PRE-BOARD EXAM d. Promotion of rest an comfort in an atmosphere c. Family history is negative for conclusions
(NURSING CARE MANAGEMENT-III-A) of limited stimulation d. Child has a low-grade fever which lasted for
NURSING EXTENSIVE (DECEMBER 2006) 3. The nurse assesses the temperature of the child. several weeks
Assessment
INSTRUCTION: Select the correct answer for each of findings revealed a temperature of 104°F rectally. Situation: The nurse provides ante partum care for
the following questions. Mark only one answer for each The nurse administers Tylenol (acetaminophen) women thirty years of age and over
item by shading the box corresponding to the letter of suppository as ordered by the physician. Which of 6. The nurse reviews the health records of a 36-year
your choice on the answer sheet provided. the following is the most appropriate action for the old client. The phrase Gravida 4 Para 2 indicates
nurse to implement? which of the following prenatal histories? A client has
Situation: A 2-year old child is admitted to the a. Request the STAT blood cultures be drawn been pregnant
pediatric ward with a tentative diagnosis of febrile while the temperature is elevated a. Four times and had two spontaneous abortions
seizures. b. Four times and had two miscarriages
b. Retake the temperature after 30 minutes
1. The nurse prepares a care plan for the child with
c. Ask the mother or caregiver to report any c. Four times and had two live-born children
febrile seizures. Which of the following interventions
seizure activity d. Four times and had two caesarean deliveries
should be included in the care plan?
d. Notify the physician immediately 7. The nurse understands that one of the following
a. Place a padded tongue blade at the beside
4. When implementing any method in reducing factors would contribute to a high-risk
b. Keep the room temperature low and
the child’s fever, chilling should be avoided. Which pregnancy. Which factor?
bedclothes to a minimum
of the following explains the reason for this principle? a. History of allergy to honey bee pollen
c. Keep the child supine
a. Chilling makes the child irritable and b. Blood type O positive
d. Place the child in respiratory isolation and
uncooperative c. First pregnancy at age 33 years
restrict visitors
b. Chilling cause peripheral vasodilation d. History of insulin–dependent diabetes mellitus
2. The nurse prepares a care plan. Which of the
c. Chilling can lead to shivering 8. The client is 32 years old, 15 weeks pregnant and
following would be the primary goal of nursing
d. Chilling can lessen the child’s ability to fight has a history of hypertension. Which of the following
care?
infection conditions pose the greatest risk?
a. Recognition of abnormal signs or behavior
a. Abruptio placenta
indicative of neurologic deficit
b. Preterm labor
b. Early detection and recognition of elevated
5. The nurse recognizes that the basis for the c. Spontaneous abortion
temperature
diagnosis of febrile seizures is that the; d. Anemia
c. Identification of the etiology of the child’s febrile
a. Seizures resulted in respiratory arrest 9. The nurse shows concern to a client who is obese.
condition
b. Seizures occurred when the child had a A maternal complication associated with obesity
respiratory infection in pregnancy is:
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, a. Mastitis c. Pre-eclampsia c. Alone in a nonjudgmental way a. 7-10 days after menses
b. Placental previa d. Abruptio placenta d. In a judgmental way with the father present b. 7-10 days before menses
10. The nurse assesses a 33-year old woman who is 13. When dealing with suspected family violence, the c. On the first day of menstruation
15 weeks pregnant. Which finding during the first nurse uses which of the following psychosocial d. Every month during ovulation
prenatal visit is abnormal? approach? 17. The nurse instructs the client to stand before
a. Weight of 144 lbs or 65.3 kg a. Get all the facts a mirror. Which of the following actions is not
b. Fundal height of 18 cm b. Punitive approach correct?
c. Blood pressure of 120/80 mm Hg c. Disgust avoidance a. Inspect with arms at the side
d. Urine negative or protein d. Supportive treatment b. Inspect with arms raised forward
14. Which of the following roles should the nurse c. Raise arms overhead to inspect for changes in
Situation: The nurse assists in the care of pregnant perform in this situation? size or contour, dimpling or changes in nipple
adolescents in a health care facility. a. Provide counsel to the pregnant adolescent d. Inspect while resting the palms on the hips and
11. A primiparous 15-year old client arrives with her client pressing down firmly to flex chest muscles
father at the clinic for her first prenatal visit. The client b. Provide counsel to the father 18. The nurse instructs the client to lie down and
is 30 weeks gestation. The father refuses to leave c. Assess the client carefully and adequately examine the right breast. The nurse instructs the
the room during examination saying that his daughter document findings client that while examining the right breast, to place a
is shy and will answer questions for her. The nurse d. Protect the rights and privacy of the client by not pillow under the:
should be most concerned in what aspect of the documenting the findings a. Right shoulder
situation? 15. The nurse is aware that a victim of sexual abuse b. Left shoulder
a. Lack of parental care until this visit may have a tendency to experience one of the c. Small of the back
b. Possible child abuse or domestic violence following: d. Left scapula
c. The possibility of the preterm labor with an a. A predisposition for becoming a sex 19. The nurse recognizes the importance of giving
adolescent pregnancy offender instructions for breast self-examination
d. Difficulties of an overprotective parent in dealing b. Have a higher hormonal levels particularly to clients with which of the following
with his daughter c. Remain celibate throughout life problems?
12. The nurse determines if the pregnant d. Have normal sexual experiences throughout life a. Endometrial polyps c. A dermoid cyst
adolescent client is a victim of domestic abuse b. Ovarian cancer d. Cervical
and violence. Which of the following actions is most? Situation: The nurse instructs a class of young dysplasia
Interview the client female clients on breast self-examination. 20. A young client who is breastfeeding asks the
a. With the physician present 16. The nurse instruct the clients to perform the nurse how to perform breast self-examination
b. With her father in the room breast self-examination
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, while nursing the infant. Which of the following c. Engorged breast with inflamed, radiating areas a. Edema c. Palpitation
instructions is best? Breast self-examination that are sore to the touch b. Dyspnea d. Chest pain
a. Should be done after the infant has emptied d. Slightly tender, cracked nipples; slightly firm, 28. One of the risk factors which may have
the breast non-tender breasts; transitional milk contributed to the client’s condition is:
b. When breastfeeding is stopped 24. The nurse understands that one of the following a. Physical activity c. Low cholesterol level
c. After the physicians examines the breasts when factors which might resulting a decrease supply b. Stress d. Low blood pressure
breastfeeding is stopped of breast milk in a post partum client is: 29. The nurse understands that the quickest, most
d. Should be continued un the same manner a. Supplemental feedings with formula accurate and most widely used diagnostic tool to
before pregnancy b. Maternal diet high in vitamin C determine the location of myocardial damage is:
c. An alcoholic drink a. Echocardiogram
Situation: The nurse assists in the care of a young d. Frequent feedings b. Electrocardiogram
mother who had delivered a 7lb healthy baby boy 25. The young mother complains of engorged c. Cardiac Catheterization
and desires to breastfeed her infant. breasts. Which of the following interventions would d. Cardiac enzymes analysis
21. The nurse instructs the young mother on be most helpful? 30. The physician orders morphine to the client with
breast care. This instructions include the following: a. Apply ice on the affected breasts a myocardial infarction. The primary reason for
(1) Avoid using soap on nipples; (2) Change b. Teach the client to express her breast while administering morphine is to:
frequently breast pads; (3) Expose nipples to air in warm shower a. Decrease pain
intermittently, and (4) Wash before handling the c. Apply a breast binder b. Decrease anxiety
breast and before breast feeding. These measures d. Administer a lactation suppressant c. Sedate the client
are specific to the prevention of Situation: A 40-year old female client who works as d. Decrease the demand for oxygen in the
a. “Left-down” reflex c. Newborn Colic an executive in a bank was admitted in the cardiac heart and chest
b. Breast engorgement d. Mastitis unit for a myocardial infarction (MI)
22. The type of milk that is present in the breast 26. The nurse formulates a nursing diagnosis. A Situation: A client is hospitalized for open
after 2 weeks post-partum is called: priority nursing diagnosis during the first 24 reduction of a fracture femur.
a. Colostrum c. Mature Milk hours following a myocardial infarction would be: 31. Which of the following statements explains an
b. Hind milk d. Transitional milk a. High Risk For Infection open reduction of a fractured femur?
23. Which findings are normal for a breast-feeding b. Fluid Volume Deficit a. Traction will be used
client on the fourth post partum day? c. Impaired Gas Exchange b. A cast will be applied
a. Tender, intact nipple; firm, non-tender d. Constipation c. Crutches will be used after surgery
breasts; transitional milk 27. The nurse recalls that the common symptom of d. Some from the screw, plate, nail or wire is
b. Symmetrical breast shape and size Myocardial Infarction is: usually used to maintain alignment
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, 32. Which of the following statements is true about 36. The nurse gives preoperative teaching to the 39. The nurse performs colostomy irrigation on
fracture reduction? client. To evaluate the effectivity of the preoperative the client. During the procedure, the client
a. Fracture reduction restores alignment teaching, the nurse expects the client to be able to: complains of abdominal cramps. Which of the
b. All fractures can be reduced a. Apply the colostomy bag properly following actions is most appropriate?
c. Non-displaced fractures may be reduced b. Explain the functions of the colostomy a. Administer pain medication and resume
d. Fracture reduction is usually performed with c. Describe the procedure irrigation
minimal discomfort d. Accept the surgical treatment b. Notify surgeon immediately
33. Which of the following conditions is a serious 37. The nurse explains that signing consent before c. Increase high of the irrigation
complication of a femoral shaft fracture? operation is necessary and a standard hospital policy. d. Stop the irrigation temporarily
a. Constipation The most appropriate procedure for signing the 40. The client expresses concerned about the odor
b. Decreased urine output operative permit is to: from stool in the ostomy drainage bag. Which of
c. Hemorrhage a. Let client sign the permit upon admission so the following foods would the nurse suggest to the
d. Pain client will know what procedure is going to be done client to reduce odor?
34. On post operative assessment, the nurse b. Let the client sign the operative permit and then a. Broccoli c. Cucumber
monitors for signs of fat embolism which include: notify the surgeon that the permit has been signed b. Yogurt d. Eggs
a. Pallor and coolness of the affected leg c. Make sure that the surgeon has explained
b. Nausea and vomiting after eating the procedure to the client and answered the Situation: A male client is brought to the surgical
c. Hypothermia and bradycardia client’s questions, then have the client sign unit after undergoing a major abdominal surgery.
d. Restlessness and petechiae the operative permit 41. The initial action the nurse performs on the
35. Which of the following signs and symptoms d. Prepare the client for surgery, administer the client after surgery is to check the:
can occur with fat embolism? pre-operative medications and let the client sign a. Vital signs
a. Tachypnea, tachycardia, short of breath, the permit before the client go to sleep b. Dressing for signs of bleeding
paresthesia 38. After the operation, the nurse teaches the client c. Patency of the airways
b. Paresthesia, bradyspnea, bradycardia, how to perform colostomy irrigation. To enhance d. Patency of tubes or drains
petechial rash on chest and neck the effectiveness of the procedure, the nurse instruct 42. The nurse checks the vital sign of the post-op
c. Bradypnea, bradycardia, short of breath, the client to: client. Blood pressure reading is 100/60 mm Hg;
petechial rash on chest and neck a. Massage abdomen gently pulse is 90 beats per minute; and respiration is 20
b. Drink something cold breaths per minute. Based on these findings, which
Situation: A nurse cares for male client with a c. Increase fluid intake of the following actions should the nurse perform?
diagnosis of ulcerative colitis. The client is d. Reduce the amount of irrigation fluid a. Notify the surgeon immediately
schedule for colostomy. b. Shake the client immediately to arouse him
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(NURSING CARE MANAGEMENT-III-A) of limited stimulation d. Child has a low-grade fever which lasted for
NURSING EXTENSIVE (DECEMBER 2006) 3. The nurse assesses the temperature of the child. several weeks
Assessment
INSTRUCTION: Select the correct answer for each of findings revealed a temperature of 104°F rectally. Situation: The nurse provides ante partum care for
the following questions. Mark only one answer for each The nurse administers Tylenol (acetaminophen) women thirty years of age and over
item by shading the box corresponding to the letter of suppository as ordered by the physician. Which of 6. The nurse reviews the health records of a 36-year
your choice on the answer sheet provided. the following is the most appropriate action for the old client. The phrase Gravida 4 Para 2 indicates
nurse to implement? which of the following prenatal histories? A client has
Situation: A 2-year old child is admitted to the a. Request the STAT blood cultures be drawn been pregnant
pediatric ward with a tentative diagnosis of febrile while the temperature is elevated a. Four times and had two spontaneous abortions
seizures. b. Four times and had two miscarriages
b. Retake the temperature after 30 minutes
1. The nurse prepares a care plan for the child with
c. Ask the mother or caregiver to report any c. Four times and had two live-born children
febrile seizures. Which of the following interventions
seizure activity d. Four times and had two caesarean deliveries
should be included in the care plan?
d. Notify the physician immediately 7. The nurse understands that one of the following
a. Place a padded tongue blade at the beside
4. When implementing any method in reducing factors would contribute to a high-risk
b. Keep the room temperature low and
the child’s fever, chilling should be avoided. Which pregnancy. Which factor?
bedclothes to a minimum
of the following explains the reason for this principle? a. History of allergy to honey bee pollen
c. Keep the child supine
a. Chilling makes the child irritable and b. Blood type O positive
d. Place the child in respiratory isolation and
uncooperative c. First pregnancy at age 33 years
restrict visitors
b. Chilling cause peripheral vasodilation d. History of insulin–dependent diabetes mellitus
2. The nurse prepares a care plan. Which of the
c. Chilling can lead to shivering 8. The client is 32 years old, 15 weeks pregnant and
following would be the primary goal of nursing
d. Chilling can lessen the child’s ability to fight has a history of hypertension. Which of the following
care?
infection conditions pose the greatest risk?
a. Recognition of abnormal signs or behavior
a. Abruptio placenta
indicative of neurologic deficit
b. Preterm labor
b. Early detection and recognition of elevated
5. The nurse recognizes that the basis for the c. Spontaneous abortion
temperature
diagnosis of febrile seizures is that the; d. Anemia
c. Identification of the etiology of the child’s febrile
a. Seizures resulted in respiratory arrest 9. The nurse shows concern to a client who is obese.
condition
b. Seizures occurred when the child had a A maternal complication associated with obesity
respiratory infection in pregnancy is:
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, a. Mastitis c. Pre-eclampsia c. Alone in a nonjudgmental way a. 7-10 days after menses
b. Placental previa d. Abruptio placenta d. In a judgmental way with the father present b. 7-10 days before menses
10. The nurse assesses a 33-year old woman who is 13. When dealing with suspected family violence, the c. On the first day of menstruation
15 weeks pregnant. Which finding during the first nurse uses which of the following psychosocial d. Every month during ovulation
prenatal visit is abnormal? approach? 17. The nurse instructs the client to stand before
a. Weight of 144 lbs or 65.3 kg a. Get all the facts a mirror. Which of the following actions is not
b. Fundal height of 18 cm b. Punitive approach correct?
c. Blood pressure of 120/80 mm Hg c. Disgust avoidance a. Inspect with arms at the side
d. Urine negative or protein d. Supportive treatment b. Inspect with arms raised forward
14. Which of the following roles should the nurse c. Raise arms overhead to inspect for changes in
Situation: The nurse assists in the care of pregnant perform in this situation? size or contour, dimpling or changes in nipple
adolescents in a health care facility. a. Provide counsel to the pregnant adolescent d. Inspect while resting the palms on the hips and
11. A primiparous 15-year old client arrives with her client pressing down firmly to flex chest muscles
father at the clinic for her first prenatal visit. The client b. Provide counsel to the father 18. The nurse instructs the client to lie down and
is 30 weeks gestation. The father refuses to leave c. Assess the client carefully and adequately examine the right breast. The nurse instructs the
the room during examination saying that his daughter document findings client that while examining the right breast, to place a
is shy and will answer questions for her. The nurse d. Protect the rights and privacy of the client by not pillow under the:
should be most concerned in what aspect of the documenting the findings a. Right shoulder
situation? 15. The nurse is aware that a victim of sexual abuse b. Left shoulder
a. Lack of parental care until this visit may have a tendency to experience one of the c. Small of the back
b. Possible child abuse or domestic violence following: d. Left scapula
c. The possibility of the preterm labor with an a. A predisposition for becoming a sex 19. The nurse recognizes the importance of giving
adolescent pregnancy offender instructions for breast self-examination
d. Difficulties of an overprotective parent in dealing b. Have a higher hormonal levels particularly to clients with which of the following
with his daughter c. Remain celibate throughout life problems?
12. The nurse determines if the pregnant d. Have normal sexual experiences throughout life a. Endometrial polyps c. A dermoid cyst
adolescent client is a victim of domestic abuse b. Ovarian cancer d. Cervical
and violence. Which of the following actions is most? Situation: The nurse instructs a class of young dysplasia
Interview the client female clients on breast self-examination. 20. A young client who is breastfeeding asks the
a. With the physician present 16. The nurse instruct the clients to perform the nurse how to perform breast self-examination
b. With her father in the room breast self-examination
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, while nursing the infant. Which of the following c. Engorged breast with inflamed, radiating areas a. Edema c. Palpitation
instructions is best? Breast self-examination that are sore to the touch b. Dyspnea d. Chest pain
a. Should be done after the infant has emptied d. Slightly tender, cracked nipples; slightly firm, 28. One of the risk factors which may have
the breast non-tender breasts; transitional milk contributed to the client’s condition is:
b. When breastfeeding is stopped 24. The nurse understands that one of the following a. Physical activity c. Low cholesterol level
c. After the physicians examines the breasts when factors which might resulting a decrease supply b. Stress d. Low blood pressure
breastfeeding is stopped of breast milk in a post partum client is: 29. The nurse understands that the quickest, most
d. Should be continued un the same manner a. Supplemental feedings with formula accurate and most widely used diagnostic tool to
before pregnancy b. Maternal diet high in vitamin C determine the location of myocardial damage is:
c. An alcoholic drink a. Echocardiogram
Situation: The nurse assists in the care of a young d. Frequent feedings b. Electrocardiogram
mother who had delivered a 7lb healthy baby boy 25. The young mother complains of engorged c. Cardiac Catheterization
and desires to breastfeed her infant. breasts. Which of the following interventions would d. Cardiac enzymes analysis
21. The nurse instructs the young mother on be most helpful? 30. The physician orders morphine to the client with
breast care. This instructions include the following: a. Apply ice on the affected breasts a myocardial infarction. The primary reason for
(1) Avoid using soap on nipples; (2) Change b. Teach the client to express her breast while administering morphine is to:
frequently breast pads; (3) Expose nipples to air in warm shower a. Decrease pain
intermittently, and (4) Wash before handling the c. Apply a breast binder b. Decrease anxiety
breast and before breast feeding. These measures d. Administer a lactation suppressant c. Sedate the client
are specific to the prevention of Situation: A 40-year old female client who works as d. Decrease the demand for oxygen in the
a. “Left-down” reflex c. Newborn Colic an executive in a bank was admitted in the cardiac heart and chest
b. Breast engorgement d. Mastitis unit for a myocardial infarction (MI)
22. The type of milk that is present in the breast 26. The nurse formulates a nursing diagnosis. A Situation: A client is hospitalized for open
after 2 weeks post-partum is called: priority nursing diagnosis during the first 24 reduction of a fracture femur.
a. Colostrum c. Mature Milk hours following a myocardial infarction would be: 31. Which of the following statements explains an
b. Hind milk d. Transitional milk a. High Risk For Infection open reduction of a fractured femur?
23. Which findings are normal for a breast-feeding b. Fluid Volume Deficit a. Traction will be used
client on the fourth post partum day? c. Impaired Gas Exchange b. A cast will be applied
a. Tender, intact nipple; firm, non-tender d. Constipation c. Crutches will be used after surgery
breasts; transitional milk 27. The nurse recalls that the common symptom of d. Some from the screw, plate, nail or wire is
b. Symmetrical breast shape and size Myocardial Infarction is: usually used to maintain alignment
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, 32. Which of the following statements is true about 36. The nurse gives preoperative teaching to the 39. The nurse performs colostomy irrigation on
fracture reduction? client. To evaluate the effectivity of the preoperative the client. During the procedure, the client
a. Fracture reduction restores alignment teaching, the nurse expects the client to be able to: complains of abdominal cramps. Which of the
b. All fractures can be reduced a. Apply the colostomy bag properly following actions is most appropriate?
c. Non-displaced fractures may be reduced b. Explain the functions of the colostomy a. Administer pain medication and resume
d. Fracture reduction is usually performed with c. Describe the procedure irrigation
minimal discomfort d. Accept the surgical treatment b. Notify surgeon immediately
33. Which of the following conditions is a serious 37. The nurse explains that signing consent before c. Increase high of the irrigation
complication of a femoral shaft fracture? operation is necessary and a standard hospital policy. d. Stop the irrigation temporarily
a. Constipation The most appropriate procedure for signing the 40. The client expresses concerned about the odor
b. Decreased urine output operative permit is to: from stool in the ostomy drainage bag. Which of
c. Hemorrhage a. Let client sign the permit upon admission so the following foods would the nurse suggest to the
d. Pain client will know what procedure is going to be done client to reduce odor?
34. On post operative assessment, the nurse b. Let the client sign the operative permit and then a. Broccoli c. Cucumber
monitors for signs of fat embolism which include: notify the surgeon that the permit has been signed b. Yogurt d. Eggs
a. Pallor and coolness of the affected leg c. Make sure that the surgeon has explained
b. Nausea and vomiting after eating the procedure to the client and answered the Situation: A male client is brought to the surgical
c. Hypothermia and bradycardia client’s questions, then have the client sign unit after undergoing a major abdominal surgery.
d. Restlessness and petechiae the operative permit 41. The initial action the nurse performs on the
35. Which of the following signs and symptoms d. Prepare the client for surgery, administer the client after surgery is to check the:
can occur with fat embolism? pre-operative medications and let the client sign a. Vital signs
a. Tachypnea, tachycardia, short of breath, the permit before the client go to sleep b. Dressing for signs of bleeding
paresthesia 38. After the operation, the nurse teaches the client c. Patency of the airways
b. Paresthesia, bradyspnea, bradycardia, how to perform colostomy irrigation. To enhance d. Patency of tubes or drains
petechial rash on chest and neck the effectiveness of the procedure, the nurse instruct 42. The nurse checks the vital sign of the post-op
c. Bradypnea, bradycardia, short of breath, the client to: client. Blood pressure reading is 100/60 mm Hg;
petechial rash on chest and neck a. Massage abdomen gently pulse is 90 beats per minute; and respiration is 20
b. Drink something cold breaths per minute. Based on these findings, which
Situation: A nurse cares for male client with a c. Increase fluid intake of the following actions should the nurse perform?
diagnosis of ulcerative colitis. The client is d. Reduce the amount of irrigation fluid a. Notify the surgeon immediately
schedule for colostomy. b. Shake the client immediately to arouse him
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