What is the nursing priority for a patient with epiglottitis?
A. administer steroids
B. assist in endotracheal intubation
C. assist in tracheostomy
D. apply warm moist pack
The correct answer is C. Epiglottitis is an emergency situation requiring immediate intervention: the
inflamed epiglottis is blocking the entrance to the trachea, therefore clearing the patient’s AIRWAY is the
priority nursing action (eliminate options A and D). Option C is better than Option B; endotracheal
intubation will be difficult because the inflamed epiglottis will not permit the insertion of a laryngoscope.
The following are clinical manifestations of nontoxic goiter (hypothyroidism), EXCEPT:
A. dry skin
B. lethargy
C. insomnia
D. sensitivity to cold
The correct answer is C. Hypothyroidism causes a decrease in thyroid hormones, which in turn causes
decreased metabolism. Options A, B and D are all consistent with decreased metabolism. Option C is a
symptom of increased metabolism found in hyperthyroidism.
Thyroid gland secretions (T3 and T4) are metabolic hormones
Thyroid hormones cause increased metabolism: CNS stimulation, increased vital signs, and increased GI motility
(diarrhea)
, HYPOTHYROIDISM HYPERTHYROIDISM
All body systems are DECREASED All body systems are INCREASED
except WEIGHT and MENSTRUATION! except WEIGHT and MENSTRUATION!
decreased CNS: drowsiness, memory problems increased CNS: tremors, insomnia
(forgetfulness)
decreased v/s: hypotension, bradycardia, bradypnea, low increased v/s: hypertension, tachycardia, tachypnea, fever
body temp
decreased GI motility: constipation increased GI motility: diarrhea
decreased appetite (anorexia) but with WEIGHT GAIN increased appetite (hyperphagia) but with WEIGHT LOSS
[low metabolism causes decreased burning of fats and [high metabolism causes increased burning of fats and
carbs] carbs]
This leads to increased serum cholesterol atherosclerosis
(hardening of arteries due to cholesterol deposits)
Because of increased cholesterol, hypothyroid patients are
prone to hypertension, myocardial infarction, CHF and stroke
decreased metabolism causes decreased perspiration increased metabolism causes increased perspiration
DRY SKIN and COLD INTOLERANCE MOIST SKIN and HEAT INTOLERANCE
Menorrhagia (excessive bleeding during menstruation) Amenorrhea (absence of menstruation)
Pathognomic sign: EXOPHTHALMOS (bulging eyeballs)
Nursing Management for hypothyroidism: Nursing Management for hyperthyroidism:
Low calorie diet High calorie diet
Warm environment Cool environment
What is the best way to prevent the spread of STDs?
A. Use condoms
B. Monogamous relationship
C. Abstinence
D. Practice Safe Sex
The correct answer is B. TEST-TAKING TIP: Pick the conservative answer. Remember the Board of Nursing is
composed of older women with traditional values who do not approve of promiscuity (implied in options A
and D). Telling the patient to abstain from sex (Option C) is not an acceptable response from the nurse.
st nd rd th
What is the nursing priority if the client is suffering from 1 , 2 , 3 or 4 degree burns?
A. fluid and electrolyte balance
B. infection
C. pain
D. airway
The correct answer is B. Infection is a priority for all types of burns. Airway is a priority only for burns to the
st nd
face and neck. Pain is a second priority for 1 and 2 degree burns. Fluid and electrolyte balance is a second
rd th
priority for 3 and 4 degree burns [no pain because nerve endings are damaged].
Page 2
, What is a normal physical finding of the thyroid gland?
A. nodular consistency
B. asymmetry
C. tenderness
D. palpable upon swallowing
The correct answer is A. The thyroid gland is symmetrical, non-tender, and palpable only if the patient has
goiter. The palpable mass on the neck is the thyroid cartilage. It is present in both males and females but is
larger in males; it develops during puberty
What food is most appropriate for a toddler?
A. hotdog
B. grapes
C. milk
D. spaghetti
The correct answer is D. Toddlers need a high-carb diet to sustain their active play lifestyle. Toddlers are also
at risk for aspiration, therefore eliminate foods that are choking hazards (options A and B). Milk is not the
best food for toddlers because of its low IRON content; Milk is the primary cause of Iron-deficiency Anemia
in children.
TEST-TAKING TIP: `Di ba may hotdog ang spaghetti? No, no, no… DO NOT ADD DETAILS TO THE QUESTION.
Do not justify a wrong answer.
What would the nurse include in the teaching plan for a paraplegic client?
A. self-catheterization
B. assisted coughing
C. adapted feeding techniques
D. compensatory swallowing
The correct answer is A. A paraplegic patient has lower extremity paralysis (paralyzed bladder and bowel).
Therefore the nursing priority is ELIMINATION.
Review:
Monoplegia -- 1 limb paralysis
Hemiplegia -- Right or Left side paralysis
Paraplegia – Lower extremity paralysis (note: there is no such thing as upper extremity paralysis)
Quadriplegia/Tetraplegia – Paralysis from the neck down. The priority for a quadriplegic patient is AIRWAY.
NERVOUS SYSTEM
CNS: brain and spinal cord
PNS: 12 cranial nerves + 31 spinal nerves
8 cervical nerves (C1 to C8)
12 thoracic nerves (T1 to T12)
5 lumbar nerves (L1 to L5)
5 sacral nerves (S1 to S5)
1 coccygeal nerve (Co)
The spinal cord terminates at L1 to L2, therefore a LUMBAR TAP is performed at L3 ,L4 or L5
(no risk of paralysis from spinal cord damage)
Page 3
A. administer steroids
B. assist in endotracheal intubation
C. assist in tracheostomy
D. apply warm moist pack
The correct answer is C. Epiglottitis is an emergency situation requiring immediate intervention: the
inflamed epiglottis is blocking the entrance to the trachea, therefore clearing the patient’s AIRWAY is the
priority nursing action (eliminate options A and D). Option C is better than Option B; endotracheal
intubation will be difficult because the inflamed epiglottis will not permit the insertion of a laryngoscope.
The following are clinical manifestations of nontoxic goiter (hypothyroidism), EXCEPT:
A. dry skin
B. lethargy
C. insomnia
D. sensitivity to cold
The correct answer is C. Hypothyroidism causes a decrease in thyroid hormones, which in turn causes
decreased metabolism. Options A, B and D are all consistent with decreased metabolism. Option C is a
symptom of increased metabolism found in hyperthyroidism.
Thyroid gland secretions (T3 and T4) are metabolic hormones
Thyroid hormones cause increased metabolism: CNS stimulation, increased vital signs, and increased GI motility
(diarrhea)
, HYPOTHYROIDISM HYPERTHYROIDISM
All body systems are DECREASED All body systems are INCREASED
except WEIGHT and MENSTRUATION! except WEIGHT and MENSTRUATION!
decreased CNS: drowsiness, memory problems increased CNS: tremors, insomnia
(forgetfulness)
decreased v/s: hypotension, bradycardia, bradypnea, low increased v/s: hypertension, tachycardia, tachypnea, fever
body temp
decreased GI motility: constipation increased GI motility: diarrhea
decreased appetite (anorexia) but with WEIGHT GAIN increased appetite (hyperphagia) but with WEIGHT LOSS
[low metabolism causes decreased burning of fats and [high metabolism causes increased burning of fats and
carbs] carbs]
This leads to increased serum cholesterol atherosclerosis
(hardening of arteries due to cholesterol deposits)
Because of increased cholesterol, hypothyroid patients are
prone to hypertension, myocardial infarction, CHF and stroke
decreased metabolism causes decreased perspiration increased metabolism causes increased perspiration
DRY SKIN and COLD INTOLERANCE MOIST SKIN and HEAT INTOLERANCE
Menorrhagia (excessive bleeding during menstruation) Amenorrhea (absence of menstruation)
Pathognomic sign: EXOPHTHALMOS (bulging eyeballs)
Nursing Management for hypothyroidism: Nursing Management for hyperthyroidism:
Low calorie diet High calorie diet
Warm environment Cool environment
What is the best way to prevent the spread of STDs?
A. Use condoms
B. Monogamous relationship
C. Abstinence
D. Practice Safe Sex
The correct answer is B. TEST-TAKING TIP: Pick the conservative answer. Remember the Board of Nursing is
composed of older women with traditional values who do not approve of promiscuity (implied in options A
and D). Telling the patient to abstain from sex (Option C) is not an acceptable response from the nurse.
st nd rd th
What is the nursing priority if the client is suffering from 1 , 2 , 3 or 4 degree burns?
A. fluid and electrolyte balance
B. infection
C. pain
D. airway
The correct answer is B. Infection is a priority for all types of burns. Airway is a priority only for burns to the
st nd
face and neck. Pain is a second priority for 1 and 2 degree burns. Fluid and electrolyte balance is a second
rd th
priority for 3 and 4 degree burns [no pain because nerve endings are damaged].
Page 2
, What is a normal physical finding of the thyroid gland?
A. nodular consistency
B. asymmetry
C. tenderness
D. palpable upon swallowing
The correct answer is A. The thyroid gland is symmetrical, non-tender, and palpable only if the patient has
goiter. The palpable mass on the neck is the thyroid cartilage. It is present in both males and females but is
larger in males; it develops during puberty
What food is most appropriate for a toddler?
A. hotdog
B. grapes
C. milk
D. spaghetti
The correct answer is D. Toddlers need a high-carb diet to sustain their active play lifestyle. Toddlers are also
at risk for aspiration, therefore eliminate foods that are choking hazards (options A and B). Milk is not the
best food for toddlers because of its low IRON content; Milk is the primary cause of Iron-deficiency Anemia
in children.
TEST-TAKING TIP: `Di ba may hotdog ang spaghetti? No, no, no… DO NOT ADD DETAILS TO THE QUESTION.
Do not justify a wrong answer.
What would the nurse include in the teaching plan for a paraplegic client?
A. self-catheterization
B. assisted coughing
C. adapted feeding techniques
D. compensatory swallowing
The correct answer is A. A paraplegic patient has lower extremity paralysis (paralyzed bladder and bowel).
Therefore the nursing priority is ELIMINATION.
Review:
Monoplegia -- 1 limb paralysis
Hemiplegia -- Right or Left side paralysis
Paraplegia – Lower extremity paralysis (note: there is no such thing as upper extremity paralysis)
Quadriplegia/Tetraplegia – Paralysis from the neck down. The priority for a quadriplegic patient is AIRWAY.
NERVOUS SYSTEM
CNS: brain and spinal cord
PNS: 12 cranial nerves + 31 spinal nerves
8 cervical nerves (C1 to C8)
12 thoracic nerves (T1 to T12)
5 lumbar nerves (L1 to L5)
5 sacral nerves (S1 to S5)
1 coccygeal nerve (Co)
The spinal cord terminates at L1 to L2, therefore a LUMBAR TAP is performed at L3 ,L4 or L5
(no risk of paralysis from spinal cord damage)
Page 3
