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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.
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.
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.
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.
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.
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:
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
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.
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.
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.
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.
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.
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.