor a cold drink will control the bleeding. Rhinoplasty is performed under a local, not general, anesthetic, so an
endotracheal tube isn't used.
A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first
response is to:
call the physician.
place saline-soaked sterile dressings on the wound.
take a blood pressure and pulse.
pull the dehiscence closed.
RATIONALE: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and
possible infection. Then the nurse should call the physician and take the client's vital signs. The dehiscence needs to be surgically
closed, so the nurse should never try to close it.
The nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes
respirations. Cheyne-Stokes respirations are:
progressively deeper breaths followed by shallower breaths with apneic periods.
rapid, deep breathing with abrupt pauses between each breath.
rapid, deep breathing and irregular breathing without pauses.
shallow breathing with an increased respiratory rate.
RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with
apneic periods. Biot's respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between
each breath. Kussmaul's respirations are rapid, deep breathing without pauses. Tachypnea is shallow breathing with increased
respiratory rate.
The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to
prevent increases in intracranial pressure (ICP)?
Suction the airway every hour and as needed.
Elevate the head of the bed 15 to 30 degrees.
Turn the client and change his position every 2 hours.
Maintain a well-lit room.
RATIONALE: To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to
30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn't be suctioned on a regular basis. Turning from
side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The
room should be kept quiet and dimly lit.
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action
should be to:
auscultate bowel sounds.

palpate the abdomen.


change the client's position.
insert a rectal tube.
RATIONALE: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel
sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the
physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing
positions and inserting a rectal tube won't relieve the client's discomfort.
The nurse is admitting a client with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
daily weight.
serum sodium levels.
measured intake and output.
blood pressure.
RATIONALE: Daily weight shows trends and can assist medical management by indicating if interventions and medications are
effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the client with
fluid balance problems. However, if a client is dehydrated, some laboratory data can show false elevations. Intake and output is
extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and
surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or
excess of fluids in some situations

CHN
1. According to the Philhealth standards, a hospital must have Wellness clinics and
health education activities such as the Diabetes Clinic. With a goal of health
promotion, which of the following activities is the LEAST concern?
A. Diagnose Illness
B. Maintain optimal function of the patient
C. Minimize health care costs
D.Offer layman forums
1. Answer: A. Diagnose Illness
Health promotion activities involves the members in order to maximize their skills
and knowledge. Its advantages to the members would include reduction of health
care costs, reduce incidence of hospital admissions and offering layman forums
wherein members can reach their optimal function.
With regards to illness prevention activities, which of the following activities help
clients MOST?
A. Maintain maximum functions

B. Reduce risk factors


C. Promote habits related to health care
D. Manage stress
2. Answer: B. Reduce risk factors
In health prevention, the risks are present but it can be reduced so that the
tendency to get sick is also minimized. The rest of options were either part of health
promotion activities or health maintenance.
Which of the following nursing goals MOST of the time taken for granted when at
the hospital?
A. Illness prevention
B. Health promotion
C. Health maintenance
D. Rehabilitation
3. Answer: B. Health Promotion
According to the World Health Organization, health promotion is the process of
encouraging the people to heighten their control over and to improve their health
status. It is geared towards a change of behaviour in order to attain optimal healthy
functioning with the use of social and environmental interventions. However, this
type of nursing goal often overlooked in hospitals.
Health maintenance involves four characteristics in order to attain its goals. Which
of the following does not belong to the group?
A. Perception of health
B. Motivation to change behaviour or status
C. Compliance to the set goals
D. Self-control
4. Answer: D. Self-control
Self-control is also a part of the motivation to change behaviour or status. The other
options were part of the major characteristics of normal health maintenance.
Which of the following completes the four characteristics of normal health
maintenance?

A. Support Group
B. Access to social and economic resources
C. Physical examination
D. Manage stress
5. Answer: B. Access to social and economic resources
Health maintenance can be achieved when the economic resources are within
reach. Health maintenance entails finances and relationships that must be made in
order to see the change within the health-seeking behaviour of the individual.
Which of the following factors can hinder the access to health programs?
A. Stress
B. Poverty
C. Work
D. Family
6. Answer: B. Poverty
Poverty is the greatest threat to access to health programs. Increased incidence of
preventable diseases, premature death and illnesses are linked to poverty which is a
worldwide problem today.
7. Which of the following activities involves primary disease prevention?
A. Immunization
B. Breast Self-Examination
C. Well-child assessment
D. Hospital admission
7. Answer: A. Immunization
Primary disease prevention involves activities that would stop something in order to
prevent worsening problem on the health. These activities involve regular exercise,
stress management, nutrition class and immunization.
Which of the following the goal of secondary disease prevention?
A. To include activities which geared towards high level of wellness
B. To reduce the risk factors present in an individual

C. To prevent disability and render intervention in the earlier stage


D. To ensure treatment and management of present illnes
8. Answer: C. To prevent disability and render intervention in the earlier stage

9. A cardiac patient came in to the hospital for his daily cardiac rehabilitation. This
type of activity is included in the following:

A. Primary Disease Prevention


B. Secondary Disease Prevention
C. Tertiary Disease Prevention
D. All of the above
9. Answer: C. Tertiary Disease Prevention
Tertiary Disease Prevention involves activities that can reduce the likelihood of
having the similar disease state through rehabilitation and assistance to reach the
optimal health status.
A hospice is a family-centered institution wherein the major goal of its existence is
to provide comfort and lifestyle of clients in the terminal stage of illness. This is an
example of:
A. A. Primary Disease Prevention
B. Secondary Disease Prevention
C. Tertiary Disease Prevention
D. All of the above
10 .Answer: C. Tertiary Disease Prevention
Tertiary Disease Prevention may not promise that a person can return to its normal
state. At some point this type of prevention may give comfort and palliative type of
care such as in terminal cases in a form of hospices.

Situation. For No. 11 12. A survey must be done in order to know the factors of
increase incidence of needle-stick injuries among nursing personnel in the hospital.

Which of the following research activities would a nurse researcher initially do?
A. Review related topics
B. Find out how many had needle stick injuries in the unit
C. Prepare a tool for collecting the data
D. Get a permission from the nursing service director
11. Answer: A. Review related topics
Since this is a survey type of study, a nurse researcher must first review related
topics in order to provide a deeper knowledge of the subject of the study. Collecting
data using tool can be the next step and getting a permission to the hospital
director will be next step when the study has been approved.
Which of the following statements contribute on the feasibility of the study?
A. Variables are diverse
B. Readability of the findings
C. Broad problems
D. Findings are inconsistent
12. Answer: B. Readability of the findings
The findings must be understood so that purpose of the study can be complete.
Other options were inconsistent to the feasibility of the study.
On the first day of community immersion, which of the following activities involve
the goal to get the whole set-up of the community?
A. Home visit
B. Mass information drive
C. Mothers Class
D. Community health survey
13. Answer: D. Community health survey
On the first day, a Community Health Nurse must be able to see the whole view of
the community through a community health survey. This involves mapping the
whole community in order to know the access roads and how many house will the
nurse serve. In this type of ocular survey, the nurse may have an initial assessment
of the whole community.

As a community health nurse, you know that this is the best tool for community
assessment:
A. Selective interview
B. Ocular survey
C. Conference
D. Home visit
14. Answer: D. Home visit
Since you are situated in a community, a home visit is the best tool in assessing the
community. This is an activity wherein the nurse goes on foot in order to visit each
houses, place a survey on each house and provide an observation on the health
status and living arrangement of the people.

15. Answer: C. Community conference


Conducting community conference can involve lot of effort in the nurses part in
order to get to know the people as a whole. Selecting a few clients can compromise
the reliability of the facts taken. Observation can also do not supply the needed
answers to questions since you really need to interact with the community.

16. Answer: B. Orientation Phase


In the orientation phase, a community health nurse must state the length of their
stay in the community in order to provide the client a space to adjust with their
presence and absence after the community immersion.

17. Answer: C. Care of families


With a premise, family is the basic unit of the society, the community health nursing
is geared towards caring this small unit because this is the major driving force of the
overall health status of the whole country.

18. Answer: A. Treatment of Illness

Treatment of Illness does not belong to the group. Community health is part of the
paramedical or medical approach that is concerned on the present health situation
of the whole community.

19. Answer: B. Assess the patient


Using the Nursing Process, assessment is the initial step upon meeting the patient.
In this manner, you will be able to plan and perform nursing procedures using the
nursing diagnosis that has been formulated.

20. Answer: A. Perform Tourniquet Test


A tourniquet test or otherwise known as Rumpel-Leede Capillary Fragility Test must
be performed upon assessment of petechial rash in order to determine the
hemorrhagic tendency of the patient. It does not conclude that the patient may
have Dengue but an initial tool in making differential diagnosis. Diagnosing and
prescribing medications are not responsibilities of a nurse.

21. Answer: A.
A blood pressure cuff is applied and inflated to a point within the average of systolic
and diastolic pressure.

22. Answer: B.
The test is positive if there are 20 or more petechiae per square inch. This can be
done by drawing an imaginary square on the cuff area.

23. Answer: B. Allowing home deliveries


It is now not allowed to have home deliveries due to the increasing maternal and
child mortality. The program focused on the prevention of maternal complications
even when a trained hilot or midwife will perform the delivery at home.

24. Answer: C. Breech Presentation

Breech presentation would need ceasarian section delivery since it is dangerous for
the mother and the unborn child. Rural health units are only catering normal
spontaneous vaginal deliveries with following criteria: cephalic presentation,
adequate pelvimetry, gravida 4.

25. Answer: D. Signs


This is an example of nonverbal communication wherein the examiner can see or
observe the changes on the body. Symptoms are complaints made by the patient.
The other options are types of verbal communication.

26. Answer: B. Respondeat superior


This action is a premise to this principle. A senior staff must be knowledgeable of
the novice nurses action so that he or she will be able to defend his or her unit
together with his or her subordinates.

27. Answer: D. Verbal Assault


This does not have a physical evidence unless the victim will speak for himself or
herself. The other options provide an evidence of the injury after the act has been
done.
28. Answer: D. Perspiration
When the patient perspires, you cannot account the total amount of fluid being lost
from the body. The skin is so vast for insensible fluid loss.
29. Answer: B. Apathy
This does not belong to the group. Apathy means being not concerned or
emotionally attached to things or events. Amnesia is loss of memory, apraxia is
inability to determine function or purpose of object. Agnosia is inability to recognize
familiar objects.
30. Answer: D. Fat embolism
Fat embolism is caused by trauma on the long bones or burns. The most common
cause of fat embolism would be fractures. This syndrome would manifest in a form
of shortness of breath until delirium and even coma.
31. Answer: D. Medical or Surgical missions.Foreign nurses can practice the nursing
proprofession during medical and surgical mission only. They could not be allowed

to practice as nurse educator in a state college since it is a government owned


school.

32.Answer: C. Operating room technician


An operating room technician is in charge of the linens, the materials being needed
as well as even the transport of patients. He is considered as not sterile.

33. Answer: B. Deep pain


Deep pain in a fracture, particularly in tibia or forearm fracture is a characteristic
feature of compartment syndrome.

34. Answer: A. Localized abscess


Localized abscess can be a predisposing factor of increase intracranial pressure. The
other options does not belong on the known predisposing factor of increased
intracranial pressure.

35. Answer: A. Assess for consciousness


the initial nursing action would be focused on the establishment of the patients
current state of consciousness. When the patient appears to be drowsy, this means
that the incident may happen in a few minutes or hours only. The conscious state
would be useful for further assessments and procedures.

36. Answer: B. Preventing increase intracranial pressure


In craniotomy, increased intracranial pressure is a common problem after the
surgery. Nurses must be able to detect it through the blood pressure, as well as on
the status of the patient.

37. Answer: A. Dehydrated


In Diabetic patients, a sign of dehydration can be elevated blood sugar levels. The
complaint of dryness of throat and mouth is also a good sign of dehydration.

38. Answer: C. 150 drops per minute


A microset has a drip factor of 60cc per minute. Using this type of drip factor will
also require to infuse 150 drops per minute in order to reach the required fluid
replacement every hour.

39. Answer: C. Arterial Blood Gas


Arterial blood gas is taken during the increase of blood glucose in order to check for
signs of Diabetic Ketoacidosis. The pH level of the blood is noted at this time.

40. Answer: B. To check for presence of ketones in the urine


A urine ketone test is done for patients with heart problems, as well as diabetes.
Since the blood sugar of the patient is more than 240 mg/dL, it is warranted to
perform such test so that ketones might be seen if the body tries to compensate
with lack of sugar or carbohydrates in the body.

41. Answer: A. Strictly monitor the intake and output


This is the correct nursing action when monitoring the hydration status of the
patient. Restricting the fluids may pose a great danger in dehydration. Increasing
oral fluid intake in this patient is not indicated, only sips of water are allowed. The
route of hydration is through intravenous line. Starting an IV line with D5NSS will
eventually increase the blood sugar level of the patient.

42. Answer: D. Altered Nutrition: Less than body requirements related to diabetes
mellitus
This statement does not belong to the group since the related factor is a medical
term. A related factor should include a medical diagnosis rather a pathophysiologic
state or current factors only.

43. Answer: C. NOC


This medical jargon is not allowed in charting. The following three statements are
well used throughout the documentation.

44. Answer: D. Sunken eyeballs


In an adult patient, the first three options would reveal the fluid status of the
patient. Sunken eyeballs are used for pediatric patients only to assess the fluid
status.

45. Answer: A. Respiratory Acidosis


This is an example of an acute respiratory acidosis. The pH level is less than 7.35;
PaCO2 is more than 45 and the Bicarbonate level is normal (26).

46. Answer: B. His mother


His mother is the most liable person to perform the consent since she is of legal age
and next to his kin. His wife is considered to be minor.

47. Answer: C. Smell


The part of the brain that is responsible for emotions is the hypothalamus . The
temporal lobe is responsible for the interpretation of semantics in speech and
vision. It is also the area wherein auditory functions are located.
48. Answer: C. Mannitol 20%
Mannitol 20% is ordered in order to reduce the intracranial pressure as evidenced
by elevated blood pressure of the patient. Magnesium sulphate and other options
are also indicated in order to decrease the blood pressure but with different
predisposing factors.

49. Answer: C. Hello Ms. Kathleen, I am Nora, your new nurse. How are you?
This statement is the most appropriate opening line for the orientation phase.
Introducing yourself as a nurse may convey authority in a none threatening way.
Asking open ended questions can also encourage the patient to elaborate his or her
feelings.

50. Answer: B. Invite other patients

Inviting other patients, which means male or female is not a proper nursing action
since she may attack the male participants. Taking in mind her previous actions
towards the male counterpart, it is better to include females only in the game.
Avoiding challenging remarks and frustrations can also minimize her crying spells
and violent actions.

51. Answer: C. delusion of persecution


This type of delusion describes that a person is like being attacked, harassed, or
cheated.

52. Answer: B. Ideas of reference


Ideas of reference has a content of holding a feeling that other people not related to
him or her is talking or rendering something for him or her personally.

53. Answer: B. Alcoholics anonymous


This type of group includes only people who want to change their behaviour towards
alcohol. The nurse need not to be an alcoholic in order to enter this group. He or she
is only there in order to make sure that everything is well facilitated and organized.

54. Answer: C. blocker


As a blocker, you are the one who controls the situation when the talking of the
topic is leading towards worthless topics.

55. Answer: C. Pia is reading a cookbook and preparing the needed materials for the
baking session that is about the begin in 30 minutes.
Culinary therapy involves the utilization of cooking and baking as a form a therapy
to its members.

56. Answer: D. Sub average intellectual functioning


Mental retardation is defined as a condition with impairment of sub average
intellectual functioning that originates during the developmental period.

57. Answer: C. Meditation


Bio-behaviour treatment means that the intervention is focused on the wellness of
the body using behavioural techniques.

58. Answer: A. symptoms of self-destruction or impulses


Antipsychotic drugs ease the dissociative symptoms such as self-destructing
behaviours.

59. Answer: B. Neurotic


This type of behaviour is influenced by phobia and compulsions. The excessing
rubbing of hands with alcohol is an example of compulsive behaviour.
60. Answer: C. 4-6 weeks
A crisis can be described as a stressing event that would occur between several
days up to 4 to 6 weeks.

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