medical and surgical MCQ 3

1. Two days after the admission, the client has a large amount of urine and a serum sodium level of 155 mEq/dl. Which, of the following conditions may be developing?

a. Myxedema coma
b. Diabetes insipidus
c. Type 1 diabetes mellitus
d. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

2. After a thorough assessment and laboratory works shall shows serum ketones and serum glucose level above 300 mg/dl, what condition would be diagnosed to patient?

a. Diabetes insipidus
b. Diabetes ketoacidosis
c. Hypoglycemia
d. Somogyi phenomena

3. Which of the following combinations of adverse effects must be carefully monitored when administering I.V. insulin to a client diagnosed with diabetic ketoacidosis?

a. Hypokalemia and hypoglycemia
b. Hypocalcemia and Hyperkalemia
c. Hyperkalemia and hyperglycemia
d. Hypernatremia and hypercalcemia

4. Which of the following method of insulin administration would be used in the initial treatment of hyperglycemia in a client with diabetic ketoacidosis.

a. Subcutaneous
b. Intramuscular
c. I.V bolus only
d. I.V. bolus followed by continuous infusion

5. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can be differentiated from diabetic ketoacidosis by which of the following conditions?

a. Hyperglycemia
b. Serum osmolarity
c. Absence of ketosis
d. Hypokalemia

Situation 2: Mr. Reynaldo Layag executive officer, was brought to the hospital because of chest pain. Diagnosis of angina was established.

6. Mr. Layag state that his anginal pain increases after activity. The nurse should realize that the angina pectoris is a sign of:

a. Mitral insufficiency
b. Myocardial infraction
c. Myocardial ischemia
d. Coronary thrombosis

7. Nitroglycerin S.L. is prescribed for Mr. Layag’s anginal pain. When teaching how to use nitroglycerine, the nurse tells him to place 1 tablet under the tongue when pain occurs and to repeat the dose in 5 minutes if pain persist. The nurse should tell Mr. Layag to:

a. Place two tablets under the tongue when the intense pain occurs
b. Swallow 1 tablet and place 1 tablet under the tongue when pain is intense
c. Place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes if pain occurs
d. Place 1 tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent reoccurrence

8. The nurse realizes that the pain associated with coronary occlusion is caused primarily by:

a. Arterial Spasm
b. Ischemia of the heart muscle
c. Blocking of the coronary veins
d. Irritation of the nerve endings in the cardiac plexus

9. When cardiovascular disease is concern, reduction of the saturated fat in the diet may be desired and substance made of polyunsaturated fat When teaching about this diet the nurse should instruct Mr. Layag to avoid :

a. Fish
b. Corn Oil
c. Whole milk
d. soft margarine

10. When teaching Mr. Layag, who has been placed on a high-unsaturated fatty acid diet, the nurse should stress the importance of increasing the intake of:

a. Enriched whole milk
b. Red meats, such as beef
c. Vegetables and Whole Grains
d. Liver and other glandular organ meals

Situation 3: A group of nursing students were discussing the normal growth and development concepts when assigned to observe the school children.

11. During the oedipal stage of growth and development, the child:

a. Loves and hates ( ambivalence) both parents
b. Loves the parent of the same sex and the parent of the opposite sex
c. Loves the parent of the opposite sex and hates the parent of the same sex
d. Love the parent of the same sex and hates the parent of the opposite sex.

12. The stage of growth and development basically concerned with the role identification is the:

a. Oral Stage
b. Genital-Stage
c. Oedipal Stage
d. Latency stage

13. Play for the preschool-age child is necessary for the emotional development of:

a. Projection
b. Introjection
c. Competition
d. Independence

14. Resolution of the oedipal complex takes place when the child overcomes the castration complex and:

a. Rejects the parent of the same sex
b. Introjects behavior of both parents
c. Identities with me parent of the same sex
d. Identifies with the parent of the opposite sex

15. Any surgery should be delayed, if possible, because of me effects on personality development during the

a. Oral Stage.
b. Anal Stage
c. Oedipal Stage
d. Latency Stage

Situation 4 – Transurethral resection prostatectomy, (TURP) is performed to Mr. Recto, 60 years old, due to prostate enlargement. Post operatively he has continuous irrigation (Cystoclysis).

16. Which of these statements explain the reason for continuous bladder irrigation?

a. To remove clot from the bladder
b. To maintain the patency of the catheter
c. To maintain the patency of me bladder
d. To dilute urine

17. Nursing assessment is vital to prevent and detect indications of postoperative complications. The following are the possible complications after prostatectomy except:

a. Residual urine
b. Urethral structure
c. Erectile dysfunction
d. The drainage has stopped

18. When should the nurse increase, the flow rate of cystoclysis of Mr.Recto?

a. The drainage appear cloudy
b. The drainage is continuous but slow
c. The drainage is bright red
d. The drainage has stopped

19. After the removal of the three way catheter, the nurse should inform Mr. Recto that he can normally experience:

a. Dribbling incontinence
b. Polyuria
c. Dysuria
d. The drainage has stopped

20. Which of the following measures should you encourage Mr. Recto to do, in order to regain urinary control?

a. Wear scrotal support
b. Take warm bath 2 times daily
c. Ambulate frequently
d. Alternately tense and relax the perineal muscles

Situation 5 – Nurses are generalist, in order to cope up with the works demand you must have broad knowledge on anything. Nurse Joan was assigned in the medical ward. During the endorsement she found out that she was assigned to several patients of different case

21. When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress

a. Glaucoma is easily corrected with eye glasses
b. White and Asian individuals are the highest risk of glaucoma
c. Yearly screening for people ages 20 to 40 years is recommended
d. Glaucoma can be painless and visions may be lost before the person is aware of the problem.

22. Which of the conditions is an early symptoms commonly seen in Myasthenia Gravis?

a. Dysphagia
b. Fatigue improving at the end of the day
c. Ptosis
d. Respiratory Distress

23. Which of the following statements best describes the Parkinson’s Disease?

a. Loss of myelin sheath surrounding peripheral nerves
b. Degeneration of the substantia nigra; depleting dopamine
c. Bleeding into the brain stem, resulting in meter dysfunction
d. An autoimmune disorder that destroys acetylcholine receptors

24. Which of the following pathophysiological processes are involved in multiple sclerosis (MS)?

a. Destruction of the brainstem and basal ganglia in the brain
b. Degeneration of the nucleus pulposus, causing pressure on the spinal cord
c. Chronic inflammation of rhizomes just outside the central nervous system
d. Development of demyelination of the myelin sheath, interfering with the nerve transmission

25. When teaching the client, with Meniere’s disease, which of the following instructions would a nurse give about vertigo.

a. Report dizziness at once
b. Drive in daylight hours only
c. Get up slowly, turning the entire body
d. Change your position using the log roll technique

Situation 6 – Mr. Punsalan is 36 years old, was admitted to the hospital with complaints of a burning sensation in the epigastric area after eating and inability to sleep at night. He was placed on bed rest and schedule for diagnostic studies. A diagnosis of Peptic Ulcer was made.

26. Mr. Punsalan with gastric pain is advised to take any one of the following antacids, except:

a. Aluminum hydroxide
b. Calcium bicarbonate
c. Magnesium carbonate
d. Sodium bicarbonate

27. An occult blood examination was ordered. The specific specimen needed from Mr. Punsalan is;

a. Stool
b. Blood
c. Sputum
d. Gastric juice

28. Preparation of Mr. Punsalan for occult blood examination is :

a. Fluid intake is limited only 1 liter/day
b. NPO for 12 hours prior to obtaining of specimen
c. Fluid intake is increased
d. Meatless diet for 48 hours prior to obtaining of specimen

29. X -ray examination for Mr. Punsalan to detect tumors or ulcerations of the stomach and duodenum is:

a. Gastroscopy
b. GIT series
c. Cold G.I. series
d. Ba enema

30. Diet that prevents gastric irritation in case of Mr. Punsalan is:
a. Bland Diet
b. Liquid Diet
c. Full Diet
d. High Protein low fat diet

Situation 7 – Mr. Reyes suffered head injuries in a motor vehicle accident

31. When caring for Mr. Reyes, the nurse should assess for

a. Decreased carotid pulses
b. Bleeding from oral cavity
c. Altered level of consciousness
d. Absence of deep tendon-reflexes

32. Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;

a. Confusion or delirium can be a defense against further stress
b. Destruction of brain cells has occurred, interrupting mental activity
c. Teaching based on information progressing from the simple to the complex
d. A minimum of information should be given, since he is unaware of surroundings

33. Mr. Reyes complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the

a. Frontal lobe
b. Occipital lobe
c. Six cranial nerve (abducent)
d. Eight Cranial Nerve (Vestibulocochlear)

34. Mr. Reyes has a possible skull fracture. The nurse should:

a. Observe him for signs of Brain injury
b. Check for hemorrhaging from the oral cavity
c. Elevate the foot of the bed if he develops symptoms of shock
d. Observe for symptoms of decreased intracranial pressure and temperature

35. Mr. Reyes has expressive aphasia. As a part of a long range planning. The nurse should ;

a. Provide positive feedback when he uses the word correctly
b. Wait for him to verbally state needs regardless of how long it may take c. Suggest that he get help at home because the disability is permanent
d. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication

Situation 8 – Patricia Zeno is a client with history myasthenia gravis.

36. Clients with myasthenia gravis, Guillain – Barre Syndrome or amyotrophic sclerosis experience:

a. Progressive deterioration until death
b. Increased risk of respiratory complications
c. Deficiencies of essential neurotransmitter
d. Involuntary twitching of small muscle groups

37. Myasthenia gravis most frequently affect:

a. Males ages 15 to 3 5 years
b. Children ages 5 to 15 years
c. Female ages 10 to 30 years old
d. Both sexes ages 20 to 40 years

38. Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

a. A genetic defect in the production of acetylcholine
b. A reduced amount of neurotransmitter acetylcholine
c. A decreased number of functioning acetylcholine receptor sites
d. An inhibition of the enzyme Ache leaving the end plates folded.

39. To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:

a. A tracheostomy set
b. An intravenous set-up
c. A hypothermia blanket
d. A syringe and edrophonium HCl(Tensilon)

40. Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:

a. For its synergistic effect
b. To rule out cholinergic crisis
c. To confirm the diagnosis of myasthenia
d. Because of the client’s resistance to Neostigmine

Situation 9 – Harriet, a 38 year-old schoolteacher with rheumatoid arthritis, is admitted to the hospital with severe and swelling of the joints of both hands.

41. A regimen of rest, exercises and physical therapy is ordered for Hariet This regimen will;

a. Prevent arthritic pain
b. Halt me inflammatory process
c. Help prevent the crippling effects of the disease
d. Provide for the return of joint motion after prolonged loss

42. Harriet ask the nurse why the physician is going to inject hydrocortisone into her affected joint. The nurse explains that the most important reason for doing this is to:

a. Relieve pain
b. Reduce inflammation
c. Provide Psychotherapy
d. Prevent ankylosis of the joint

43. When planning nursing care for Hariet, the nurse should take into consideration the fact that:

a. Inflammation of the synovial membrane will rarely occur
b. Bony ankylosis of the joint is irreversible and causes immobility
c. Complete immobility is desired during the acute phase of inflammation
d. If the redness and swelling of a joint occur, they signify irreversible damage

44. The diet the nurse would expect the physician to order for Harriet would be:

a. Salt free and low fiber
b. High calorie with low cholesterol
c. High protein with minimal calcium
d. Regular diet with vitamins and minerals

45. The medication the nurse would expect to prescribed to relieve Harriet’s pain;

a. Xanax 0.5 mg, TID
b. Aspirin, 0.6 g_q4
c. Codeine , 30 mg, q4
d. Meperidine 30 mg q4 pm

Situation 10 – Lizbeth 20 year-old college student is brought to the hospital by her mother who states that for the past week her behavior has become very strange. She has become more and more withdrawn – Diagnosis: Schizophrenia Catatonic.

46. During the physical assessment Lizbeth’s arms remains outstretched after her pulse and blood pressure were taken and the nurse has to reposition it for her. Lizbeth is showing;

a. Distractibility
b. Muscle rigidity
c. Waxy flexibility
d. Echopraxia

47. Lizbeth keeps her eyes closed and does not answer the questions asked by the nurse or physician. The nurse know that;

a. The patient can cannot hear nor understand what is being asked
b. The patient is aware of what is happening around her even though she does not respond
c. The patient is in regressed state and should be treated like a frightened child
d. The patient is aware of what is going on around her and could respond if she wants to.

48. While Lizbeth remains in an unreasonable state, does not eat or drink, the nurse first priority id to assess her:

a. Fluid intake and output
b. Skin turgor
c. Bowel elimination
d. Vital signs such as T.P.R. and blood pressure

49. One evening, Lizbeth suddenly begins running up and down the hall. She strips her clothing and strikes out widely at anyone she sees. All of the following interventions would be appropriate except:

a. Restrain me patient and call for help
b. Call for the assistance of at least three staff members
c. Clear the area of other patients
d. Obtain me order and prepare chlorpromazine (thorazine)

50. When Lizbeth become agitated, the therapeutic approach of the nurse is one that is:

a. Authoritarian and directive
b. Related casual and friendly
c. Permissive and comforting
d. Calm and firm but not threatening

Situation 11- Michelle, 36 weeks gestation visits the hospital because the suspects that her bag of water was ruptured. –

51. While the nurse is assessing Michelle, she states that her bag of water ruptured few minutes ago. Which of the following should the nurse do first?

a. Check the status of the fetal heart rate
b. Turn the client to her right side
c. Test the leaking fluid with nitrazine paper
d. Perform a sterile vaginal examination

52. To confirm Michelle’s statement, the nurse uses nitrazine paper; if the membrane has ruptured the paper which of the following color?

a. Yellow
b. Green
c. Blue
d. Blue

53. After being confirmed that membranes has been ruptured and there was no evidence of labor, which of me following would the nurse expect the physician to order?

a. Frequent assessment of cervical dilation
b. Intravenous oxytocin administration
c. Vaginal culture for Neisseria Gonorrhoeae
d. Sonogram for amniotic fluid volume index

54. Few hours after, the nurse noted that her cervix is 2 cm dilated and 50% effaced. Which of the following would the priority assessment for this client?

a. Red blood cell count
b. Degree of Discomfort
c. Urinary Output
d. Temperature

55. Michelle is to be discharged home on bed rest with follow -tip by the community health nurse. After instruction about care while at home, which of the following client’s statements indicates effective teaching?

a. “It is permissible to douche if the fluid irritates my vaginal area.”
b. ” I can take either a tub Bath or a shower when I feel it”
c. “I shouldn’t limit my fluid intake to less than 1 quart daily.”
d. ” I should contact the doctor if my temperature is 100.4 F or higher.”

Situation 12 – Jerome, a 37 years old man, was admitted to the hospital with periodic episode of manic behavior alternating with me depression. Diagnosis: Bipolar I disorder.

56. Which of the following statements is true and manic reaction? It is;

a. An expression of destructive impulse
b. A means of coping with frustrations and disappointments
c. A Means of Ignoring reality
d. An attempt toward off feeling of underlying depression.

57. Nursing care plan for a hyperactive patient like Jerome, should give priority to:

a. Discourage him from manipulating the staff
b. Prevent him from assaulting other patients
c. Protect him against suicidal attempts
d. Provide adequate food and fluid intake

58. During a nurse patient interaction, Jerome jumps rapidly from one topic to another. This is known as:

a. Flight of Ideas
b. Idea of Reference
c. Clang association
d. Neologism

59. A priority nursing diagnosis would be

a. Ineffective individual coping
b. Altered family process
c. Potential for violence, self directed
d. Sensory perceptual disturbance

60. Initially one of the following activities would be appropriate for Jerome;

a. Playing basketball
b. Playing chess
c. Gardening
d. Writing

Situation 13 – Mr. Baldo , 36 years old patient complaints of fatigue, weight loss, and low-grade fever. He also has pain his fingers, elbows, and ankles.

61. Which of the following conditions is suspected?

a. Anemia
b. Leukemia
c. Rheumatic arthritis
d. Systemic Lupus Erythematosus (SLE)

62. Systemic lupus erythematosus (SLE) primarily attacks which of the following tissues?

a. Connective
b. B. Heart
c. Lung
d. Nerve

63. Which of the following elements shows that the client does not understand the cause of exacerbation of system lupus erythematosus (SLE)?

a. ” I need to stay away from sunlight”
b. “I don’t have to worry if I get a strep. throat
c. I need to work on managing stress in life.”
d. “I don’t have to worry about changing my diet.”

64. Which of the following symptoms is a classic sign of systemic lupus erythematosus (SLE)?

a. Vomiting
b. Weight loss
c. Difficulty urinating
d. Superficial lesions over the cheek and nose

65. Mr Balao asks the nurse as to the source of this disease. The nurse is aware that this is a disease of:

a. Joints
b. Bones
c. connective tissue
d. purine metabolism

Situation 14 – Mr Gil age 86 years, has been diagnosed with Alzheimer’s disease.

66. Which characteristics could the nurse expect when observing Mr. Gil?

a. Transient ischemic attacks
b. Remissions and exacerbations
c. Rapid deterioration of mental functioning because of arteriosclerosis
d. Slowly progressive deficits in intellect, which may be noted for a long time

67. Mr. Gil frequently switches from being pleasant and happy to being hostile and sad without apparent external cause. How can the nurse best care for Mr. Gil?

a. Try to point out reality to him
b. Avoid Mr. Gil when he is angry and sad
c. Encourage him to talk about his feelings
d. Attempt to give nursing care when he is in a pleasant mood

68. What type of environment should be provided by the health care team for Mr. Gil?

a. Familiar
b. Variable
c. Challenging
d. Non-stimulating

69. Mr. Gil will need assistance in maintaining contact with society for as long as possible. Which therapy might help him achieve this goal?

a. Psychodrama
b. Recreation therapy
c. Occupational therapy
d. Remotivation therapy

70. What is the nurse’s primary objective for Mr. Gil when he is experiencing dementia and delirium?

a. Diminished psychological faculties
b. Interaction with the environment
c. Participation with the environment
d. Face to face contact with the other clients

Situation I5: Baby Philip, a full term male child, is delivered by his mother who is RH negative.

71. At the time of delivery, baby Philip’s blood is typed to determine the ABO group and the presence of the RH factor. The nurse is aware that:

a. The RH factor is not genetically determined
b. Not all infants of RH-positive fathers are RH positive
c. The RH factor of the fetus is determined by the father
d. During gestation, the RH factor of the fetus may change

72. Baby Philip is RH positive and his mother is RH negative. Baby Philip is to receive an exchange transfusion. The nurse know that he will receive RH-negative blood because:

a. It is me same as die mother’s blood
b. It is neutral and will not react with his blood
c. It eliminates the possibility of a transfusion reaction occurring
d. His RBC’s will not be destroyed by the maternal anti-RH antibodies

73. Hyperbilirubinemia is anticipated to baby Philip because of RH incompatibility. Hyperbilirubinemia occurs with incompatibility between mother and fetus because

a. The mother’s blood does not contain the RH factor, so she produces anti-RH antibodies that cross the placental barrier and cause hemolysis of red blood cells in infants
b. The mother’s blood contains the RH factor and the infant’s does not, and antibodies are formed in the fetus that destroy red blood cells.
c. The mother has the history of previous yellow jaundice caused by a blood transfusion, which was passed the fetus through the placenta.
d. The infant develops a congenital defect shortly after birth that causes the destruction of red blood cells.

74. If RhoGAm is given to Baby Philip’s mother after delivering Baby Philip, the condition that must be present rbr the globulin to be effective is that:

a. Philip’s mother is Rh positive
b. Baby Philip is Rh negative
c. Philip’s mother has no titer in her blood
d. Philip’s mother has some titer in her blood

75. When the nurse brings Philip to his mother, she comments about the milia on the baby’s face. The nurse should:

a. Tell her that all babies have them and they clear up in 2 to 3 days
b. Explain that these are birthmarks that will disappear within a few months
c. Instruct her about proper hand washing since the milia can be infectious
d. Instruct her to avoid squeezing them or attempting to wash them off

Situation 16: Ronald 23 years old was voluntarily admitted to the in-patient unit with a diagnosis of paranoid schizophrenia.

76. As the nurse approaches Ronald he says, “If come any closer. I’ll die.” This is an example of:

a. Hallucination
b. Delusion
c. Illusion
d. Idea of reference

77. The best response for the nurse to make to this behavior is:

a. “How can I hurt you?”
b. “I’m the nurse.”
c. “Tell me more about this.”
d. “That’s a silly thing to say.”

78. When communicating with the paranoid client, the main principle is to:

a. Use logic and be persistent
b. Provide an anxiety-free environment
c. Express doubt and do not argue
d. Encourage ventilation of anger

79. Ronald is pacing the hall and is agitated. The nurse hears him saying, “Those doctors are faying to commit me to the state hospital. The nurse’s continued assessment should include:

a. Clarifying information with the doctor
b. Observing Ronald for rising anxiety
c. Reviewing history of involuntary commitment
d. Checking dosage of prescribed medication

80. An appropriate activity for the nurse is to recommend for a client who is extremely agitated is:

a. Competitive sports
b. Bingo
c. Trivial Pursuit
d. Daily walks

Situation 17: Mrs. Lim has had confirmation of her pregnancy. She presents the emergency room with abdominal pain not yet. diagnosed.

81. The nurse would suspect an ectopic pregnancy if Mrs Lim complained of:

a. An adherent painful ovarian mass
b. Lower abdominal cramping for a long period of time
c. Leukorrhea and dysuria a few days after the first missed period
d. Sharp lower right or left abdominal pain radiating to the shoulder

82. The most common type of ectopic pregnancy is tubal. Within a few weeks after conception the tube may rupture suddenly, causing:

a. Painless vaginal bleeding
b. Intermittent abdominal contractions
c. Continues dull, upper-quadrant abdominal pain
d. Sudden knife-like, lower-quadrant abdominal pain

83. Mrs. Lim has been complaining of vaginal bleeding and one sided lower quadrant pain. The nurse suspects mat she has:

a. Abruptio placenta
b. An incomplete abortion
c. An ectopic pregnancy
d. A rupture of graafian follicle

84. A few hours after being admitted with a diagnosis of inevitable abortion, a client begins to experience bearing down sensations and suddenly expels the products of conception in bed. To give safe nursing care, the nurse should first

a. Check the fundus for firmness
b. Give her the sedation
c. Immediately notify the physician
d. take her immediately to the delivery home

85. After a spontaneous abortion the nurse should observe the client for:

a. Hemorrhage and infection
b. Dehydration and hemorrhage
c. Subinvolution and dehydration
d. Signs of pregnancy-induced hypertension

Situation 18: Arnold, age 67, has had successfully treated depressive disease for more than 10 years. Lately he has been developing a plan of action. Arnold is admitted to hospital for reassessment.

86. Which assessment would best aid the nurse in evaluating Arnold’s potential for suicide?

a. Ask him about plans for the future
b. Ask other clients about suicide while in a group
c. Ask the family if he had ever attempted suicide
d. Ask him if suicide was ever or is now being considered

87. Which factor is most important in evaluating Arnold’s risk for suicide?

a. Presence of multiple personal problems
b. Length of time the depression has existed
c. Impending of the loss of a loved one
c. development plans for discharge from hospital or program

88. Arnold confides to the nurse that he has been thinking of suicide. Which of the following motivations should the nurse recognize in Arnold?

a. Wishes to frighten the nurse
b. Wants attention from the staff
c. Feels safe and can share his feelings with the nurse
d. Shows fearful of his own impulses and is seeking protection from them

89. Arnold is placed on suicide precautions. Which would be the most therapeutic way to provide his safety measures?

a. Not allow him to leave his room
b. Remove all sharp and cutting objects
c. Give him the opportunity to ventilate feelings
d. Assign staff member to be with him at all times

90. The psychiatrist prescribes Electro convulsive therapy for Arnold. The nurse when discussing ECT with Arnold, should tell him which of the following information?

a. Sleep will be induced and treatment will not cause pain
b. There will be a memory loss aa a result of the treatment
c. It is better not to talk about it, but he can asks any question

Situation 19: Josh is a 2-year old child who was bom with a unilateral cleft lip and palate. He is being readmitted for a palate repair.

91. When a toddler is hospitalized, age appropriate toys would include:

a. Wind-up toys, music boxes, and electric trains
b. Toys requiring pushing, pulling and to big to be swallowed
c. Marble tracks and small blocks encouraging fine-motor coordination
d. Colorful mobiles, wind-up toys, and marble tracks

92. Which of the following would be the most important factor in preparing Josh for his hospitalization?

a. Gratification of Josh wishes
b. Josh’s previous hospitalization
c. Never leaving Josh with strangers
d. Assurance of affection and security

93. Prior to a repair of a unilateral cleft lip and palate, feeding will probably be:

a. Limited to IV fluids
b. Wish a soft, large altered nipple
c. Accomplished per gastrostomy tube
d. Facilitated by the use of spoon or medicine dropper

94. Which of the following nursing actions would have been included for Josh following his cleft lip repair?

a. Using a spoon to administer oral feedings
b. Cleansing the suture line to prevent infection
c. Allowing Josh to suck on a pacifier to prevent crying
d. Positioning Josh on the abdomen to avoid aspiration

95. Why will Josh be unable to use toothbrush postoperatively?

a. The suture line might be injured
b. Josh would probably have no teeth
c. The toothbrush might be frightening to Josh
d. Josh would not be accustomed to a brush at home

Situation 20: Vincent, age 26, who is caught in me raging conflict between his mother and his wife, complains of pains in his right leg that has progressed to the point of paralysis. After orthopedic consultation has shown no pathology, he is referred for a psychiatric consultation and is found to have a conversion disorder.

96. The nurse understands which of the following concepts about Vincent’s conversion disorder?

a. It is an unconscious method for him to cope with the present situation
b. It is usually necessary for him to cope with the present situation
c. It is reversible and will subside if he is helped to focus on other things
d. It will probably be solved when he learns to deal with ongoing family conflicts

97. Vincent’s conflict may be caused by which of the following stimuli?

a. Hostile feelings towards his home
b. Ambivalent feelings toward his wife
c. Needs to be a dependent child and an independent adult
d. Inadequate feelings in regard to assuming the role of husband

98. Which behavior is Vincent most likely to manifest?

a. Demonstrate a spread of paralysis to other body parts
b. Require continuous psychiatric treatment to maintain individual functioning
c. Recover the use of the affected leg but under stress, again develop similar symptoms
d. Follow a rather unpredictable emotional course I the future, depending on exposure to stress

99. How would the nurse expect Vincent to behave?

a. Appear gently depressed
b. Exhibit free floating anxiety
c. Appear calm and composed
d. Demonstrate anxiety when discussing symptoms

100. Which intervention would be most therapeutic for the nurse to make?

a. Encourage him to try to walk
b. Tell him there is nothing wrong
c. Avoid focusing on his physical symptoms
d. Help him follow through with the physical therapy plan

Answers

Unfortunately, rationales are not given in this exam. If you need clarifications or disputes, please direct them to the comments section. We’d be glad to give you an explanation.

1. b. Diabetes insipidus
2. c. Hypoglycemia
3. a. Hypokalemia and hypoglycemia
4. d. I.V. bolus followed by continuous infusion
5. c. Absence of ketosis
6. c. Myocardial ischemia
7. c. Place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes if pain occurs
8. b. Ischemia of the heart muscle
9. c. Whole milk
10. c. Vegetables and Whole Grains
11. c. Loves the parent of the opposite sex and hates the parent of the same sex
12. b. Genital-Stage
13. b. Introjection
14. c. Identities with me parent of the same sex
15. c. Oedipal Stage
16. a. To remove clot from the bladder
17. a. Residual urine
18. c. The drainage is bright red
19. a. Dribbling incontinence
20. d. Alternately tense and relax the perineal muscles
21. d. Glaucoma can be painless and visions may be lost before the person is aware of the problem.
22. c. Ptosis
23. b. Degeneration of the substantia nigra; depleting dopamine
24. d. Development of demyelinization of the myelin sheath, interfering with the nerve transmission
25. c. Get up slowly, turning the entire body
26. d. Sodium bicarbonate
27. a. Stool
28. d. Meatless diet for 48 hours prior to obtaining of specimen
29. b. GIT series
30. a. Bland Diet
31. c. Altered level of consciousness
32. a. Confusion or delirium can be a defense against further stress
33. d. Eight Cranial Nerve (Vestibulocochlear)
34. b. Check for hemorrhaging from the oral cavity
35. a. Provide positive feedback when he uses the word correctly
36. b. Increased risk of respiratory complications
37. c. Female ages 10 to 30 years old
38. c. A decreased number of functioning acetylcholine receptor sites
39. a. A tracheostomy set
40. b. To rule out cholinergic crisis
41. c. Help prevent the crippling effects of the disease
42. b. Reduce inflammation
43. b. Bony ankylosis of the joint is irreversible and causes immobility
44. d. Regular diet with vitamins and minerals
45. b. Aspirin, 0.6 g_q4
46. c. Waxy flexibility
47. b. The patient is aware of what is happening around her even though she does not respond
48. d. Vital signs such as T.P.R. and blood pressure
49. a. Restrain me patient and call for help
50. d. Calm and firm but not threatening
51. a. Check the status of the fetal heart rate
52. c. Blue
53. d. Sonogram for amniotic fluid volume index
54. d. Temperature
55. d. ” I should contact the doctor if my temperature is 100.4 F or higher.”
56. d. An attempt to ward off feeling of underlying depression.
57. d. Provide adequate food and fluid intake
58. a. Flight of Ideas
59. c. Potential for violence, self directed
60. c. Gardening
61. d. Systemic Lupus Erythematosus (SLE)
62. a. Connective
63. b. “I don’t have to worry if I get a strep. throat
64. d. Superficial lesions over the cheek and nose
65. c. connective tissue
66. d. Slowly progressive deficits in intellect, which may be noted for a long time
67. d. Attempt to give nursing care when he is in a pleasant mood
68. a. Familiar
69. d. Remotivation therapy
70. b. Interaction with the environment
71. c. The RH factor of the fetus is determined by the father
72. d. His RBC’s will not be destroyed by the maternal anti-RH antibodies
73. d. The infant develops a congenital defect shortly after birth that causes the destruction of red blood cells.
74. c. Philip’s mother has no titer in her blood
75. d. Instruct her to avoid squeezing them or attempting to wash them off
76. b. Delusion
77. c. “Tell me more about this.”
78. b. Provide an anxiety-free environment
79. b. Observing Ronald for rising anxiety
80. d. Daily walks
81. d. Sharp lower right or left abdominal pain radiating to the shoulder
82. d. Sudden knife-like, lower-quadrant abdominal pain
83. c. An ectopic pregnancy
84. a. Check the fundus for firmness
85. a. Hemorrhage and infection
86. d. Ask him if suicide was ever or is now being considered
87. c. Impending of the loss of a loved one
88. d. Shows fearful of his own impulses and is seeking protection from them
89. d. Assign staff member to be with him at all times
90. a. Sleep will be induced and treatment will not cause pain
91. b. Toys requiring pushing, pulling and too big to be swallowed
92. d. Assurance of affection and security
93. b. Wish a soft, large altered nipple
94. b. Cleansing the suture line to prevent infection
95. a. The suture line might be injured
96. b. It is usually necessary for him to cope with the present situation
97. c. Needs to be a dependent child and an independent adult
98. c. Recover the use of the affected leg but under stress, again develop similar symptoms
99. c. Appear calm and composed
100. c. Avoid focusing on his physical symptoms