RECALLS 3 NP 1

Situation: On 19 September 2019, an outbreak of polio was declared in the Philippines.

Children in the Philippines are at risk of lifelong paralysis because of this outbreak.

1. What is the mode of transmission of poliomyelitis?

a. Blood-borne transmission
b. Fecal- oral route
c. Vector-borne transmission
d. Airborne droplets
2. What is the route of administration of OPV?
a. oral
b. intradermal
c. intramuscular
D. subcutaneous
3. What is the appropriate temperature to store oral polio vaccine?
A. -15 c to -25 c
B. +2 c to +8 c
C. -2 c to -8 c
D. +15 c to +25 c
4. Along with the oral polio vaccine which of the following vaccines is also one of the
most sensitive to heat?
A. DPT/ Hep B
B. BCG
C. Tetanus Toxoid
D. Measles
5. The following are the general principles which apply in vaccinating children. Select
all that apply.
1. It is safe and immunologically effective to administer all EPI vaccines on the same
day at different sites of the body
2. The vaccination schedule should be restarted from the beginning if the interval
between doses exceeds the recommended interval by months or years.
3. Moderate fever, malnutrition, mild respiratory infection, cough, diarrhea, and
vomiting are not contraindications to vaccination.
4. Giving doses of a vaccine at less than the recommended 4-week interval may lessen
the antibody response.
5. Lengthening the interval between doses of vaccines leads to lesser antibody levels
A. 1,2,3
B. 1,3,5
C. 1,2,4
D. 1,3,4

Situation: Community Health Nurse Elsa is providing health teaching to Brgy. Macamot
regarding the Patterns of occurrence and distribution of diseases. The following
questions are discussed.

6. This pertains to the intermittent occurrence of a few isolated and unrelated cases in
a given locality.
A. sporadic
B. epidemic

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C. endemic
D. pandemic
7. ___________ is the continuous occurrence throughout a period of time, of the usual
number of cases in given locality.
A. sporadic
B. epidemic
C. endemic
D. pandemic
8. ___________ is the unusually large number of cases in a relatively short period of
time.
A. sporadic
B. epidemic
C. endemic
D. pandemic
9. _____________ is the simultaneous occurrence of an epidemic of the same disease
in several countries.
A. sporadic
B. epidemic
C. endemic
D. pandemic
10. Rabies is an example of_______________.
A. sporadic
B. epidemic
C. endemic
D. pandemic
SITUATION: Patient Nora arrived at the Seattle Grace Hospital with complaints of
fever, profuse sweating, malaise, and recurrent chills. Upon assessment, she also
reported a recent vacation in Palawan. Nurse Grace suspects Malaria, further
assessment is performed.
11. Patient Nora asked Nurse Grace, what is the vector of Malaria?
A. Oncomelania quadrasi Schistosomiasis
B. Female Anopheles
C. Aedes poecilius Filariasis
D. Aedes aegypti Dengue
12. Upon health teaching, Nurse Grace includes measures for the prevention and
control of the malaria parasite and the mosquito vector. Which of the following should
not be included?
A. Construction of bio-ponds for larvivorous fish propagation.
B. Cutting of vegetation overhanging along stream banks to expose breeding stream to
sunlight.
C. Avoid outdoor night activities, particularly during the vectors' peak biting hours from
9 pm-3 pm.
D. Changing water and scrubbing sides of lower vases once a week.
13. There are various species of plasmodium, among the choices which of the
following is found to be common in the Philippines?
A. P. ovale
B. P. malariae
C. P. vivax
D. P. falciparum
14. Which blood cells are affected by Malaria parasite?
A. Red blood cells

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Matured parasites goes to the bloodstream and infect RBC > multiplies inside >
destruction of RBC > Breakdown within 2-3 days
B. white blood cells
C. platelets
D. all of the above
15. Which of the following is not a clinical manifestation of Malaria?
A. fatigue
B. petechiae
C. pale skin
D. cold extremities

Nurse Sara is a newly employed community health nurse. She is advocating the use of
the ten herbal plants.

16. The herbal plant used to expel round worms ascariasis is ____________.
A. Akapulko
B. ampalaya
C. niyog niyogan
D. tsaang gubat
17. The herbal medicine appropriate for kidney stones is ______________.
A. Sambong
B. tsaang gubat
C. niyog niyogan
D. bayabas
18. “Botika ng Barangay or BnB” refers to a drug outlet to sell, distribute, offer for
sale, and or make available low-priced generic home remedies over the counter drugs.
Which one is not included?
A. Cotrimoxazole
B. amoxicillin
C. metformin
D. aspirin
19. Public Health Nurse Kiara is assigned to pediatric clients in the barangay to
administer medications and vaccines. As a registered nurse she should be
knowledgeable on how to provide the proper administration. When administering
vaccines, the first step Nurse Kiara should do is to?
A. Reconstitute using diluent supplied.
B. Check the content prior to drawing up.
C. Select the proper needle size.
D. Check the vial for the expiration date.
20. After administering the vaccine, which of the following Nurse Kiara should not
include in the documentation?
A. Date
B. lot number
C. Manufacturer
D. Needle Gauge

SITUATION: A recent Nurse licensure examination passer Nurse Kelsey took the
opportunity to work in a rural health unit in the Municipality of Bombon. She reviews
the concepts and principles in Primary health care.

21. The global agency that initiated the alma ata conference on Primary Health is the
________.
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A. World Health Organization (WHO)
B. United Nations Children’s Fund (UNICEF)
C. Department of Health
D. Centers for Disease Control and Prevention (CDC)
22. Which of the following is not included in the four cornerstones/ pillars of Primary
health care?
A. Active community participation
B. Intra and Intersectoral linkages
C. Use of the latest technology. Appropriate
D. Support mechanism made available
23. Nurse Kelsey is correct in enumerating the Village or barangay health workers if
she answers _______.
A. Health auxiliary volunteers, traditional birth attendants, and healers.
B. Health auxiliary volunteers, traditional birth attendants, and midwives.
C. Health auxiliary volunteers, Public Health Nurses, and midwives Intermediate level
health workers
D. Public health Nurses and midwives only.
24. Nurse Kelsey recognizes that health services offered are to be in accordance with
the prevailing beliefs and practices of the intended clients of care. This Primary health
care key principle is known as ________.
A. Availability
B. acceptability
C. affordability
D. accessibility
25. When the hospital reaches out to the Department of Social Welfare and
Development this linkage is an example of __________.
A. Network linkages
B. inter-sectoral linkages
C. intra-sectoral linkages
D. multiple linkages

SITUATION: Patient Mina went to the outpatient department. She reported 3 weeks of
cough, coughing up blood, and fatigue. She also noticed that she lost 6 kilograms
within 1 month, and excessive sweating particularly at night. The doctor ordered
several tests and confirmed the diagnosis of Pulmonary tuberculosis.
26. Patient Mina is concerned about how she acquired pulmonary tuberculosis. How
should Nurse Glenda respond?
A. It is acquired through ingestion of contaminated foods.
B. It is acquired through inhalation of bacteria which travel in droplet nuclei
that become aerosolized.
C. It is acquired through the use of infected needles.
D. It is acquired through a bite of a mosquito carrying the bacteria.
27. Patient Mina is asking, “Why did the doctor order a chest x-ray?”. Nurse Glenda
should answer?
A. To confirm the diagnosis of PTB.
B. To know the extent of the lesion in the lungs.
C. To know which medication the doctor will prescribe.
D. to know if there is an affectation in the heart.

28. Further assessment is performed on Patient Mina, her history revealed that she is
previously treated and is experiencing a relapse. What is her treatment regimen?

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A. 2HRZE/4HR new smear positive & negative (extensive lesion) Category I, new
smear negative (minimal) III
B. 2HRZE/10HR
C. 2HRZES/1HRZE/5HRE Category II
D. 2HRZES/1HRZE/9HRE
29. After weeks of treatment Patient Mina went back to the hospital with the complaint
of numbness, pain, and tingling in the hands and feet. Which drug may have caused
this?
A. Rifampin
B. Isoniazid
C. Pyrazinamide
D. Ethambutol
30. Nurse Grace is now performing health teaching. Which of the following she should
not include?
a. Encourage intake of tuna, aged cheese, red wine, and soy sauce. Tyramine
rich food can lead to HTN crisis.
b. Encourage intake of dark leafy vegetables, banana, and papaya.
c. Encourage adherence to Treatment Regimen.
d. Encourage socialization after 2 to 3 weeks of continuous medication therapy.
31. Which of the following would best indicate a maturational crisis?
a. Illness
b. Death
c. Marriage
d. Unemployment
32. Providing crisis intervention is an important part of _________________.
a. Primary prevention
b. Health promotion
c. Secondary prevention prompt immediate intervention
d. Tertiary prevention
33. Nurse Anne observes that the family is exhibiting strengths in the face of hardships
they are facing. The best description of the strengths Nurse Anne observing
is___________.
a. Power
b. Resilience
c. Projection
d. Faith
34. Nurse Leslie is educating the family regarding the general need for adequate
nutrition, rest, and physical activity. Which level of prevention does this describe?
a. Tertiary prevention
b. Secondary prevention
c. Health maintenance
d. Primary Prevention
35. Nurse Alex is assigned to perform a Home visit to Brgy. Kasinay. Which of the
following is the first step in conducting a home visit?
a. Greet the patient and introduce self
b. State the purpose of the visit
c. Observe the patient and determine the health needs
d. Make an appointment for a return visit
36. As Nurse Alex is performing a home visit to family Lopez, they asked, “How often
are you going to visit us?”. Nurse Alex shouldn't respond:
a. “It will be based on your physical, psychological needs, and educational needs”
b. “It will be based on your acceptance of the services to be rendered”
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c. “It will be based on Nurse’s convenience”
d. “It will be based on the ability of the patient and his family to recognize their needs”
37. Nurse Alex then proceeded to perform the bag technique, which of the following is
a principle of bag technique? (select all that apply)
1. Bag technique minimizes, if not prevents the spread of any infection
2. It saves time and effort in performance of nursing procedures
3. It should show effectiveness of total care given to family
4. It can be performed in a variety of ways depending on agency's policy and home
situation, as long as it avoids transfer of infection is always observed.
a. 1,2,4
b. 1,2,3
c. 1 and 3 only
d. 1,2,3,4

Situation:
Rabies is endemic in the Philippines and remains to be a public health concern.
Community health Nurse Lisa provides health teaching regarding its prevention and
control program.

38. Karen a resident of the community asked Nurse Lisa on the initial symptoms of
rabies. Nurse Lisa is right when she answered:
a. “Karen, the initial symptoms of rabies include cough, body malaise, syncope,
hyperemia and hematemesis”
b. “Karen, the initial symptom of Rabies include fever with pain and unusual
or unexplained tingling, pricking or burning sensation at the wound site”
c. “ Karen, the initial symptom of rabies includes severe fatigue, muscle weakness,
hyperthyroidism and painless wound site
d. “Karen, the initial symptoms of rabies includes burning sensation on wound site,
hemorrhage, hematemesis, hematuria and hematochezia.”
39. Karen continues to ask Nurse Lisa, how can rabies be transmitted?
a. highly contagious virus that lives in the nose and throat mucus of an infected
person. It can spread to others through coughing and sneezing.
b. by being bitten by an infective female Anopheles mosquito.
c. has lymphatic, microscopic worms circulating in the person's blood enter and infect
the mosquito.
d. when infectious material, usually saliva, comes into direct contact with a
victim’s fresh skin lesions
40. The public health nurse is responsible for presenting the municipal health statistics
using graphs and tables. To compare the frequency of the leading causes of mortality
in the municipality, which graph will you prepare?
A. Line Trends
B. Bar
C. Pie Population
D. Scatter diagram Correlation
41. Which step in community organizing involves training of potential leaders in the
community?
A. Integration
B. Community organization
C. Community study
D. Core group formation
42. In which step are plans formulated for solving community problems?
A. Mobilization
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B. Community organization
C. Follow-up/extension
D. Core group formation
43. Isolation of a child with measles belongs to what level of prevention?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
44. Which type of family-nurse contact will provide you with the best opportunity to
observe family dynamics?
A. Clinic consultation
B. Group conferences
C. Home visit
D. Written communication
45. The youngest child of the Reyes family has been diagnosed as mentally retarded.
According to categories of health problem, this is classified as:
A. Health threat
B. Health deficit
C. Foreseeable crisis
D. Salience
46.The Miranda couple have 6-year old child entering school for the first time. The
Miranda family has a:
A. Health threat
B. Health deficit
C. Foreseeable crisis
D. salience
47. Which of the following is an advantage of a home visit?
A. It allows the nurse to provide nursing care to a greater number of people
B. It provides an opportunity to do first hand appraisal of the home
situation
C. It allows sharing of experience among people with similar health problems
D. It develops the family’s initiative in providing for health needs of its members
48. To maintain the cleanliness of the bag and its contents, which of the following
must the nurse do?
A. Wash his/her hands before and after providing nursing care to the family
members
B. In the care of family member’s, as much as possible, use only articles taken from
the bag
C. Put on an apron to protect her uniform and fold it with the right side out before
putting it back into the bag.
D. At the end of the visit, fold the lining on which the bag was placed, ensuring that
the contaminated side is on the outside.
49. Which of the following is an epidemiologic function of the nurse during an
epidemic?
A. Conducting assessment of suspected cases to detect the communicable diseases
B. Monitoring the condition of the cases affected by the communicable disease
C. Participating in the investigation to determine the source of epidemic
D. Teaching the community on preventive measures against the disease
50. What law created the Philippine institute of Traditional and Alternative Health
Care?
A. RA 8423
B. RA 4823
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C. RA 2483
D. RA 3482
51. Which of the following demonstrates inter-sectoral linkages?
A. Two-way referral system
B. Team approach
C. Endorsement done by a midwife to another midwife
D. Cooperation between PHN and public school teacher
52. Which statistic can give the most accurate reflection of the health status of a
community?
A. 1-4 year old age-specific mortality rate
B. Infant mortality rate
C. Swaroop’s index
D. Crude death arate
53. This shows the relationship between a vital event and those persons exposed to
the occurrence of said event.
a. Ratio
b. Rate
c. Crude
d. Specific rate
54. The Field Health Services and information System (FHSIS) is the recording and
reporting system in public health) care in the Philippines. The monthly field health
service activity report is a form used in which of the components of the FHSIS?
A. Tally report
B. Output report
C. Target/client list
D. Individual health record
55. To monitor clients registered in long-term regimens, such as the Multi-Drug
Therapy, which component will be most useful?
A. Tally report
B. Output report
C. Target/client list
D. Individual health record
56. This is the fundamental building block of the Field Health Services and information
System (FHSIS).
A. Tally report
B. Output report
C. Target/client list
D. Individual health record
57. Which of the following women should be considered as special targets for family
planning?
A. Those who have two children or more
B. Those with medical conditions such as anemia
C. Those younger than 20 years and older than 35 years
D. Those who just had a delivery within the past 15 months Birth spacing: 2
years above
58. Freedom of choice in one of the policies of the Family Planning Program of the
Philippines. Which of the following illustrates this principle?
A. Information dissemination about the need for family planning
B. Support of research and development in family planning methods
C. Adequate information for couples regarding the different methods
D. Encouragement of couples to take family planning as a joint responsibility
59. Which immunization produces a permanent scar?
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A. DPT
B. BCG
C. Measles vaccination
D. Hepatitis B vaccination
60. Inadequate intake by the pregnant woman of which vitamin may cause neural
tube defects?
A. Niacin
B. Iron
C. Folic Acid 400 mcg/day
D. Thiamine
61. A 4 week old baby was brought to the health center for his first immunization.
Which can be given to him?
A. DPT1
B. OPV1
C. BCG Not always for first vaccination depending on hospital vaccination
D. Hepatitis B Vaccine
62. You will not give DPT 2 if the mother says that the infant had?
A. Seizures a day after DPT1 > encephalopathy
B. Fever for 3 days after DPT1
C. Abscess formation after DPT1
D. Local tenderness for 3 days after DPT1
63. A 2-month old infant was brought to the health center for immunization. During
assessment, the infant’s temperature registered at 38.1 C. Which is the best course of
action that you will take? Do not give > 38.5
A. Continue with the infants immunization
B. Give paracetamol and wait for his fever to subside
C. Refer the infant to the physician for further assessment
D. Advise the infant’s mother to bring him back for immunization when he is well
64. A pregnant woman had just received her 4th dose of tetanus toxoid. Subsequently,
her baby will have protection against tetanus for how long?
A. 1 year
B. 3 years
C. 10 years
D. Lifetime
65. Using IMCI guidelines, you classify a child as having severe pneumonia. What is
the best management for the child?
A. Prescribe antibiotic
B. Refer him urgently to the hospital
C. Instruct the mother to increase fluid intake
D. Instruct the mother to continue breastfeeding
66. Which of the following signs will indicate that a young child is suffering from
severe pneumonia?
A. Dyspnea
B. Wheezing
C. Fast breathing
D. Chest indrawing
67. A 5-month old infant was brought by his mother to the health center because of
diarrhea occurring 4 to 5 times a day. His skin goes back slowly after a skin pinch and
his eyes are sunken. Using the IMCI guidelines, you will classify this infant in which
category?
A. No signs of dehydration
B. Some dehydration
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C. Severe dehydration
D. hypovolemia
68. Given the situation in no. 67 you as a community health nurse what would be your
intervention based on the IMCI management guidelines?
A. Bring the infant to the nearest facility where IV fluids can be given
B. Supervise the mother in giving 200 to 400 ml of Oresol in 4 hours
C. Give the infant’s mother instructions on home management
D. Keep the infant in your health center for close observation
69. In IMCI, severe conditions generally require urgent referral to a hospital. Which of
the following severe conditions Does not always require urgent referral to hospital?
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease.
70. The pathognomonic sign of measles is Koplik’s spot. You may see Koplik’s spot by
inspecting the:
A. Nasal Mucosa
B. Buccal mucosa
C. Skin on the abdomen
D. Skin on the antecubital surface
71. Among the following diseases, which is transmitted through airborne?
A. Viral conjunctivitis
B. Acute poliomyelitis
C. Diphtheria
D. Measles
72. A 6-year old client was brought to the health center with chief complaint of severe
diarrhea and the passage of “rice water”. The client is most probably suffering from
which condition?
A. Giardiasis
B. Cholera
C. Amebiasis
D. Dysentery
73. A 32 year old man came for consultation at the health center with the chief
complaint of fever for a week. Accompanying symptoms were muscle pains and body
malaise. A week after the start of fever, the client noted yellowish discoloration of his
sclera. History showed that he waded in flood waters about 2 weeks before the onset
of symptoms. Based on this history, which disease condition will you suspect?
A. Hepatitis A
B. Hepatitis B
C. Tetanus
D. Leptospirosis
74. Sigmund Freud's stages of psychosexual development, in chronological order, are:
a. oral, anal, phallic, latent, and genital.
B. oral, anal, latent, phallic, and genital.
C. oral, genital, anal, phallic, and latent.
D. oral, phallic, anal, latent, and genital.
75. The ____________ acts immediately in an impulsive, irrational way and pays no
attention to the consequences of its actions; therefore, often behaves in ways harmful
to self and others
A. Id
B. ego
C. superego
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D. conscience
76. The ___________ functions include reality testing and problem solving and follows
the Reality Principle
A Id
B. ego
C. superego
D. conscience
77. The ____________ includes internalization of the values, ideals, and moral
standards of parents and society.
A. Id
B. ego
C. superego
D. conscience
78. The clinic nurse is preparing to explain the concepts of Kohlberg’s theory of moral
development with a parent. The nurse should tell the parent that which factor
motivates good and bad actions for the child at the preconventional level?
a. Peer pressure
b. Social pressure
c. Parents’ behavior
d. Punishment and reward
79. A client with a diagnosis of depression who has attempted suicide says to the
nurse, “I should have died. I’ve always been a failure. Nothing ever goes right for me.”
Which response by the nurse demonstrates therapeutic communication?
a. “You have everything to live for.”
b. “Why do you see yourself as a failure?”
c. “Feeling like this is all part of being depressed.”
d. “You’ve been feeling like a failure for a while?”
80. The nurse visits a client at home. The client states, “I haven’t slept at all the last
couple of nights.” Which response by the nurse demonstrates therapeutic
communication?
a. “I see.”
b. “Really?”
c. “You’re having difficulty sleeping?”
d. “Sometimes I have trouble sleeping too.”
81. A client diagnosed with terminal cancer says to the nurse, “I’m going to die, and I
wish my family would stop hoping for a cure! I get so angry when they carry on like
this. After all, I’m the one who’s dying.” Which response by the nurse is therapeutic?
a. “Have you shared your feelings with your family?”
b. “I think we should talk more about your anger with your family.”
c. “You’re feeling angry that your family continues to hope for you to be
cured?”
d. “You are probably very depressed, which is understandable with such a diagnosis.”
82. The nurse employed in a mental health clinic is greeted by a neighbor in a local
grocery store. The neighbor says to the nurse, “How is Carol doing? She is my best
friend and is seen at your clinic every week.” Which is the most appropriate nursing
response?
a. “I cannot discuss any client situation with you.”
b. “If you want to know about Carol, you need to ask her yourself.”
c. “Only because you’re worried about a friend, I’ll tell you that she is improving.”
d. “Being her friend, you know she is having a difficult time and deserves her privacy.”
83. A client says to the nurse, “The federal guards were sent to kill me.” Which is the
best response by the nurse to the client’s concern?
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a. “I don’t believe this is true.”
b. “The guards are not out to kill you.”
c. “Do you feel afraid that people are trying to hurt you?”
d. “What makes you think the guards were sent to hurt you?”
84. A client is unwilling to go to his church because his ex-girlfriend goes there and he
feels that she will laugh at him if she sees him. Because of this hypersensitivity to a
reaction from her, the client remains homebound. The home care nurse develops a
plan of care that addresses which personality disorder?
A. Avoidant
B. Borderline
C. Schizotypal
D. Obsessive-compulsive
85. The nurse is developing a teaching plan for a client with glaucoma. Which
instruction should the nurse include in the plan of care?
a. Avoid overuse of the eyes.
b. Decrease the amount of salt in the diet.
c. Eye medications will need to be administered for life.
d. Decrease fluid intake to control the intraocular pressure.
86.The nurse is performing an admission assessment on a client with a diagnosis of
detached retina. Which sign or symptom is associated with this eye problem?
a. Total loss of vision
b. Pain in the affected eye
c. A yellow discoloration of the sclera
d. A sense of a curtain falling across the field of vision
87. A client is diagnosed with a problem involving the inner ear. Which is the most
common client complaint associated with a problem involving this part of the ear?
a. Pruritus
b. Tinnitus
c. Hearing loss Middle ear
d. Burning in the ear

Situation: Nursing theories play a vital role in the evolution of nursing as a discipline.
They not only establish the critical contributions made by the profession, but also
provide nurses with frameworks to guide their practice, grow professionally, and
improve the care they deliver to patients. First year student Nurse Angela is assigned
to make a report about Nursing theorists.

88. The four major concepts in nursing theory are the:

A. Person, Environment, Nurse, Health
B. Nurse, Person, Environment, Cure
C. Promotive, Preventive, Curative, Rehabilitative
D. Person, Environment, Nursing, Health
89. The act of utilizing the environment of the patient to assist him in his recovery is
theorized by:
A. Nightingale
B. Benner
C. henderson
D. Levin
90. She believe the unique function of the nurse is to assist the individual, sick or well,
in the performance of those activities contributing to health that he would perform
unaided if he has the necessary strength, will and knowledge, and do this in such a
way as to help him gain independence as rapidly as possible.
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A. Henderson
B. Abdellah
C. Nightingale
D. Peplau
91. Nurse Sabrina is planning a seminar on leadership styles. Which of the following
statements describes a democratic leadership style?
a. The leader assumes a “hands-off" approach.
b. Under this leadership style, the group may feel secure because procedures are well
defined and activities are predictable.
c. This leadership style demands that the leader have faith in the group
members to accomplish the goals.
d. This leadership style does not trust self or others to make decisions and instead
relies rules, policies, and procedures to direct the group’s work efforts on the
organization's rules, policies, and procedures to direct the group’s work efforts
92. A Chief nurse who fosters creativity, risk taking, commitment, and collaboration by
empowering the group to share in the organization’s vision is which type of leader?
a. Charismatic
b. Transactional
c. Transformational
d. Shared
93. The head nurse who has the ability and willingness to assume responsibility for
one’s actions and to accept the consequences of one’s behavior is demonstrating what
management principle?
a. Accountability
b. Authority
c. Responsibility
d. Coordinating

Situation: Nurse Danielle is planning a seminar on wellness care and promoting fluid
and electrolyte balance.

94. All except one action is appropriate for Nurse Danielle who is starting an
intravenous (IV) infusion? Nurse Danielle:
a. Adjusts the IV pole so that the solution container is suspended about 1 m (3 ft)
above the client’s head.
b. Completely fills the drip chamber with solution.
c. Uses the client’s nondominant arm, unless contraindicated.
d. Cleans the skin at the site of entry with a topical antiseptic swab
95. As nurse Danielle is doing her rounds one patient caught her attention. The patient
has complaints of discomfort in her IV site as nurse Danielle assess the patient she
found out it has localized swelling, coolness, and pallor. The patient is experiencing:
A. Extravasation
B. phlebitis
C. infiltration
D. hypersensitivity reaction
96. A client complains of a headache 10 minutes after the transfusion of a unit of
packed red blood cells was initiated. The nurse assesses that the client has slight
shortness of breath and feels warm to the touch. What action by the nurse is priority?
a. Notify the client’s physician.
b. Discontinue the transfusion.
c. Slow the rate of the transfusion.
d. Prepare to resuscitate the client.
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97. A client was discharged after having a 1 day surgery on her gallbladder. The
registered nurse discharging the client failed to give the client oral or written discharge
instructions. This failure to carry out the provision of discharge instructions could result
in charges of:
a. malpractice.
b. negligence.
c. assault.
d. battery.
98. A nurse threatens to give a loud, disruptive client an injection that will “knock the
client out.” The nurse follows through on the threat and gives the injection Without the
client’s consent. What has the nurse committed?
a. Threat, assault
b. Battery, invasion of privacy
c. Assault, invasion of privacy
d. Assault, battery
99. Nurse Richard is taking care of an adult client when he throws a temper tantrum
because he does not get his own way. Which defense mechanism is the adult client
displaying?
a. Repression
b. Regression
c. Reaction formation
d. Rationalization
100. A client comes into the clinic with tremors and pitch changes in her voice. She
also has facial twitches and shakiness. Her respiratory and heart rates are slightly
elevated. At the end of her assessment she tells you, “I feel like I have butterflies in
my stomach.” Which level of anxiety is this client experiencing?
a. Mild
b. Moderate
c. Severe
d. Panic

14
RECALLS 3 NP 2

SITUATION: Caroll is a part-time model who has come to your clinic for her first
prenatal visit. She has a 3-year-old at home. She tells you she missed her period 4
weeks ago and immediately took a home pregnancy test. She’s happy it was positive
but also sad because she had to turn down a modeling assignment in Paris for the
summer.

1. Among the listed signs and symptoms reported by Caroll, which of the following are
the probable signs of pregnancy?
1.​ General feeling of tiredness
2.​ Softening of the cervix
3.​ Uterus can be palpated over the symphysis pubis
4.​ A venipuncture of blood serum reveals the presence of human chorionic
gonadotropin hormone
5.​ Fetal movement felt by the examiner
6.​ Sonographic evidence of gestational sac
A. 2,3,4
B. 2,4,6
C. 2,4,5
D. 2,3,5
2. Patient Anna arrived at the Outpatient department she suspects that she is
pregnant. The nurse read in the patient chart that the lower uterine segment is soft.
As a knowledgeable registered nurse, you know that this is called:
A. Ballottement
B. Hegar’s Sign
C. Goodell’s Sign
D. Chadwick’s Sign
3. During a prenatal visit a patient tells you her last menstrual period was August 13,
2023. Based on the Naegele's Rule, when is the estimated due date of her baby?
A. May 22, 2023
B. April 2. 2024
C. May 2, 2024
D. May 20, 2024
4. During a prenatal visit a patient tells you her last menstrual period was January 29,
2024. Based on the Naegele's Rule, when is the estimated due date of her baby?
A. November 5, 2024
B. October 24, 2024
C. November 3, 2024
D. October 21, 2024
5. During a prenatal visit a patient tells you her last menstrual period was August 25,
2023. Based on the Naegele's Rule, when is the estimated due date of her baby?
A. July 1, 2024
B. May 31, 2024
C. June 1, 2024
D. June 28, 2024

SITUATION: Nurse Carla is caring to a primigravida woman who is about to give birth.
6. Which phases are included in the first stage of labor, and in what order?
A. Transition, Latent, Active
B. Active, Latent, Transition

15
C. Active, Transition, Latent
D. Latent, Active, Transition
7. What statement is not true about the transition phase of 1st stage of labor?
A. The mother may experience intense pain, irritation, nausea, and deep
concentration.
B. The transition phase is the longest phase of stage 1 and contractions are
very intense and long in duration.
C. The cervix will dilate from 8 to 10 cm.
D. The transition phase ends and progresses to stage 2 of labor when the cervix has
dilated to 10 cm.
8. Patient Kim has transitioned to stage 2 of labor. What changes in the perineum
indicate the birth of the baby is imminent?
A. Increase in meconium-stained fluid and retracting perineum
B. Retracting perineum and anus
C. Rapid and intense contractions
D. Bulging perineum and rectum
9. After birth, where do you expect to assess fundal height?
A. At the xiphoid process
B. 5 cm below the umbilicus
C. 2 cm above the pubic symphysis
D. At or near the umbilicus
10. During stage 3 of labor, you note a gush of blood and that the uterus changes
shape from an oval shape to globular shape. This indicates?
A. Postpartum hemorrhage
B. Imminent delivery of the baby
C. Signs of placental separation
D. Answers B and C
11. Nurse Klara is performing an assessment on a newborn. Which of the following
assessment findings should the nurse report to the healthcare provider?
a. Caput succedaneum
b. Mongolian spot
c. Yellow sclera
d. Vernix caseosa
12. A newborn’s APGAR score at 1 minute is 8. Which of the following is the most
appropriate action by the nurse?
a. Provide positive pressure ventilation
b. Initiate chest compression
c. Place the newborn in the radiant warmer and continue routine care.
d. Administer oxygen via face mask
13. A nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On
admission assessment, which data would the nurse expect to obtain when asking the
mother about the child’s symptoms?
a. Vomiting large amounts of bile
b. Watery diarrhea
c. Increased urine output
d. Projectile vomiting
14. A 3-year-old child is hospitalized because of persistent vomiting. A nurse monitors
the child closely for:
a. Diarrhea
b. metabolic acidosis
c. Metabolic alkalosis
d. Hyperactive bowel sounds
16
15. A nurse provides home care instructions to the parents of a child with celiac
disease. The nurse teaches the parents to include which of the following food items in
the child’s diet?
a. Rice
b. Rye toast
c. Oatmeal
d. Wheat bread
16. The nurse in the practice of her profession is guided by:
a. Code of Ethics
b. Standards of care
c. Code of nursing
d. Standards of care for nurses
17. The PRC-BON in its resolution no. 220 series of 2004 promulgated the code of
ethics for registered nurses on:
a. July 14, 2004
b. October 23, 2003
c. October 21, 2002
d. July 27, 1986
18. Code of ethics important articles include which of the following? (Select all that
apply)
1. Registered nurses and people
2. Registered nurses and practice
3. Registered nurses and Nursing Education
4. Registered nurses and co-workers
5. Registered nurses, society, and environment
6. Registered nurses and the profession
a. 1,2,4,5,6
b. 1,2,3,5,6
c. 2,3,4,5,6
d. 2,3,5
19. Code of ethics was consulted with the______________.
a. Philippine Nurses Association
b. Commission on higher Education
c. Professional Regulation Commission
d. Board of Nursing
20. A patient is admitted for a medical procedure that goes against the nurse’s
personal views. Despite the objections to the procedure, the nurse provides a high
level of care. When this nurse made the decision to provide care based on what is
right and wrong or good or bad, and to understand it related to the client, the decision
was granted from which of the following?
a. Laws
b. Torts
c. Ethics
d. Breach of duty
21. Nurse Pat is observing fetal heart rate (FHR) accelerations in a nonstress test
(NST) for Patient Mae who is 26 weeks pregnant. The average FHR baseline is 145 to
155 beats per minute (bpm). Within 20 minutes, the FHR accelerated to 165 bpm six
times, for 10 to 15 seconds. How should you interpret this information?
a. Results are nonreassuring, and another 20 minutes of monitoring is needed.
b. Results are nonreassuring because of too few accelerations within the time period.
c. Results are reassuring because the FHR accelerated by 10 bpm for 10
seconds.
17
d. Results are reassuring because the fetus was inactive during the monitoring.
22. Nurse Kallie knows that the abbreviation LOA means that the fetal occiput is:
a. On the examiner’s left and in the front of the pelvis.
b. In the left front part of the mother’s pelvis.
c. Anterior to the fetal breech.
d. Lower than the fetal breech.
23. Celeste a first-time mother did not recognize for over an hour that she was in
labor. A sign of true labor is:
a. Sudden increased energy from epinephrine release.
b. “Nagging” but constant pain in the lower back.
c. Urinary urgency from increased bladder pressure.
d. “Show” or release of the cervical mucus plug.
24. When performing Leopold’s maneuvers, Nurse Mara palpates a hard round object
in the uterine fundus. A smooth rounded surface is on the mother’s right side, and
irregular movable parts are felt on her left side. An irregularly shaped fetal part is felt
in the suprapubic area and is easily moved upward. How should these findings be
interpreted?
a. The fetal presentation is cephalic, position is ROA, and the presenting part is
engaged.
b. The fetal presentation is cephalic, position is LOP, and the presenting part is not
engaged.
c. The fetal presentation is breech, position is RST, and the presenting part is engaged.
d. The fetal presentation is breech, position is RSA, and the presenting part
is not engaged.
25. A student nurse approached you, she asked you which drug class causes newborn
babies with total absence of extremities. You as a knowledgeable nurse would answer:
a. Antiemetic
b. Antibiotic
c. Antiviral
d. Antihypertensive
26. The rubella vaccine has been prescribed for a new mother. Which statement
should the nurse make when providing information about the vaccine to the client?
a. “You should avoid sexual intercourse for 2 weeks after administration of the
vaccine.”
b. “You should not become pregnant for 2-3 months after administration of
the vaccine.”
c. “You should avoid heat and extreme temperature changes for 1 week after
administration of the vaccine”
d. “You must sign an informed consent because anaphylactic reactions can occur with
the administration of this vaccine.”
27. Nurse Leni is preparing a plan of care for client Lisa with pre-eclampsia and
documents that if client Lisa progresses from preeclampsia to eclampsia, nurse Leni
should take which first action?
a. Administer oxygen by face mask.
b. Clear and maintain an open airway
c. Administer magnesium sulfate intravenously
d. Assess the blood pressure and fetal heart rate
28. Nurse Bailey is caring for a client who is receiving oxytocin for induction of labor
and notes a nonreassuring fetal heart rate pattern on the fetal monitor. Based on this
finding, nurse Bailey should take which action first?
a. Stop the oxytocin infusion
b. Administer oxygen via face mask
18
c. Report to physician
d. Place the client in a side-lying position
29. Patient Marie is in labor and is at risk for abruptio placenta. Which of the following
assessments would most convince Nurse Jennie and Patient Marie to believe that this
has happened?
a. Painless vaginal bleeding and a downward trend in blood pressure
b. An increase in blood pressure and scanty urination
c. Pain at the lower quadrant and increased pulse rate.
d. Sharp fundal pain and discomfort between contractions.
30. Patient Sally is helped with ambulation for the first time, she mentioned that she
had a heavy lochial discharge. Which of the following assessment findings would best
help the nurse decide that the flow is expected?
a. Her flow is over 500ml
b. The color of the flow is red
c. Her uterus is soft and boggy
d. The flow contains large clots
31. Which of the following are present in pregnancy-induced hypertension?
a. Hypertension, proteinuria, and edema.
b. Hypertension, gestational diabetes, and edema.
c. Hypertension, seizure, and proteinuria.
d. Proteinuria, edema, and seizure.
32. Regarding the fontanelles, which of the following is true?
a. The anterior fontanelle closes at 2 months
b. The posterior fontanelles closes between 6 and 18 months
c. The posterior fontanelle closes at 2 months
d. Both fontanelles close at 2 months
33. Which of the following signs would alert the nurse to administer calcium
gluconate?
a. Urine output of 30ml/hr
b. Respiratory rate of 35 cpm
c. Blood pressure of 130/80 mmHg
d. Absent of patellar reflexes
34. When should an infant's startle reflex generally go away?
a. 10 months
b. 12 months
c. 5 months
d. 8 months
35. Which of the following observations about a boy who was born 24 hours ago
requires a pediatric referral?
a. Yellowing of the skin
b. Irregular respiration
c. Audible bowel sounds
d. Pseudomenstruation
36. A term baby was recently born to a primiparous woman. The nurse’s top priority
for instruction include knowledge of:
a. Sudden infant syndrome
b. Breastfeeding
c. Infant bathing
d. Infant-sleep wake cycle

SITUATION: A neonate is born by primary cesarean section at 36 weeks gestation. The

temperature in the birthing room is 21 degree celsius.
19
37. To prevent heat loss from convection, which action should Nurse Calvin do?
a. Dry the neonate quickly
b. Keep the neonate away from air conditioning vents
c. Pre-warm the bed
d. None of the above
38. Nurse Calvin is exploring other options, which of the following method will prevent
heat loss from evaporation?
a. Dry the neonate quickly
b. Keep the neonate away from airconditioning vents
c. Pre-warm the bed
d. None of the above
39. Nurse Calvin want to try a method that will prevent heat loss from conduction,
which action he will choose?
a. Dry the neonate quickly
b. Keep the neonate away from airconditioning vents
c. Pre-warm the bed
d. None of the above
40. The nurse is assisting a new mother in helping her child's sensory system develop.
In order to enhance the baby's most developed sense even further, the nurse ought to
advise the mother to?
a. Speak in high-pitched voice to get the newborn’s attention
b. Place the newborn about 14 inches from maternal face for best sight
c. Stroke the newborn’s cheek with her nipple to direct the baby’s mouth to
nipple
d. Give infants formula with a sweetened taste to stimulate feeding
41. Nurse Alex teaches the mother on the introduction of solid foods to her baby.
Which of these lists best describes the order in which to introduce solid foods?
a. Vegetable, fruit,cereal, meat, fish
b. Fruit, meat, cereal, vegetable, fish
c. Cereal, vegetable, fruit, meat, fish
d. Cereal, meat, fruit, vegetable, fish
42. Mavi, age one, is evaluated by the clinic nurse. Her results include a 21-pound
weight. Understanding normal growth of children, the nurse is likely correct to assume
that Mavi's birth weight is which of these?
a. 7 lb
b. 5 lb
c. 6 ½ lb
d. 8 lb
43. At which age can weaning of infants from breast to feeding bottle be started?
a. 8-9 months
b. 6-7 months
c. 9-10 months
d. 10-12 months
44. Which of the following conditions in infant that is characterized by extreme calorie
deficiency?
a. Marasmus
b. Scurvy Vitamin C
c. Kwashiorkor Protein deficiency
d. Avitaminosis Essential Vitamins
45. Approximate 1 hour and 30 minutes after birth, Nurse Kai should encourage the
mother of a term neonate to do which of the following?
a. Breastfeed the neonate
20
b. Allow the neonate to sleep
c. Change the neonate’s diaper
d. Skin-to-skin contact
46. A health baby was born and in stable condition. In addition to thoroughly drying,
what is the preferred method to prevent heat loss?
a. Placing the infant in a radiant warmer
b. Wrapping the infant in blanket
c. Applying knit hats and mittens
d. Placing the infant skin-to-skin on mother.
47. Nurse Bailey is assigned in Neonatal Intensive Care Unit she is preparing to assess
the respirations of a newborn. Nurse Bailey performs the procedure and determine
that the normal respiratory rate for an infant is:
a. Respiratory rate of 20 cpm
b. Respiratory rate of 40 cpm
c. Respiratory rate of 90 cpm
d. Respiratory rate of 100 cpm
48. Nurse Pat is assessing an infant. She palpates the anterior fontanelle and notes
that it feels soft. She determines that this finding indicates:
a. Normal finding
b. Increased intracranial pressure
c. dehydration
d. Decreased intracranial pressure
49. It is the bluish milk that is produced early during the breastfeeding
a. Hind milk
b. Fore milk
c. Mature milk
d. Transitional milk
50. Which of the following are true about colostrum?
1. a thin, watery, yellow fluid composed of protein, sugar, fat, water, minerals,
vitamins, and maternal antibodies.
2. secreted by the acinar breast cells starting in the fourth month of pregnancy.
3. easy to digest and capable of providing adequate nutrition
a. 1 and 3 are correct
b. 1 and 2 are correct
c. 2 and 3 are correct
d. All are correct
51. Which of the following least describes how you would respond if the mother had
questioned the nurse why her 7-day-old baby had lost weight?
a. Decrease maternal hormones
b. Passage of urine and stools
c. Inadequate oral intake
d. Presence of sepsis
52. At which month is the infant will be able to Says first word like “da-da”?
a. 8-9 months
b. 4-5 months
c. 12-15 months
d. 12-12 months
53. A 2 month old infant is being assessed by Nurse Lexi for developmental
milestones. What is advance to the infant’s age?
a. Closed posterior fontanelle
b. Holds head up when prone
c. Exhibit social smile
21
d. Uses palmar grasp
54. You are caring for a newborn of an RH negative mother. You determine that the
newborn may be at risk for which of the following conditions?
a. Hemolytic anemia
b. Sepsis
c. Petechiae
d. Cardiac abnormalities
55. Nurse Carmella is caring for a macrosomic baby. She monitors the blood glucose to
detect hypoglycemia as the result of:
a. Limited glycogen stores
b. Hyperinsulinemia
c. Large body surface to weight ratio
d. Excessive brown fat stores
56. Which of the following is the priority of nurse Carmella to monitor in an infant born
to another who has a diabetes mellitus?
a. Hypoglycemia
b. Hyperglycemia
c. Rh sensitization
d. Respiratory distress
57. When using otoscope to examine the ears of a 24 months old child, you should:
a. Pull pinna up and back
b. Pull pinna down and back
c. Gently and firmly hold the pinna in its normal position
d. Pull the pinna forward and up
58. Which of the following approaches by Nurse Denise towards the physical
examination of the toddler is best?
a. Complete the procedure while the toddler is in the parent’s lap
b. Ask the parent to leave the room before the procedure
c. Never perform complete physical examination, only the complaints of parents
d. Begin with the rectal temperature then assess the heart rate.
59. Infants with not complicated ventricular septal defect are not usually cyanotic due
to this type of anomaly:
a. Pressure in the right side is greater than the pressure on the left side
b. The left ventricle enlarges to accommodate an increase in blood volume
c. Pressure is decreased in an abnormally dilated pulmonary artery
d. Blood is shunted from the left to the right ventricle
60. A hemophilic toddler fell on his left arm while playing. There is no overt bleeding
but the part is observed to be swelling. The most appropriate action at this time would
be:
a. Apply warm moist compress
b. Apply pressure at least 5 minutes
c. Begin passive range of motion exercises unless pain is severe
d. Elevate the area above the level of the heart
61. It is the practice of placing the newborn in the same room as the mother right
after delivery up to discharge to facilitate mother-infant bonding to initiate
breastfeeding.
a. Unang yakap
b. Skin-to-skin contact
c. Rooming-in
d. Breastfeeding act
62. Which of the following does not support exclusive breastfeeding?
a. Baby given a pacifier
22
b. Baby given any drinks other than breastmilk
c. Baby given any food other than breastmilk
d. All of the above
63. All statements are breastfeeding recommendations, except?
a. Give supplementary vitamins and minerals starting at 3 months
b. No time limit during one feeding
c. Continue breastfeeding up to 2 years of age or beyond
d. Give complementary foods to all children from 6 months of age
64. Which of the following statements should be taught by Nurse Meredith to her
patient regarding breastfeeding?
1. Breastfeed babies have less diarrhea, less gastrointestinal and respiratory
infections than artificially fed babies
2. There is less illness requiring health care among exclusively breastfed babies.
3. Exclusive breastfeeding provides the best infant nutrition and growth
4. Each mother’s milk has antibodies to protect her baby against disease to which
she has been exposed.
a. A and B are correct; C and D are incorrect
b. A, b, d are correct; c is incorrect
c. A and c are correct; b and d are incorrect
d. All are correct
65. A mother of a term neonate asks the nurse, “What is the thick, white, cheesy
coating on his skin?” Which correctly describes this finding?
a. Lanugo
b. Milia
c. Nevus flammeus
d. Vernix caseosa
66. Nurse Cristina is a new board passer. When teaching umbilical cord care to a new
mother, Nurse Cristina would include which information?
a. Apply hydrogen peroxide to the cord each diaper change.
b. Cover the cord with petroleum jelly after bathe
c. Cleanse the cord with betadine twice each day
d. Keep the cord dry and open to air
67. For a term newborn, the best time to initiate breastfeeding is:
a. After bath
b. 3-4 hours after delivery
c. 24 hours after delivery
d. Immediately after birth
68. Which of the following findings in a 3-hour-old full-term neonate would the nurse
record as an abnormal finding when assessing the head?
a. Two soft spots between the cranial bones
b. Head circumference of 32 cm and chest circumference of 34
c. Asymmetry of the head with overriding bones
d. All of the above
69. Nurse Trixie is assessing a neonate’s primitive reflexes. When the tonic neck reflex
is elicited, Nurse Trixie should expect:
a. Head turned to one side then arms and legs extend on that side, opposite
leg flexes.
b. Baby’s mouth is stroked then baby opens their mouth
c. The bottom of the foot is stroked then the big toe bends back and the other toes
fan out
d. When a sudden loud noise or movement the baby’s arms extend and palms up

23
70. Nurse Thomas documents which of the following reflexes is responsible for an
infant uncurling and fanning out of the toes when the lateral plantar surface is stroked.
a. Moro Reflex
b. Rooting reflex
c. Babinski reflex
d. Startle reflex
71. When assessing a neonate, Nurse Clay notes that one side of his body has a deep
pink color and the other side appears pale. This condition is known as:
a. Jaundice
b. Acrocyanosis
c. Harlequin sign
d. Erythema toxicum
72. Nurse Janice is performing phototherapy on a neonate. To meet safety needs while
performing phototherapy, nurse Janice would do:
a. Limit breastfeed
b. Cover the neonate’s eye while he is under the light
c. Keep him clothed to prevent skin burns
d. Make sure the light is not closer than 10 inches
73. When is the appearance of neonatal jaundice of greatest concern?
a. When the mother breastfeeds exclusively
b. If the neonate refuses to take water from the bottle
c. In the first 24 hours of life
d. When a family history of jaundice
74. Milk ejection reflex is influenced by which of the following hormone:
a. Prolactin
b. Oxytocin
c. Progesterone
d. Estrogen
75. It is the antibody to appear in response to allergies:
a. IgG
b. IgA
c. IgM
d. IgE
76. In newborns, positive Babinski reflex is:
a. Fanning of toes
b. Withdrawing of foot from stimuli
c. Dorsiflexion hand
d. Indicates a neurological deficit
77. Nurse Camilla is assessing the reflexes of a newborn. Nurse Camilla assesses which
of the following reflexes by placing a finger in the newborn’s mouth?
a. Moro reflex
b. Sucking reflex
c. Rooting reflex
d. Babinski reflex
78. When a newborn is placed on a cold crib or wrapped in a cold blanket, cold stress
may occur due to heat loss by:
a. Convection
b. Conduction
c. Radiation
d. Evaporation
79. The first teeth to erupt in infancy are:
a. Upper central incisor
24
b. Lower central incisor
c. Lower cuspids
d. Lateral incisor
80. A Mother asked Nurse Belle, “When will my baby have her first tooth?”. Nurse Belle
should respond:
a. 6 months
b. 12 months
c. 9 month
d. 3 months
81. Nurse Belinda explained to a mother of a 10-year-old that according to Erikson’s
Psychosocial Theory play as a vehicle of development can help her child to develop:
a. Initiative
b. Industry
c. Identity
d. Intimacy
82. A 16-year-old patient has just undergone an open appendectomy and has a
dressing over the surgical site. Which of the following will the patient most likely to
ask?
a. “When can I return to school?”
b. “What are the complications of an open appendectomy?”
c. “Will I have a large scar?”
d. “When can I go out?”
83. An 18-year-old patient arrived at the outpatient department with a complaint of
fatigue. Nurse Celestine assesses the skin color as pallor and cold hands and feet.
Which of the following data may explain these findings?
a. Cerebrospinal fluid with elevated white cells
b. Hemoglobin of 6g/dl
c. Platelet count of 250,000/mm3
d. Sodium level of 140mg/dl
84. In normal term infants, there is no need to provide iron supplementation:
a. Until 6 months of age
b. When the mother feeds the infant with iron-fortified formula
c. When an infant is breastfeeding by the mother
d. Until 1 year of age
85. The losing of heat to the surrounding air by the newborn is:
a. Convection
b. Conduction
c. Airborne
d. Evaporation
86. The best site for Vitamin K administration is:
a. Vastus lateralis, Subcutaneous
b. Vastus lateralis, Intramuscular
c. Oral Route
d. Medial thigh, intramuscular
87. After Nurse Kelsey explains to the mother of a male neonate scheduled to receive
an injection of Vitamin K after birth. Which of the following statements does not need
further teaching?
a. “My baby doesn't have enough have the normal bacteria in his intestines
to produce vitamin K.”
b. “My baby is at high risk for a problem involving his blood’s ability to clot.”
c. “The red blood cells my baby formed during pregnancy are destroying the vitamin
K.”
25
d. “My baby’s liver is not able to produce enough of this vitamin so soon after birth.”
88. When performing a newborn assessment, the nurse should measure the vital signs
in the following sequence:
a. Pulse, respirations, temperature
b. Temperature, pulse, respirations
c. Respirations, temperature, pulse
d. Pulse, respirations, temperature
89. All of the following are important in the immediate care of the premature neonate.
Which activity should have the greatest priority?
a. Instillation of antibiotics in the eyes
b. Identification by bracelet and footprints
c. Placement in a warm environment
d. Neurological assessment to determine gestational age
90. A nurse in the delivery room is assisting with the delivery of a newborn infant.
After the delivery, the nurse prepares to prevent heat loss in the newborn resulting
from evaporation by:
a. Warming the crib pad
b. Turning on the overhead radiant warmer
c. Closing the doors to the room
d. Thoroughly drying the infant with a towel
91. Which of the following milestones would you expect an infant to accomplish by 8
months of age?
a. Sit without support
b. Pull self into a standing position
c. Creep on all fours
d. Reaches out in anticipation of being picked up
92. A newborn with a tracheoesophageal fistula is waiting to be transferred to a
neonatal intensive care unit. The Nurse’s priority intervention is:
a. Providing psychological support to parents
b. Prevention of aspiration
c. Allowing parents to bond before admission to the neonatal intensive care unit
d. Provide sensory stimulation by talking to the baby
93. What laboratory tests are expected to be ordered when a pregnant woman is
suspected of having HELLP Syndrome?
A. CBC, liver enzymes, liver biopsy
B. CBC, Liver Enzymes, and platelet count
C. ABO typing and CBC
D. ABO Typing and RH factor

Situation: Nurse Cindy is performing a health teaching to barangay masagana

regarding the menstrual cycle.

94. __________ is responsible for the regeneration of the new inner lining of the
uterus.
a. Estrogen
b. Progesterone
c. Luteinizing hormone
d. Follicle-stimulating hormone
95. ___________ is responsible for maintaining the lining of the uterus.
a. Estrogen
b. Progesterone
c. Luteinizing hormone
26
d. Follicle-stimulating hormone
96. Passage of a fetus through the birth canal involves several different position
changes to keep the smallest diameter of the fetal head always presenting to the
smallest diameter of the pelvis. These position changes are termed the cardinal
movements of labor, the proper order is:
a. engagement, descent, flexion, external rotation, extension, internal rotation, and
expulsion
b. engagement, descent, flexion, extension, internal rotation, external rotation, and
expulsion
c. engagement, descent, internal rotation, extension, flexion, external rotation, and
expulsion
d. engagement, descent, flexion, internal rotation, extension, external
rotation, and expulsion
97. Baby Mel has surfactant administered at birth. The purpose of surfactant is to:
a. Help raise lung secretions by relaxing the airway.
b. Prevent alveoli from collapsing on expiration.
c. Paralyze respiratory muscles to synchronize breathing.
d. Reduce gastric secretions by action on the pancreas.
98. Breast self-examination is best performed:
a. A week after menses
b. Two weeks after menses
c. A week before menses
d. A day after menses
99. A patient arrived at the ER with complaints of bleeding and cramping. Upon
assessment, the patient is 16 weeks pregnant her cervical os is open. This type of
abortion is called:
a. Inevitable
b. Threatened
c. Incomplete
d. complete
100. Nurse Sheena is assessing a 16-week pregnant woman who has complaints of
bleeding and cramping the patient also verbalized fear of abortion. Upon assessment,
the cervical os is still closed. This type of abortion is called:
a. Inevitable
b. Threatened
c. Incomplete
d. Complete

27
RECALLS 3 NP 3

SITUATION:Patient Elena arrives at the clinic with the chief complaint of vomiting,
Nurse Arra is the assigned nurse.
1. What physiologically occurs with vomiting?
a. The acid-base imbalance most commonly associated with persistent vomiting is
metabolic acidosis caused by loss of bicarbonate.
b. Stimulation of the vomiting center by the chemoreceptor trigger zone (CTZ) is
commonly caused by stretch and distention of hollow organs.
c. Vomiting requires the coordination of activities of structures including the glottis,
respiratory expiration, relaxation of the pylorus, and closure of the lower esophageal
sphincter.
d. Immediately before the act of vomiting, activation of the
parasympathetic nervous system causes increased salivation, increased
gastric motility, and relaxation of the lower esophageal sphincter.
2. Which laboratory findings should the nurse expect in the patient with persistent
vomiting?
a. ↓ pH, ↑ sodium, ↓ hematocrit
b. ↑ pH, ↓ chloride, ↓ hematocrit
c. ↑ pH, ↓ potassium, ↑ hematocrit
d. ↓ pH, ↓ potassium, ↑ hematocrit
3. Which acid-base imbalance usually occurs in vomiting?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic alkalosis
d. Metabolic acidosis
4. Patient Elena also reported that she has been vomiting for several days from an
unknown cause. What should the nurse anticipate will be included in collaborative
care?
a. Oral administration of broth and tea
b. IV replacement of fluid and electrolytes
c. Administration of parenteral antiemetics
d. Insertion of a nasogastric (NG) tube for suction
5. Patient Elena is being treated for vomiting. She begins oral intake as the symptoms
have subsided To promote rehydration, the nurse plans to administer which fluid first?
a. Water
b. Hot tea
c. Gatorade
d. Warm broth
6. A patient with AIDS has dark purplish brown lesions on the mucus membranes of
the mouth. As the nurse you know these lesions correlate with what type of
opportunistic disease?
A. Epstein-Barr Virus
B. Herpes Simplex Virus
C. Cytomegalovirus
D. Kaposi’s Sarcoma
7. Which statement below is not true regarding the role of the helper t cell?
A. The helper T cell releases cytokines to help activate other immune system cells.
B. The helper T cell is part of the adaptive immune system.
C. The helper T cell is cytotoxic and kills invaders.
D. The helper T cell has CD4 receptors found on its surface.
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8. The Human Immunodeficiency Virus (HIV) can NOT be spread in what type of fluid
below? Select all that apply:
1. Breastmilk
2. Blood
3. Tears
4. Semen
5. Vaginal Fluid
6. Sweat
A. 1,3,6
B. 3,6
C. 1,4,5
D. 3,4,5,6
9. A 30-year-old patient is in the Acute Stage of HIV. What findings below correlate
with this stage of HIV? Select all that apply:
1. CD4 level <500 cells/mm3
2. No presence of Opportunistic Infections
3. High viral load
4. Patient reports flu-like symptoms
5. Patient is asymptomatic
A. 2,3,4,5
B. 1,2,4
C. 1,3,4
D. All of the above
10. Nurse Steph is providing education to a patient with AIDS on how to prevent
opportunistic infections. Which statement below requires the nurse to re-educate the
patient about this topic?
A. “I limit myself to visiting relatives who are confined in the hospital.”
B. “I’ve switched to buying raw organic milk.”
C. “Last month I received the Pneumovax.”
D. “My neighbor bought a cat last week.”
11. Patient Elena has just been prescribed isocarboxazid. The patient requires further
teaching if their meal includes:
a. Aged cheese
b.Broccoli and garlic
c. Grapefruit
d. Eggs and spices
12. Patient Lily taking beta-blockers should be instructed to change position slowly and
sit on the edge of their bed for 30 seconds prior to standing. These are suggested to
prevent:
A.​ Orthostatic hypotension
B.​ Vomiting
C.​ Severe headache
D.​ incontinence
13. Patient Josh with a vancomycin infusion begins developing flushing and facial
redness which spreads to the trunk. This adverse reaction is called:
A.​ Penicillin induced anaphylaxis
B.​ Red Man syndrome
C.​ Contact dermatitis
D.​ Erythema multiforme
14. Patient Sophia reports slightly increased blood sugar readings after being
prescribed prednisone for an upper respiratory infection. Nurse Claire advises the
patient:
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a. This is abnormal and should be seen immediately
b. This is normal and continue to monitor
c. To stop the prednisone immediately
d. To hold their insulin during the prednisone course
15. Nitroglycerin is used for:
a. Migraines
b. Angina
c. Clot-dissolving
d. Orthostatic hypotension
16. Nurse Jin is administering Nitroglycerin to patient Mina. Which of the following
should Nurse Jin educate patient Mina on for a possible side effect:
a. Flushing of the face
b. Bilateral leg cramping
c. Numbness to the arm
d. Cramping of the hands
17. Nurse Jin has another order to administer nitroglycerin via the sublingual route.
Further teaching is required if the patient says:
a. I will let this dissolve beneath my tongue
b. I take this as needed for chest pain at home
c. I will take this with a sip of water
d. I carry these in my purse in case of angina
18. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if
noted in the client, should be reported immediately to the primary health care
provider?
a. Dry cough
b. Hematuria
c. Bronchospasm
d. Blood-streaked sputum
19. The antidote for benzodiazepine (such as lorazepam, alprazolam, etc.) is:
a. Naloxone
b. Acetylcysteine
c. Diazepam
d. Flumazenil
20. The emergency department nurse is caring for a client who has been identified as
a victim of physical abuse. In planning care for the client, which is the priority nursing
action?
a. Adhering to the mandatory abuse-reporting laws
b. Notifying the caseworker of the family situation
c. Removing the client from any immediate danger
d. Obtaining treatment for the abused family member
21. A patient with pneumonia’s vital signs are checked at 4:00 pm. They read BP:
80/60 mmHg, HR:124bpm, temperature: 103.1 F, RR: 22cpm. Which of the following
should the nurse suspect?
a. Side effects from nebulizer
b. Possible sepsis
c. Increased pain levels
d. Pulmonary tuberculosis
22. A nurse is caring for a patient who exhibits an increase in heart rate from 80 bpm
to 120 bpm after morning medications. Which of the following medications may cause
this?
a. Atenolol
b. Amlodipine
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c. Albuterol
d. Allopurinol
23. Oropharyngeal airways are best for patients who are:
a. Elderly
b. Pediatric
c. Conscious
d. Unconscious
24. The convalescence stage of infection is most similar to:
a. Recovery and improvement
b. Onset of symptoms
c. Pathogens multiplying
d. Just prior to symptom onset
25. The community nurse is educating summer camp staff about education control.
Which of the following is the most effective way to prevent infection?
a. Stay at home when ill
b. Use 10% bleach solution on surfaces
c. Proper hand hygiene
d. Checking temperature on arrival
26. Nurse Fatima is assessing a patient with suspected appendicitis. Which of the
following would she expect to find upon assessment?
a. Cullen’s sign
b. Abdominal pain that is most intense at McBurney’s point
c. Grey-turner sign
d. Olive-shaped mass to the upper epigastric region
27. A client has undergone an esophagogastroduodenoscopy. The nurse should
place the highest priority on which item is part of the client’s care plan?
a. Monitoring the temperature
b. Monitoring complaints of heartburn
c. Giving warm gargles for a sore throat
d. Assessing for the return of the gag reflex
28. After a tonsillectomy, a child begins to vomit bright red blood. The nurse should
take which initial action?
a. Turn the child to the side.
b. Administer the prescribed antiemetic.
c. Maintain NPO (nothing by mouth) status.
d. Notify the primary health care provider (PHCP).
29. Which of the following interventions is most appropriate for a patient with
increased intracranial pressure?
a. Elevating the head of the bed
b. Placing the patient in a modified Trendelenburg position
c. Administering hypotonic IV solutions
d. Encouraging the patient to do coughing and deep breathing exercises
30. Which of the following status changes should Nurse Elizabeth address immediately
in a patient being treated for sepsis?
a. WBC of 7,000
b. Potassium 3.7mEq/L
c. Platelet 250,000
d. Urine output of <30ml/hr
31. Patient Beth is admitted for left calf tenderness, warmth, and redness after an
international flight. In addition to a Doppler ultrasound, which of the following lab
tests would Nurse Ally expect to be ordered?
a. Troponin T
31
b. Troponin I
c. Creatinine
d. D-Dimer
32. The nurse is monitoring a client admitted to the hospital with a diagnosis of
appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of
increased abdominal pain and begins to vomit. On assessment, the nurse notes that
the abdomen is distended and bowel sounds are diminished. Which is the most
appropriate nursing intervention?
a. Administer the prescribed pain medication.
b. Notify the primary health care provider (PHCP).
c. Call and ask the operating room team to perform surgery as soon as possible.
d. Reposition the client and apply a heating pad on the warm setting to the client’s
abdomen.

Situation: Patient Betty with hyperthyroidism is admitted to your unit. She asks you as
her nurse about the endocrine system functions.
33. Nurse Zyra explains to patient Betty that the endocrine glands include which of
the following?
a. Pituitary, thyroid, parathyroid, adrenals, pancreatic islets, and hypothalamus.
b. Pituitary, thyroid, parathyroid, pancreatic islets, ovaries, and testes.
c. pituitary, thyroid, parathyroid, adrenals, and pancreatic islets.
d. Pituitary, thyroid, parathyroid, adrenals, pancreatic islets, ovaries, and
testes.

34. The ______ is the link between the nervous system and the endocrine system.
a. Spinal cord
b. Hypothalamus
c. Pituitary gland
d. Thyroid gland
35. This endocrine disorder is rare but this serious disorder results from persistently
low thyroid production
a. Myxedema
b. Thyrotoxicosis
c. Cushing’s syndrome
d. Hashimoto’s disease
36. A patient asks you about Pheochromocytoma. You describe this disorder incorrectly
if you answer____________.
a. A common cause is Graves’ disease, also known as toxic diffuse goiter.
b. Excessive amounts of epinephrine and norepinephrine are secreted
c. Surgical removal of the adrenal gland is the primary treatment.
d. Catecholamine-producing tumor usually found in the adrenal medulla, but extra
adrenal locations include the chest, bladder, abdomen, and brain; typically is a benign
tumor but can be malignant
37. Nurse Olivia observes continuous bubbling in the water-seal chamber of a closed
chest drainage system. What would Nurse Olivia conclude?
a. The system is functioning normally
b. The client has a pneumothorax
c. The system has an air leak
d. The chest tube is obstructed
38. Nurse Olivia caring for a client with a chest tube turns to the right side, and the
chest tube accidentally disconnects. The initial nursing action to do is:
a. Report to the physician
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b. Place the tube in a bottle of sterile water
c. Clamp the tube using forceps
d. Place a sterile dressing over the disconnection site.
39. Nurse Olivia is presenting a class on chest tubes. Which statement describes a
tension pneumothorax?
a. occurs with the rupture of a pulmonary bleb, or small air-containing spaces deep in
the lung
b. occurs when an opening through the chest wall allows the entrance of positive
atmospheric air pressure into the pleural space
c. occurs from a blunt chest injury or from mechanical ventilation with PEEP
when a buildup of positive pressure occurs in the pleural space
d. Occurs when insufficient oxygen is transported to the blood or inadequate carbon
dioxide is removed from the lungs and the client’s compensatory mechanisms fail
40. During the assessment of the patient’s respiratory status the nurse notes the
paradoxical lung movements. This finding is consistent with what health problem?
a. Flail chest
b. Pleurisy
c. Pneumothorax
d. Pneumonia
41. A client has experienced pulmonary embolism. The nurse should assess for which
symptom, which is most commonly reported?
a. Hot, flushed feeling
b. Sudden chills and fever
c. Chest pain that occurs suddenly
d. Dyspnea when deep breaths are taken
42. A client who is human immunodeficiency virus (HIV)–positive has had a tuberculin
skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test
and interprets the result as which finding?
a. Positive
b. Negative
c. Inconclusive
d. Need for repeat testing
43. A client with chronic kidney disease is receiving epoetin alfa. Which laboratory
result would indicate a therapeutic effect of the medication?
a. Hematocrit of 33%
b. Platelet count of 400,000 mm3
c. White blood cell count of 6000 mm3
d. Blood urea nitrogen level of 15 mg/dL
44. A client with a urinary tract infection is receiving ciprofloxacin by the intravenous
(IV) route. The nurse appropriately administers the medication by performing which
action?
a. Infusing slowly over 60 minutes
b. Infusing in a light-protective bag
c. Infusing only through a central line
d. Infusing rapidly as a direct IV push medication
45. A client is brought to the emergency department in an unresponsive state, and a
diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would
immediately prepare to initiate which anticipated primary health care provider’s
prescription?
a. Endotracheal intubation
b. 100 units of NPH insulin
c. Intravenous infusion of normal saline
33
d. Intravenous infusion of sodium bicarbonate
46. A client with diabetes mellitus demonstrates acute anxiety when admitted to the
hospital for the treatment of hyperglycemia. What is the appropriate intervention to
decrease the client’s anxiety?
a. Administer a sedative.
b. Convey empathy, trust, and respect toward the client.
c. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear.
d. Make sure that the client is familiar with the correct medical terms to promote
understanding of what is happening.
47. The nurse provides instructions to a client newly diagnosed with type 1 diabetes
mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic
ketoacidosis when the client makes which statement?
a. “I will stop taking my insulin if I’m too sick to eat.”
b. “I will decrease my insulin dose during times of illness.”
c. “I will adjust my insulin dose according to the level of glucose in my urine.”
d. “I will notify my primary health care provider (PHCP) if my blood glucose
level is higher than 250 mg/dL.”
48. The nurse is instructing a client to perform a testicular self-examination (TSE). The
nurse should provide the client with which information about the procedure?
a. To examine the testicles while lying down
b. That the best time for the examination is after a shower
c. To gently feel the testicle with one finger to feel for a growth
d. That TSEs should be done at least every 6 months
49. The nurse reviews a client’s electrolyte laboratory report and notes that the
potassium level is 2.5 mEq/L. Which patterns should the nurse watch for on the
electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.
1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment
5. Widened QRS complex
a. 1,2,3
b. 1,3,4
c. 1,3,4
d. 1,2,4
50. The nurse is providing instructions to a client and the family regarding home care
after right eye cataract removal. Which statement by the client would indicate an
understanding of the instructions?
a. “I should sleep on my left side.”
b. “I should sleep on my right side.”
c. “I should sleep with my head flat.”
d. “I should not wear my glasses at any time.”
51. Dr. Garcia writes the following order for the client who has been recently admitted
“Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse
document this order onto the medication administration record?
A. “Digoxin .1250 mg P.O. once daily”
B. “Digoxin 0.1250 mg P.O. once daily”
C. “Digoxin 0.125 mg P.O. once daily”
D. “Digoxin .125 mg P.O. once daily”
52. A newly admitted female client was diagnosed with deep vein thrombosis. Which
nursing diagnosis should receive the highest priority?
A. Ineffective peripheral tissue perfusion related to venous congestion.
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B. Risk for injury related to edema.
C. Excess fluid volume related to peripheral vascular disease.
D. Impaired gas exchange related to increased blood flow.
53. Nurse Betty is assigned to the following clients. The client that the nurse would
see first after endorsement?
A. A 34 year-old post operative appendectomy client of five hours who is complaining
of pain.
B. A 44 year-old myocardial infarction (MI) client who is complaining of
nausea.
C. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
D. A 63 year-old post operative’s abdominal hysterectomy client of three days whose
incisional dressing is saturated with serosanguinous fluid.
54. Nurse Gail places a client in a four-point restraint following orders from the
physician. The client care plan should include:
A. Assess temperature frequently.
B. Provide diversional activities.
C. Check circulation every 15-30 minutes.
D. Socialize with other patients once a shift.
55. A male client who has severe burns is receiving H2 receptor antagonist therapy.
The nurse In-charge knows the purpose of this therapy is to:
A. Prevent stress ulcer
B. Block prostaglandin synthesis
C. Facilitate protein synthesis.
D. Enhance gas exchange
56. The doctor orders hourly urine output measurement for a postoperative male
client. The nurse Trish records the following amounts of output for 2 consecutive
hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the
nurse take?
A. Increase the I.V. fluid infusion rate
B. Irrigate the indwelling urinary catheter
C. Notify the physician
D. Continue to monitor and record hourly urine output
57. Nurse Amy is aware that the following is true about functional nursing
A. Provides continuous, coordinated and comprehensive nursing services.
B. One-to-one nurse patient ratio.
C. Emphasize the use of group collaboration.
D. Concentrates on tasks and activities.

58.Which type of medication order might read “Vitamin K 10 mg I.M. daily × 3 days?”
A. Single order
B. Standard written order
C. Standing order
D. Stat order
59.Nurse Linda prepares to perform an otoscopic examination on a female client. For
proper visualization, the nurse should position the client’s ear by:
A. Pulling the lobule down and back
B. Pulling the helix down and back
C. Pulling the helix up and back
D. Pulling the lobule down and forward
60. In assisting a female client for immediate surgery, the nurse In-charge is aware
that she should:
A. Encourage the client to void following preoperative medication.
35
B. Explore the client’s fears and anxieties about the surgery.
C. Assist the client in removing dentures and nail polish.
D. Encourage the client to drink water prior to surgery.

Situation: Leo lives in the squatter area. He goes to nearby school. He helps his
mother gather molasses after school. One day, he was absent because of fever,
malaise, anorexia and abdominal discomfort.

61. Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of
transmission has the agent taken?
A. Fecal-oral
B. Droplet
C. Airborne
D. Sexual contact
62. Which of the following is concurrent disinfection in the case of Leo?
A. Investigation of contact
B. Sanitary disposal of feces, urine and blood
C. Quarantine of the sick individual
D. Removing all detachable objects in the room, cleaning lighting and air duct surfaces
in the ceiling, and cleaning everything downward to the floor
63. Which of the following must be emphasized during mother’s class to Leo’s mother?
A. Administration of Immunoglobulin to families
B. Thorough hand washing before and after eating and toileting
C. Use of attenuated vaccines
D. Boiling of food especially meat
64. Disaster control should be undertaken when there are 3 or more hepatitis A cases.
Which of these measures is a priority?
A. Eliminate faecal contamination from foods
B. Mass vaccination of uninfected individuals
C. Health promotion and education to families and communities about the
disease it’s cause and transmission
D. Mass administration of Immunoglobulin
65. What is the average incubation period of Hepatitis A?
A. 30 days
B. 60 days
C. 50 days
D. 14 days

Situation: As a nurse researcher you must have a very good understanding of the
common terms of concept used in research.

66. The information that an investigator collects from the subjects or participants in a
research study is usually called;
A. Hypothesis
B. Variable
C. Data
D. Concept
67. Which of the following usually refers to the independent variables in doing
research
A. Result
B. output
C. Cause
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D. Effect
68. The recipients of experimental treatment is an experimental design or the
individuals to be observed in a non-experimental design are called;
a. Setting
b. Treatment
c. Subjects
d. Sample
69. The device or techniques an investigator employs to collect data is called;
a. Sample
b. Hypothesis
c. Instrument
d. Concept

70. The use of another person’s ideas or wordings without giving appropriate credit
results from inaccurate or incomplete attribution of materials to its sources. Which of
the following is referred to when another person’s idea is inappropriate credited as
one’s own;
A. Plagiarism
B. Assumption
C. Quotation
D. Paraphrase

Diabetes Mellitus has been a chronic problem being faced of many Filipinos. The
following questions are about Diabetes mellitus.

71. A client who was diagnosed with type 1 diabetes14 years ago is admitted to the
medical-surgical unit with abdominal pain. On admission, the client's blood glucose
level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
A. Cool, moist skin
B. Rapid, thready pulse
C. Arm and leg trembling
D. Slow, shallow respirations

72. A nurse administered neutral protamine Hagedorn (NPH) insulin to a client with
diabetes mellitus at 7 a.m. At what time should the nurse expect the client to be most
at risk for hypoglycemia?
A. 10:00 AM
B. 12 noon
C. 4 PM
D. 10 PM

73. A client with type 1 diabetes must undergo bowel resection in the morning. How
should the nurse proceed while caring for him on the morning of surgery?
A. Administer half of the client's typical morning insulin dose as ordered.
B. Administer an oral antidiabetic agent as ordered.
C. Administer an I.V. insulin infusion as ordered.
D. Administer the client’s normal daily dose of insulin as ordered.
74. A client with type 1 diabetes is scheduled to receive 30 units of 70/30 insulin.
There is no 70/30 insulin available. As a substitution, the nurse may give the client:
A. 9 units regular insulin and 21 units neutral protamine Hagedorn (NPH).
B. 21 units regular insulin and 9 units NPH.
C. 10 units regular insulin and 20 units NPH.
37
D. 20 units regular insulin and 10 units NPH.
75. A nurse expects to find which signs and symptoms in a client experiencing
hypoglycemia?
A. Polyuria, headache, and fatigue
B. Polyphagia and flushed, dry skin
C. Polydipsia, pallor, and irritability
D. Nervousness, diaphoresis, and confusion

Jenny, 32 years old, has been experiencing hot flashes for a week already. She became
thin and was not able to sleep at night. She was diagnosed with hyperthyroidism.

76. Which of the following assessment findings characterize thyroid storm?

A. Increased body temperature, decreased pulse, and increased blood pressure
B. Increased body temperature, increased pulse, and increased blood
pressure
C. Increased body temperature, decreased pulse, and decreased blood pressure
D. Increased body temperature, increased pulse, and decreased blood pressure

77. After thyroidectomy, which of the following is the priority assessment to observe
laryngeal nerve damage?
a. Hoarseness of voice
b. Difficulty in swallowing
c. Tetany
d. Fever

78. Early this morning, a female client had a subtotal thyroidectomy. During evening
rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F
(40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of
these signs?
a. Diabetic ketoacidosis
b. Thyroid crisis
c. Hypoglycemia
d. Tetany

79. A female client with hypothyroidism (myxedema) is receiving levothyroxine

(Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an
adverse drug effect?
a. Dysuria
b. Leg cramps
c. Tachycardia
d. Blurred vision

80. A physician prescribes levothyroxine sodium (Synthroid), 0.15 mg orally daily, for a
client with hypothyroidism. The nurse will prepare to administer this medication:
a. In the morning to prevent insomnia
b. Only when the client complains of fatigue and cold intolerance
c. At various times during the day to prevent tolerance from occurring
d. Three times daily in equal doses of 0.5 mg each to ensure consistent serum drug
levels

A patient came in with a puffy face and hunch back. You suspect Cushing’s disease.

38
81. An emergency nurse cares for a client who is experiencing an acute adrenal crisis.
Which action should the nurse take first?
a. Obtain intravenous access.
b. Administer hydrocortisone (Solu-Cortef).
c. Assess blood glucose.
d. Administer insulin and dextrose.
82. A nurse is reviewing discharge teaching with a client who has Cushing's syndrome.
Which statement by the client indicates that the instructions related to dietary
management were understood?
a. "I can eat foods that contain potassium."
b. "I will need to limit the amount of protein in my diet."
c. "I am fortunate that I can eat all the salty foods I enjoy."
d. "I am fortunate that I do not need to follow any special diet."
83. The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency
(Addison's disease). Which clinical manifestations should the nurse expect to assess?
a. Moon face, buffalo hump, and hyperglycemia.
b. Hirsutism, fever, and irritability.
c. Bronze pigmentation, hypotension, and anorexia.
d. Tachycardia, bulging eyes, and goiter.
84. The nurse is instructing a young adult with Addison's disease how to adjust the
dose of glucocorticoids. The nurse should explain that the client may need an
increased dosage of glucocorticoids in which of the following situations?
a. Completing the spring semester of school.
b. Gaining 4 lb (1.8 kg).
c. Becoming engaged.
d. Undergoing a root canal.

85. A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which
patient statement supports a nursing diagnosis of ineffective self-health management
related to lack of knowledge about management of Addison's disease?

a. "I frequently eat at restaurants, and my food has a lot of added salt."
b. "I had the stomach flu earlier this week, so I couldn't take the
hydrocortisone."
c. "I always double my dose of hydrocortisone on the days that I go for a long run."
d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

The endocrine system, made up of all the body's different hormones, regulates all
biological processes in the body from conception through adulthood and into old age,
including the development of the brain and nervous system, the growth and function
of the reproductive system, as well as the metabolism and blood sugar.

86. A patient in the medicine ward was admitted because of peptic ulcer disease. She
has been taking huge amounts of oral antacids to manage her peptic ulcer disease.
Knowing the effects of oral antacids, nurse Ryuu interprets that the client is at MOST
at risk for which acid-base balance?
a. Metabolic Acidosis
b. Respiratory Alkalosis
c. Metabolic alkalosis
d. Respiratory acidosis
87. The nurse is preparing to administer a.m. medications to clients. Which medication
should the nurse question before administering?
39
a. Pancreatic enzymes to the client who has finished breakfast.
b. The pain medication, morphine, to the client who has a respiratory rate of 20.
c. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L.
d. The beta blocker to the client who has an apical pulse of 68 bpm.
88. Lorelei is patient with diabetes mellitus has an Hba1c level of 8%. On the basis of
this test result, the nurse plans to teach the client about the need for which measure?
a. Avoiding infection
b. Drinking plenty of water
c. Preventing and recognizing hypoglycemia
d. Preventing and recognizing hyperglycemia
89. June, a patient with a brain tumor presents with DI. He is treated first with nasal
desmopressin. The nurse recognize that the drug is not having an adequate
therapeutic effect?
a. patient experiences headache and weight gain
b. Nasal irritation and nausea
c. A urine specific gravity of 1.002
d. An oral intake greater than urinary output
90. A client is diagnosed with syndrome of inappropriate antidiuretic hormone
(SIADH). The nurse informs the client that the physician will prescribe diuretic therapy
and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply
with the recommended treatment, which complication may arise?
a. Cerebral edema
b. Hypovolemic shock
c. Severe hyperkalemia
d. Tetany

Tess, 60 years old, presented to the emergency department due to sudden loss of
vision. You suspect glaucoma.

91. Which finding related to primary open-angle glaucoma would the nurse expect to
find when reviewing a patient's history and physical examination report?
A. Absence of pain or pressure
B. Blurred vision in the morning
C. Seeing colored halos around lights
D. Eye pain accompanied with nausea and vomiting
92. When teaching a patient about the pathophysiology related to open-angle
glaucoma, which statement is most appropriate?
A. "The retinal nerve is damaged by an abnormal increase in the production of
aqueous humor."
B. "There is decreased draining of aqueous humor in the eye, causing
pressure damage to the optic nerve."
C. "The lens enlarges with normal aging, pushing the iris forward, which then covers
the outflow channels of the eye."
D. "There is a decreased flow of aqueous humor into the anterior chamber by the lens
of the eye blocking the papillary
93. When administering eye drops to a patient with glaucoma, which nursing measure
is most appropriate to minimize systemic effects of the medication?
A. Apply pressure to each eyeball for a few seconds after administration.
B. Have the patient close the eyes and move them back and forth several times.
C. Have the patient put pressure on the inner canthus of the eye after
administration.

40
D. Have the patient try to blink out excess medication immediately after
administration.
94. What type of vision loss is found in glaucoma.
a. Tunnel vision
b. Central vision loss
c. Blurred vision
d. Curtain-like vision
95. What is the drug of choice for glaucoma
a. Atropine sulfate
b. Mydriatics
c. Miotics
d. Eye mo
96. What is the main pathophysiology of retinal detachment?
a. Opacity of the lens usually associated with aging, prolonged intake of steroids and
chromosomal aberrations.
b. Increased intraocular pressure due to accumulation of aqueous humor.
c. Separation of the sensory retina from the pigment epithelium of the
retina.
d. Most common cause of visual loss in people older than 60 y/o.
97. The client is post op retinal detachment surgery, and gas tamponade was used to
flatten the retina. Which intervention should the nurse implement first?
a. Teach the signs of increased intraocular pressure.
b. Position the client as prescribed by the surgeon.
c. Assess the eye for signs or symptoms of complications
d. Explain the importance of follow-ups visits
98. The nurse is performing an admission assessment on a client with a diagnosis of
detached retina. Which of the following is associated with this eye disorder?
a. Pain in the affected eye
b. Total loss of vision
c. A sense of a curtain falling across the field of vision
d. A yellow discoloration of the sclera.
99. The nurse is caring for a client with a diagnosis of detached retina. Which
assessment sign would indicate that bleeding has occurred as a result of the retinal
detachment?
a. Complaints of a burst of black spots or floaters
b. sudden sharp pain in the eye
c. Total loss of vision
d. A reddened conjunctiva
100. The nurse who is at a local park sees a young man on the ground who has fallen
and has a stick lodged in his eye. Which intervention should the nurse implement at
the scene?
a. Carefully remove the stick from the eye.
b. Stabilize the stick as best as possible.
c. Flush the eye with water if available.
d. Place the young man in a high-Fowler's position

41
RECALLS 3 NP 4

1. The nurse, Sam, is assessing a 48-year-old client, Antha, diagnosed with multiple
sclerosis. Which clinical manifestation warrants immediate intervention?

A. The client has scanning speech and diplopia.

B. The client has dysarthria and scotomas.
C. The client has muscle weakness and spasticity.
D. The client has a congested cough and dysphagia.

2. Nicole, 30-year-old female client, is admitted with complaints of numbness, tingling,

a crawling sensation affecting the extremities, and double vision which has occurred
two (2) times in the month. Which question is most important for the nurse to ask the
client?

A. "Have you experienced any difficulty with your menstrual cycle?"

B. "Have you noticed a rash across the bridge of your nose?"
C. "Do you get tired easily and sometimes have problems swallowing?"
D. "Are you taking birth control pills to prevent conception?"

3. The 45-year-old client, Ashley, is diagnosed with primary progressive multiple

sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to
progressive loss." Which intervention should be implemented?

A. Consult the physical therapist for assistive devices for mobility.

B. Determine if the client has a legal power of attorney.
C. Ask if the client would like to talk to the hospital chaplain.
D. Discuss the client's wishes regarding end-of-life care.

4. The client diagnosed with an acute exacerbation of multiple sclerosis is placed on

high-dose intravenous injections of corticosteroid medication. Which nursing
intervention should be implemented?

A. Discuss discontinuing the proton pump inhibitor with the HCP.

B. Hold the medication until after all cultures have been obtained.
C. Monitor the client's serum blood glucose levels frequently
D. Provide supplemental dietary sodium with the client's meals.

5. A female client is admitted to the hospital who has a diagnosis of Guillain-Barre

syndrome. The nurse asks during the nursing admission interview if the client has
history of:

A. Seizures or trauma to the brain

B. Meningitis during the last 5 years
C. Back injury or trauma to the spinal cord
D. Respiratory or gastrointestinal infection during the previous month.

6. A 25 year-old presents to the ER with unexplained paralysis from the hips

downward. The patient explains that a few days ago her feet were feeling weird and
she had trouble walking and now she is unable to move her lower extremities. The
patient reports suffering an illness about 2 weeks ago, but has no other health history.

42
The physician suspects Guillain-Barré Syndrome and orders some diagnostic tests.
Which finding below during your assessment requires immediate nursing action?

A. The patient reports a headache.

B. The patient has a weak cough.
C. The patient has absent reflexes in the lower extremities.
D. The patient reports paresthesia in the upper extremities.

7. A patient with Guillain-Barré Syndrome has a feeding tube for nutrition. Before
starting the scheduled feeding, it is essential the nurse? Select all that apply:

A. Assesses for bowel sounds

B. Keeps the head of bed less than 30' degrees
C. Checks for gastric residual
D. Weighs the patient

8. You're about to send a patient for a lumbar puncture to help rule out Guillain-Barré
Syndrome. Before sending the patient you will have the patient?

A. Clean the back with antiseptic

B. Drink contrast dye
C. Void
D. Lie flat

9. A patient with myasthenia Gravis will be eating lunch at 12:00 PM. It is now 10:00
AM and the patient is scheduled to take Pyridostigmine. At what time should you
administer this medication so the patient will have the maximum benefit of this
medication?

A. As soon as possible.
B. 1 hour after the patient has eaten (at 1:00 PM)
C. 1 hour before the patient eats (at 11:00 AM)
D. At 12:00 right before the patient eats.

10. The neurologist is conducting a Tensilon test (Edrophonium) at the bedside of a

patient who is experiencing unexplained muscle weakness, double vision, difficulty
breathing, and ptosis. Which findings after the administration of Edrophonium would
represent the patient has myasthenia Gravis?

A. The patient experiences worsening of the muscle weakness

B. The patient experiences wheezing along with facial flushing.
C. The patient reports a tingling sensation in the eyelids and sudden ringing in the
ears.
D. The patient experiences improved muscle strength

11. Which patient below is MOST at risk for developing a cholinergic crisis?

A. A patient with myasthenia Gravis is who is not receiving sufficient amounts of their
anticholinesterase medication.
B. A patient with myasthenia Gravis who reports not taking the medications
Pyridostigmine for 2 weeks.

43
C. A patient with myasthenia Gravis who is experiencing a respiratory infection and
recently had left hip surgery.
D. A patient with myasthenia gravis who reports taking too much of their
anticholinesterase medication.

12. You're a home health nurse providing care to a patient with myasthenia gravis.
Today you plan on helping the patient with bathing and exercising. When would be the
best time to visit the patient to help with these tasks?

A. Mid-Afternoon.
B. Morning.
C. Evening.
D. Before bedtime

13. A patient who is diagnosed with Parkinson disease (PD) states, “I can’t tie my
shoelaces anymore.” The healthcare provider recognizes that this patient’s problem is
due to a deficiency in which of these neurotransmitters?

a. Glutamate
b. Norepinephrine
c. Dopamine
d. Serotonin

14. When planning care for a patient diagnosed with Parkinson disease (PD), which of
these patient outcomes should receive priority in the patient’s plan of care?

a. Working on a favorite hobby

b. Taking a vitamin supplement each day
c. Toileting and bathing independently
d. Taking a daily walk around the neighborhood

15. A patient who has been prescribed the antiparkinsonian medication

carbidopa/levodopa, asks the healthcare provider, “Why am I getting these two
medications?” How should the healthcare provider respond?

A. “This drug combination is composed of two types of the same medication.”

B. “You will experience fewer side effects when you take both medications together.”
C. “The carbidopa prevents the breakdown of the levodopa.”
D. “The levodopa turns the carbidopa into dopamine when it reaches the brain.”

16. A patient diagnosed with Parkinson disease (PD) is prescribed levodopa. The
medication therapy can be considered effective when the healthcare provider assesses
improvement in which of the following?

A. Visual acuity
B. Appetite
C. Hearing
D. Urinary frequency

17. When communicating with patients who have dementia, which of the following
responses is most effective?

44
A. Speak louder to the patient who has delayed response time
B. Utilize visual cues such as pointing or touching items
C. Repeat questions and comments frequently
D. Have the patients begin tasks on their own to promote independence

18. A 62-year-old patient is brought to the clinic by a family member who is concerned
about the patient's inability to solve common problems. To obtain information about
the patient's current mental status, which question should the nurse ask the patient?

A. "Where were you were born?"

B. "Do you have any feelings of sadness?"
C. "What did you have for breakfast?"
D. "How positive is your self-image?"

19. A 68-year-old patient who is hospitalized with pneumonia is disoriented and

confused 3 days after admission. Which information indicates that the patient is
experiencing delirium rather than dementia?

A. The patient was oriented and alert when admitted.

B. The patient's speech is fragmented and incoherent.
C. The patient is oriented to person but disoriented to place and time.
D. The patient has a history of increasing confusion over several years.

20. For which patient should the nurse prioritize an assessment for depression?

A. A patient in the early stages of Alzheimer's disease

B. A patient who is in the final stages of Alzheimer's disease
C. A patient experiencing delirium secondary to dehydration.
D. A patient who has become delirious following an atypical drug response.

21. In the eye clinic, Nurse Leah is discussing various eye conditions with her patient,
Mrs. Peterson, who has been experiencing difficulties with near vision as she’s gotten
older. Leah explains one condition characterized by a reduction in the eye’s power of
accommodation. According to Nurse Leah, what is the term for the eye disorder
characterized by a decrease in the effective powers of accommodation?

A. Presbycusis
B. Hypertropia
C. Presbyopia
D. Myopia

22. Nurse Adrian is assisting Mr. Johnson, a patient who recently learned he has
hyperopia or farsightedness. While discussing options for corrective lenses, Nurse
Adrian talks about the type of lens that would typically be used to help with this
condition. According to Nurse Adrian, what type of lens is typically used to correct
hyperopia?

A. Aphakic lens.
B. Bifocal lens.
C. Concave lens.
D. Convex lens.

45
23. A client has received a diagnosis of hyperopia and is wondering if there is a
physical condition that has caused these vision changes. In explaining hyperopia, what
does the nurse indicate is the cause of this clients vision changes?

A. Eyeballs that are shorter than normal

B. Eyeballs that are longer than normal
C. Unequal curvatures in the corneas
D. Irregularly shaped corneas

24. The client’s vision is tested with a Snellen chart. The results of the tests are
documented as 20/100. The nurse interprets this as:

A. The client can read at a distance of 100 feet what a client with normal vision can
read at 20 feet.
B. The client is legally blind.
C. The client’s vision is normal.
D. The client can read only at a distance of 20 feet what a client with normal
vision can read at 100 feet.

25. A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse
explains that the chief aim of treatment is to meet which goal?

A. Rest the eye

B. Dilate the pupil
C. Prevent secondary infections
D. Control the intraocular pressure

26. Nurse Emma is evaluating a patient who has been referred to the clinic due to
ocular hypertension. As she goes over the typical characteristics of this condition, she
tries to identify which feature does not belong. Which is not a feature of ocular
hypertension?

A. Normal optic discs.

B. A closed angle.
C. Normal visual fields.
D. Increased intraocular pressure.

27. A nurse is administering eye drops of two different drugs to a patient. How long
should the nurse wait between the instillation of the first medication and the second
Medication?

Q. At least 1 minute
B. At least 5 minutes
C. At least 15 minutes
D. At least 20 minutes

28. John will be undergoing cataract surgery. Nurse Victor is preparing to instill eye
drops to a patient prior to cataract surgery. He is aware that:

A. Mydriatics will be used to dilate the pupil

B. Miotics will be used to constrict the pupil
C. Miotics will be used to dilate the pupil
46
D. Mydriatics will be used to constrict the pupil

29. John has recently had cataract surgery. About which symptom does the nurse
Victor instruct the client to notify the health care provider?

A. Increased tearing
B. Itching of the eye
C. Reduction in vision
D. Swollen eyelid

30. Nurse Victor is preparing John for discharge following the removal of a cataract.
The nurse should tell the client to:

A. Take aspirin for discomfort

B. Avoid bending over to put on his shoes
C. Remove the eye shield before going to sleep
D. Continue showering as usual

31. During the early postoperative period, the client who had a cataract extraction
complains of nausea and severe eye pain over the operative site. The initial nursing
action is to:

A. Call the physician.

B. Administer the ordered main medication and antiemetic.
C. Reassure the client that this is normal.
D. Turn the client on his or her operative side.

32. A client has been diagnosed with retinal detachment. The nurse knows that which
among the following are the manifestations of retinal detachment (select all that
apply):

A. Painless
B. Flashes of Lights
C. Floaters or black spots
D. Sense of a curtain being drawn over the eye
E. Increase in blurred vision

33. A nurse performs an assessment of a client with a diagnosis of macular

degeneration of the eye. The nurse would expect the client to report which of the
following symptoms?

A. Loss of peripheral vision

B. Blurred central vision
C. Increased clarity when looking at objects
D. Clear vision when reading

34. The 65-year-old client is diagnosed with macular degeneration. Which statement
by the nurse indicates the client needs more discharge teaching?

a. "I should use magnification devices as much as possible."

b. "I will look at my Amsler grid at least twice a week."
c. "I am going to use low-watt light bulbs in my house."
47
d. "I am going to contact a low-vision center to evaluate my home."

35. Although all of the following measures might be useful in reducing the visual
disability of a client with adult macular degeneration (AMD), which measure should the
nurse teach the client primarily as a safety precaution?

A. Wear a patch over one eye.

B. Place personal items on the sighted side.
C. Lie in bed with the unaffected side toward the door.
D. Turn the head from side to side when walking.

36. The student nurse is performing a Weber tuning fork test. What technique is most
appropriate?

A. Holding the vibrating tuning fork 10 to 12 inches from the clients ear
B. Placing the vibrating fork in the middle of the clients head
C. Starting by placing the vibrating fork on the mastoid process
D. Tapping the vibrating tuning fork against the bridge of the nose

37. The clients chart indicates a sensorineural hearing loss. What assessment question
does the nurse ask to determine the possible cause?

A. Do you feel like something is in your ear?

B. Do you have frequent ear infections?
C. Have you been exposed to loud noises?
D. Have you been told your ear bones don't move?

38. The nurse works with clients who have hearing problems. Which action by a client
best indicates goals for an important diagnosis have been met?

A. Babysitting the grandchildren several times a week

B. Having an adaptive hearing device for the television
C. Being active in community events and volunteer work
D. Responding agreeably to suggestions for adaptive devices

39. An older adult in the family practice clinic reports a decrease in hearing over a
week. What action by the nurse is most appropriate?

A. Assess for cerumen buildup.

B. Facilitate audiological testing.
C. Perform tuning fork tests.
D. Review the medication list.

40. A client with Meniere's disease is in the hospital when the client has an attack of
this disorder. What action by the nurse takes priority?

A. Assess vital signs every 15 minutes.

B. Dim or turn off lights in the clients room.
C. Place the client in bed with the upper side rails up.
D. Provide a cool, wet cloth for the clients ear.

48
41. A client has just received a diagnosis of breast cancer from her physician. When
the nurse asks if she would like to talk about the diagnosis, the client replies, “Oh, no,
I’m sure they are wrong—i’ve always had cysts in my breasts.” The nurse recognizes
that this may be a grief response, which probably means that the client is

A. Not ready to accept the diagnosis.

B. In the disbelief stage of the grief process.
C. Not comfortable in discussing the diagnosis with the nurse.
D. Mourning the loss she will have to experience.

42. A client with breast cancer receives diagnostic testing and scan results that
indicate a tumor that is 4.2 cm in size with evidence of metastasis to movable
ipsilateral axillary nodes only. According to the TNM staging​ system, how should this​
client's breast cancer be​staged?

a. T1 N0 MO
b. Tis N1 M0
c. T3 N2 M1
d. T2 N1 M0

43. When teaching a 22-year-old patient when to perform breast self-examination

(BSE), the nurse will instruct the patient that:

A. BSE will be done 7-10 days before menstruation

B. BSE will be done 7-10 days after menstruation
C. BSE will be done 1 day before menstruation
D. BSE will be done 1 day after menstruation

44. While the nurse is obtaining a nursing history

from a 52-year-old patient who has found a small lump in her breast, which question is
most pertinent?

A. "Do you currently smoke cigarettes?"

B. "Have you ever had any breast injuries?"
C. "Is there any family history of fibrocystic breast changes?"
D. "At what age did you start having menstrual periods?"

45. A nurse is providing a program for older men in a senior community about
measures that can be taken to reduce the risk for prostate cancer. Which of the
following would the nurse include in the program?

A. Decrease red meat and fat intake.

B. Decrease lycopene intake.
C. Increase fiber intake.
D. Avoid foods high in sodium.

46. A nurse is teaching a 53-year old man about prostate cancer. What information
should the nurse provide to best facilitate the early identification of prostate cancer?

A. Have a digital rectal examination and prostate specific antigen (PSA) test
done yearly.
B. Have a transrectal ultrasound done every 5 years.
49
C. Perform monthly testicular self-examinations, especially after age 60.
D. Have a complete blood count (CBC), blood urea nitrogen (BUN) and creatinine
assessment performed annually.

47. The patient who underwent prostate cancer surgery is approaching the time of
discharge from the hospital. What instruction should the nurse provide to this client as
part of discharge teaching? Select all that apply.

A. "Maintain a high fluid intake after you go home."

B. "Call the healthcare provider immediately if you notice blood in your urine."
C. "You may drive yourself home."
D. "Avoid strenuous activity for 4-8 weeks."
E. "Avoid heavy lifting for 2-4 weeks."

48. A patient has just been diagnosed with prostate cancer and is scheduled for
brachytherapy next week. The patient and his wife are unsure of having the procedure
because their daughter is 3 months pregnant. What is the most appropriate teaching
the nurse should provide to this family?

A. The patient should not be in contact with the baby after delivery.
B. The patients treatment poses no risk to his daughter or her infant.
C. The patients brachytherapy may be contraindicated for safety reasons.
D. The patient should avoid close contact with his daughter for 2 months.

49. A client, age 41, visits the gynecologist. After examining her, the physician
suspects cervical cancer. The nurse reviews the client's history for risk factors for this
disease. Which history finding is a risk factor for cervical cancer?

A) Pregnancy complicated with eclampsia at age 27

B) Spontaneous abortion at age 19
C) Onset of sporadic sexual activity at age 17
D) Human papillomavirus infection at age 32

50. A cervical radiation implant is placed in the client for treatment of cervical cancer.
The nurse initiates what most appropriate activity order for this client

A. Out of bed ad lib

B. Ambulation to the bathroom only
C. Bed rest
D. Out of bed in a chair only

51. The nurse is caring for a female client experiencing neutropenia as a result of
chemotherapy and develops a plan of care for the client. The nurse plans to:

A) Teach the client and family about the need for hand hygiene
B) Insert an indwelling urinary catheter to prevent skin breakdown
C) Restrict fluid intake
D) Restrict all visitors

52. A 33-yr-old patient has recently been diagnosed with stage II cervical cancer.
Which statement by the nurse best explains the diagnosis?

50
A. "The cancer is found at the point of origin only."
B. "Tumor cells have been identified in the cervical region."
C. "The cancer has been identified in the cervix and the liver."
D. "Your cancer was identified in the cervix and has limited local spread."

53. When obtaining a focused health history for a patient with possible testicular
cancer, the nurse will ask the patient about any history of

A. Testicular torsion.
B. STD infection.
C. Undescended testicles.
D. Testicular trauma.

54. When planning teaching for a patient who has had a unilateral orchiectomy and
chemotherapy for testicular cancer, the nurse will include information about the need
for:

A. Regular follow-up appointments to detect other types of malignancies.

B. Aspiration of sperm from the remaining testis if infertility occurs.
C. Testosterone supplements to help maintain erectile function.
D. Application of ice to the scrotum to minimize pain and swelling.

55. Which information will the nurse plan to include when teaching a young adult who
has a family history of testicular cancer about testicular self-examination?

A. Testicular self-examination should be done at least weekly.

B. Testicular self-examination should be done in a warm room.
C. The only structure normally felt in the scrotal sac is the testis.
D. Call the health care provider if one testis is larger than the other.

56. A 27-yr-old patient who has testicular cancer is being admitted for a unilateral
orchiectomy. The patient does not talk to his wife and speaks to the nurse only to
answer the admission questions. Which action is appropriate for the nurse to take?

A. Teach the patient and the wife that impotence is unlikely after unilateral
Orchiectomy.
B. Ask the patient if he has any questions or concerns about the diagnosis
and treatment.
C. Inform the patient's wife that concerns about sexual function are common with this
diagnosis.
D. Document the patient's lack of communication on the health record and continue
preoperative care.

57. The client asks the nurse, "They say I have cancer. How can they tell if I have
Hodgkin's disease from a biopsy?" The nurse's answer is based on which scientific
rationale?

A. Biopsies are nuclear medicine scans that can detect cancer.

B. A biopsy is a laboratory test that detects cancer cells.
C. It determines which kind of cancer the client has.
D. The HCP takes a small piece out of the tumor and looks at the cells.

51
58. The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma.
Which assessment data support this diagnosis?

A. Night sweats and fever without "chills."

B. Edematous lymph nodes in the groin.
C. Malaise and complaints of an upset stomach.
D. Pain in the neck area after a fatty meal.

59. Which information about reproduction should be taught to the 27-year-old female
client diagnosed with Hodgkin's disease?

A. The client's reproductive ability will be the same after treatment is completed.
B. The client should practice birth control for at least two (2) years
following therapy.
C. All clients become sterile from the therapy and should plan to adopt.
D. The therapy will temporarily interfere with the client's menstrual cycle.

60. Which clinical manifestation of Stage I non-Hodgkin's lymphoma would the nurse
expect to find when assessing the client?

A. Enlarged lymph tissue anywhere in the body.

B. Tender left upper quadrant.
C. No symptom in this stage.
D. Elevated B-cell lymphocytes on the CBC.

61.. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid
arthritis. The nurse should conduct a focused assessment for:

A. Limited motion of joints.

B. Deformed joints of the hands.
C. Early morning stiffness.
D. Rheumatoid nodules.

62. A client has just recently been diagnosed with rheumatoid arthritis (RA). The client
asks the nurse if RA always causes crippling deformities. The nurse tells the client that
to decrease the likelihood of deformities, it is important to: Select all that apply.

A. Ignore pain as a warning signal.

B. Type instead of hand-writing items if possible.
C. Use stronger joints for most activity.
D. Avoid stress to any current area of deformity.
E. Stop an activity if it is beyond your ability to perform.

A. A, B, C, D, E
B. C, D, E
C. B, C, D, E
D. A only

63. The nurse is collecting a health history for a client being seen in an outpatient
clinic. The client complains of joint pain and swelling that have lasted for about 2
months. The nurse devises a plan of care based on the nursing diagnosis of Activity
Intolerance based on which client statement?
52
A. "I seem to get tired early in the day and require a nap."
B. "My joints are stiffest at night before I go to sleep."
C. "I find it difficult to move when I first get up in the morning."
D. "I take ibuprofen for the pain as needed."

64. The nurse is completing a health screening for a school-age child with rheumatoid
arthritis. The parents ask the nurse to recommend activities that will promote exercise
for their child. Which is an appropriate teaching by the nurse?

A. Swimming
B. Football
C. Softball
D. Basketball the therapy and should plan to adopt.

65. A client asks the nurse what the difference is between osteoarthritis (OA) and
rheumatoid arthritis (RA). Which response is correct?

A. "OA and RA are very similar. OA affects the smaller joints and RA affects the larger,
weight-bearing joints."
B. "OA is more common in women. RA is more common in men."
C. "OA affects joints on both sides of the body. RA is usually unilateral."
D. "OA is a noninflammatory joint disease. RA is characterized by inflamed,
swollen joints."

66. The nurse is teaching a class about the joints commonly affected by osteoarthritis​
(OA). Which joints should the nurse​include?

A. Ankles, feet, and spine

B. Knees, feet, and spine
C. Hands, knees, and hips
D. Neck, shoulders, and ankles

67. A nurse is managing the care of a client with osteoarthritis. What is the
appropriate treatment strategy the nurse will teach the about for osteoarthritis?

A. Vigorous physical therapy for the joints.

B. Administration of opioids for pain control.
C. Administration of monthly intra-articular injections of corticosteroids.
D. Administration of nonsteroidal anti-inflammatory drugs (nsaids)

68. Which is an appropriate nursing intervention in the care of the client with
osteoarthritis?

A. Encourage weight loss and an increase in aerobic activity

B. Avoid the use of topical analgesics
C. Provide an analgesic after exercise
D. Assess for gastrointestinal complications associated with COX-2 inhibitors

69. A patient with an acute attack of gout is treated with colchicine. The nurse
determines that the drug is effective upon finding:

53
A. Relief of joint pain.
B. Increased urine output.
C. Decreased serum uric acid.
D. Decreased white blood cells (WBC).

70. When caring for a patient with gout and a red and painful left great toe, which
nursing action will be included in the plan of care?

A. Gently palpate the toe to assess swelling.

B. Use pillows to keep the left foot elevated.
C. Use a footboard to hold bedding away from the toe.
D. Teach patient to avoid use of acetaminophen (Tylenol).

71. Which statement best describes the method of actions of febuxostat (Uloric)?

A. Febuxostat reduces the synthesis of uric acid

B. Febuxostat increases the renal excretion of uric acid
C. Febuxostat reduces inflammation associated with gout
D. Febuxostat increases purine metabolism

72. What is the most important information for the nurse to include in a teaching plan
for the patient receiving allopurinol?

A. "do not take this medication during an acute attack of gout"

B. "include salmon and organ meats in your diet weekly"
C. "take the medication with an antacid to minimize gastrointestinal distress"
D. "this medication may cause your urine to turn orange"

73. What does the nurse teach a patient with osteomalacia to include in the daily diet?

A. Vitamin A
B. Vitamin B Complex
C. Vitamin C
D. Vitamin D

74. During a health screening event which assessment finding would alert the nurse to
the possible presence of osteoporosis in a white 61-year-old female?

A. The presence of bowed legs

B. A measurable loss of height
C. Poor appetite and aversion to dairy products
D. Development of unstable, wide-gait ambulation

75. The nurse determines that dietary teaching for a 75-year-old patient with
osteoporosis has been successful when the patient selects which highest-calcium
meal?

A. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice
B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an
apple
C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt,
and 1 cup of skim milk
54
D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast,
and a half grapefruit

76. The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of
the tibia. Which symptom will the nurse most likely find on physical examination of the
patient?

A. Nausea and vomiting

B. Localized pain and warmth
C. Paresthesia in the affected extremity
D. Generalized bone pain throughout the leg

77. Which statement by the nurse describes a comminuted fracture to the​client?

A. The ends of the broken bones are forced together."

B. The bone is breaking through the skin."
C. The bone is broken into many pieces."
D. A fragment of the bone is separated from the rest of the bone."

78. A client sustained a radial fracture and a cast was just applied. The client states
that there is unrelieved pain and numbness in the fingers on the affected side. Which
intervention should be a ​priority?

A. Notifying the healthcare provider for cast removal

B. Elevating the extremity
C. Preparing for fasciotomy
D. Performing frequent neurovascular checks

79. A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with
bathroom privileges with the affected foot elevated on two pillows. The nurse would
place highest priority on which intervention?

A. Ambulate the patient to the bathroom every 2 hours.

B. Ask the patient about preferred activities to relieve boredom.
C. Allow the patient to dangle legs at the bedside every 2 to 4 hours.
D. Perform frequent position changes and range-of-motion exercises.

80. The nurse instructs the client with a right BKA to lie on the stomach for at least 30
minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?"
Which statement is the most appropriate statement by the nurse?

A. "This position will help your lungs expand better."

B. "Lying on your stomach will help prevent contractures."
C. "Many times this will help decrease pain in the limb."
D. "The position will take pressure off your backside."

81. A person's right thumb was accidentally severed with an axe. The amputated right
thumb was recovered. Which action by the nurse preserves the thumb so it could
possibly be reattached in surgery?

A. Place the right thumb directly on some ice.

B. Put the right thumb in a glass of warm water.
55
C. Wrap the thumb in a clean piece of material.
D. Secure the thumb in a plastic bag and place on ice.

82. Which is the correct gait when a patient is ascending stairs on crutches?

A. A two-point gait (The affected leg is advanced between the crutches to the stairs.)
B. A three-point gait (The unaffected leg is advanced between the crutches
to the stairs.)
C. A swing-through gait
D. A four-point gait. (Both legs advance between the crutches to the stairs.)

83. A 26-year-old woman has been diagnosed with early systemic lupus erythematosus
(SLE) involving her joints. In teaching the patient about the disease, the nurse
includes the information that SLE is a(n):

A. Hereditary disorder of women but usually does not show clinical symptoms unless a
woman becomes pregnant.
B. Autoimmune disease of women in which antibodies are formed that destroy all
nucleated cells in the body.
C. Disorder of immune function, but it is extremely variable in its course,
and there is no way to predict its progression.
D. Disease that causes production of antibodies that bind with cellular estrogen
receptors, causing an inflammatory response.

84. A nurse is collecting data on a client who complains of fatigue, weakness, malaise,
muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic
lupus erythematosus (SLE) is suspected. The nurse further checks for which of the
following that is also indicative of the presence of SLE?

A. Emboli
B. Ascites
C. Two hemoglobin S genes
D. Butterfly rash on cheeks and bridge of nose

85. The nurse is caring for a client with systemic lupus erythematosus​ (SLE). Which
system should the nurse consider as being most affected by the formation of immune
complexes and tissue​damage?

A. Cardiac
B. Integumentary
C. Respiratory
D. Renal

86. In an individual with Sjögren's syndrome, nursing care should focus on:

A. Moisture replacement.
B. Electrolyte balance.
C. Nutritional supplementation.
D. Arrhythmia management.

56
87. An immune system disorder characterized by dry eyes and dry mouth. With this
disorder, the body's immune system attacks its own healthy cells that produce saliva
and tears. The main symptoms are dry mouth and dry eyes. Treatments include eye
drops, medications, and eye surgery.

A. Sjogren’s syndrome
B. Rheumatoid arthritis
C. Scleroderma
D. Xerostomia

88. A 40-year-old woman was diagnosed with Raynaud's phenomenon several years
earlier and has sought care because of a progressive worsening of her symptoms. The
patient also states that many of her skin surfaces are stiff, like the skin is being
stretched from all directions. The nurse should recognize the need for medical referral
for the assessment of what health problem?

A. Giant cell arteritis (GCA)

B. Fibromyalgia (FM)
C. Rheumatoid arthritis (RA)
D. Scleroderma

89. A patient has just been told by his physician that he has systemic sclerosis. The
physician tells the patient that he is going to order some tests to assess for systemic
involvement. The nurse knows that priority systems to be assessed include what?

A. Hepatic
B. Gastrointestinal
C. Genitourinary
D. Neurologic

90. A nurse is teaching a client who has a history of allergic rhinitis about the
mechanism of type I hypersensitivity. Which of the following statements should the
nurse include in the teaching?

A. "Type I hypersensitivity is caused by the binding of igg antibodies to antigens on

the surface of target cells."
B. "Type I hypersensitivity is caused by the deposition of immune complexes in the
tissues and blood vessels."
C. "Type I hypersensitivity is caused by the activation of cytotoxic T cells that destroy
the cells expressing foreign antigens."
D. "Type I hypersensitivity is caused by the cross-linking of ige antibodies to
mast cells and basophils that release histamine and other mediators."

91. A nurse is administering a blood transfusion to a client who has type AB blood. The
nurse notices that the client develops fever, chills, back pain, and hemoglobinuria after
receiving the blood. The nurse suspects that the client has developed what type of
reaction?

A. "A hemolytic transfusion reaction."

B. "An anaphylactic transfusion reaction."
C. "A febrile nonhemolytic transfusion reaction."
D. "A transfusion-related acute lung injury."
57
92. A nurse is caring for a client who has a history of bee sting allergy. The client
reports that he was stung by a bee while gardening and is feeling dizzy and short of
breath. The nurse observes that the client has urticaria, angioedema, and wheezes.
The nurse recognizes that the client is experiencing what type of reaction?

A. "A type I hypersensitivity reaction."

B. "A type II hypersensitivity reaction."
C. "A type III hypersensitivity reaction."
D. "A type IV hypersensitivity reaction."

93. Which of the following nursing interventions has the highest priority for the client
scheduled for an intravenous pyelogram?

A. Providing the client with a favorite meal for dinner

B. Asking if the client has allergies to shellfish
C. Encouraging fluids the evening before the test
D. Telling the client what to expect during the test

94. James asks Nurse Monty if an anaphylactic reaction can be as simple as developing
a rash after exposure to an allergen. Nurse Monty responds that this is:

A. True
B. False

95. Your patient is having a sudden and severe anaphylactic reaction to a medication.
You immediately stop the medication and call a rapid response. The patient's blood
pressure is 80/52, heart rate 120, and oxygen saturation 87%. Audible wheezing is
noted along with facial redness and swelling. As the nurse you know that the first
initial treatment for this patient's condition is?

A. IV Diphenhydramine
B. IV Normal Saline Bolus
C. IM Epinephrine
D. Nebulized Albuterol

96. Which member of the health care team demonstrates reducing the risk for
infection for the client with acquired immunodeficiency syndrome (AIDS)?

A. The dietary worker hands the disposable meal trays to the LPN assigned
to the client.
B. The social worker encourages the client to verbalize about stressors at home.
C. Housekeeping thoroughly cleans and disinfects the hallways near the client's room.
D. Health care provider orders vital signs including temperature every 8 hours.

97. The nurse is instructing an unlicensed health care worker on the care of the client
with HIV who also has active genital herpes. Which statement by the health care
worker indicates effective teaching of standard precautions?

A. ''I need to know my HIV status, so I must get tested before caring for any clients."
B. ''Putting on a gown and gloves will cover up the itchy sores on my elbows.''

58
C. ''Washing my hands and putting on a gown and gloves is what I must do
before starting care.''
D. ''I will wash my hands before going into the room, and then put on gown and
gloves only for direct contact with the client's genitals."

98. Which statement made to the nurse by a health care worker assigned to care for
the client with HIV indicates a breach of confidentiality and requires further education
by the nurse?

A. ''I told the family members they needed to wash their hands when they enter and
leave the room.''
B. ''The other health care worker and I were out in the hallway discussing
how we were concerned about getting HIV from our client, so no one could
hear us in the client's room.''
C. ''Yes, I understand the reasons why I have to wear gloves when I bathe my client.''
D. ''The client's spouse told me she got HIV from a blood transfusion.

99. When preparing the newly diagnosed client with HIV and significant other for
discharge, which explanation by the nurse accurately describes proper condom use?

A. ''Condoms should be used when lesions on the penis are present.''

B. ''Always position the condom with a space at the tip of an erect penis.''
C. ''Make sure it fits loosely to allow for penile erection.''
D. ''Use adequate lubrication such as petroleum jelly.''

100. A client with acquired immunodeficiency syndrome (AIDS) is experiencing

shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure
should the nurse include in the plan of care to assist the client in performing activities
of daily living?

A. Provide supportive care with hygiene needs

B. Provide meals and snacks with high-protein, high calorie, and high-nutritional value
C. Provide small, frequent meals
D. Offer low microbial foods

59
RECALLS 3 NP 5

1. The focus of this therapy is to have a positive environmental manipulation, physical

and social to effect a positive change.

a. Milieu
b. Psychotherapy
c. Behavior
d. Group

2.The client asks the nurse about milieu therapy. The nurse responds knowing that the
primary focus of milieu therapy can be best described by which of the following?

a. A form of behavior modification therapy

b. A cognitive approach of changing the behavior
c. A living, learning or working environment
d. A behavioral approach to changing behaviour

3. A nurse is caring for a client with phobia who is being treated for the condition. The
client is introduced to short periods of exposure to the phobic object while in relaxed
state. The nurse understands that this form of behavior modification can be best
described as:

a. Systematic desensitization
b. Self-control therapy
c. Aversion therapy
d. Operant conditioning

4. A client with major depression is considering cognitive therapy. The client say to the
nurse, “how does this treatment works?” The nurse responds by telling the client that:

a. “this type of treatment helps you examine how your thoughts and
feelings contribute to your difficulties”
b. “this type of treatment helps you examine how your past life has contributed to
your problems.”
c. “this type of treatment helps you to confront your fears by exposing you to the
feared object abruptly.
d. “this type of treatment will help you relax and develop new coping skills.”

5. A client state, “I get down on myself when I make mistake.” Using cognitive therapy
approach, the nurse should:

a. Teach the client relaxation exercise to diminish stress

b. Provide the client with mastery experience to boost self esteem
c. Explore the client’s past experiences that causes the illness
d. Help client modify the belief that anything less than perfect is horrible

6. The most advantageous therapy for a preschool age child with a history of physical
and sexual abuse would be:

a. Play

60
b. Psychoanalysis
c. Group
d. Family

7. An 18 year old client is admitted with the diagnosis of anorexia nervosa. A cognitive
behavioral approach is used as part of her treatment plan. The nurse understands that
the purpose of this approach is to:

a. Help the client identify and examine dysfunctional thoughts and beliefs
b. Emphasize social interaction with clients who withdraw
c. Provide a supportive environment and a therapeutic community
d. Examine intrapsychic conflicts and past events in life

8. The nurse is preparing to provide reminiscence therapy for a group of clients. Which
of the following clients will the nurse select for this group?

a. A client who experiences profound depression with moderate cognitive impairment

b. A catatonic, immobile client with moderate cognitive impairment
c. An undifferentiated schizophrenic client with moderate cognitive impairment
d. A client with mild depression who exhibits who demonstrates normal
cognition

9. Which intervention would be typical of a nurse using cognitive-behavioral approach

to a client experiencing low self-esteem?

a. Use of unconditional positive regard

b. Analysis of free association
c. Classical conditioning
d. Examination of negative thought patterns

10. Which of the following therapies has been strongly advocated for the treatment of
post- traumatic stress disorders?

a. ECT
b. Group therapy
c. Hypnotherapy
d. Psychoanalysis

11. The nurse knows that in group therapy, the maximum number of members to
include is:

a. 4
b. 8
c. 10
d. 16

12. The nurse is providing information to a client with the use of disulfiram (Antabuse)
for the treatment of alcohol abuse. The nurse understands that this form of therapy
works on what principle?

a. Negative reinforcement
b. Operant conditioning
61
c. Aversion therapy
d. Gestalt therapy

13. A biological or medical approach in treating psychiatric patient is:

a. Million therapy
b. Behavioral therapy
c. Somatic therapy
d. Psychotherapy

14. Which of these nursing actions belong to the secondary level of preventive
intervention?

a. Providing mental health consultation to health care providers

b. Providing emergency psychiatric services
c. Being politically active in relation to mental health issues
d. Providing mental health education to members of the community

15. When the nurse identifies a client who has attempted to commit suicide the nurse
should:

a. Call a priest
b. Counsel the client
c. Refer the client to the psychiatrist
d. Refer the matter to the police

Situation: Rose seeks psychiatric consultation because of intense fear of flying in an

airplane which has greatly affected her chances of success in her job.

16. The most common defense mechanism used by phobic clients is:

a. Suppression
b. Denial
c. Rationalization
d. Displacement

17. The goal of the therapy in phobia is:

a. Change her lifestyle

b. Ignore tension producing situation
c. Change her reaction towards anxiety
d. Eliminate fear producing situations

18. The therapy most effective for client’s with phobia is:

a. Hypnotherapy
b. Cognitive therapy
c. Group therapy
d. Behavior therapy

19. The fear and anxiety related to phobia is said to be abruptly decreased when the
patient is exposed to what is feared through:
62
a. Guided imagery
b. Systematic desensitization
c. Flooding
d. Hypnotherapy

20. Based on the presence of symptom, the appropriate nursing diagnosis is:

a. Self-esteem disturbance
b. Activity intolerance
c. Impaired adjustment
d. Ineffective individual coping

Situation: Mang Jose, 39 year old farmer, unmarried, had been confined in the national
center for mental health for three years with a diagnosis of schizophrenia.

21. The most common defense mechanism used by a paranoid client is:

a. Displacement
b. Rationalization
c. Suppression
d. Projection

22. When Mang Jose says to you: “the voices are telling me bad things again!” The
best response is:

a. “whose voices are those?”

b. “I doubt what the voices are telling you”
c. “I do not hear the voice you say you hear”
d. “are you sure you hear these voices?”

23. A relevant nursing diagnosis for clients with auditory hallucination is:

a. Sensory perceptual alteration

b. Altered thought process
c. Impaired social interaction
d. Impaired verbal communication

24. During mealtime, Jose refused to eat telling that the food was poisoned. The nurse
should:

a. Ignore his remark

b. Offer him food in his own container
c. Show him how irrational his thinking is
d. Respect his refusal to eat

25. When communicating with Jose, the nurse considers the following except:

a. Be warm and enthusiastic

b. Refrain from touching Jose
c. Do not argue regarding his hallucination and delusion
d. Use simple, clear language
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Situation: Gringo seeks psychiatric counselling for his ritualistic behavior of counting
his money as many as 10 times before leaving home.

26. An initial appropriate nursing diagnosis is:

a. Impaired social interaction

b. Ineffective individual coping
c. Impaired adjustment
d. Anxiety moderate

27. Obsessive compulsive disorder is best described by:

a. Uncontrollable impulse to perform an act or ritual repeatedly

b. Persistent thoughts
c. Recurring unwanted and disturbing thought alternating with a behavior
d. Pathological persistence of unwilled thought, feeling, or impulse

28. The defense mechanism used by persons with obsessive compulsive disorder is
undoing and itis best described in one of the following statements:

a. Unacceptable feelings or behavior are kept out of awareness by developing the

opposite behavior or emotion
b. Consciously unacceptable instinctual drives are diverted into personally and socially
acceptable channels
c. Something unacceptable already done is symbolically acted out in reverse
d. Transfer of emotions associated with a particular person, object or situation to
another less threatening person, object or situation

29. To be more effective, the nurse who cares for persons with obsessive compulsive
disorder must possess one of the following qualities:

a. Compassion
b. Patience
c. Consistency
d. Friendliness

30. Persons with OCD usually manifest:

a. Fear
b. Apathy
c. Suspiciousness
d. Anxiety

Situation:
The patient who is depressed will undergo electroconvulsive therapy.

31. Studies on biological depression support electroconvulsive therapy as a mode of

treatment. The rationale is:

a. ECT produces massive brain damage which destroys the specific area containing
memories related to the events surrounding the development of psychotic condition
64
b. The treatment serves as a symbolic punishment for the client who feels guilty and
worthless.
c. ECT relieves depression psychologically by increasing the norepinephrine
level
d. ECT is seen as a life-threatening experience and depressed patients mobilize all
their bodily defenses to deal with this attack.

32. The preparation of a patient for ECT ideally is most similar to preparation for a
patient for:

a. Electroencephalogram
b. General anesthesia
c. X-ray
d. Electrocardiogram

33. Which of the following is a possible side effect which you will discuss with the
patient?

a. Hemorrhage within the brain

b. Encephalitis
c. Robot-like body stiffness
d. Confusion, disorientation and short term memory loss

34. Informed consent is necessary for the treatment for involuntary clients. When this
cannot be obtained, permission may be taken from the:

a. Social worker
b. Next of kin or guardian
c. Doctor
d. Chief nurse

35. After ECT, the nurse should do this action before giving the client fluids, food or
medication:

a. Assess the gag reflex

b. Next of kin or guardian
c. Assess the sensorium
d. Check o2 sat with a pulse oximeter

Situation: Mrs. Ethel Agustin 50 y/o, teacher is afflicted with myasthenia gravis.

36. Looking at Mrs. Agustin, your assessment would include the following except;

a. Nystagmus
b. Difficulty of hearing
c. Weakness of the levator palpebrae
d. Weakness of the ocular muscle

37. In an effort to combat complications which might occur relatives should he

taught;

a. Checking cardiac rate

65
b. Taking blood pressure reading
c. Techniques of oxygen inhalation
d. Administration of oxygen inhalation

38. The drug of choice for her condition is;

a. Prostigmine
b. Morphine
c. Codeine
d. Prednisone

39. As her nurse, you have to be cautious about administration of medication, if she
is under medicated this can cause;

a. Emotional crisis
b. Cholinergic crisis
c. Menopausal crisis
d. Myasthenic crisis

40. If you are not extra careful and by chance you give over medication, this would
lead to;

a. Cholinergic crisis
b. Menopausal crisis
c. Emotional crisis
d. Myasthenia crisis

Situation: Rosanna 20 y/o unmarried patient believes that the toilet for the female
patient in contaminated with aids virus and refuses to use it unless she flushes it three
times and wipes the seat same number of times with antiseptic solution.

41. The fear of using “contaminated” toilet seat can be attributed to Rosanna’s
inability to;

a. Adjust to a strange environment

b. Express her anxiety
c. Develop the sense of trust in other person
d. Control unacceptable impulses or feelings

42. Assessment data upon admission help the nurse to identify this appropriate
nursing diagnosis

a. Ineffective denial
b. Impaired adjustment
c. Ineffective individual coping
d. Impaired social interaction

43. An effective nursing intervention to help Rosana is;

a. Convincing her to use the toilet after the nurse has used it first
b. Explaining to her that aids cannot be transmitted by using the toilet

66
c. Allowing her to flush and clear the toilet seat until she can manage her
anxiety
d. Explaining to her how aids is transmitted

44. The goal for treatment for Rosana must be directed toward helping her to;

a. Walk freely about her past experience

b. Develop trusting relationship with others
c. Gain insight that her behavior is due to feeling of anxiety
d. Accept the environment unconditionally

45. Psychotherapy which is prescribed for Rosana is described as;

a. Establishing an environment adapted to an individual patient needs

b. Sustained interaction between the therapist and client to help her
develop more functional behavior
c. Using dramatic techniques to portray interpersonal conflicts
d. Biologic treatment for mental disorder

Situation: Dennis 40 y/o married man, an electrical engineer was admitted with the
diagnosis of paranoid disorders. He has become suspicious and distrustful 2 months
before admission. Upon admission, he kept on saying, “my wife has been planning to
kill me.”

46. A paranoid individual who cannot accept the guilt demonstrate one of the
following defense mechanism;

a. Denial
b. Projection
c. Rationalization
d. Displacement

47. One morning, Dennis was seen tilting his head as if he was listening to someone.
An appropriate nursing intervention would be;

a. Tell him to socialize with other patient to divert his attention

b. Involve him in group activities
c. Address him by name to ask if he is hearing voices again
d. Request for an order of antipsychotic medicine

48. When he says, “these voices are telling me my wife is going to kill me.” A
therapeutic communication of the nurse is which one of the following;

a. “I do not hear the voices you say you hear”

b. “are you really sure you heard those voices?”
c. “I do not think you heard those voices?”
d. “whose voices are those?”

49. The nurse confirms that Dennis is manifesting auditory hallucination. The
appropriate nursing diagnosis she identifies is;

a. Sensory perceptual alteration

67
b. Self-esteem disturbance
c. Ineffective individual coping
d. Defensive coping

50. Most appropriate nursing intervention for a client with suspicious behavior is
one of the following;

a. Talk to the client constantly to reinforce reality

b. Involve him in competitive activities
c. Use non-judgmental and consistent approach
d. Project cheerfulness in interacting with the patient

Situation:
Clients with bipolar disorder receives a very high nursing attention due to the
increasing rate of suicide related to the illness.

51. The nurse is assigned to care for a recently admitted client who has attempted
suicide. What should the nurse do?

a. Search the client's belongings and room carefully for items that could be
used to attempt suicide.
b. Express trust that the client won't cause self-harm while in the facility.
c. Respect the client's privacy by not searching any belongings.
d. Remind all staff members to check on the client frequently.

52. In planning activities for the depressed client, especially during the early stages of
hospitalization, which of the following plan is best?

a. Provide an activity that is quiet and solitary to avoid increased fatigue such as
working on a puzzle and reading a book.
b. Plan nothing until the client asks to participate in the milieu
c. Offer the client a menu of daily activities and ask the client to participate in all of
them
d. Provide a structured daily program of activities and encourage the client
to participate

53. A client with a diagnosis of major depression, recurrent with psychotic features
is admitted to the mental health unit. To create a safe environment for the client, the
nurse most importantly devises a plan of care that deals specifically with the clients:
a. Disturbed thought process
b. Imbalanced nutrition
c. Self-care deficit
d. Deficient knowledge

54. The client is taking a tricyclic anti-depressant, which of the following is an

example of TCA?

a. Paxil
b. Nardil
c. Zoloft
d. Pamelor

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55. A client visits the physician's office to seek treatment for depression, feelings of
hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poor concentration,
and difficulty making decisions. The client states that these symptoms began at least 2
years ago. Based on this report, the nurse suspects:

a. Cyclothymic disorder.
b. Bipolar disorder
c. Major depression.
d. Dysthymic disorder.

56. The nurse is planning activities for a client who has bipolar disorder, which
aggressive social behavior. Which of the following activities would be most appropriate
for this client?

a. Ping pong
b. Linen delivery
c. Chess
d. Basketball

57. The nurse assesses a client with admitted diagnosis of bipolar affective disorder,
mania. The symptom presented by the client that requires the nurse’s immediate
intervention is the client’s:

a. Outlandish behavior and inappropriate dress

b. Grandiose delusion of being a royal descendant of King Arthur
c. Nonstop physical activity and poor nutritional intake
d. Constant incessant talking that includes sexual topics and teasing the staff

58. A nurse is conducting a group therapy session and during the session, a client with
mania consistently talks and dominates the group. The behavior is disrupting the
group interaction, the nurse would initially:

a. Ask the client to leave the group session

b. Tell the client that she will not be allowed to attend any more group sessions
c. Tell the client that she needs to allow other client in a group time to talk
d. Ask another nurse to escort the client out of the group session

59. A professional artist is admitted to the psychiatric unit for treatment of bipolar
disorder. During the last 2 weeks, the client has created 154 paintings, slept only 2 to
3 hours every 2 days, and lost 18 lb (8.2 kg). Based on Maslow’s hierarchy of needs,
what should the nurse provide this client with first?

a. The opportunity to explore family dynamics

b. Help with re-establishing a normal sleep pattern
c. Experiences that build self-esteem
d. Art materials and equipment

60. The physician orders lithium carbonate (Lithonate) for a client who's in the manic
phase of bipolar disorder. During lithium therapy, the nurse should watch for which
adverse reactions?

a. Anxiety, restlessness, and sleep disturbance

69
b. Nausea, diarrhea, tremor, and lethargy
c. Constipation, lethargy, and ataxia
d. Weakness, tremor, and urine retention

Situation: Annie has a morbid fear of heights.She asks the nurse what desensitization
therapy is:

61. The accurate information of the nurse of the goal of desensitization is:

a. To help the clients relax and progressively work up a list of anxiety

provoking situations through imagery.
b. To provide corrective emotional experiences through a one-to-one intensive
relationship.
c. To help clients in a group therapy setting to take on specific roles and reenact in
front of an audience, situations in which interpersonal conflict is involved.
d. To help clients cope with their problems by learning behaviors that are more
functional and be better equipped to face reality and make decisions.

62. It is essential in desensitization for the patient to:

a. Have rapport with the therapist

b. Use deep breathing or another relaxation technique
c. Assess one’s self for the need of an anxiolytic drug
d. Work through unresolved unconscious conflicts

63. In this level of anxiety, cognitive capacity diminishes. Focus becomes limited and
client experiences tunnel vision. Physical signs of anxiety become more pronounced.

a. Severe anxiety
b. Mild anxiety
c. Panic
d. Moderate anxiety

64. Antianxiety medications should be used with extreme caution because long term
use can lead to:

a. Parkinsonian like syndrome

b. Hepatic failure
c. Hypertensive crisis
d. Risk of addiction

65. The nursing management of anxiety related with post-traumatic stress disorder
includes all of the following except:

a. Encourage participation in recreation or sports activities

b. Reassure client’s safety while touching client
c. Speak in a calm soothing voice
d. Remain with the client while fear level is high

Situation: You are fortunate to be chosen as part of the research team in the hospital.
A review of the following
important nursing concepts was made.
70
66. As a professional, a nurse can do research for varied reason except:

a. Professional advancement through research participation

b. To validate results of new nursing modalities
c. For financial gains
d. To improve nursing care

67. Each nurse participants was asked to identify a problem. After the identification of
the research problem, which of the following should be done?

a. Methodology
b. Acknowledgement
c. Review of related literature
d. Formulate hypothesis

68. Which of the following communicate the results of the research to the readers.
They facilitate the description of the data.

a. Hypothesis
b. Research problem
c. Statistics
d. Tables and graphs

69. In quantitative date, which of the following is described as the distance in the
scoring unites of the variable from the highest to the lower?

a. Frequency
b. Median
c. Mean
d. Range

70. This expresses the variability of the data in reference to the mean. It provides as
with a numerical estimate of how far, on the average the separate observation are
from the mean:

a. Mode
b. Median
c. Standard deviation
d. Frequency

Situation: Survey and statistics are important part of research that is necessary to
explain the characteristics of the population.

71. According to the who statistics on the homeless population around the world,
which of the following groups of people in the world disproportionately represents the
homeless population?

a. Hispanics
b. Asians
c. African Americans
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d. Caucasians

72. All but one of the following is not a measure of central tendency:

a. Mode
b. Standard deviation
c. Variance
d. Range

73. In the value: 87, 85, 88, 92, 90; what is the Mean?

a. 88.2
b. 88.4
c. 87
d. 88.6

74. In the value: 80, 80, 80, 82, 82, 90, 90, 100; what is the mode?

a. 80
b. 82
c. 90
d. 85.5

75. In the value: 80, 80, 10, 10, 25, 65, 100, 200; What is the median?

a. 71.25
b. 22.5
c. 10 and 25
d. 72.5

76. Draw lots, lottery, table of random numbers or a sampling that ensures that each
element of the population has an equal and independent chance of being chosen is
called:

a. Cluster
b. Stratified
c. Simple
d. Systematic

77. An investigator wants to determine some of the problems that are experienced by
diabetic clients when using an insulin pump. The investigator went into a clinic where
he personally knows several diabetic clients having problem with insulin pump. The
type of sampling done by the investigator is called:

a. Probability
b. Snowball
c. Purposive
d. Incidental

78. If the researcher implemented a new structured counselling program with a

randomized group of subject and a routine counselling program with another
randomized group of subject, the research is utilizing which design?
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a. Quasi experimental
b. Comparative
c. Experimental
d. Methodological

79. Which of the following is not true about a pure experimental research?

a. There is a control group

b. There is an experimental group
c. Selection of subjects in the control group is randomized
d. There is a careful selection of subjects In the experimental group

80. The researcher implemented a medication regimen using a new type of

combination drugs to manic patients while another group of manic patient receives the
routine drugs. The researcher however handpicked the experimental group for they
are the clients with multiple episodes of bipolar disorder. The researcher utilized which
research design?

a. Quasi-experimental
b. Phenomenological
c. Pure experimental
d. Longitudinal

Situation 19: As a nurse, you are expected to participate in initiating or participating in

the conduct of research studies to improve nursing practice. For you to be updated on
the latest trends and issues affected the profession and the best practices arrived at by
the profession.

81. You are interested to study the effects of mediation and relaxation on the pain
experienced by cancer patients. What type of variable is pain?

a. Dependent
b. Independent
c. Correlational
d. Demographic

82. You would like to compare the support system of patient with chronic illness to
those with acute illness. How will you best state your problem?

a. A descriptive study to compare the support system of patients with chronic illness
and those with acute illness in terms of demographic data and knowledge about
intervention.
b. The effects of the types of support system of patients with chronic illness and those
with acute illness.
c. A comparative analysis of the support system of patients with chronic illness and
those with acute illness.
d. A study to compare the support system of patients with chronic illness and those
with acute illness.
e. What are the differences of the support system being received by patient
with chronic illness and patients with acute illness?

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83. You would like to compare the support system of patients with chronic illness to
those with acute illness. Considering that the hypothesis was: “client’s with chronic
illness have lesser support system than client’s with acute illness.” What type of
research is this?

a. Descriptive
b. Correlational, non-experimental
c. Experimental
d. Quasi experimental

84. In any research study where individual persons are involved, it is important that
an informed consent of the study is obtained. The following are essential information
about the consent that you should disclose to the prospective subjects except:

a. Consent to incomplete disclosure

b. Description of benefits, risks and discomforts
c. Explanation of procedure
d. Assurance of anonymity and confidentiality

85. In the hypothesis: “the utilization of technology in teaching improves the retention
and attention of the nursing students.” Which is the dependent variable?

a. Utilization of technology
b. Improvement in the retention and attention
c. Nursing students
d. Teaching

Situation:
A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration
secondary to starvation.

86. Which of the following nursing diagnoses will be given priority for the client?

a. Altered self-image
b. Fluid volume deficit
c. Altered nutrition less than body requirements
d. Altered family process

87. What is the best intervention to teach the client when she feels the need to
starve?

A. Allow her to starve to relieve her anxiety

B. Do a short term exercise until the urge passes
C. Approach the nurse and talk out her feelings
D. Call her mother on the phone and tell her how she feels

88. The client with anorexia nervosa is improving if:

A. She eats meals in the dining room.

B. Weight gain
C. She attends ward activities.
D. She has a more realistic self-concept.
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89. The characteristic manifestation that will differentiate bulimia nervosa from
anorexia nervosa is that bulimic individuals

a. Have episodic binge eating and purging

b. Have repeated attempts to stabilize their weight
c. Have peculiar food handling patterns
d. Have threatened self-esteem

90. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in
control of eating habits. The goal for this problem is:

a. Patient will learn problem solving skills

b. Patient will have decreased symptoms of anxiety.
c. Patient will perform self-care activities daily.
d. Patient will verbalize how to set limits on others.

Situation: Mastery of research design determination is essential in passing the NLE.

91. Ana wants to know if the length of time she will study for the board examination
is proportional to her board rating. During the June 2008 board examination, she
studied for 6 months and gained 68%, on the next board exam, she studied for 6
months again for a total of 1 year and gained 74%, on the third board exam, she
studied for 6 months for a total of 1 and a half Year and gained 82%. The research
design she used is:

a. Comparative
b. Experimental
c. Correlational
d. Qualitative

92. Anton was always eating high fat diet. You want to determine if what will be the
effect of high cholesterol food to Anton in the next 10 years. You will use:

a. Comparative
b. Historical
c. Correlational
d. Longitudinal

93. Community a was selected randomly as well as community b, nurse Edna

conducted teaching to community a and assess if community a will have a better
status than community b. This is an example of:

a. Comparative
b. Experimental
c. Correlational
d. Qualitative

94. Ana researched on the development of a new way to measure intelligence by

creating a 100 item questionnaire that will assess the cognitive skills of an individual.
The design best suited for this study is:
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a. Historical
b. Survey
c. Methodological
d. Case study

95. Gen is conducting a research study on the lived experiences of First-generation

graduates of the pandemic. What is the best research design to be used for this?

a. Historical
b. Phenomenological
c. Case study
d. Ethnographic

96. Marco is to perform a study about how nurses perform surgical asepsis during
world war II. A design best for this study is:

a. Historical
b. Phenomenological
c. Case study
d. Ethnographic

97. Tonyo conducts sampling at barangay 412. He collected 100 random individuals
and determine who is their favorite comedian actor. 50% said Dolphy, 20% said Vic
sotto, while some answered Joey De Leon, Allan K, Michael v. Tonyo conducted what
type of research study?

a. Phenomenological
b. Non experimental
c. Case study
d. Survey

98. Jane visited a tribe located somewhere in China, it is called the shin Jea tribe.
She studied the way of life, tradition and the societal structure of these people. Jane
will best use which research design?

a. Historical
b. Phenomenological
c. Case study
d. Ethnographic

99. Anjoe researched on tb. Its transmission, causative agent and factors, treatment
sign and symptoms as well as medication and all other in depth information about
tuberculosis. This study is best suited for which research design?

a. Historical
b. Phenomenological
c. Case study
d. Ethnographic

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100. Diana is to conduct a study about the relationship of the number of family
members in the household and the electricity bill. Which of the following is the best
research design suited for this study?

1. Descriptive
2. Exploratory
3. Explanatory
4. Correlational
5. Comparative
6. Experimental

a. 1,4
b. 2,5
c. 3,6
d. 1,5
e. 2,4

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