100 item Comprehensive Exam with Answers and B) A 14 month-old who chewed 2 leaves of a philodendron

Rationale plant
1. The nurse enters the room as a 3 year-old is having a C) A 20 month-old who is found sitting on the bathroom floor
generalized seizure. Which intervention should the nurse do beside an empty bottle of diazepam (Valium)
first? D) A 30 month-old who has swallowed a mouthful of charcoal
A) Clear the area of any hazards lighter fluid
B) Place the child on the side
C) Restrain the child The correct answer is A: An 18 month-old who ate an
D) Give the prescribed anticonvulsant undetermined amount of crystal drain cleaner. Drain cleaner is
very alkaline. The orange juice is acidic and will help to
The correct answer is B: Place the child on the side neutralize this substance.
Protecting the airway is the top priority in a seizure. If a child is
actively convulsing, a patent airway and oxygenation must be 7. A 23 year-old single client is in the 33rd week of her first
assured. pregnancy. She tells the nurse that she has everything ready
for the baby and has made plans for the first weeks together at
2. A client has just returned to the medical-surgical unit home. Which normal emotional reaction does the nurse
following a segmental lung resection. After assessing the client, recognize?
the first nursing action would be to A) Acceptance of the pregnancy
A) Administer pain medication B) Focus on fetal development
B) Suction excessive tracheobronchial secretions C) Anticipation of the birth
C) Assist client to turn, deep breathe and cought D) Ambivalence about pregnancy
D) Monitor oxygen saturation
The correct answer is C: Anticipation of the birth
The correct answer is B: Suction excessive tracheobronchial Directing activities toward preparation for the newborn''s needs
secretions and personal adjustment are indicators of appropriate
Suctioning the copious tracheobronchial secretions present in emotional response in the third trimester.
post-thoracic surgery clients maintains an open airway which is
always the priority nursing intervention. 8. Upon examining the mouth of a 3 year-old child, the nurse
discovers that the teeth have chalky white-to-yellowish staining
3. A nurse from the surgical department is reassigned to the with pitting of the enamel. Which of the following conditions
pediatric unit. The charge nurse should recognize that the child would most likely explain these findings?
at highest risk for cardiac arrest and is the least likely to be A) Ingestion of tetracycline
assiged to this nurse is which child? B) Excessive fluoride intake
A) Congenital cardiac defects C) Oral iron therapy
B) An acute febrile illness D) Poor dental hygiene
C) Prolonged hypoxemia
D) Severe multiple trauma The correct answer is B: Excessive fluoride intake
The described findings are indicative of fluorosis, a condition
The correct answer is C: Prolonged hypoxemia characterized by an increase in the extent and degree of the
Most often, the cause of cardiac arrest in the pediatric enamel''s porosity. This problem can be associated with
population is prolonged hypoxemia. Children usually have both repeated swallowing of toothpaste with fluoride or drinking
cardiac and respiratory arrest. water with high levels of fluoride.

4. Which of the following would be the best strategy for the 9. Which of the following should the nurse teach the client to
nurse to use when teaching insulin injection techniques to a avoid when taking chlorpromazine HCL (Thorazine)?
newly diagnosed client with diabetes? A) Direct sunlight
A) Give written pre and post tests B) Foods containing tyramine
B) Ask questions during practice C) Foods fermented with yeast
C) Allow another diabetic to assist D) Canned citrus fruit drinks
D) Observe a return demonstration
The correct answer is A: Avoid direct sunlight
The correct answer is D: Observe a return demonstration Phenothiazine increases sensitivity to the sun, making clients
Since this is a psychomotor skill, this is the best way to know if especially susceptible to sunburn.
the client has learned the proper technique.
10. The nurse is discussing dietary intake with an adolescent
5. The nurse is assessing a 2 year-old client with a possible who has acne. The most appropriate statement for the nurse is
diagnosis of congenital heart disease. Which of these is most A) "Eat a balanced diet for your age."
likely to be seen with this diagnosis? B) "Increase your intake of protein and Vitamin A."
A) Several otitis media episodes in the last year C) "Decrease fatty foods from your diet."
B) Weight and height in 10th percentile since birth D) "Do not use caffeine in any form, including chocolate."
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes The correct answer is A: "Eat a balanced diet for your age."
A diet for a teenager with acne should be a well balanced diet
The correct answer is C: Takes frequent rest periods while for their age. There are no recommended additions and
playing subtractions from the diet.
Children with heart disease tend to have exercise intolerance.
The child self-limits activity, which is consistent with 11. The nurse is caring for a child who has just returned from
manifestations of congenital heart disease in children. surgery following a tonsillectomy and adenoidectomy. Which
action by the nurse is appropriate?
6. The nurse is reassigned to work at the Poison Control Center A) Offer ice cream every 2 hours
telephone hotline. In which of these cases of childhood B) Place the child in a supine position
poisoning would the nurse suggest that parents have the child C) Allow the child to drink through a straw
drink orange juice? D) Observe swallowing patterns
A) An 18 month-old who ate an undetermined amount of
crystal drain cleaner The correct answer is D: Observe swallowing patterns
1
The nurse should observe for increased swallowing frequency to A) A 13 month-old unable to walk
check for hemorrhage. B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
12. The nurse is caring for a client with acute pancreatitis. After D) A 30 month-old only drinking from a sippy cup
pain management, which intervention should be included in the
plan of care? The correct answer is D: A 30 month-old only drinking from a
A) Cough and deep breathe every 2 hours sippy cup
B) Place the client in contact isolation A 30 month-old should be able to drink from a cup without a
C) Provide a diet high in protein cover.
D) Institute seizure precautions
18. Which of the following conditions assessed by the nurse
The correct answer is A: Cough and deep breathe every 2 hours would contraindicate the use of benztropine (Cogentin)?
Respiratory infections are common because of fluid in the retro A) Neuromalignant syndrome
peritoneum pushing up against the diaphragm causing shallow B) Acute extrapyramidal syndrome
respirations. Encouraging the client to cough and deep breathe C) Glaucoma, prostatic hypertrophy
every 2 hours will diminish the occurrence of this complication. D) Parkinson's disease, atypical tremors

13. The nurse is caring for a client with trigeminal neuralgia (tic The correct answer is C: Glaucoma, prostatic hypertrophy
douloureaux). To assist the client with nutrition needs, the Glaucoma and prostatic hypertrophy are contraindications to
nurse should the use of benztropine (Cogentin) as the drug is an
A) Offer small meals of high calorie soft food anticholinergic agent.
B) Assist the client to sit in a chair for meals
C) Provide additional servings of fruits and raw vegetables 19. A 15 year-old client with a lengthy confining illness is at risk
D) Encourage the client to eat fish, liver and chicken for altered growth and development of which task?
A) Loss of control
The correct answer is A: Offer small meals of high calorie soft B) Insecurity
food C) Dependence
If the client is losing weight because of poor appetite due to the D) Lack of trust
pain, assist in selecting foods that are high in calories and
nutrients, to provide more nourishment with less chewing. The correct answer is C: Dependence
Suggest that frequent, small meals be eaten instead of three The client role fosters dependency. Adolescents may react to
large ones. To minimize jaw movements when eating, suggest dependency with rejection, uncooperativeness, or withdrawal.
that foods be pureed.
20. The nurse is caring for a client with cirrhosis of the liver
14. A client treated for depression tells the nurse at the mental with ascites. When instructing nursing assistants in the care of
health clinic that he recently purchased a handgun because he the client, the nurse should emphasize that
is thinking about suicide. The first nursing action should be to A) The client should remain on bed rest in a semi-Fowler's
A) Notify the health care provider immediately position
B) Suggest in-patient psychiatric care B) The client should alternate ambulation with bed rest with
C) Respect the client's confidential disclosure legs elevated
D) Phone the family to warn them of the risk C) The client may ambulate and sit in chair as tolerated
D) The client may ambulate as tolerated and remain in semi-
The correct answer is A: Notify the health care provider Fowlers position in bed
immediately
The health care provider must be contacted immediately as the The correct answer is B: The client should alternate ambulation
client is a danger to self and others. Hospitalization is indicated. with bed rest with legs elevated. Encourage alternating periods
ambulation and bed rest with legs elevated to mobilize edema
15. The initial response by the nurse to a delusional client who and ascites. Encourage and assist the client with gradually
refuses to eat because of a belief that the food is poisoned is increasing periods of ambulation.
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?" 21. In providing care to a 14 year-old adolescent with scoliosis,
C) "These feelings are a symptom of your illness." which of the following will be most difficult for this client?
D) "You’re safe here. I won’t let anyone poison you." A) Compliance with treatment regimens
B) Looking different from their peers
The correct answer is A: "You think that someone wants to C) Lacking independence in activities
poison you?" D) Reliance on family for their social support
This response acknowledges perception through a reflective
question which presents opportunity for discussion, clarification The correct answer is B: Looking different from their peers
of meaning, and expressing doubt. Conformity to peer influences peaks at around age 14. Since
many persons view any disability as deviant, the client will need
16. A client has just been admitted with portal hypertension. help in learning how to deal with reactions of others. Treatment
Which nursing diagnosis would be a priority in planning care? of scoliosis is long-term and involves bracing and/or surgery.
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage 22. The nurse is preparing to perform a physical examination
C) Ineffective individual coping on an 8 month-old who is sitting contentedly on his mother's
D) Fluid volume excess lap. Which of the following should the nurse do first?
A) Elicit reflexes
The correct answer is B: Potential complication hemorrhage B) Measure height and weight
Esophageal varices are dilated and tortuous vessels of the C) Auscultate heart and lungs
esophagus that are at high risk for rupture if portal circulation D) Examine the ears
pressures rise.
The correct answer is C: Auscultate heart and lungs
17. The nurse in a well-child clinic examines many children on a The nurse should auscultate the heart and lungs during the first
daily basis. Which of the following toddlers requires further quiet moment with the infant so as to be able to hear sounds
follow up? clearly. Other assessments may follow in any order.
2
 D) "Have you tried waking her to urinate?"
23. Which of these principles should the nurse apply when
performing a nutritional assessment on a 2 year-old client? The correct answer is B: "How long has this been occurring?"
A) An accurate measurement of intake is not reliable Nighttime control should be present by this age, but may not
B) The food pyramid is not used in this age group occur until age 5. Involuntary voiding may occur due to
C) A serving size at this age is about 2 tablespoons infectious, anatomical and/or physiological reasons.
D) Total intake varies greatly each day
29. A client was admitted to the psychiatric unit after refusing
The correct answer is C: A serving size at this age is about 2 to get out of bed. In the hospital the client talks to unseen
tablespoons people and voids on the floor. The nurse could best handle the
In children, a general guide to serving sizes is 1 tablespoon of problem of voiding on the floor by
solid food per year of age. Understanding this, the nurse can A) Requiring the client to mop the floor
assess adequacy of intake. B) Restricting the client’s fluids throughout the day
C) Withholding privileges each time the voiding occurs
24. The nurse is assessing a client with delayed wound healing. D) Toileting the client more frequently with supervision
Which of the following risk factors is most important in this
situation? The correct answer is D: Toileting the client more frequently
A) Glucose level of 120 with supervision
B) History of myocardial infarction With altered thought processes the most appropriate nursing
C) Long term steroid usage approach to alter the behavior is by attending to the physical
D) Diet high in carbohydrates need.

The correct answer is C: Long term steroid usage 30. The nurse is caring for a client with a sigmoid colostomy
Steroid dependency tends to delay wound healing. If the client who requests assistance in removing the flatus from a 1 piece
also smokes, the risk is increased. drainable ostomy pouch. Which is the correct intervention?
A) Piercing the plastic of the ostomy pouch with a pin to vent
25. Which of the following nursing assessments indicate the flatus
immediate discontinuance of an antipsychotic medication? B) Opening the bottom of the pouch, allowing the flatus to be
A) Involuntary rhythmic stereotypic movements and tongue expelled
protrusion C) Pulling the adhesive seal around the ostomy pouch to allow
B) Cheek puffing, involuntary movements of extremities and the flatus to escape
trunk D) Assisting the client to ambulate to reduce the flatus in the
C) Agitation, constant state of motion pouch
D) Hyperpyrexia, severe muscle rigidity, malignant
hypertension The correct answer is B: Opening the bottom of the pouch,
allowing the flatus to be expelled. The only correct way to vent
The correct answer is D: Hyperpyrexia, severe muscle rigidity, the flatus from a 1 piece drainable ostomy pouch is to instruct
malignant hypertension, hyperpyrexia, sever muscle rigidity, the client to obtain privacy (the release of the flatus will cause
and malignant hypertension are assessment signs indicative of odor), and to open the bottom of the pouch, release the flatus
NMS (neuroleptic malignant syndrome). and dose the bottom of the pouch.

26. A client with HIV infection has a secondary herpes simplex 31. The nurse is teaching parents of an infant about
type 1 (HSV-1) infection. The nurse knows that the most likely introduction of solid food to their baby. What is the first food
cause of the HSV-1 infection in this client is they can add to the diet?
A) Immunosuppression A) Vegetables
B) Emotional stress B) Cereal
C) Unprotected sexual activities C) Fruit
D) Contact with saliva D) Meats

The correct answer is A: Immunosuppression The correct answer is B: Cereal

The decreased immunity leads to frequent secondary infections. Cereal is usually introduced first because it is well tolerated,
Herpes simplex virus type 1 is an opportunistic infection. The easy to digest, and contains iron.
other options may result in HSV-1. However they are not the
most likely cause in clients with HIV. 32. When counseling parents of a child who has recently been
diagnosed with hemophilia, what must the nurse know about
27. The nurse measures the head and chest circumferences of the offspring of a normal father and a carrier mother?
a 20 month-old infant. After comparing the measurements, the A) It is likely that all sons are affected
nurse finds that they are approximately the same. What action B) There is a 50% probability that sons will have the disease
should the nurse take? C) Every daughter is likely to be a carrier
A) Notify the health care provider D) There is a 25% chance a daughter will be a carrier
B) Palpate the anterior fontanel
C) Feel the posterior fontanel The correct answer is D: There is a 25% chance a daughter will
D) Record these normal findings be a carrier
Hemophilia A is a sex-linked recessive trait seen almost
The correct answer is D: Record these normal findings exclusively in males. With a normal father and carrier mother,
The question is D. The rate of increase in head circumference affected individuals are male. There is a 25% chance of having
slows by the end of infancy, and the head circumference is an affected male, 25% chance of having a carrier female, 25%
usually equal to chest circumference at 1 to 2 years of age. chance of having a normal female and 25% chance of having a
normal male.
28. At a routine clinic visit, parents express concern that their 4
year-old is wetting the bed several times a month. What is the 33. When teaching a client with chronic obstructive pulmonary
nurse's best response? disease about oxygen by cannula, the nurse should also instruct
A) "This is normal at this time of day." the client's family to
B) "How long has this been occurring?" A) Avoid smoking near the client
C) "Do you offer fluids at night?" B) Turn off oxygen during meals
3
C) Adjust the liter flow to 10 as needed B) Stay in school
D) Remind the client to keep mouth closed C) Keep in contact with the child's father
D) Get adequate sleep
The correct answer is A: Avoid smoking near the client
Since oxygen supports combustion, there is a risk of fire if The correct answer is A: Maintaining good nutrition
anyone smokes near the oxygen equipment. Nurses can serve a pivotal role in providing nutritional
education and case management interventions. Weight gain
34. The nurse is caring for a post-op colostomy client. The during pregnancy is one of the strongest predictors of infant
client begins to cry saying, "I'll never be attractive again with birth weight. Specifically, teens need to increase their intake of
this ugly red thing." What should be the first action by the protein, vitamins, and minerals including iron. Pregnant teens
nurse? who gain between 26 and 35 pounds have the lowest incidence
A) Arrange a consultation with a sex therapist of low-birth-weight babies.
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care 39. A client continually repeats phrases that others have just
D) Determine the client's understanding of her colostomy said. The nurse recognizes this behavior as
A) Autistic
The correct answer is D: Determine the client''s understanding B) Ecopraxic
of her colostomy. One of the greatest fears of colostomy clients C) Echolalic
is the fear that sexual intimacy is no longer possible. However, D) Catatonic
the specific concern of the client needs to be assessed before
specific suggestions for dealing with the sexual concerns are The correct answer is C: Echolalic
given. Echolalic - repeating words heard.

40. A client is admitted for hemodialysis. Which abnormal lab

35. A schizophrenic client talks animatedly but the staff are value would the nurse anticipate not being improved by
unable to understand what the client is communicating. The hemodialysis?
client is observed mumbling to herself and speaking to the A) Low hemoglobin
radio. A desirable outcome for this client’s care will be B) Hypernatremia
A) Expresses feelings appropriately through verbal interactions C) High serum creatinine
B) Accurately interprets events and behaviors of others D) Hyperkalemia
C) Demonstrates improved social relationships
D) Engages in meaningful and understandable verbal The correct answer is A: Low hemoglobin
communication Although hemodialysis improves or corrects electrolyte
imbalances it has not effect on improving anemia.
The correct answer is D: Engages in meaningful and
understandable verbal communication. Data support impaired 41. The nurse is caring for a 7 year-old child who is being
verbal communication deficit. The outcome must be related to discharged following a tonsillectomy. Which of the following
the diagnosis and supporting data. No data is presented related instructions is appropriate for the nurse to teach the parents?
to feelings or to thinking processes. A) Report a persistent cough to the health care provider
B) The child can return to school in 4 days
36. A 7 year-old child is hospitalized following a major burn to C) Administer chewable aspirin for pain
the lower extremities. A diet high in protein and carbohydrates D) The child may gargle with saline as necessary for discomfort
is recommended. The nurse informs the child and family that
the most important reason for this diet is to The correct answer is A: Report a persistent cough to the health
A) Promote healing and strengthen the immune system care provider. Persistent coughing should be reported to the
B) Provide a well balanced nutritional intake health care provider as this may indicate bleeding.
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs 42. The nurse is caring for a 14 month-old just diagnosed with
Cystic Fibrosis. The parents state this is the first child in either
The correct answer is D: Spare protein catabolism to meet family with this disease, and ask about the risk to future
metabolic needs children. What is the best response by the nurse?
Because of the burn injury, the child has increased metabolism A) 1in 4 chance for each child to carry that trait
and catabolism. By providing a high carbohydrate diet, the B) 1in 4 risk for each child to have the disease
breakdown of protein for energy is avoided. Proteins are then C) 1in 2 chance of avoiding the trait and disease
used to restore tissue. D) 1in 2 chance that each child will have the disease

37. The parents of a 7 year-old tell the nurse their child has The correct answer is B: 1 in 4 risk for each child to have the
started to "tattle" on siblings. In interpreting this new behavior, disease
how should the nurse explain the child's actions to the parents? Cystic Fibrosis is an autosomal recessive transmission pattern.
A) The ethical sense and feelings of justice are developing In this situation, both parents must be carriers of the trait for
B) Attempts to control the family use new coping styles the disease since neither one of them has the disease.
C) Insecurity and attention getting are common motives Therefore, for each pregnancy, there is a 25% chance of the
D) Complex thought processes help to resolve conflicts child having the disease, 50% chance of carrying the trait and a
25% chance of having neither the trait or the disease.
The correct answer is A: The ethical sense and feelings of
justice are developing. The child is developing a sense of justice 43. The nurse is performing an assessment on a client with
and a desire to do what is right. At seven, the child is pneumococcal pneumonia. Which finding would the nurse
increasingly aware of family roles and responsibilities. They also anticipate?
do what is right because of parental direction or to avoid A) Bronchial breath sounds in outer lung fields
punishment. B) Decreased tactile fremitus
C) Hacking, nonproductive cough
38. A school nurse is advising a class of unwed pregnant high D) Hyperresonance of areas of consolidation
school students. What is the most important action they can
perform to deliver a healthy child? The correct answer is A: Bronchial breath sounds in outer lung
A) Maintain good nutrition fields
4
Pneumonia causes a marked increase in interstitial and alveolar
fluid. Consolidated lung tissue transmits bronchial breath 49. A 3 year-old child is treated in the emergency department
sounds to outer lung fields. after ingestion of 1ounce of a liquid narcotic. What action
should the nurse do first?
44. During seizure activity which observation is the priority to A) Provide the ordered humidified oxygen via mask
enhance further direction of treatment? B) Suction the mouth and the nose
A) Observe the sequence or types of movement C) Check the mouth and radial pulse
B) Note the time from beginning to end D) Start the ordered intravenous fluids
C) Identify the pattern of breathing
D) Determine if loss of bowel or bladder control occurs The correct answer is C: Check the mouth and radial pulse
The first step in treatment of a toxic exposure or ingestion is to
The correct answer is A: Protect the client from injury assess the airway, breathing and circulation; then stabilize the
It is a priority to note, and then record, what movements are client. The other nursing actions will follow.
seen during a seizure because the diagnosis and subsequent
treatment often rests solely on the seizure description. 50. The charge nurse on the eating disorder unit instructs a
new staff member to weigh each client in his or her hospital
45. Which of the following statements describes what the nurse gown only. What is the rationale for this nursing intervention?
must know in order to provide anticipatory guidance to parents A) To reduce the risk of the client feeling cold due to decreased
of a toddler about readiness for toilet training? fat and subcutaneous tissue
A) The child learns voluntary sphincter control through B) To cover the bony prominence and areas where there is skin
repetition breakdown
B) Myelination of the spinal cord is completed by this age C) So the client knows what type of clothing to wear when
C) Neuronal impulses are interrupted at the base of the ganglia weighed
D) The toddler can understand cause and effect D) To reduce the tendency of the client to hide objects under
his or her clothing
The correct answer is B: Myelination of the spinal cord is
completed by this age. Voluntary control of the sphincter The correct answer is D: To reduce the tendency of the client to
muscles can be gradually achieved due to the complete hide objects under his or her clothing. The client may conceal
myelination of the spinal cord, sometime between the ages of weights on their body to increase weight gain.
18 to 24 months of age.
51. In teaching parents to associate prevention with the
46. A client complaining of severe shortness of breath is lifestyle of their child with sickle cell disease, the nurse should
diagnosed with congestive heart failure. The nurse observes a emphasize that a priority for their child is to
falling pulse oximetry. The client's color changes to gray and A) Avoid overheating during physical activities
she expectorates large amounts of pink frothy sputum. The first B) Maintain normal activity with some restrictions
action of the nurse would be which of the following? C) Be cautious of others with viruses or temperatures
A) Call the health care provider D) Maintain routine immunizations
B) Check vital signs
C) Position in high Fowler's The correct answer is A: Avoid overheating
D) Administer oxygen Fluid loss caused by overheating and dehydration can trigger a
crisis.
The correct answer is D: Administer oxygen
When dealing with a medical emergency, the rule is airway first, 52. The nurse understands that during the "tension building"
then breathing, and then circulation. Starting oxygen is a phase of a violent relationship, when the batterer makes
priority. unreasonable demands, the battered victim may experience
feelings of
47. The nurse is caring for a client with benign prostatic A) Anger
hypertrophy. Which of the following assessments would the B) Helplessness
nurse anticipate finding? C) Calm
A) Large volume of urinary output with each voiding D) Explosive
B) Involuntary voiding with coughing and sneezing
C) Frequent urination The correct answer is B: Helplessness
D) Urine is dark and concentrated The battered individual internalizes appropriate anger at the
batterer’s unfairness and instead feels depressed with a sense
The correct answer is C: Frequent urination of helplessness, when the partner explodes in spite of best
Clients with Benign Prostatic Hypertrophy have overflow efforts to please the batterer.
incontinence with frequent urination in small amounts day and
night. 53. A parent has numerous questions regarding normal growth
and development of a 10 month-old infant. Which of the
48. An anxious parent of a 4 year-old consults the nurse for following parameters is of most concern to the nurse?
guidance in how to answer the child's question, "Where do A) 50% increase in birth weight
babies come from?" What is the nurse's best response to the B) Head circumference greater than chest
parent? C) Crying when the parents leave
A) "When a child asks a question, give a simple answer." D) Able to stand up briefly in play pen
B) "Children ask many questions, but are not looking for
answers." The correct answer is A: 50% increase in birth weight
C) "This question indicates interest in sex beyond this age." Birth weight should be doubled at 6 months of age, tripled at 1
D) "Full and detailed answers should be given to all questions." year, and quadrupled by 18 months.

The correct answer is A: "When a child asks a question, give a 54. The nurse has been assigned to these clients in the
simple answer." During discussions related to sexuality, honesty emergency room. Which client would the nurse go check first?
is very important. However, honesty does not mean imparting A) Viral pneumonia with atelectasis
every fact of life associated with the question. When children B) Spontaneous pneumothorax with a respiratory rate of 38
ask 1 question, they are looking for 1 answer. When they are C) Tension pneumothorax with slight tracheal deviation to the
ready, they will ask about the other pieces. right
5
D) Acute asthma with episodes of bronchospasm Hip flexion should not exceed 60 degrees.

The correct answer is C: Tension pneumothorax with slight 60. A nurse who travels with an agency is uncertain about what
tracheal deviation to the right. Tracheal deviation indicates a tasks can be performed when working in a different state. It
significant volume of air being trapped in the chest cavity with a would be best for the nurse to check which resource?
mediastinal shift. In tension pneumothorax the tracheal A) The state nurse practice act in which the assignment is made
deviation is away from the affected side. The affected side is B) With a nurse colleague who has worked in that state 2 years
the side where the air leak is in the lung. This situation also ago
results in sudden air hunger, agitation, hypotension, pain in the D) The Nursing Social Policy Statement within the United States
affected side, and cyanosis with a high risk of cardiac C) The policies and procedures of the assigned agency in that
tamponade and cardiac arrest. state

55. The nurse is assessing a 4 year-old for possible The correct answer is A: The state nurse practice act in which
developmental dysplasia of the right hip. Which finding would the assignment is made. The state nurse practice act is the
the nurse expect? governing document of what can be done in the assigned state.
A) Pelvic tip downward
B) Right leg lengthening 61. Parents of a 7 year-old child call the clinic nurse because
C) Ortolani sign their daughter was sent home from school because of a rash.
D) Characteristic limp The child had been seen the day before by the health care
provider and diagnosed with Fifth Disease (erythema
The correct answer is D: Characteristic limp infectiosum). What is the most appropriate action by the nurse?
Developmental dysplasia produces a characteristic limp in A) Tell the parents to bring the child to the clinic for further
children who are walking. evaluation
B) Refer the school officials to printed materials about this viral
56. A 2 year-old child has recently been diagnosed with cystic illness
fibrosis. The nurse is teaching the parents about home care for C) Inform the teacher that the child is receiving antibiotics for
the child. Which of the following information is appropriate for the rash
the nurse to include? D) Explain that this rash is not contagious and does not require
A) Allow the child to continue normal activities isolation
B) Schedule frequent rest periods
C) Limit exposure to other children The correct answer is D: Explain that this rash is not contagious
D) Restrict activities to inside the house and does not require isolation. Fifth Disease is a viral illness
with an uncertain period of communicability (perhaps 1 week
The correct answer is A: Allow the child to continue their prior to and 1 week after onset). Isolation of the child with Fifth
normal activities Physical activity is important in a two year-old Disease is not necessary except in cases of hospitalized children
who is developing autonomy. Physical activity is a valuable who are immunosuppressed or having aplastic crises. The
adjunct to chest physical therapy. Exercise tends to stimulate parents may need written confirmation of this from the health
mucous secretion and help develop normal breathing patterns. care provider.

57. The nurses on a unit are planning for stoma care for clients 62. What principle of HIV disease should the nurse keep in
who have a stoma for fecal diversion. Which stomal diversion mind when planning care for a newborn who was infected in
poses the highest risk for skin breakdown utero?
A) Ileostomy A) The disease will incubate longer and progress more slowly in
B) Transverse colostomy this infant
C) Ileal conduit B) The infant is very susceptible to infections
D) Sigmoid colostomy C) Growth and development patterns will proceed at a normal
rate
The correct answer is A: Ileostomy D) Careful monitoring of renal function is indicated
Ileostomy output contains gastric and enzymatic agents that
when present on skin can denuded skin in several hours. The correct answer is B: The infant is very susceptible to
Because of the caustic nature of this stoma output adequate infections
peristomal skin protection must be delivered to prevent skin HIV infected children are susceptible to opportunistic infections
breakdown. due to a compromised immune system.

58. A client is unconscious following a tonic-clonic seizure. What 63. While teaching a client about their medications, the client
should the nurse do first? asks how long it will take before the effects of lithium take
A) Check the pulse place. What is the best response of the nurse?
B) Administer Valium A) Immediately
C) Place the client in a side-lying position B) Several days
D) Place a tongue blade in the mouth C) 2 weeks
D) 1 month
The correct answer is C: Place the client in a side-lying position
Place the client in a side-lying position to maintain an open The correct answer is C: 2 weeks
airway, drain secretions, and prevent aspiration if vomiting Lithium is started immediately to treat bipolar disorder because
occurs. it is quite effective in controlling mania. Lithium takes
approximately 2 weeks to effect change in a client’s symptoms.
59. The nurse is teaching a client who has a hip prostheses
following total hip replacement. Which of the following should 64. The nurse is caring for a 12 year-old with an acute illness.
be included in the instructions for home care? Which of the following indicates the nurse understands common
A) Avoid climbing stairs for 3 months sibling reactions to hospitalization?
B) Ambulate using crutches only A) Younger siblings adapt very well
C) Sleep only on your back B) Visitation is helpful for both
D) Do not cross legs C) The siblings may enjoy privacy
D) Those cared for at home cope better
The correct answer is D: Do not cross legs
6
The correct answer is B: Visitation is helpful for both competent valve to prevent back flow into the pulmonary vein.
Contact with the ill child helps siblings understand the reasons
for hospitalization and maintains the relationship. 71. In assessing the healing of a client's wound during a home
visit, which of the following is the best indicator of good
65. Following a cocaine high, the user commonly experiences healing?
an extremely unpleasant feeling called A) White patches
A) Craving B) Green drainage
B) Crashing C) Reddened tissue
C) Outward bound D) Eschar development
D) Nodding out
The correct answer is C: Reddened tissue
The correct answer is B: Crashing As the wound granulates, redness indicates healing.
Following cocaine use, the intense pleasure is replaced by an
equally unpleasant feeling referred to as crashing. 72. The nursing intervention that best describes treatment to
deal with the behaviors of clients with personality disorders
66. One reason that domestic violence remains extensively include
undetected is A) Pointing out inconsistencies in speech patterns to correct
A) Few battered victims seek medical care thought disorders
B) There is typically a series of minor, vague complaints B) Accepting client and the client's behavior unconditionally
C) Expenses due to police and court costs are prohibitive C) Encouraging dependency in order to develop ego controls
D) Very little knowledge is currently known about batterers and D) Consistent limit-setting enforced 24 hours per day
battering relationships
The correct answer is D: Consistent limit-setting enforced 24
The correct answer is B: There is typically a series of minor, hours per day
vague complaints. Signs of abuse may not be clearly Treatment approaches that include restructuring the
manifested and a series a minor complaints such as headache, personality, assisting the person with developmental level and
abdominal pain, insomnia, back pain, and dizziness may be setting limits for maladaptive behavior such as acting out.
covert indications of abuse undetected. Complaints may be
vague. 73. A client has received her first dose of fluphenazine (Prolixin)
2 hours ago. She suddenly experiences torticollis and
67. When making a home visit to a client with chronic involuntary spastic muscle movement. In addition to
pyelonephritis, which nursing action has the highest priority? administering the ordered anticholinergic drug, what other
A) Follow-up on lab values before the visit measure should the nurse implement?
B) Observe client findings for the effectiveness of antibiotics A) Have respiratory support equipment available
C) Ask for a log of urinary output B) Immediately place her in the seclusion room
D) As for the log of the oral intake C) Assess the client for anxiety and agitation
D) Administer prn dose of IM antipsychotic medication
The correct answer is C: Ask for a log of urinary output
The nurse must monitor the urine output as a priority because The correct answer is A: Have respiratory support equipment
it is the best indictor of renal function. The other options would available
be done after an evaluation of the urine output. Persons receiving neuroleptic medication experiencing torticollis
and involuntary muscle movement are demonstrating side
68. When a client is having a general tonic clonic seizure, the effects that could lead to respiratory failure.
nurse should
A) Hold the client's arms at their side 74. The nurse asks a client with a history of alcoholism about
B) Place the client on their side the client’s drinking behavior. The client states "I didn’t hurt
C) Insert a padded tongue blade in client's mouth anyone. I just like to have a good time, and drinking helps me
D) Elevate the head of the bed to relax." The client is using which defense mechanism?
A) Denial
The correct answer is B: Place the client on their side B) Projection
This position keeps the airway patent and prevents aspiration. C) Intellectualization
D) Rationalization
69. The nurse is teaching a client with dysrhythmia about the
electrical pathway of an impulse as it travels through the heart. The correct answer is D: Rationalization
Which of these demonstrates the normal pathway? Rationalization is justifying illogical or unreasonable ideas,
A) AV node, SA node, Bundle of His, Purkinje fibers actions, or feelings by developing acceptable explanations that
B) Purkinje fibers, SA node, AV node, Bundle of His satisfies the teller as well as the listener.
C) Bundle of His, Purkinje fibers, SA node , AV node
D) SA node, AV node, Bundle of His, Purkinje fibers 75. The nurse is teaching a smoking cessation class and notices
there are 2 pregnant women in the group. Which information is
The correct answer is D: SA node, AV node, Bundle of His, a priority for these women?
Purkinje fibers A) Low tar cigarettes are less harmful during pregnancy
The pathway of a normal electrical impulse through the heart B) There is a relationship between smoking and low birth
is: SA node, AV node, Bundle of His, Purkinje fibers. weight
C) The placenta serves as a barrier to nicotine
70. Clients with mitral stenosis would likely manifest findings D) Moderate smoking is effective in weight control
associated with congestion in the
A) Pulmonary circulation The correct answer is B: There is a relationship between
B) Descending aorta smoking and low birth weight. Nicotine reduces placental blood
C) Superior vena cava flow, and may contribute to fetal hypoxia or placenta previa,
D) Bundle of His decreasing the growth potential of the fetus.

The correct answer is A: Pulmonary circulation 76. The nurse is caring for a client with end stage renal disease.
Congestion occurs in the pulmonary circulation due to the What action should the nurse take to assess for patency in a
inefficient emptying of the left ventricle and the lack of a fistula used for hemodialysis?
7
A) Observe for edema proximal to the site divided every 8 hours. 15kg x 40mg = 600mg, divided by 3 =
B) Irrigate with 5 mls of 0.9% Normal Saline 200 mg per dose. The prescribed dose is correct and should be
C) Palpate for a thrill over the fistula given as ordered.
D) Check color and warmth in the extremity
82. The nurse is performing a developmental assessment on an
The correct answer is C: Palpate for a thrill over the fistula 8 month-old. Which finding should be reported to the health
To assess for patency in a fistula or graft, the nurse auscultates care provider?
for a bruit and palpates for a thrill. Other options are not A) Lifts head from the prone position
related to evaluation for patency. B) Rolls from abdomen to back
C) Responds to parents' voices
77. Which therapeutic communication skill is most likely to D) Falls forward when sitting
encourage a depressed client to vent feelings?
A) Direct confrontation The correct answer is D: Falls forward when sitting
B) Reality orientation Sitting without support is expected at this age.
C) Projective identification
D) Active listening 83. The nurse is participating in a community health fair. As
part of the assessments, the nurse should conduct a mental
The correct answer is D: Active listening status examination when
Use of therapeutic communication skills such as silence and A) An individual displays restlessness
active listening encourages verbalization of feelings. B) There are obvious signs of depression
C) Conducting any health assessment
78. The nurse walks into a client's room and finds the client D) The resident reports memory lapses
lying still and silent on the floor. The nurse should first
A) Assess the client's airway The correct answer is C: Conducting any health assessment
B) Call for help A mental status assessment is a critical part of baseline
C) Establish that the client is unresponsive information, and should be a part of every examination.
D) See if anyone saw the client fall
84. The nurse caring for a 14 year-old boy with severe
The correct answer is C: Establish that the client is Hemophilia A, who was admitted after a fall while playing
unresponsive basketball. In understanding his behavior and in planning care
The first step in CPR is to establish unresponsiveness. Second is for this client, what must the nurse understand about
to call for help. Third is opening the airway. adolescents with hemophilia?
A) Must have structured activities
79. What is the best way for the nurse to accomplish a health B) Often take part in active sports
history on a 14 year-old client? C) Explain limitations to peer groups
A) Have the mother present to verify information D) Avoid risks after bleeding episodes
B) Allow an opportunity for the teen to express feelings
C) Use the same type of language as the adolescent The correct answer is B: Often take part in active sports
D) Focus the discussion of risk factors in the peer group Establish an age-appropriate safe environment. Adolescent
hemophiliacs should be aware that contact sports may trigger
The correct answer is B: Allow an opportunity for the teen to bleeding. However, developmental characteristics of this age
express feelings group such as impulsivity, inexperience and peer pressure,
Adolescents need to express their feelings. Generally, they talk place adolescents in unsafe environments.
freely when given an opportunity and some privacy to do so.
85. When assessing a client who has just undergone a
80. A new nurse on the unit notes that the nurse manager cardioversion, the nurse finds the respirations are 12. Which
seems to be highly respected by the nursing staff. The new action should the nurse take first?
nurse is surprised when one of the nurses states: "The A) Try to vigorously stimulate normal breathing
manager makes all decisions and rarely asks for our input." The B) Ask the RN to assess the vital signs
best description of the nurse manager's management style is C) Measure the pulse oximetry
A) Participative or democratic D) Continue to monitor respirations
B) Ultraliberal or communicative
C) Autocratic or authoritarian The correct answer is D: 4. Continue to monitor respirations
D) Laissez faire or permissive 12 respirations per minute is tolerated post-operatively. A range
from 8 to 10 gives cause for concern. At that point pulse
The correct answer is C: Autocratic or authoritarian oximetry is taken, as that rate could be tolerated. Vigorous
Autocratic leadership style is suggested in this situation. It is stimulation is not indicated beyond deep breathing and
appropriate for groups with little education and experience and coughing. It is not necessary to ask the RN to check findings.
who need strong direction, while participative or democratic
style is usually more successful on nursing units. 86. In order to enhance a client's response to medication for
chest pain from acute angina, the nurse should emphasize
81. A 2 year-old child is being treated with Amoxicillin A) Learning relaxation techniques
suspension, 200 milligrams per dose, for acute otitis media. The B) Limiting alcohol use
child weighs 30 lb. (15 kg) and the daily dose range is 20-40 C) Eating smaller meals
mg/kg of body weight, in three divided doses every 8 hours. D) Avoiding passive smoke
Using principles of safe drug administration, what should the
nurse do next? The correct answer is A: Learning relaxation techniques
A) Give the medication as ordered The only factor that can enhance the client''s response to pain
B) Call the health care provider to clarify the dose medication for angina is reducing anxiety through relaxation
C) Recognize that antibiotics are over-prescribed methods. Anxiety can be great enough to make the pain
D) Hold the medication as the dosage is too low medication totally ineffective.

The correct answer is A: Give the medication as ordered 87. The primary nursing diagnosis for a client with congestive
Amoxicillin continues to be the drug of choice in the treatment heart failure with pulmonary edema is
of acute otitis media. The dose range is 20-40 mg/kg/day A) Pain
8
B) Impaired gas exchange problem is one of an air leak in the lung. This client may need
C) Cardiac output altered: decreased to be returned to surgery to deal with the sustained air leak.
D) Fluid volume excess Action by the health care provider is required to prevent further
complications.
The correct answer is C: Cardiac output altered: decreased
All nursing interventions should be focused on improving 92. The nurse is caring for a newborn who has just been
cardiac output. Increasing cardiac output is the primary goal of diagnosed with hypospadias. After discussing the defect with
therapy. Comfort will improve as the client improves and the the parents, the nurse should expect that
respiratory status will improve as cardiac output increases. A) Circumcision can be performed at any time
B) Initial repair is delayed until ages 6-8
88. After talking with her partner, a client voluntarily admitted C) Post-operative appearance will be normal
herself to the substance abuse unit. After the second day on D) Surgery will be performed in stages
the unit the client states to the nurse, "My husband told me to
get treatment or he would divorce me. I don’t believe I really The correct answer is D: Surgery will be performed in stages
need treatment but I don’t want my husband to leave me." Hypospadias, a condition in which the urethral opening is
Which response by the nurse would assist the client? located on the ventral surface or below the penis, is corrected
A) "In early recovery, it's quite common to have mixed feelings, in stages as soon as the infant can tolerate surgery.
but unmotivated people can’t get well."
B) "In early recovery, it’s quite common to have mixed feelings, 93. A client has been receiving lithium (Lithane) for the past
but I didn’t know you had been pressured to come." two weeks for the treatment of bipolar illness. When planning
C) "In early recovery it’s quite common to have mixed feelings, client teaching, what is most important to emphasize to the
perhaps it would be best to seek treatment on an outclient client?
bases." A) Maintain a low sodium diet
D) "In early recovery, it’s quite common to have mixed feelings. B) Take a diuretic with lithium
Let’s discuss the benefits of sobriety for you." C) Come in for evaluation of serum lithium levels every 1-3
months
The correct answer is D: "In early recovery, it’s quite common D) Have blood lithium levels drawn during the summer months
to have mixed feelings. Let’s discuss the benefits of sobriety for
you." This response gives the client the opportunity to decrease The correct answer is D: Have blood lithium levels drawn during
ambivalent feelings by focusing on the benefits of sobriety. the summer months. Clients taking lithium therapy need to be
Dependence issues are great for the client fostering aware that hot weather may cause excessive perspiration, a
ambivalence. loss of sodium and consequently an increase in serum lithium
concentration.
89. Clients taking which of the following drugs are at risk for
depression? 94. When an autistic client begins to eat with her hands, the
A) Steroids nurse can best handle the problem by
B) Diuretics A) Placing the spoon in the client’s hand and stating, "Use the
C) Folic acid spoon to eat your food."
D) Aspirin B) Commenting "I believe you know better than to eat with
your hand."
The correct answer is A: Steroids C) Jokingly stating, "Well I guess fingers sometimes work better
Adverse medication effects can cause a syndrome that may or than spoons."
may not remit when the medication is discontinued. Examples D) Removing the food and stating "You can’t have anymore
include: phenothiazines, steroids, and reserpine. food until you use the spoon."

90. The nurse is assessing a client on admission to a The correct answer is A: Placing the spoon in the client’s hand
community mental health center. The client discloses that she and stating "Use the spoon to eat your food." This response
has been thinking about ending her life. The nurse's best identifies adaptive behavior with instruction and verbal
response would be expectation.
A) "Do you want to discuss this with your pastor?"
B) "We will help you deal with those thoughts." 95. A client develops volume overload from an IV that has
C) "Is your life so terrible that you want to end it?" infused too rapidly. What assessment would the nurse expect to
D) "Have you thought about how you would do it?" find?
A) S3 heart sound
The correct answer is D: "Have you thought about how you B) Thready pulse
would do it?" C) Flattened neck veins
This response provides an opening to discuss intent and means D) Hypoventilation
of committing suicide.
The correct answer is A: Auscultation of an S3 heart sound
91. The nurse is caring for a client 2 hours after a right lower Auscultation of an S3 heart sound. This is an early sign of
lobectomy. During the evaluation of the water-seal chest volume overload (or CHF) because during the first phase of
drainage system, it is noted that the fluid level bubbles diastole, when blood enters the ventricles, an extra sound is
constantly in the water seal chamber. On inspection of the chest produced due to the presence of fluid left in the ventricles.
dressing and tubing, the nurse does not find any air leaks in the
system. The next best action for the nurse is to 96. A neonate born 12 hours ago to a methadone maintained
A) Check for subcutaneous emphysema in the upper torso woman is exhibiting a hyperactive MORO reflex and slight
B) Reposition the client to a position of comfort tremors. The newborn passed one loose, watery stool. Which of
C) Call the health care provider as soon as possible these is a nursing priority?
D) Check for any increase in the amount of thoracic drainage A) Hold the infant at frequent intervals.
B) Assess for neonatal withdrawl syndrome
The correct answer is A: Check for subcutaneous emphysema in C) Offer fluids to prevent dehydration
the upper torso. Continuous bubbling in the water seal chamber D) Administer paregoric to stop diarrhea
is an abnormal finding 2 hours after a lobectomy. Further
assessment of appropriate factors was done by the nurse to The correct answer is B: Assess for neonatal withdrawl
rule out an air leak in the sytem. Thus the conclusion is that the syndrome
9
Neonatal withdrawl syndrome is a cluster of findings that signal
the withdrawal of the infant from the opiates. The findings seen
in methadone withdrawal are often more severe than for other
substances. Initial signs are central nervous system hyper
irritability and gastro-intestinal symptoms. If withdrawal signs
are severe, there is an increased mortality risk. Scoring the
infant ensures proper treatment during the period of
withdrawal.

97. While planning care for a preschool aged child, the nurse
understands developmental needs. Which of the following
would be of the most concern to the nurse?
A) Playing imaginatively
B) Expressing shame
C) Identifying with family
D) Exploring the playroom

The correct answer is B: Expressing shame

Erikson describes the stage of the preschool child as being the
time when there is normally an increase in initiative. The child
should have resolved the sense of shame and doubt in the
toddler stage.

98. A depressed client who has recently been acting suicidal is

now more social and energetic than usual. Smilingly he tells the
nurse "I’ve made some decisions about my life." What should
be the nurse’s initial response?
A) "You’ve made some decisions."
B) "Are you thinking about killing yourself?"
C) "I’m so glad to hear that you’ve made some decisions."
D) "You need to discuss your decisions with your therapist."

The correct answer is B: "Are you thinking about killing

yourself?"
Sudden mood elevation and energy may signal increased risk of
suicide. The nurse must validate suicide ideation as a beginning
step in evaluating seriousness of risk.

99. The nurse is caring for 2 children who have had surgical
repair of congenital heart defects. For which defect is it a
priority to assess for findings of heart conduction disturbance?
A) Artrial septal defect
B) Patent ductus arteriosus
C) Aortic stenosis
D) Ventricular septal defect

The correct answer is D: Ventricular septal defect

While assessments for conduction disturbance should be
included following repair of any defect, it is a priority for this
condition. A ventricular septal defect is an abnormal opening
between the right and left ventricles. The atrioventricular
bundle (bundle of His), a part of the electrical conduction
system of the heart, extends from the atrioventricular node
along each side of the interventricular septum and then divides
into right and left bundle branches. Surgical repair of a
ventricular septal defect consists of a purse-string approach or
a patch sewn over the opening. Either method involves
manipulation of the ventricular septum, thereby increasing risk
of interrupting the conduction pathway. Consequently,
postoperative complications include conduction disturbances.

100. The nurse is caring for a post myocardial infarction client

in an intensive care unit. It is noted that urinary output has
dropped from 60 -70 ml per hour to 30 ml per hour. This
change is most likely due to
A) Dehydration
B) Diminished blood volume
C) Decreased cardiac output
D) Renal failure

The correct answer is C: Decreased cardiac output

Cardiac output and urinary output are directly correlated. The
nurse should suspect a drop in cardiac output if the urinary
output drops. 60 item PEDIATRIC NURSING Questions and Rationale

10
Situation 1: Raphael, a 6 year’s old prep pupil is seen at the is under Pre-conventional where a child learns about
school clinic for growth and development monitoring (Questions instrumental purpose and exchange, that is they will something
1-5) do for another if that that person does something with the child
in return. Letter A is applicable for Toddlers and letter B is for a
1. Which of the following is characterized the rate of growth School age child.
during this period?
a. most rapid period of growth Situation 2 Baby boy Lacson delivered at 36 weeks gestation
b. a decline in growth rate weighs 3,400 gm and height of 59 cm (6-10)
c. growth spurt
d. slow uniform growth rate 6. Baby boy Lacson’s height is
a. Long
Correct answer is letter B. During the Preschooler stage growth b. Short
is very minimal. Weight gain is only 4.5lbs (2kgs) per year and c. Average
Height is 3.5in (6-8cm) per year. d. Too short
Review:
Most rapid growth and development- Infancy Correct answer is Letter A because the normal length of a
Slow growth- Toddler hood and Preschooler newborn is 47.5-53.75 cm (19.5-21in) with an average of 50cm
Slower growth- School age (Filipino standards po ito, pag kay Pilliteri nyo tinignan, 53cm
Rapid growth- Adolescence for female and 54cm for male)

2. In assessing Raphael’s growth and development, the nurse is 7. Growth and development in a child progresses in the
guided by principles of growth and development. Which is not following ways EXCEPT
included? a. From cognitive to psychosexual
a. All individuals follow cephalo-caudal and proximo-distal b. From trunk to the tip of the extremities
b. Different parts of the body grows at different rate c. From head to toe
c. All individual follow standard growth rate d. From general to specific
d. Rate and pattern of growth can be modified
Growth and development occurs in cephalo-caudal (head to
Growth and development occurs in cephalo-caudal meaning toe), proximo-distal (trunk to tips of the extremities and
development occurs through out the body’s axis. Example: the general to specific, but it doesn’t occurs in cognitive to
child must be able to lift the head before he is able to lift his psychosexual because they can develop at the same time.
chest. Proximo-distal is development that progresses from
center of the body to the extremities. Example: a child first 8. As described by Erikson, the major psychosexual conflict of
develops arm movement before fine-finger movement. Different the above situation is
parts of the body grows at different range because some body a. Autonomy vs. Shame and doubt
tissue mature faster than the other such as the neurologic b. Industry vs. Inferiority
tissues peaks its growth during the first years of life while the c. Trust vs. mistrust
genital tissue doesn’t till puberty. Also G&D is predictable in the d. Initiation vs. guilt
sequence which a child normally precedes such as motor skills
and behavior. Lastly G&D can never be modified “Haller? According to Erikson, children 0-18 months are under the
(Pwede mo bang turuan mag basa ang Infant? Or patayuin sya developmental task of Trust vs. Mistrust.
bago pa nakakagapang?)
9. Which of the following is true about Mongolian Spots?
3. What type of play will be ideal for Raphael at this period? a. Disappears in about a year
a. Make believe b. Are linked to pathologic conditions
b. Hide and seek c. Are managed by tropical steroids
c. Peek-a-boo d. Are indicative of parental abuse
d. Building blocks
Mongolian spots are stale grey or bluish patches of discoloration
Correct answer is Letter A, make believe is most appropriate commonly seen across the sacrum or buttocks due to
because it enhances the imitative play and imagination of the accumulation of melanocytes and they disappears in 1 year.
preschooler. C and D are for infants while letter A is B is They are not linked to steroid use and pathologic conditions.
recommended for schoolers because it enhances competitive
play. 10. Signs of cold stress that the nurse must be alert when
caring for a Newborn is:
4. Which of the following information indicate that Raphael is a. Hypothermia
normal for his age? b. Decreased activity level
a. Determine own sense self c. Shaking
b. Develop sense of whether he can trust the world d. Increased RR
c. Has the ability to try new things
d. Learn basic skills within his culture Correct answer is letter D. Hypothermia is inaccurate cause
normally, temperature of a newborn drop, Also a child under
The correct answer is letter C; because Erickson defines the cold stress will kick and cry to increase the metabolic rate
developmental task of a preschool period is learning Initiative thereby increasing heat so B isn’t a good choice. A newborn
vs. Guilt. Children can initiate motor activities of various sorts doesn’t have the ability to shiver (Pag ikaw ay nag pa anak at
on their own and no longer responds to or imitate the actions of ang beybe ay nanga-ngatog, naku itapon mo yan..di yan beybe
other children or of their parents. Letter A and B is.. for you!! itik yan.. hehe). So letter B and C is wrong. A newborn will
increase its RR because the NB will need more oxygen because
5. Based on Kohlberg’s theory, what is the stage of moral of too much activity.
development of Raphael?
a. Punishment-obedience Situation 3 Nursing care after delivery has an important aspect
b. “good boy-Nice girl” in every stages of delivery
c. naïve instrumental orientation
d. social contact 11. After the baby is delivered, the cord was cut between two
clamps using a sterile scissors and blade, then the baby is
Correct answer is letter C: According to Kohlber, a preschooler 11
placed at the: established, the pressure will shift from the R to the L side, and
a. Mother’s breast will facilitate the closure of Foramen Ovale. (Note: that is why
b. Mother’s side you should position the NB in R side lying position to increase
c. Give it to the grandmother pressure in the L side of the heart.)
d. Baby’s own mat or bed Review:
Increase PO2-> closure of ductus arteriosus
Of course, place it at the mother’s breast for latch-on. (Note: Decreased bloodflow -> closure of the ductus venosus
for NSD breast feed ASAP while for CS delivery, breast feed Circulation in the lungs is initiated by -> lung expansion and
after 4 hours) Lol, syempre d naman pwede sa grandma dba? pulmonary ventilation
Kasi naman hindi gatas ang ipapadede nyan, yogurt na sosyal. What will sustain 1st breath-> decreased artery pressure
ewwww. LOL What will complete circulation-> cutting of the cord

12. The baby’s mother is RH(-). Which of the following 17. Failure of the Foramen Ovale to close will cause what
laboratory tests will probably be ordered for the newborn? Congenital Heart Disease?
a. Direct Coomb’s a. Total anomalous Pulmunary Artery
b. Indirect Coomb’s b. Atrial Septal defect
c. Blood culture c. Transposition of great arteries
d. Platelet count d. Pulmunary Stenosis

Coomb’s test is the test to determine if RH antibodies are Foramen ovale is the opening between two Atria so, if its will
present. Indirect Coomb’s is done to the mother and Direct not close Atrial Septal defect can occur.
Coomb’s is the one don’t to the baby. Blood culture and Platelet
count doesn’t help detect RH antibodies. Situation 4 Children are vulnerable to some minor health
problems or injuries hence the nurse should be able to teach
13. Hypothermia is common in newborn because of their mothers to give appropriate home care.
inability to control heat. The following would be an appropriate
nursing intervention to prevent heat loss except 18. A mother brought her child to the clinic with nose bleeding.
a. Place the crib beside the wall The nurse showed the mother the most appropriate position for
b. Doing Kangaroo care the child which is:
c. By using mechanical pressure a. Sitting up
d. Drying and wrapping the baby b. With low back rest
c. With moderate back rest
Placing the crib beside the wall is un-appropriate because it can d. Lying semi flat
provide heat loss by radiation. Doing Kangaroo care or hugging
the baby, mechanical pressure or incubators and drying and The correct position is making the child having an upright
wrapping the baby will help conserve heat, sitting position with the head slightly tilted forward. This
position will minimize the amount of blood pressure in nasal
14. The following conditions are caused by cold stress except vessels and keep blood moving forward not back into the
a. Hypoglycemia nasopharynx, which will have the choking sensation and
b. Increase ICP increase risk of aspiration. Choices b, c, d, are inappropriate
c. Metabolic acidosis cause they can cause blood to enter the nasopharynx.
d. Cerebral palsy
19. A common problem in children is the inflammation of the
Hypoglycemia may occur due to increase metabolic rate, And middle ear. This is related to the malfunctioning of the:
because of newborns are born slightly acidic, and they a. Tympanic membrane
catabolize brownfat which will produce ketones which is an acid b. Eustachian tube
will cause metabolic acidosis. Also a NB with severe c. Adenoid
hypothermia is in high risk for kernicterus (too much bilirubin in d. Nasopharynx
the brain) can lead to Cerebral palsy. There is no connection in
the increase of ICP with hypothermia. This is because children has short, horizontal Eustachian tubes.
(NOTE: pathognomonic sign of Kernicterus in adult- asterexis, The dysfunction in the Eustachian tube enables bacterial
or involuntary flapping of the hand.) invasion of the middle ear and obstructs drainage of secretions.

15. During the feto-placental circulation, the shunt between two 20. For acute otitis media, the treatment is prompt antibiotic
atria is called therapy. Delayed treatment may result in complications of:
a. Ductus venosous a. Tonsillitis
b. Foramen Magnum b. Eardrum Problems
c. Ductus arteriosus c. Brain damage
d. Foramen Ovale d. Diabetes mellitus

Foramen ovale is opening between two atria, Ductus venosus is One of the complication of recurring acute otitis media is risk
the shunt from liver to the inferior vena cava, and your Ductus for having Meningitis, thereby causing possible brain damage.
Arteriosus is the shunt from the pulmonary artery to the aorta. That is why patient must follow a complete treatment regimen
(hindi kasali sa feto-placental circulation ang Foramen Magnum, and follow up care. A and B are not complications of AOM, (lalo
sa skull un!) na ung D!!)

16. What would cause the closure of the Foramen ovale after 21. When assessing gross motor development in a 3 year old,
the baby had been delivered? which of the following activities would the nurse expect to
a. Decreased blood flow finds?
b. Shifting of pressures from right side to the left side of the a. Riding a tricycle
heart b. Hopping on one foot
c. Increased PO2 c. Catching a ball
d. Increased in oxygen saturation d. Skipping on alternate foot.

During feto-placental circulation, the pressure in the heart is Answer is A, riding a tricycle is appropriate for a 3 y/o child.
much higher in the right side, but once breathing/crying is 12
Hopping on one foot can be done by a 4 y/o child, as well as and Edema weren’t.
catching and throwing a ball over hand. Skipping can be done
by a 5 y/o. 28. When assessing a family for potential child abuse risks, the
nurse would observe for which of the following?
22. When assessing the weight of a 5-month old, which of the a. Periodic exposure to stress
following indicates healthy growth? b. Low socio-economic status
a. Doubling of birth weight c. High level of self esteem
b. Tripling of birth weight d. Problematic pregnancies
c. Quadrupling of birth weight
d. Stabilizing of birth weight Answer is D, Typical factors that may be risk for Child abuse are
problematic pregnancies, chronic exposure to stress not
During the first 6 months of life the weight from birth will be periodic, low level of self esteem not high level. Also child
doubled and as soon as the baby reaches 1 year, its birth abuse can happen in all socio-economic status not just on low
weight is tripled. socio-economic status.

23. An appropriate toy for a 4 year old child is: 29. Which of the following is a possible indicator of Munchausen
a. Push-pull toys syndrome by proxy type of child abuse?
b. Card games a. Bruises found at odd locations, with different stages of
c. Doctor and nurse kits healing
d. Books and Crafts b. STD’s and genital discharges
c. Unexplained symptoms of diarrhea, vomiting and apnea with
Letter C is appropriate because it will enhance the creativity no organic basis
and imagination of a pre-school child. Letter B and D are d. Constant hunger and poor hygiene
inappropriate because they are too complex for a 4 y/o. Push-
pull toys are recommended for infants. Munchausen syndrome by Proxy is the fabrication or
inducement of an illness by one person to another person,
24. Which of the following statements would the nurse expects usually mother to child. It is characterized by symptoms such
a 5-year old boy to say whose pet gerbil just died as apnea and siezures, which may be due to suffocation, drugs
a. “The boogieman (kamatayan- the man with the scythe) got or poisoning, vomiting which can be induced with poisons and
him” diarrhea with the use of laxatives. Letter A can be seen in a
b. “He’s just a bit dead” Physical abuse, Letter B for sexual abuse and Letter C is for
c. “Ill be good from now own so I wont die like my gerbil” Physical Neglect.
d. “Did you hear the joke about…”
30. Which of the following is an inappropriate intervention when
A 5 y/o views death in “degrees”, so the child most likely will caring for a child with HIV?
say that “he is just a bit dead”. Personification of death like a. Teaching family about disease transmission
boogeyman or “kamatayan” occurs in ages 7 to 9 as well as b. Offering large amount of fresh fruits and vegetables
denying death can if they will be good. Denying death using c. Encouraging child to perform at optimal level
jokes and attributing life qualities to death occurs during age 3- d. Teach proper hand washing technique
5.
A child with HIV is immunocompromised. Fresh fruits and
25. When assessing the fluid and electrolyte balance in an vegetables, which may be contaminated with organisms and
infant, which of the following would be important to remember? pesticides can be harmful, if not fatal to the child, therefore
a. Infant can concentrate urine at an adult level these items should be avoided.
b. The metabolic rate of an infant is slower than in adults
c. Infants have more intracellular water that adult do Situation 5 Agata, 2 years old is rushed to the ER due to
d. Infant have greater body surface area than adults cyanosis precipitated by crying. Her mother observed that after
playing she gets tired. She was diagnosed with Tetralogy of
Infants have greater body surface area than adult, increasing Fallot.
their risk to F&E imbalances. Also infants cant concentrate a
urine at an adult level and their metabolic rate, also called 31. The goal of nursing care fro Agata is to:
water turnover, is 2 to 3 times higher than adult. Plus more a. Prevent infection
fluids of the infants are at the ECF spaces not in the ICF spaces. b. Promote normal growth and development
c. Decrease hypoxic spells
26. When assessing a child with aspirin overdose, which of the d. Hydrate adequately
following will be expected?
a. Metabolic alkalosis The correct answer is letter C. Though letter B would be a good
b. Respiratory alkalosis answer too, this goal is too vague and not specific. Nursing
c. Metabolic acidosis interventions will not solely promote normal G&D unless he will
d. Respiratory acidosis undergo surgical repair. So decreasing Hypoxic Spells is more
SMART. (alam nyo na kung ano yun! Specific, measurable,
Remember that Aspirin is acid (Acetylsalicylic ACID), so what attainable, realistic and time bounded). Letter A and D are
do you expect? (ang taray LOL) UN NA! inappropriate.
Review: REVIEW! REVIEW! REVIEW!
Pag galling sa bibig: alkalosis (hyper-emesis) Tetralogy of Fallot is a cyanotic Congenital Heart disease. Kaya
Pag galling sap wet: acidosis (diarrhea) sa tinawag na Tetralogy cause it has 4 anomalies;
1. VSD- ventricular septal defect
27. Which of the following is not a possible systemic clinical 2. Pulmunary Stenosis
manifestation of severe burns? 3. Over-riding of the Aorta- the aorta overrides both ventricles
a. Growth retardation 4. Right ventricular hypertrophy
b. Hypermetabolism
c. Sepsis We have 14 congenital heart defects. 8 acyanotic and 6
d. Blisters and edema cyanoyic.
8 Acyanotice includes: ASD, VSD, PDA, endocardial cushion
The question was asking for a SYSTEMIC clinical manifestation, defect, pulmonary stenosis, doupling of the aorta, Aortic
Letters A,B and C are systemic manifestations while Blisters 13
stenosis and Coarctation of the Aorta procedures like this cannot assure total recovery. So letter D is
6 Cyanotic includes: Tetralogy of fallot, Total anomalous a more appropriate Nursing diagnosis.
pulmonary artery, Transposition of the great arteries, Truncus NOTE: GANATO NA PO ANG PATTERN NG NLE, LAGING MAY
arteriousus, Hypoplastic Left heart syndrome. HALONG THERAPUETIC COMMUNICATION AT NURSING
(Acyanotic causes L->R shunting while cyanotic cause R->L DIAGNOSIS.
shunting. Para madaling matandaan lahat ng may “T” eh
cyanotic OK? 36. Which of the following respiratory condition is always
considered a medical emergency?
32. The immediate nursing intervention for cyanosis of Agata a. Laryngeotracheobronchitis (LTB)
is: b. Epiglottitis
a. Call up the pediatrician c. Asthma
b. Place her in knee chest position d. Cystic Fibrosis
c. Administer oxygen inhalation
d. Transfer her to the PICU Correct answer is letter B, because acute and sever
inflammation of the epiglottis can cause life threatening airway
The immediate intervention would be to place her on knee- obstruction, that is why its always treated as a medical
chest or “squatting” position because it traps blood into the emergency. NSG intervention : Prepare tracheostomy set at bed
lower extremities. Though also letter C would be a good choice side.
but the question is asking for “Immediate” so letter B is more LTB, can also cause airway obstruction but its not an
appropriate. Letter A and D are incorrect because its normal for emergency. Asthma is also not an emergency (ung status
a child who have ToF to have hypoxic or “tets” spells so there is asthmaticus ang kaylangan ng prompt treatment). CF is a
no need to transfer her to the NICU or to alert the Pediatrician. chronic disease, so its not a medical emergency.
REVIEW: Medical emergency of GI: peritonitis
33. Agata was scheduled for a palliative surgery, which creates
anastomosis of the subclavian artery to the pulmonary artery. 37. Which of the following statements by the family of a child
This procedure is: with asthma indicates a need for additional teaching?
a. Waterston-Cooley a. “We need to identify what things triggers his attacks”
b. Raskkind Procedure b. “He is to use bronchodilator inhaler before steroid inhaler”
c. Coronary artery bypass c. “We’ll make sure he avoids exercise to prevent asthma
d. Blalock-Taussig attacks”
d. “he should increase his fluid intake regularly to thin
Correct answer is Blalock-Taussig procedure its just a temporary secretions”
or palliative surgery which creates a shunt between the aorta
and pulmonary artery (oist parang ductus arteriosus) so that Asthmatic children don’t have to avoid exercise. They can
the blood can leave the aorta and enter the pulmonary artery participate on physical activities as tolerated. Using a
and thus oxygenating the lungs and return to the left side of bronchodilator before administering steroids is correct because
the heart, then to the aorta then to the body. This procedure steroids are just anti-inflammatory and they don’t have effects
also makes use of the subclavian vein so pulse is not palpable on the dilation of the bronchioles. OF course letters A and B are
at the right arm. obviously correct.
The full repair for ToF is called the Brock procedure. Raskkind is
a palliative surgery for TOGA. 38. Which of the following would require careful monitoring in
the child with ADHD who is receiving Methylphenidate (Ritalin)?
34. Which of the following is not an indicator that Agata a. Dental health
experiences separation anxiety brought about her b. Mouth dryness
hospitalization? c. Height and weight
a. Friendly with the nurse d. Excessive appetite
b. Prolonged loud crying, consoled only by mother
c. Occasional temper tantrums and always says NO Dental problems are more likely to occur in children under
d. Repeatedly verbalizes desire to go home going TCA therapy. Mouth dryness is a expected side effects of
Ritalin since it activates the SNS. Also loss of appetite is more
Because toddlers views hospitalization is abandonment, likely to happen, not increase in appetite. The correct answer is
separation anxiety is common. Its has 3 phases: PDD (parang c letter C, because Ritalin can affect the child’s G&D.
puff daddy LOL) Intervention: medication “holidays or vacation”. (This means
1. Protest 2. despair 3. detachment (or denial). Choices B, C, D na.. during weekends or holidays or school vacations, where
are usually seen in a child with separation anxiety (usually in the child wont be in school, the drug can be withheld.)
the protest stage).
REVIEW: Situation 6 Laura is assigned as the Team Leader during the
Separation anxiety begin at: 9 months immunization day at the RHU
Peaks: 18 months
39. What program for the DOH is launched at 1976 in
35. When Agata was brought to the OR, her parents where cooperation with WHO and UNICEF to reduce morbidity and
crying. What would be the most appropriate nursing diagnosis? mortality among infants caused by immunizable disease?
a. Infective family coping r/t situational crisis a. Patak day
b. Anxiety r/t powerlessness b. Immunization day on Wednesday
c. Fear r/t uncertain prognosis c. Expanded program on immunization
d. Anticipatory grieving r/t gravity of child’s physical status d. Bakuna ng kabtaan

In this item letter A and be are inappropriate response so SUS me! Dapat pa bang I-rationalize? Ang di nakakuha ng
remove them. The possible answers are C and D. Fear defined tamang sagot… hala… JOKE.. hehehe
as the perceived threat (real or imagined) that is consciously
recognized as danger (NANDA) is applicable in the situation but 40. One important principle of the immunization program is
its defining characteristics are not applicable. Crying per se can based on?
not be a subjective cue to signify fear, and most of the a. Statistical occurrence
symptoms of fear in NANDA are physiological. Anticipatory b. Epidemiologic situation
grieving on the other hand are intellectual and EMOTIONAL c. Cold chain management
responses based on a potential loss. And remember that 14
d. Surveillance study • if the child is 2 months up to less than 12 months- 50 bpm or
more
Letters A, C and D are not included in the principles of EPI. • if the child is 12 months to 4 y/o- 40 bpm or more
The principle of EPI are the following:
1. Its is based on epidemiological situation 46. You asked Braguda if her baby received all vaccines under
2. Mass approach utilization- the whole community is to be EPI. What legal basis is used in implementing the UN’s goal on
protected rather than the individual Universal Child Immunization?
3. Immunization is a basic health service, and should be a. PD no. 996
provided by the RHU b. PD no. 6
c. PD no. 46
41. The main element of immunization program is one of the d. RA 9173
following?
a. Information, education and communication Correct answer is letter B. Presidential Proclamation no. 6 (April
b. Assessment and evaluation of the program 3, 1986) is the “Implementing a United Nations goal on
c. Research studies Universal Child Immunization by 1990”. PD 996 (September 16,
d. Target setting 1976) is “providing for compulsory basic immunization for
infants and children below 8 years of age. PD no. 46
Correct answer is D. (September 16, 1992) is the “Reaffirming the commitment of
The following are the elements of EPI: the Philippines to the universal Child and Mother goal of the
• Target seting World Health Assembly. RA 9173 is of course the “Nursing act
• Cold chain logistic management of 2002”
• Information, education and communication
• Assessment and evaluation of the program’s over all 47. Braguda asks you about Vitamin A supplementation. You
performance responded that giving Vitamin A starts when the infant reaches
• Surveillance, studies and research 6 months and the first dose is”
a. 200,000 “IU”
42. What does herd immunity means? b. 100,000 “IU”
a. Interruption of transmission c. 500,000 “IU”
b. All to be vaccinated d. 10,000 “IU”
c. Selected group for vaccination
d. Shorter incubation An infant aging 6-11 months will be given Vitamin
supplementation of 100, 000 IU and for Preschoolers ages 12-
43. Measles vaccine can be given simultaneously. What is the 83 months 200,000 “IU” will be given.
combined vaccine to be given to children starting at 15
months? 48. As part of CARI program, assessment of the child is your
a. MCG main responsibility. You could ask the following question to the
b. MMR mother except:
c. BCG a. “How old is the child?”
d. BBR b. “IS the child coughing? For how long?”
c. “Did the child have chest indrawing?”
MMR or Measles, Mumps, Rubella is a vaccine furnished in one d. “Did the child have fever? For how long?”
vial and is routinely given in one injection (Sub-Q). It can be
given at 15 months but can also be given as early as 12th The CARI program of the DOH includes the “ASK” and “LOOK,
month. LISTEN” as part of the assessment of the child who has
suspected Pneumonia. Choices A, B and D are included in the
Situation 7: Braguda brought her 5-month old daughter in the “ASK” assessment while Chest indrawings is included in the
nearest RHU because her baby sleeps most of the time, with “LOOK, LISTEN” and should not be asked to the mother.
decreased appetite, has colds and fever for more than a week.
The physician diagnosed pneumonia. 49. A newborn’s failure to pass meconium within 24 hours after
birth may indicate which of the following?
44. Based on this data given by Braguda, you can classify a. Aganglionic Mega colon
Braguda’s daughter to have: b. Celiac disease
a. Pneumonia: cough and colds c. Intussusception
b. Severe pneumonia d. Abdominal wall defect
c. Very severe pneumonia
d. Pneumonia moderate Failure to pass meconium of Newborn during the first 24 hours
of life may indicate Hirschsprung disease or Congenital
For a child aging 2months up to 5 years old can be classified to Aganglionic Megacolon, an anomaly resulting in mechanical
have sever pneumonia when he have any of the following obstruction due to inadequate motility in an intestinal segment.
danger signs: B, C, and D are not associated in the failure to pass meconium
• Not able to drink of the newborn.
• Convulsions
• Abnormally sleepy or difficult to wake 50. The nurse understands that a good snack for a 2 year old
• Stridor in calm child or with a diagnosis of acute asthma would be:
• Severe under-nutrition a. Grapes
b. Apple slices
45. For a 3-month old child to be classified to have Pneumonia c. A glass of milk
(not severe), you would expect to find RR of: d. A glass of cola
a. 60 bpm
b. 40 bpm Correct answer is B, apple slices. Grapes is in appropriate
c. 70 bpm because of its “balat” that can cause choking. A glass of milk is
d. 50 pbm not a good snack because it’s the most common cause of Iron-
deficiency anemia in children (milk contains few iron), A glass
Correct answer is letter D. A child can be classified to have of cola is also not appropriate cause it contains complex sugar.
Pneumonia (not severe) if: (walang kinalaman ang asthma dahil ala naman itong diatery
• the young infant is less than 2 months- 60 bpm or more 15
restricted foods na nasa choices.) consideration when planning ongoing nursing care?
a. Muscle coordination
51. Which of the following immunizations would the nurse b. Sexual maturation
expect to administer to a child who is HIV (+) and severely c. Intellectual development
immunocomromised? d. Body image
a. Varicella
b. Rotavirus Because of edema, associated with nephroitic syndrome,
c. MMR potential self concept and body image disturbance related to
d. IPV changes in appearance and social isolation should be
considered.
IPV or Inactivated polio vaccine does not contain live micro
organisms which can be harmful to an immunocompromised HEY! NARARAMDAMAN KO NA LALABAS ULIT ANG MGA SAKIT
child. Unlike OPV, IPV is administered via IM route. RELATED SA NEW BORN SCREENING KAYA ARALIN NA ITO. I
WILL POST A SIMPLE LECTURE DITO. (LATER…. Kasi tamad
52. When assessing a newborn for developmental dysplasia of ako,,, hehehe)
the hip, the nurse would expect to assess which of the
following/ 57. An inborn error of metabolism that causes premature
a. Symmetrical gluteal folds destruction of RBC?
b. Trendelemburg sign a. G6PD
c. Ortolani’s sign b. Hemocystinuria
d. Characteristic limp c. Phenylketonuria
d. Celiac Disease
Correct answer is Ortolani’s sign; it is the abnormal clicking
sound when the hips are abducted. The sound is produced G6PD is the premature destruction of RBC when the blood is
when the femoral head enters the acetabulum. Letter A is exposed to antioxidants, ASA (ano un? Aspirin), legumes and
wrong because its should be “asymmetrical gluteal fold”. Letter flava beans.
B and C are not applicable for newborns because they are seen
in older children. 58. Which of the following would be a diagnostic test for
Phenylketonuria which uses fresh urine mixed with ferric
53. While assessing a male neonate whose mother desires him chloride?
to be circumcised, the nurse observes that the neonate’s a. Guthrie Test
urinary meatus appears to be located on the ventral surface of b. Phenestix test
the penis. The physician is notified because the nurse would c. Beutler’s test
suspect which of the following? d. Coomb’s test
a. Phimosis
b. Hydrocele Phenestix test is a diagnostic test which uses a fresh urine
c. Epispadias sample (diapers) and mixed with ferric chloride. If positive,
d. Hypospadias there will be a presence of green spots at the diapers. Guthrie
test is another test for PKU and is the one that mostly used.
Hypospadias is a c condition in which the urethral opening is The specimen used is the blood and it tests if CHON is
located below the glans penis or anywhere along the ventral converted to amino acid.
surface of the penile shaft. Epispadias, the urethral meatus is
located at the dorsal surface of the penile shaft. (Para di ka 59. Dietary restriction in a child who has Hemocystenuria will
malilto, I-alphabetesize mo Dorsal, (Above) eh mauuna sa include which of the following amino acid?
Ventral (Below) , Epis mauuna sa Hypo.) a. Lysine
b. Methionine
54. When teaching a group of parents about seat belt use, c. Isolensine tryptophase
when would the nurse state that the child be safely restrained d. Valine
in a regular automobile seatbelt?
a. 30 lb and 30 in Hemocystenuria is the elevated excretion of the amino acid
b. 35 lb and 3 y/o hemocystiene, and there is inability to convert the amino acid
c. 40 lb and 40 in methionine or cystiene. So dietary restriction of this amino
d. 60 lb and 6 y/o acids is advised. This disease can lead to mental retardation.

Basta tandaan ang rule of 4! 4 years old, 40 lbs and 40 in. 60. A milk formula that you can suggest for a child with
Galactosemia:
55. When assessing a newborn with cleft lip, the nurse would a. Lofenalac
be alert which of the following will most likely be compromised? b. Lactum
a. Sucking ability c. Neutramigen
b. Respiratory status d. Sustagen
c. Locomotion
d. GI function Neutramigen is suggested for a child with Galactosemia.
Lofenalac is suggested for a child with PKU. Sustagen is for
Because of the defect, the child will be unable to form the Susy and Geno, Lactum.. lactum.. inom ka ng inom!
mouth adequately arounf the nipple thereby requiring special
devices to allow feeding and sucking gratification. Respiratory
status may be compromised when the child is fed improperly or
during post op period.
REVIEW!
Repair of cleft lip-cheiloplasty-should be done within 1-3
months- to save sucking reflex- position post-op side lying
Repair of cleft palate- Uranoplasty- should be done within 4-6
months-to preserve speech- position post-op is prone.

56. For a child with recurring nephritic syndrome, which of the

following areas of potential disturbances should be a prime 16