1.

She is the first one to coin the term “NURSING PROCESS” She introduced 3 steps of
nursing process which are Observation, Ministration and Validation.

A. Nightingale
B. Johnson
C. Rogers
D. Hall

2. The American Nurses association formulated an innovation of the Nursing process. Today,
how many distinct steps are there in the nursing process?

A. APIE – 4
B. ADPIE – 5
C. ADOPIE – 6
D. ADOPIER – 7

3. They are the first one to suggest a 4 step nursing process which are : APIE , or
assessment, planning, implementation and evaluation.

1. Yura
2. Walsh
3. Roy
4. Knowles

A. 1,2
B. 1,3
C. 3,4
D. 2,3

4. Which characteristic of nursing process is responsible for proper utilization of human

resources, time and cost resources?

A. Organized and Systematic

B. Humanistic
C. Efficient …Complete…
D. Effective

5. Which characteristic of nursing process addresses the INDIVIDUALIZED care a client

must receive?
A. Organized and Systematic
B. Humanistic
C. Efficient
D. Effective

6. A characteristic of the nursing process that is essential to promote client satisfaction and
progress. The care should also be relevant with the client’s needs.

A. Organized and Systematic

B. Humanistic
C. Efficient
D. Effective

7. Rhina, who has Menieres disease, said that her environment is moving. Which of the
following is a valid assessment?

1. Rhina is giving an objective data

2. Rhina is giving a subjective data
3. The source of the data is primary
4. The source of the data is secondary

A. 1,3
B. 2,3
C. 2.4
D. 1,4

8. Nurse Angela, observe Joel who is very apprehensive over the impending operation. The
client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a
diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?

A. Actual
B. Probable
C. Possible
D. Risk

9. Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF
ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen
her lost leg, Angela already anticipated the diagnosis. This is what type of Diagnosis?

A. Actual
B. Probable
C. Possible
D. Risk

10. Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is
experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY
ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her
diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type
of Diagnosis is this?

A. Actual
B. Probable
C. Possible
D. Risk

11. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an
incision near the diaphragm. She knew that this will contribute to some complications later
on. She then should develop what type of Nursing diagnosis?

A. Actual
B. Probable
C. Possible
D. Risk

12. Which of the following Nursing diagnosis is INCORRECT?

A. Fluid volume deficit R/T Diarrhea

B. High risk for injury R/T Absence of side rails
C. Possible ineffective coping R/T Loss of loved one
D. Self esteem disturbance R/T Effects of surgical removal of the leg

13. Among the following statements, which should be given the HIGHEST priority?

A. Client is in extreme pain

B. Client’s blood pressure is 60/40
C. Client’s temperature is 40 deg. Centigrade
D. Client is cyanotic

14. Which of the following need is given a higher priority among others?

A. The client has attempted suicide and safety precaution is needed

B. The client has disturbance in his body image because of the recent operation
C. The client is depressed because her boyfriend left her all alone
D. The client is thirsty and dehydrated

15. Which of the following is TRUE with regards to Client Goals?

A. They are specific, measurable, attainable and time bounded

B. They are general and broadly stated
C. They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and
WHEN.
D. Example is : After discharge planning, Client demonstrated the proper psychomotor skills
for insulin injection.

16. Which of the following is a NOT a correct statement of an Outcome criteria?

A. Ambulates 30 feet with a cane before discharge

B. Discusses fears and concerns regarding the surgical procedure
C. Demonstrates proper coughing and breathing technique after a teaching session
D. Reestablishes a normal pattern of elimination

17. Which of the following is a OBJECTIVE data?

A. Dizziness
B. Chest pain
C. Anxiety
D. Blue nails

18. A patient’s chart is what type of data source?

A. Primary
B. Secondary
C. Tertiary
D. Can be A and B

19. All of the following are characteristic of the Nursing process except

A. Dynamic
B. Cyclical
C. Universal
D. Intrapersonal

20. Which of the following is true about the NURSING CARE PLAN?

A. It is nursing centered
B. Rationales are supported by interventions
C. Verbal
D. Atleast 2 goals are needed for every nursing diagnosis

21. A framework for health assessment that evaluates the effects of stressors to the mind,
body and environment in relation with the ability of the client to perform ADL.

A. Functional health framework

B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework

22. Client has undergone Upper GI and Lower GI series. Which type of health assessment
framework is used in this situation?

A. Functional health framework

B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework

23. Which of the following statement is true regarding temperature?

A. Oral temperature is more accurate than rectal temperature

B. The bulb used in Rectal temperature reading is pear shaped or round
C. The older the person, the higher his BMR
D. When the client is swimming, BMR Decreases

24. A type of heat loss that occurs when the heat is dissipated by air current

A. Convection
B. Conduction
C. Radiation
D. Evaporation

25. Which of the following is TRUE about temperature?

A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N
B. The lowest temperature is usually in the Afternoon, Around 12 P.M
C. Thyroxin decreases body temperature
D. Elderly people are risk for hyperthermia due to the absence of fats, Decreased
thermoregulatory control and sedentary lifestyle.

26. Hyperpyrexia is a condition in which the temperature is greater than

A. 40 degree Celsius
B. 39 degree Celsius
C. 100 degree Fahrenheit
D. 105.8 degree Fahrenheit
27. Tympanic temperature is taken from John, A client who was brought recently into the
ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse,
you conclude that this temperature is

A. High
B. Low
C. At the low end of the normal range
D. At the high end of the normal range

28. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to
38.5 degrees 6 times today in a typical pattern. What kind of fever is John having?

A. Relapsing
B. Intermittent
C. Remittent
D. Constant

29. John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal
temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of
fever is John having?

A. Relapsing
B. Intermittent
C. Remittent
D. Constant

30. John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever
with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of
the following best describe the fever john is having?

A. Relapsing
B. Intermittent
C. Remittent
D. Constant

31. The characteristic fever in Dengue Virus is characterized as:

A. Tricyclic
B. Bicyclic
C. Biphasic
D. Triphasic

32. When John has been given paracetamol, his fever was brought down dramatically from
40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this
event as:

A. The goal of reducing john’s fever has been met with full satisfaction of the outcome
criteria
B. The desired goal has been partially met
C. The goal is not completely met
D. The goal has been met but not with the desired outcome criteria
33. What can you expect from Marianne, who is currently at the ONSET stage of fever?

A. Hot, flushed skin

B. Increase thirst
C. Convulsion
D. Pale,cold skin

34. Marianne is now at the Defervescence stage of the fever, which of the following is
expected?

A. Delirium
B. Goose flesh
C. Cyanotic nail beds
D. Sweating

35. Considered as the most accessible and convenient method for temperature taking

A. Oral
B. Rectal
C. Tympanic
D. Axillary

36. Considered as Safest and most non invasive method of temperature taking

A. Oral
B. Rectal
C. Tympanic
D. Axillary

37. Which of the following is NOT a contraindication in taking ORAL temperature?

A. Quadriplegic
B. Presence of NGT
C. Dyspnea
D. Nausea and Vomitting

38. Which of the following is a contraindication in taking RECTAL temperature?

A. Unconscious
B. Neutropenic
C. NPO
D. Very young children

39. How long should the Rectal Thermometer be inserted to the clients anus?

A. 1 to 2 inches
B. .5 to 1.5 inches
C. 3 to 5 inches
D. 2 to 3 inches

40. In cleaning the thermometer after use, The direction of the cleaning to follow Medical
Asepsis is :
A. From bulb to stem
B. From stem to bulb
C. From stem to stem
D. From bulb to bulb

41. How long should the thermometer stay in the Client’s Axilla?

A. 3 minutes
B. 4 minutes
C. 7 minutes
D. 10 minutes

42. Which of the following statement is TRUE about pulse?

A. Young person have higher pulse than older persons

B. Males have higher pulse rate than females after puberty
C. Digitalis has a positive chronotropic effect
D. In lying position, Pulse rate is higher

43. The following are correct actions when taking radial pulse except:

A. Put the palms downward

B. Use the thumb to palpate the artery
C. Use two or three fingers to palpate the pulse at the inner wrist
D. Assess the pulse rate, rhythm, volume and bilateral quality

44. The difference between the systolic and diastolic pressure is termed as

A. Apical rate
B. Cardiac rate
C. Pulse deficit
D. Pulse pressure

45. Which of the following completely describes PULSUS PARADOXICUS?

A. A greater-than-normal increase in systolic blood pressure with inspiration

B. A greater-than-normal decrease in systolic blood pressure with inspiration
C. Pulse is paradoxically low when client is in standing position and high when supine.
D. Pulse is paradoxically high when client is in standing position and low when supine.

46. Which of the following is TRUE about respiration?

A. I:E 2:1
B. I:E : 4:3
C I:E 1:1
D. I:E 1:2

47. Contains the pneumotaxic and the apneutic centers

A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
48. Which of the following is responsible for deep and prolonged inspiration

A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

49. Which of the following is responsible for the rhythm and quality of breathing?

A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

50. The primary respiratory center

A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies

51. Which of the following is TRUE about the mechanism of action of the Aortic and Carotid
bodies?

A. If the BP is elevated, the RR increases

B. If the BP is elevated, the RR decreases
C. Elevated BP leads to Metabolic alkalosis
D. Low BP leads to Metabolic acidosis

52. All of the following factors correctly influence respiration except one. Which of the
following is incorrect?

A. Hydrocodone decreases RR
B. Stress increases RR
C. Increase temperature of the environment, Increase RR
D. Increase altitude, Increase RR

53. When does the heart receives blood from the coronary artery?

A. Systole
B. Diastole
C. When the valves opens
D. When the valves closes

54. Which of the following is more life threatening?

A. BP = 180/100
B. BP = 160/120
C. BP = 90/60
D. BP = 80/50

55. Refers to the pressure when the ventricles are at rest

A. Diastole
B. Systole
C. Preload
D. Pulse pressure

56. Which of the following is TRUE about the blood pressure determinants?

A. Hypervolemia lowers BP
B. Hypervolemia increases GFR
C. HCT of 70% might decrease or increase BP
D. Epinephrine decreases BP

57. Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year
old diabetic?

A. Females, after the age 65 tends to have lower BP than males

B. Disease process like Diabetes increase BP
C. BP is highest in the morning, and lowest during the night
D. Africans, have a greater risk of hypertension than Caucasian and Asians.

58. How many minutes are allowed to pass if the client had engaged in strenuous activities,
smoked or ingested caffeine before taking his/her BP?

A. 5
B. 10
C. 15
D. 30

59. Too narrow cuff will cause what change in the Client’s BP?

A. True high reading

B. True low reading
C. False high reading
D. False low reading

60. Which is a preferable arm for BP taking?

A. An arm with the most contraptions

B. The left arm of the client with a CVA affecting the right brain
C. The right arm
D. The left arm

61. Which of the following is INCORRECT in assessing client’s BP?

A. Read the mercury at the upper meniscus, preferably at the eye level to prevent
error of parallax
B. Inflate and deflate slowly, 2-3 mmHg at a time
C. The sound heard during taking BP is known as KOROTKOFF sound
D. If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is
normal.

62. Which of the following is the correct interpretation of the ERROR OF PARALLAX
A. If the eye level is higher than the level of the meniscus, it will cause a false high reading
B. If the eye level is higher than the level of the meniscus, it will cause a false low
reading
C. If the eye level is lower than the level of the meniscus, it will cause a false low reading
D. If the eye level is equal to that of the level of the upper meniscus, the reading is accurate

63. How many minute/s is/are allowed to pass before making a re-reading after the first
one?

A. 1
B. 5
C. 15
D. 30

64. Which of the following is TRUE about the auscultation of blood pressure?

A. Pulse + 4 is considered as FULL

B. The bell of the stethoscope is use in auscultating BP
C. Sound produced by BP is considered as HIGH frequency sound
D. Pulse +1 is considered as NORMAL

65. In assessing the abdomen, Which of the following is the correct sequence of the physical
assessment?

A. Inspection, Auscultation, Percussion, Palpation

B. Palpation, Auscultation, Percussion, Inspection
C. Inspection, Palpation, Auscultation, Percussion
D. Inspection, Auscultation, Palpation, Percussion

66. The sequence in examining the quadrants of the abdomen is:

A. RUQ,RLQ,LUQ,LLQ
B. RLQ,RUQ,LLQ,LUQ
C. RUQ,RLQ,LLQ,LUQ
D. RLQ,RUQ,LUQ,LLQ

67. In inspecting the abdomen, which of the following is NOT DONE?

A. Ask the client to void first

B. Knees and legs are straighten to relax the abdomen
C. The best position in assessing the abdomen is Dorsal recumbent
D. The knees and legs are externally rotated

68. Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which
of the following, if done by a nurse, is a Correct preparation before the procedure?

A. Provide the necessary draping to ensure privacy

B. Open the windows, curtains and light to allow better illumination
C. Pour warm water over the ophthalmoscope to ensure comfort
D. Darken the room to provide better illumination

69. If the client is female, and the doctor is a male and the patient is about to undergo a
vaginal and cervical examination, why is it necessary to have a female nurse in attendance?

A. To ensure that the doctor performs the procedure safely

B. To assist the doctor
C. To assess the client’s response to examination
D. To ensure that the procedure is done in an ethical manner

70. In palpating the client’s breast, Which of the following position is necessary for the
patient to assume before the start of the procedure?

A. Supine
B. Dorsal recumbent
C. Sitting
D. Lithotomy

71. When is the best time to collect urine specimen for routine urinalysis and C/S?

A. Early morning
B. Later afternoon
C. Midnight
D. Before breakfast

72. Which of the following is among an ideal way of collecting a urine specimen for culture
and sensitivity?

A. Use a clean container

B. Discard the first flow of urine to ensure that the urine is not contaminated
C. Collect around 30-50 ml of urine
D. Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol

73. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by
a Nurse indicate a NEED for further procedural debriefing?

A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the
urine in the 24 hour urine specimen
B. The nurse discards the Friday 9:00 A M urine of the client
C. The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
D. The nurse added preservatives as per protocol and refrigerates the specimen

74. This specimen is required to assess glucose levels and for the presence of albumin the
the urine

A. Midstream clean catch urine

B. 24 hours urine collection
C. Postprandial urine collection
D. Second voided urine

75. When should the client test his blood sugar levels for greater accuracy?

A. During meals
B. In between meals
C. Before meals
D. 2 Hours after meals
76. In collecting a urine from a catheterized patient, Which of the following statement
indicates an accurate performance of the procedure?

A. Clamp above the port for 30 to 60 minutes before drawing the urine from the port
B. Clamp below the port for 30 to 60 minutes before drawing the urine from the
port
C. Clamp above the port for 5 to 10 minutes before drawing the urine from the port
D. Clamp below the port for 5 to 10 minutes before drawing the urine from the port

77. A community health nurse should be resourceful and meet the needs of the client. A
villager ask him, Can you test my urine for glucose? Which of the following technique allows
the nurse to test a client’s urine for glucose without the need for intricate instruments.

A. Acetic Acid test

B. Nitrazine paper test
C. Benedict’s test
D. Litmus paper test

78. A community health nurse is assessing client’s urine using the Acetic Acid solution.
Which of the following, if done by a nurse, indicates lack of correct knowledge with the
procedure?

A. The nurse added the Urine as the 2/3 part of the solution
B. The nurse heats the test tube after adding 1/3 part acetic acid
C. The nurse heats the test tube after adding 2/3 part of Urine
D. The nurse determines abnormal result if she noticed that the test tube becomes cloudy

79. Which of the following is incorrect with regards to proper urine testing using Benedict’s
Solution?

A. Heat around 5ml of Benedict’s solution together with the urine in a test tube
B. Add 8 to 10 drops of urine
C. Heat the Benedict’s solution without the urine to check if the solution is contaminated
D. If the color remains BLUE, the result is POSITIVE

80. +++ Positive result after Benedicts test is depicted by what color?

A. Blue
B. Green
C. Yellow
D. Orange

81. Clinitest is used in testing the urine of a client for glucose. Which of the following, If
committed by a nurse indicates error?

A. Specimen is collected after meals

B. The nurse puts 1 clinitest tablet into a test tube
C. She added 5 drops of urine and 10 drops of water
D. If the color becomes orange or red, It is considered postitive

82. Which of the following nursing intervention is important for a client scheduled to have a
Guaiac Test?
A. Avoid turnips, radish and horseradish 3 days before procedure
B. Continue iron preparation to prevent further loss of Iron
C. Do not eat read meat 12 hours before procedure
D. Encourage caffeine and dark colored foods to produce accurate results

83. In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse,
indicates inadequate knowledge and skills about the procedure?

A. The nurse scoop the specimen specifically at the site with blood and mucus
B. She took around 1 inch of specimen or a teaspoonful
C. Ask the client to call her for the specimen after the client wiped off his anus
with a tissue
D. Ask the client to defecate in a bedpan, Secure a sterile container

84. In a routine sputum analysis, Which of the following indicates proper nursing action
before sputum collection?

A. Secure a clean container

B. Discard the container if the outside becomes contaminated with the sputum
C. Rinse the client’s mouth with Listerine after collection
D. Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine
sputum analysis

85. Who collects Blood specimen?

A. The nurse
B. Medical technologist
C. Physician
D. Physical therapist

86. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the
following health teaching is important to ensure accurate reading?

A. Tell the patient to eat fatty meals 3 days prior to the procedure
B. NPO for 12 hours pre procedure
C. Ask the client to drink 1 glass of water 1 hour prior to the procedure
D. Tell the client that the normal serum lipase level is 50 to 140 U/L

87. The primary factor responsible for body heat production is the

A. Metabolism
B. Release of thyroxin
C. Muscle activity
D. Stress

88. The heat regulating center is found in the

A. Medulla oblongata
B. Thalamus
C. Hypothalamus
D. Pons
89. A process of heat loss which involves the transfer of heat from one surface to another is

A. Radiation
B. Conduction
C. Convection
D. Evaporation

90. Which of the following is a primary factor that affects the BP?

A. Obesity
B. Age
C. Stress
D. Gender

91. The following are social data about the client except

A. Patient’s lifestyle
B. Religious practices
C. Family home situation
D. Usual health status

92. The best position for any procedure that involves vaginal and cervical examination is

A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy

93. Measure the leg circumference of a client with bipedal edema is best done in what
position?

A. Dorsal recumbent
B. Sitting
C. Standing
D. Supine

94. In palpating the client’s abdomen, Which of the following is the best position for the
client to assume?

A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy

95. Rectal examination is done with a client in what position?

A. Dorsal recumbent
B. Sims position
C. Supine
D. Lithotomy

96. Which of the following is a correct nursing action when collecting urine specimen from a
client with an Indwelling catheter?
A. Collect urine specimen from the drainage bag
B. Detach catheter from the connecting tube and draw the specimen from the port
C. Use sterile syringe to aspirate urine specimen from the drainage port
D. Insert the syringe straight to the port to allow self sealing of the port

97. Which of the following is inappropriate in collecting mid stream clean catch urine
specimen for urine analysis?

A. Collect early in the morning, First voided specimen

B. Do perineal care before specimen collection
C. Collect 5 to 10 ml for urine
D. Discard the first flow of the urine

98. When palpating the client’s neck for lymphadenopathy, where should the nurse position
himself?

A. At the client’s back

B. At the client’s right side
C. At the client’s left side
D. In front of a sitting client

99. Which of the following is the best position for the client to assume if the back is to be
examined by the nurse?

A. Standing
B. Sitting
C. Side lying
D. Prone

100. In assessing the client’s chest, which position best show chest expansion as well as its
movements?

A. Sitting
B. Prone
C. Sidelying
D. Supin

Steven, an athletic 20-year-old college student, suffered a fractured

shoulder and sprained wrist in a fall at a ski resort.

1. In developing Steven's care plan following surgery, which of the

following typical problems would you anticipate?

A. He will undergo an alteration in self-concept.

B. He will experience anxiety as a result of flashbacks about the skiing

accident.
C. He will have impaired mobility caused by immobilization of upper extremity.

D. There will be abnormal tissue perfusion caused by swelling.

If you use both the information provided and your understanding of

surgical needs following reduction of a fracture, the only problem that
would normally occur is impaired mobility. In analyzing data you would
first attempt to recall and understand typical scenarios or patterns of
needs that commonly occur. Validate your problem definition by
incorporating specialized data or individualized signs and symptoms
presented by your client. These specialized data should be accompanied
by a statement of cause. For example, if you note that Steven's
fingertips are cold and pitting edema is forming on the back of the hand,
your analytic statement might be option D, abnormal tissue perfusion
caused by swelling. An accurate analysis of data provides a valid and
useful framework for planning patient care.

Jean Thomas is a 25-year-old secretary admitted to the emergency room

with diaphoresis, hyperventilation, palpitations, and trembling. Jean tells
the nurse that she has been "very upset and nervous" over a poor
employment evaluation. A tentative diagnosis of acute anxiety episode
is made.

1. Which of the following acid-base imbalances would likely occur as a

result of Jean's hyperventilation?

A. Respiratory acidosis

B. Respiratory alkalosis

C. Metabolic acidosis

D. Metabolic alkalosis

The intended response is B, since hyperventilation will cause an

increased loss of CO2,

Mrs. Durham is recovering from a colon resection for removal of a

malignant mass in the large bowel. Following breakfast one morning,
she told the nurse, "I'm tired of waiting, I want my bath now. You're
never here when I need you."
 1. Which of the following responses by the nurse is most appropriate?

A. What do you mean, I'm never here? I spent all three hours with you
yesterday, Mrs. Durham.

B. I'm sorry you've been waiting Mrs. Durham. Let's get you comfortable
now and I'll be back in twenty minutes to give you a bath.

C. I'm doing my best, Mrs. Durham. You know I have three other
patients to take care of today, besides you.

D. I must see Mrs. Jones right now, Mrs. Durham. She's really sick
today. I'll be back as soon as I can.

The only appropriate response is option B. Acknowledge her

feelings and give her a clear, factual response to her concern.
Never challenge a patient's statements and don't be defensive
(option C). Do not reprimand the patient unnecessarily or talk
about the needs of the other patients ( options C and D). In this
case you did not need to know a lot about colon resections to
answer this question. You did need to have skill in basic
communication and human interaction.

Brian, aged 4 years, is sitting in the pediatric day room with Michael,
another patient. He suddenly realizes that he has wet his pants and runs
to the nurse, crying.

1. The most appropriate initial response by the nurse is:

A. Why, Brian, what happened? Why did you wet your pants?

B. You know better than this, Brian; next time you'll get a good spanking.

C. Let's take off those wet pants, Brian, and put on something dry so you'll be
more comfortable.

D. Wait until I tell Michael what you did. Aren't you ashamed of yourself?

Several relevant principles come into play in this item in selecting the
correct answer. A very basic principle is, "The nurse shows respect for
the individual in treating human responses to actual or potential health
problems." In other words, focus on treating the patient with respect
first and then attempt to modify wrong behavior. This principle shows an
acceptable standard of nursing action. The intended response is C.

Margaret O'Hara, a 30-year-old known diabetic, is brought to the

emergency department by ambulance. The paramedic team reports
symptoms of apparent hyperglycemia. Stat blood glucose is 640.

1. The nurse is aware that excess serum glucose acts to draw fluids
osmotically with resultant polyuria. In addition to increased urinary
output, the nurse should expect to observe which of the following sets of
symptoms in Margaret?

A. Polydipsia, diaphoresis, bradycardia

B. Thirst, dry mucous membranes, hot dry skin

C. Hypotension, bounding pulse, headache

D. Nervousness, rapid respirations, diarrhea

The intended response is B, because these are all symptoms associated

with the dehydration that occurs in hyperglycemia. Although polydypsia
is expected (response A), diaphoresis does not occur in the body's
effort to compensate by holding back fluid. The patient would
experience tachycardia as a cardiac compensatory mechanism, causing
a rapid, thready pulse. Headache and nervousness (responses C and D)
are symptoms associated with hypoglycemia.

Molly Flannery is a 67-year-old female with chronic congestive heart

failure and hypertension. She is being evaluated for complaints of
muscular weakness and general fatigue.

1. Molly's serum electrolyte studies reveal a K+ level of 2.9. Which of the

following medications taken by the patient at home contributed most to
her hypokalemic state?

A. Digoxin, .125 mg, PO, daily

B. Lasix, 80 mg, PO, daily

C. Aldomet, 250 mg, PO, tid

D. Aspirin, 10 grains, bid

The intended response is B, since Lasix, in addition to its diuretic

action, also wastes K+ by increasing urinary excretion. Digoxin,
response A, contributes to K+ loss by enhancing urinary output, but
Lasix is much more directly related to the development of hypokalemia.
Response C is an anti-hypertensive that is not related to K+ loss.
Response D, aspirin, may have been prescribed as myocardial infarction
prophylaxis, and is not related to K+ loss.

Mr. Robert Bacchus is a 63-year-old retired business executive who

comes to the emergency room with complaints of dyspnea, shortness of
breath, and chest pain radiating to the left arm.

1. The nurse caring for Mr. Bacchus should implement which of the
following actions FIRST?

A. Administer prescribed pain medication

B.. Apply oxygen per nasal cannula as ordered

C. Assess vital signs

D. Apply electrocardiogram electrodes to the patient's chest

The intended response is C, since vital sign assessment will provide

baseline data of vital cardiac and respiratory function, which will then
serve as a guideline for diagnosis and therapy measures.

Loberta Jackson, a 21-year-old college student, is admitted to a medical

unit with diagnosis of uncontrolled diabetes, acute hypoglycemic
reaction.

1. Loberta explains to the admitting nurse that she had been feeling "sick
to my stomach, like I was coming down with the flu" for the past 48
hours. She has continued to take her usual daily dosage of insulin.
Noting that Loberta has been admitted with a blood-glucose value of 46,
which of the following assessment questions would provide the most
valuable information about Loberta's status?

A.. "Have you been under a great deal of stress lately, Loberta?"
B. "Were you having difficulty sleeping after this illness started?"

C. "Have you eaten anything in the past 48 hours?"

D. "Did you take any medications for this illness other than your insulin?"

The intended response is C, because it is highly probable that Loberta,

feeling "sick to her stomach," has not taken in adequate foods and
fluids, and coupled with taking her usual dosage of daily insulin, has
brought about an acute hypoglycemic reaction. (Higher than normal
circulating levels of insulin with insufficient food intake of essential
nutrients will result in acute decreased blood-glucose levels). Response
A, focusing on increased stress, would more than likely stimulate a
hyperglycemic reaction, since stress causes elevations of blood
glucose. Response D, focusing on other medications the patient has
taken, would probably not trigger a hypoglycemic reaction. Response B
is unrelated to her present status.

Jerry is a 32-year-old white male. He has been married for 10 months,

and he and his wife, Sue, are expecting their first child in 6 months. Prior
to marrying Sue, Jerry was sexually active and nonmonogamous. He
has been sexually active since the age of 18. Recently Jerry has
complained of persistent dry cough, night sweats, and a temperature
over 100?F. Although Jerry is concerned about his weight and watches
his diet, he has lost 15 pounds without even trying. Upon assessing
Jerry, he admits to having had sexual intercourse with prostitutes, both
male and female, during the last 10 years.

1. Jerry's symptoms of elevated temperature, chills, and dry cough are

probably related to which undiagnosed condition?

A. Alteration in tissue perfusion

B. An infection, etiology unknown

C. Indigestion from too frequent traveling

D. Lack of knowledge related to frequent travel

The intended response is B. Classic signs and symptoms of infection

are fever, chills, loss of appetite, generalized myalgias, or localized pain
and discomfort. The dry cough that Jerry experiences can be associated
with the system of involvement. Pulmonary etiology should be assessed
and evaluated.

Mrs. Brown's husband was admitted to the emergency room in delirium

tremens (DTs). This admission is his third visit in 2 weeks. While waiting
to see her husband, Mrs. Brown said to the nurse, "What in the world
can I do to help Joe get over this drinking problem?"

1. The best initial response for the nurse is:

A. Don't feel guilty, Mrs. Brown; I know this must be difficult for you.

B. Let's go into the lounge so we can talk more about your concern, Mrs.
Brown.

C. You need to convince Joe to seek professional help, Mrs. Brown.

D. How long has your husband been drinking, Mrs. Brown?

If you chose Option A, you are reading into the question and adding a
factor that was not provided-- that Mrs. Brown is feeling guilty. Perhaps
you know of someone who did feel guilty in a situation like this, or
perhaps you thought she should feel guilty. Because this background
statement does not tell you how Mrs. Brown feels, you can't make this
assumption (option A).

Option C is incorrect because you don't have enough information about

the situation to offer this advice. You should be in the assessment or
data collection phase of the nursing process. Option D is not the best
choice because it focuses on Mr. Brown's problem and channels the
interaction specifically, rather than encouraging Mrs. Brown to express
her concerns. Since Mrs. Brown is concerned about what she can do to
help her husband, the correct response is one that first encourages her
to verbalize how she is feeling (option B).

Amy Stevens is a 17-year-old student admitted for evaluation of lower

abdominal pain. She tells the nurse, "I wish my friends would come to
visit me. I don't like being here alone."

1. Which of the following would be the most appropriate response of the

nurse?
A. "You sound very lonely. Shall I stay with your for awhile?"

B. "I'm sure your friends will come to see you soon."

C. "It's a little too early for visiting hours. You'll have to wait until this
afternoon."

D. "It's hard to be alone. Would you like me to stay with you?"

The intended response is D, since this response acknowledges the

patient's feelings and offers support. Response A tends to catastrophize
the patient's situation by saying "you must be very lonely." Response B
provides false reassurance because the nurse has no real way of
knowing if in fact friends will come to visit Amy. Finally, C is incorrect
because it provides only a factual response and does not attend to the
feeling tone of Amy's remarks.

Patty Daniels is a 25-year-old white female, pregnant with her first child.
She is being seen in the obstetrical clinic for her first prenatal visit.

1. Patty tells the nurse, "I drank a glass of wine at a party before I found
out that I was pregnant. I'm worried that I might have hurt the baby."
Based on an understanding of alcohol use in pregnancy, which of the
following responses is the most appropriate?

A. "We don't really know how much alcohol is too much during pregnancy.
Don't drink anymore and try not to worry about it."

B. "As long as your drinking is moderate, I wouldn't worry about it. There were
plenty of healthy babies born to drinking mothers before they ever discovered
fetal alcohol syndrome."

C. "An occasional drink shouldn't hurt the baby. Research has shown that the
risk to the fetus increases as the amount and frequency of alcohol
consumption increases."

D. "I can understand why you're so upset, but an occasional drink shouldn't
hurt the baby."

The correct response is C. This patient needs two things from the nurse:
information about alcohol use in pregnancy and reassurance about the
potential risk to her own baby. Alcohol is a known teratogenic
substance, but it is unclear how much alcohol it takes and at what point
in development to adversely affect the fetus. Research has shown that
the incidence of fetal alcohol syndrome and related disorders increases
as the amount and frequency of alcohol consumption increase. An
occasional drink should not harm the fetus. C is the correct response
because it is the only answer that offers reassurance and accurate
information without catastrophizing the situation.

Kelly Jones, aged 3 years, is brought to the emergency room by her

mother following an accidental ingestion of acetaminophen. When
questioned, Mrs. Jones states that she believes that Kelly ingested
approximately 20 tablets. She further states that she believes that the
ingestion occurred within the last hour.

1. Immediately upon arrival in the emergency room the nurse should:

A. Assess vital signs

B. Administer O2

C. Start IV fluids

D. Perform an arterial puncture for blood gases

A is the correct response. The establishment of baseline vital signs

should always be done first. Although hyperventilation and resultant
respiratory alkalosis is the most obvious clinical manifestation,
acetaminophen does not exert its peak effect until 2 to 4 hours following
ingestion. Performing an arterial puncture for blood-gas analysis will be
important, but it is not the first thing that the nurse should do. There is
no indication at this time for the administration of O2 or IV fluids.