1.

Mental health is defined as:

B. A state of well-being where a person can realize his own abilities can cope
with normal stresses of life and work productively.

2. Which of the following describes the role of a technician?

A. Administers medications to a schizophrenic patient.

3. Liza says, “Give me 10 minutes to recall the name of our college professor who failed
many students in our anatomy class.” She is operating on her:
A. Subconscious

4. The superego is that part of the psyche that:

D. The censoring portion of the mind.

5. Primary level of prevention is exemplified by:

C. Teaching the client stress management techniques

6. Situation: In a home visit done by the nurse, she suspects that the wife and her
child are victims of abuse.
Which of the following is the most appropriate for the nurse to ask?
A. “Are you being threatened or hurt by your partner?

7. The wife admits that she is a victim of abuse and opens up about her persistent
distaste for sex. This sexual disorder is:
A. Sexual desire disorder

8. What would be the best approach for a wife who is still living with her abusive
husband?
A. “Here’s the number of a crisis center that you can call for help .”

9. Which comment about a 3 year old child if made by the parent may indicate child
abuse?
B. “When I tell my child to do something once, I don’t expect to have
to tell”

10. The primary nursing intervention for a victim of child abuse is:
C. Ensure the safety of the victim

11. Situation: A 30 year old male employee frequently complains of low back pain that
leads to frequent absences from work. Consultation and tests reveal negative results.
The client has which somatoform disorder?
D. Somatoform Pain Disorder
12. Freud explains anxiety as:
B. Conflict between id and superego

13. The following are appropriate nursing diagnosis for the client
EXCEPT:
D. Impaired social interaction

14. The following statements describe somatoform disorders:

C. Expression of conflicts through bodily symptoms

15. What would be the best response to the client’s repeated complaints of pain:
A. “I know the feeling is real tests revealed negative results.”

Situation: A widow age 28, whose husband died one year ago due to AIDS, has just
been told that she has AIDS.
1. Pamela says to the nurse, “Why me? How could God do this to me?” This reaction is
one of:
C. anger

2. The nurse’s therapeutic response is:

D. ”It must really be frustrating for you. How can I best help you?”

3. One morning the nurse sees the client in a depressed mood. The nurse asks her
“What are you thinking about?” This communication technique is:
D. giving broad opening

4. The client says to the nurse ” Pray for me” and entrusts her wedding ring to the
nurse. The nurse knows that this may signal which of the following:
B. suicidal ideation

5. Which of the following interventions should be prioritized in the care of the suicidal
client?
A. Remove all potentially harmful items from the client’s room.

Situation: A 14 year old male was admitted to a medical ward due to bronchial
asthma after learning that his mother was leaving soon for U.K. to work as nurse.
6. The client has which of the following developmental focus:
A. Establishing relationship with the opposite sex and career planning.

7. The personality type of Ryan is:

B. dependent
 8. The nurse ensures a therapeutic environment for the client. Which of the
following best describes a therapeutic milieu?
C. A living, learning or working environment.

9. Included as priority of care for the client will be:

C. Place in semi-fowlers position and render O2 inhalation as ordered

10. The client is concerned about his coming discharge, manifested by being
unusually sad. Which is the most therapeutic approach by the nurse?
C. “You seem to have concerns about going home.”

Situation: The nurse may encounter clients with concerns on sexuality.

11. The most basic factor in the intervention with clients in the area of sexuality is:
C. Comfort with one’s sexuality

12. Which of the following statements is true for gender identity disorder?
D. It is the desire to live or involve in reactions of the opposite sex

13. The sexual response cycle in which the sexual interest continues to build:
B. Sexual arousal

14. The inability to maintain the physiologic requirements in sexual intercourse is:
B. Sexual Arousal Disorder

15. The nurse asks a client to roll up his sleeves so she can take his blood pressure. The
client replies “If you want I can go naked for you.” The most therapeutic response by
the nurse is:
D. “I only need access to your arm. Putting up your sleeve is fine.”

SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while
crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene.
1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is
D. Move the person to a safer place.

2. Arthur suspects a hip fracture when he noticed that the old woman’s leg is
D. Shortened, Adducted and Externally Rotated.

3. The old woman complains of pain. John noticed that the knee is reddened, warm to
touch and swollen. John interprets that this signs and symptoms are likely related to
C. Inflammation

4. The old woman told John that she has osteoporosis; Arthur knew that all of the
following factors would contribute to osteoporosis except
A. Hypothyroidism

5. Martha, The old woman was now Immobilized and brought to the emergency room.
The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor
Martha for which of the following sign and symptoms?
A. Tachycardia and Hypotension

SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due
to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his
right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the
cane
B. On his left hand, because of reciprocal motion.

7. You also told Mr. Rojas to hold the cane

C. 6 Inches at the lateral side of the foot.

8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of
the hospital because he suffered a mild stroke. The right side of the brain was affected. At
the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you
intervene if you see him
A. Moves the cane when the right leg is moved.

SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and
fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did
not receive a BCG vaccine during childhood
9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known
as
A. PPD

10. The nurse would inject the solution in what route?

C. ID

11. The nurse notes that a positive result for Alfred is

D. 10 mm Induration

12. The nurse told Alfred to come back after

B. 48 hours
13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should
be the nurse’s next action?
A. Call the Physician

14. Why is Mantoux test not routinely done in the Philippines?

D. Almost all Filipinos will test positive for Mantoux Test

15. Mang Alfred is now a new TB patient with an active disease. What is his category
according to the DOH?
A. I

1. Which of the following should be included in the health teachings among clients
receiving Valium:
A. Avoid taking CNS depressant like alcohol.

Situation: A 20 year old college student is admitted to the medical ward because of
sudden onset of paralysis of both legs. Extensive examination revealed no physical basis
for the complaint.
2. The nurse plans intervention based on which correct statement about conversion
disorder?
C. The conversion symptom has symbolic meaning to the client

3. Nina reveals that the boyfriend has been pressuring her to engage in premarital sex.
The most therapeutic response by the nurse is:
D. “How do you feel about being pressured into sex by your boyfriend?”

4. Malingering is different from somatoform disorder because the former:

B. It is a deliberate effort to handle upsetting events

5. Unlike psychophysiologic disorder Linda may be best managed with:

C. stress management techniques

6. Which is the best indicator of success in the long term management of the client?
C. He learns to verbalize his feelings and concerns

Situation: A young woman is brought to the emergency room appearing depressed. The
nurse learned that her child died a year ago due to an accident.
7. The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that
supports this diagnosis is:
B. “I haven’t been able to open the door and go into my baby’s room “
8. The client said “I can’t even take care of my baby. I’m good for nothing.” Which is the
appropriate nursing diagnosis?
C. Low esteem related to failure in role performance

9. The following medications will likely be prescribed for the client EXCEPT:
D. Zyprexa

10. Which is the highest priority in the post ECT care?

B. Monitor respiratory status

Situation: A 27 year old writer is admitted for the second time accompanied by his wife.
He is demanding, arrogant talked fast and hyperactive.
11. Initially the nurse should plan this for a manic client:
A. set realistic limits to the client’s behavior

12. An activity appropriate for the client is:

D. cleaning

13. The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse
does one of the following:
A. Agree on a consistent approach among the staff assigned to the client.

14. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings

15. A client on Lithium has diarrhea and vomiting. What should the nurse do first:
D. Hold the next dose and obtain an order for a stat serum lithium level

1. The supervisor reprimands the nurse in charge of the nursing unit because the charge
nurse has not adhered to the unit budget. Later that afternoon, the charge nurse accuses
the nursing staff of wasting supplies. This behavior is an example of?
b. Displacement

2. A client is taking tranylcypromine (Parnate) for depression. Which of the following

statements indicates a need for further instruction regarding intake of the medication?
a. “I am glad I can still enjoy taking aged cheese and wine.”

3. A female client who’s at high risk for suicide needs close supervision. To best ensure the
client’s safety, Nurse Mary should:
a. Check the client frequently at irregular intervals throughout the night
4. Which of the following drugs should Nurse Mary prepare to administer to a client with a
toxic acetaminophen (Tylenol) level?
d. Acetylcysteine (Mucomyst)

5. When interviewing the parents of an injured child, which of the following is the
strongest indicator that child abuse may be a problem?
a. The injury isn’t consistent with the history or the child’s age.

6. Nurse Luna is assigned to care for a suicidal client. Initially, which is the nurse’s highest
care priority?
b. Exploring the nurse’s own feelings about suicide.

7. A female client with borderline personality disorder is admitted to the psychiatric unit.
Initial nursing assessment reveals that the client’s wrists are scratched from a recent
suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing
diagnosis of:
c. Risk for violence: Self-directed related to impulsive mutilating acts.

8. During an interview, Cham notices that the client’s response is similar to what she says.
This is:
b. Echolalia

9. Which of the following is an appropriate nursing action to a patient with a delusion?

b. Do not challenge the patient in proving the delusion

10. In working with the patient, when is the best time to prepare the patient for the
termination phase?
b. Orientation

11. Ben is assigned to a psychiatric ward; he notices that one of the patients would follow
every move he would make. When he moves his hand, the patient would also move his
hand. This is:
d. Echopraxia

12. A client who abuses alcohol and cocaine tells a nurse that he only uses substances
because of his stressful marriage and difficult job. Which defense mechanisms is this
client using?
c. Rationalization

13. Which neurotransmitter has been implicated in the development of Alzheimer’s

disease?
a. Acetylcholine

14. Which factors are the most essential for the nurse to assess when providing crisis
intervention for a client?
c. The client’s perception of the triggering event and availability of situational
support.

15. The nurse enters the room of a client with a cognitive impairment disorder and asks
what day of the week it is: what the date, month, and year are; and where the client is. The
nurse is attempting to assess:
c. Orientation

1. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric
unit.
A nurse observes that a client with a potential for violence is agitated, pacing up and
down the hallway and making aggressive remarks. Which of the following statements is
most appropriate to make to this patient?
A. What is causing you to become agitated?

2. The nurse closely observes the client who has been displaying aggressive behavior. The
nurse observes that the client’s anger is escalating. Which approach is least helpful for the
client at this time?
D. Initiate confinement measures

3. The charge nurse of a psychiatric unit is planning the client assignment for the day. The
most appropriate staff to be assigned to a client with a potential for violence is which of
the following:
B. A mature experienced nurse

4. The nurse exemplifies awareness of the rights of a client whose anger is escalating by:
A. Taking a directive role in verbalizing feelings

5. The client jumps up and throws a chair out of the window. He was restrained after his
behavior can no longer be controlled by the staff. Which of these documentations
indicates the safeguarding of the patient’s rights?
D. The staff carried out less restrictive measures but were unsuccessful.

6. Situation: Clients with personality disorders have difficulties in their social and
occupational functions. Clients with personality disorder will most likely:
C. manifest enduring patterns of inflexible behaviors
7. A client tends to be insensitive to others, engages in abusive behaviors and does not
have a sense of remorse. Which personality disorder is he likely to have?
D. Antisocial

8. The client joins a support group and frequently preaches against abuse, is
demonstrating the use of:
B. reaction formation

9. A teenage girl is diagnosed to have borderline personality disorder. Which

manifestations support the diagnosis?
A. Lack of self esteem, strong dependency needs and impulsive behavior

10. The plan of care for clients with borderline personality should include:
D. Ensuring she adheres to certain restrictions

11. Situation: A 42 year old male client, is admitted in the ward because of bizarre
behaviors. He is given a diagnosis of schizophrenia paranoid type. The client should have
achieved the developmental task of:
D. Ego integrity vs. despair

12. Clients who are suspicious primarily use projection for which purpose:
B. to deal with feelings and thoughts that are not acceptable

13. The client says “ the NBI is out to get me.” The nurse’s best response is:
C. “I don’t know anything about that. You are afraid of being harmed.”

14. The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting:
B. Pseudoparkinsonism

15. The client is very hostile toward one of the staff for no apparent reason. The client is
manifesting:
B. Transference

Situation: An old woman was brought for evaluation due to the hospital for evaluation
due to increasing forgetfulness and limitations in daily function.
1. The daughter revealed that the client used her toothbrush to comb her hair. She is
manifesting:
C. agnosia

2. She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.”
Which response by the nurse will be most therapeutic?
C. “This must be difficult for you and your mother.”

3. The primary nursing intervention in working with a client with moderate stage
dementia is ensuring that the client:
C. remains in a safe and secure environment

4. She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We
will eat together” The therapeutic response by the nurse is:
A. “Your husband is dead. Let me serve you your breakfast.”

5. Dementia unlike delirium is characterized by:

B. insidious onset

6. Which of the following nursing diagnoses will be given priority for the client?
B. fluid volume deficit

7. What is the best intervention to teach the client when she feels the need to starve?
C. Approach the nurse and talk out her feelings

8. The client with anorexia nervosa is improving if:

B. Weight gain

9. The characteristic manifestation that will differentiate bulimia nervosa from anorexia
nervosa is that bulimic individuals
A. have episodic binge eating and purging

10. 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

11. In the management of bulimic patients, the following nursing interventions will
promote a therapeutic relationship EXCEPT:
B. Discuss their eating behavior.

Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will
die inside.” This has affected his studies
12.The client is suffering from:
C. claustrophobia

13.Initial intervention for the client should be to:

D. Accept her fears without criticizing.
14.The nurse develops a countertransference reaction. This is evidenced by:
A. Revealing personal information to the client

15.Which is the desired outcome in conducting desensitization:

D. The client will be able to overcome his disabling fear.

1.Cocaine is derived from the leaves of coca plant; the nurse knows that cocaine is
classified as:
B. Stimulant

2. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign
the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients
could the nurse manager safely assign to the float nurse?
C. A child who has had a nephrectomy for Wilm’s tumor

3. The nurse is teaching the client about breast self-examination. Which observation
should the client be taught to recognize when doing the examination for detection of
breast cancer?
D. dimpling of the breast tissue

4. May arrives at the health care clinic and tells the nurse that her last menstrual period
was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she
began to have mild cramps and is now having moderate vaginal bleeding. During the
physical examination of the client, the nurse notes that May has a dilated cervix. The nurse
determines that May is experiencing which type of abortion?
A. Inevitable

5. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit.
Which of the following data, if noted on the client’s record, would alert the nurse that the
client is at risk for a spontaneous abortion?
B. History of syphilis

6. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a
possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client
and determines that which of the following nursing actions is the priority?
C. Monitoring apical pulse

7. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid
colostomy when the stool is:
C. Loose, bloody
8. Where would nurse Kristine place the call light for a male client with a right-sided brain
attack and left homonymous hemianopsia?
A. On the client’s right side

9. A male client is admitted to the emergency department following an accident. What

are the first nursing actions of the nurse?
C. Check respirations, stabilize spine, and check circulation.

10. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker.
Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s
teaching was effective?
B. The client lifts the walker, moves it forward 10 inches, and then takes several small
steps forward.

11. Nurse Deric is supervising a group of elderly clients in a residential home setting. The
nurse knows that the elderly are at greater risk of developing sensory deprivation for what
reason?
C. Isolation from their families and familiar surroundings.

12. A male client with emphysema becomes restless and confused. What step should
nurse Jasmine take next?
A. Encourage the client to perform pursed lip breathing.

13. The physician prescribed gentamicin (Garamycin) to a child who is also receiving
chemotherapy. Before administering the drug, the nurse should check the results of the
child’s:
B. Renal function test

14. An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a
chest physiotherapy treatment. The therapy should be properly coordinated by the nurse
with the respiratory therapy department so that treatments occur during:
C. Between meals

15. A clinical instructor is conducting a lecture about chemotherapy. Which of the

following statements is correct about the rate of cell growth in relation to chemotherapy?
A. Faster growing cells are more susceptible to chemotherapy

1. A client with multiple fractures of both lower extremities is admitted for 3 days ago and
is on skeletal traction. The client is complaining of having difficulty in bowel movement.
Which of the following would be the most appropriate nursing intervention?
C. Ensure maximum fluid intake (3000ml/day)
2. John is diagnosed with Addison’s disease and admitted in the hospital. What would be
the appropriate nursing care for John?
A. Reducing physical and emotional stress

3. Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was
transferred to the nursing care unit. The nurse assigned to him knows that 72 hours after
the procedure the client should be positioned properly to prevent contractures. Which of
the following is the best position to the client?
C. Lying on abdomen several times daily

4. A client is scheduled to have an inguinal herniorraphy in the outpatient surgical

department. The nurse is providing health teaching about post surgical care to the client.
Which of the following statement if made by the client would reflect the need for more
teaching?
B. “I will be able to drive soon after surgery”

5. Ms Jones is brought to the emergency room and is complaining of muscle spasms,

numbness, tremors and weakness in the arms and legs. The client was diagnosed with
multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent
fatigue to the client to alleviate the discomfort. Which of the following teaching is
necessary to prevent fatigue?
A. Avoid extremes in temperature

6. Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of
breathing. On the assessment of the nurse, his temperature is 38.1 ºC. The physician
ordered Morphine sulfate via patient-controlled analgesia (PCA), and oxygen at 4L/min. A
priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to
assist in preventing infection is:
A. Using standard precautions and medical asepsis

7. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she
experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency
department. On assessment, the nurse notes that the blood pressure of the client is
139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on
medication to control her BP. Which potential nursing diagnosis will be a priority for
discharge teaching?
C. Noncompliance

8. Following a needle biopsy of the kidney, which assessment is an indication that the
client is bleeding?
B. Dull, abdominal discomfort
9. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the
client is making a plan of care regarding expectoration of thick sputum. Which nursing
action is most effective?
D. Offer fluids at regular intervals

10. The nurse is going to assess the bowel sound of the client. For accurate assessment of
the bowel sound, the nurse should listen for at least:
D. 2 minutes

11. The nurse encourages the client to wear compression stockings. What is the rationale
behind in using compression stockings?
A. Compression stockings promote venous return

12. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best
nursing intervention is most likely to assist the client?
A. Placing food in the unaffected side of the mouth

13. Following nephrectomy, the nurse closely monitors the urinary output of the client.
Which assessment finding is an early indicator of fluid retention in the postoperative
period?
D. Daily weight gain of 2 lb or more

14. A nurse is completing an assessment to a client with cirrhosis. Which of the following
nursing assessment is important to notify the physician?
A. Expanding ecchymosis

15. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the
game, the client complains of becoming diaphoretic and light-headedness. The client
asks the nurse how to avoid this reaction. The nurse will recommend to:
B. Eat a carbohydrate snack before and during the badminton match

1. A client is rushed to the emergency room due to serious vehicle accident. The nurse is
suspecting of head injury. Which of the following assessment findings would the nurse
report to the physician?
C. Polyuria and dilute urinary output

2. Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on
a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that
the object pierced the skin until later that evening. What problem does the client most
probably have?
D. Peripheral neuropathy

3. A client with gangrenous foot has undergone a below-knee amputation. The nurse in
the nursing care unit knows that the priority nursing intervention in the immediate
post-operative care of this client is:
A. Elevate the stump on a pillow for the first 24 hours

4. A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What
would be the initial nursing intervention by the nurse?
B. Keep the client on bed rest

5. After a right lower lobectomy on a 55-year-old client, which action should the nurse
initiate when the client is transferred from the post anesthesia care unit?
D. Encourage coughing and deep breathing every 2 hours

6. The nurse is providing a discharge instruction about the prevention of urinary stasis to a
client with frequent bladder infection. Which of the following will the nurse include in the
instruction?
B. Empty the bladder every 2-4 hours while awake

7. A male client visits the clinic for check-up. The client tells the nurse that there is a yellow
discharge from his penis. He also experiences a burning sensation when urinating. The
nurse is suspecting of gonorrhea. What teaching is necessary for this client?
D. Sex partner needs to be evaluated

8. A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While
the nurse is assessing the IV site, the client becomes confused and restless and the
intravenous catheter becomes disconnected and minimal amount of the client’s blood
spills onto the floor. Which action will the nurse take to remove the blood spill?
A. Promptly clean with a 1:10 solution of household bleach and water

9. Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to
sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One
hour later the client is still unable to sleep. The nurse review the client’s chart and note the
physician’s prescription with an order to repeat. What should the nurse do next?
D. Explore the client’s feelings about surgery

10. The nurse on the night shift is making rounds in the nursing care unit. The nurse is
about to enter to the client’s room when a ventilator alarm sounds, what is the first action
the nurse should do?
C. Look at the client
11. What effective precautions should the nurse use to control the transmission of
methicillin-resistant Staphylococcus aureus (MRSA)?
A. Use gloves and handwashing before and after client contact

12. The postoperative gastrectomy client is scheduled for discharge. The client asks the
nurse, “When I will be allowed to eat three meals a day like the rest of my family?”. The
appropriate nursing response is:
D. “ It varies from client to client, but generally in 6-12 months most clients can return
to their previous meal patterns”

13. A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are
getting larger and also the abdomen. The client is so upset because of the discomfort and
asks the nurse why his breast and abdomen are getting larger. Which of the following is
the appropriate nursing response?
A. “How much of a difference have you noticed”

14. A client is diagnosed with detached retina and scheduled for surgery. Preoperative
teaching of the nurse to the client includes:
C. Eye patches may be used postoperatively

15. A 70-year-old client is brought to the emergency department with a caregiver. The
client has manifestations of anorexia, wasting of muscles and multiple bruises. What
nursing interventions would the nurse implement?
B. Complete a gastrointestinal and neurological assessment

1. The nurse is caring for a patient who is scheduled for a biopsy of a tumor. The patient
asks what distinguished a benign tumor from a malignant tumor. Which info should the
nurse provide?
D. Malignant tumors are composed of disorganized, abnormal cells that may spread
to other parts of the body

2. To monitor patients who are taking antineoplastic drugs, the nurse must be aware that
the most dangerous adverse effect is:
C. Bone marrow suppression

3. Which precaution is most important for the nurse to teach a client receiving radiation
therapy for head and neck cancer?
C. See your dentist twice yearly for the rest of your life.

4. Which action is most important for the nurse to implement to prevent nausea and
vomiting in a client who is prescribed to receive the first round of IV chemotherapy?
B. Administer antiemetic drugs before administering chemotherapy.

5. A client being treated for advanced breast cancer with chemotherapy reports that she
must be allergic to one of her drugs because her entire face is swollen. What assessment
does the nurse perform?
C. Examines the client's neck and chest for edema and engorged veins

6. The nurse is caring for a client with end-stage ovarian cancer who needs clarification on
the purpose of palliative surgery. Which outcome should the nurse teach the client is the
goal of palliative surgery?
B. Relief of symptoms or improved quality of life

7. The nurse corrects the nursing student when caring for a client with neutropenia
secondary to chemotherapy in which circumstance?
C. The student teaches the client that symptoms of neutropenia include fatigue and
weakness.

8. A client who is undergoing chemotherapy for breast cancer reports problems with
concentration and memory. Which nursing intervention is indicated at this time?
D. Allow the client an opportunity to express her feelings.

9. The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of
lymphoma. During the infusion, it is essential for the nurse to observe for which side
effect?
B. Allergy

10. To prevent further urinary tract infections in a preschooler, what measures would you
teach her mother?
B. Teach her to wipe her perineum front to back after voiding.

11. A client with bladder cancer receives local radiation therapy and experiences a dry skin
reaction. When teaching the client about skin care, the nurse should instruct the client to
avoid:
C. cold packs

12. The nurse is caring for a child admitted with acute glomerulonephritis. Which of the
following clinical manifestations would likely have been noted in the child with this
diagnosis?
A. Smoky colored urine

13. The child with nephrotic syndrome who has ascites and difficulty breathing is probably
most comfortable sleeping in which position?
D. Fowler's

14. A school nurse is trying to prevent poststreptococcal glomerulonephritis in children.

Which of the following would be the best way to prevent this?
D. Encourage the child to take all the antibiotics if diagnosed with strep throat.

15. The nurse knows which of the following is a description of peritoneal dialysis when
compared to hemodialysis?
C. The child can live a more normal lifestyle.

1. A nurse is providing a discharge instruction to the client about the self-catheterization

at home. Which of the following instructions would the nurse include?
a. Wash the catheter with soap and water after each use

2. The nurse in the nursing care unit is assigned to care to a client who is
Immunocompromised. The client tells the nurse that his chest is painful and the blisters
are itchy. What would be the nursing intervention to this client?
d. Use gown and gloves while assessing the lesions

3. A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis.
The infection control registered nurse visits the staff nurse caring to the client. What
statement made by the nurse reflects an understanding of the management of this
client?
b. Respiratory isolation is necessary for 24 hours after antibiotics are started

4. A 18-year-old male client had sustained a head injury from a motorbike accident. It is
uncertain whether the client may have minimal but permanent disability. The family is
concerned regarding the client’s difficulty accepting the possibility of long term effects.
Which nursing diagnosis is best for this situation?
d. Anticipatory grieving, due to the loss of independence

5. A client with AIDS is scheduled for discharge. The client tells the nurse that one of his
hobbies at home is gardening. What will be the discharge instruction of the nurse to the
client knowing that the client is prone to toxoplasmosis?
b. Wear gloves when gardening

6. Which expected outcome is correctly written?

c. “The patient will identify all the high-salt food from a prepared list by discharge.”

7. The theorist who believes that adaptation and manipulation of stressors are related to
foster change is:
b. Sister Callista Roy

8. What nursing action is appropriate when obtaining a sterile urine specimen from an
indwelling catheter to prevent infection?
d. Aspirate urine from the tubing port using a sterile syringe.

9. A child was brought to the emergency department with complaints of nausea,

vomiting, fruity-scented breath. The resident on duty diagnosed the child with diabetes
ketoacidosis. Which of the following should the nurse expect to administer?
d. Normal saline IV infusion.

10. Nurse Christine is planning a client education program for sickle cell disease (SCD) in
children. Which of the following interventions would be included in the care plan?
a. Health teaching to help reduce sickling crises

11. Which of the following will probably result in a break in sterile technique for respiratory
isolation?
c. Opening the door of the patient’s room leading into the hospital corridor

12. Managers may or may not be leaders; however, managers do all of the following
EXCEPT:
c. Avoid addressing complexity so that the staff does not worry and change may
occur anyway.

13. An RN is orienting a new graduate nurse to the unit and has found this individual's
charting to be inadequate. What is the most appropriate statement to initiate a
discussion with the new RN?
a. "Tell me in your own words what you intend your charting to convey."

14. Which statement would best explain the role of the nurse when planning care for a
culturally diverse population? The nurse will plan care to:
d. Provide care while aware of one's own bias, focusing on the client's individual
needs rather than the staff's practices

15. A client who had a "Do Not Resuscitate" order passed away. After verifying there is no
pulse or respirations, the nurse should next:
c. Remove all tubes and equipment (unless organ donation is to take place), clean
the body, and position appropriately.