NURSING 12 Maternal and Child Health Nursing Exam 1

NURSING 12 Maternal and Child Health Nursing Exam 1 1. A client asks the nurse what a third degree laceration is. She was informed that she had one. The nurse explains that this is: A. that extended their anal sphincter B. through the skin and into the muscles C. that involves anterior rectal wall D. that extends through the perineal muscle. 2. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client understands her care at home when she says: A. I am happy to note that we can have sex occasionally when I have no bleeding. B. I am afraid I might have an operation when my due comes C. I will have to remain in bed until my due date comes D. I may go back to work since I stay only at the office. 3. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at about the: A. 8th week of pregnancy B. 10th week of pregnancy C. 12th week of pregnancy D. 18th week of pregnancy 4. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester: A. frequency B. dysuria C. incontinence D. burning 5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and revealed 142 lbs. She asked the student nurse how much should she gain weight in her pregnancy. A. 20-30 lbs B. 25-35 lbs C. 30- 40 lbs D. 10-15 lbs 6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse consider when implementing nursing care? A. Explain the surgery, expected outcome and kind of anesthetics. B. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth. C. Arrange for a staff member of the anesthesia department to explain what to expect post-operatively. D. Instruct the mother’s support person to remain in the family lounge until after the delivery. 7. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following represents an unusual finding for this condition? A. generalized edema B. proteinuria 4+ C. blood pressure of 160/110 D. convulsions 8. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus: A. Need to be modified in any way by either partner B. Is permitted if penile penetration is not deep. C. Should be restricted because it may stimulate uterine activity. D. Is safe as long as she is in side-lying position. 9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3 pregnancies in short stage one of labor. The nurses decide to observe her closely. The physician determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse can advise her to: A. lie face down B. not drink fluids C. practice holding breaths between contractions D. assume Sim’s position 10. Which is true regarding the fontanels of the newborn? A. The anterior is large in shape when compared to the posterior fontanel. B. The anterior is triangular shaped; the posterior is diamond shaped. C. The anterior is bulging; the posterior appears sunken. D. The posterior closes at 18 months; the anterior closes at 8 to 12 months. 11. Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after birth, he is crying and moving actively. His birth weight is 6.8 lbs. What do you expect baby Quijones to weigh at 6 months? A. 13 -14 lbs B. 16 -17 lbs C. 22 -23 lbs D. 27 -28 lbs 12. During the first hours following delivery, the post partum client is given IVF with oxytocin added to them. The nurse understands the primary reason for this is: A. To facilitate elimination B. To promote uterine contraction C. To promote analgesia D. To prevent infection 13. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if the newborn is sleeping? A. 80 beats per minute B. 100 beats per minute C. 120 beats per minute D. 140 beats per minute 14. The infant with Down Syndrome should go through which of the Erikson’s developmental stages first? A. Initiative vs. Self doubt B. Industry vs. Inferiority C. Autonomy vs. Shame and doubt D. Trust vs. Mistrust 15. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of the following complications? A. Irreversible brain damage B. Kidney failure C. Blindness D. Neutropenia 16. Which age group is with imaginative minds and creates imaginary friends? A. Toddler B. Preschool C. School D. Adolescence 17. Which of the following situations would alert you to a potentially developmental problem with a child? A. Pointing to body parts at 15 months of age. B. Using gesture to communicate at 18 months. C. Cooing at 3 months. D. Saying “mama” or “dada” for the first time at 18 months of age. 18. Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper tantrums. What is the best way to deal with her behavior? A. Tell her that she would not be loved by others is she behaves that way.. B. Withholding giving her toys until she behaves properly. C. Ignore her behavior as long as she does not hurt herself and others. D. Ask her what she wants and give it to pacify her. 19. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By this period, baby Villanueva has already increased his height by how many inches? A. 3 inches B. 4 inches C. 5 inches D. 6 inches 20. Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under aerosol administration of Terbutaline. After sometime, you observe that the child does not show any relief from the treatment given. Upon assessment, you noticed that both the heart and respiratory rate are still elevated and the child shows difficulty of exhaling. You suspect: A. Bronchiectasis B. Atelectasis C. Epiglotitis D. Status Asthmaticus 21. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms the nurse observes that suggest this problem include: A. Lymphedema and nerve palsy B. Hearing loss and ataxia C. Headaches and vomiting D. Abdominal mass and weakness 22. Which of the following danger sings should be reported immediately during the antepartum period? A. blurred vision B. nasal stuffiness C. breast tenderness D. constipation 23. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following symptoms would the nurse anticipate finding? A. periorbital edema, absent light reflex and translucent tympanic membrane B. irritability, purulent drainage in middle ear, nasal congestion and cough C. diarrhea, retracted tympanic membrane and enlarged parotid gland D. Vomiting, pulling at ears and pearly white tympanic membrane 24. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks gestation? A. Sensory stimulation including several senses at a time B. tactile stimulation until signs of over stimulation develop C. An attitude of extension when prone or side lying D. Kangaroo care 25. The parent of a client with albinism would need to be taught which preventive healthcare measure by the nurse: A. Ulcerative colitis diet B. Use of a high-SPF sunblock C. Hair loss monitoring D. Monitor for growth retardation Answers and Rationales 1. (A) that extended their anal sphincter. Third degree laceration involves all in the second degree laceration and the external sphincter of the rectum. Options B, C and D are under the second degree laceration. 2. (C) I will have to remain in bed until my due date comes. Placenta previa means that the placenta is the presenting part. On the first and second trimester there is spotting. On the third trimester there is bleeding that is sudden, profuse and painless. 3. (D) 18th week of pregnancy. On the 8th week of pregnancy, the uterus is still within the pelvic area. On the 10th week, the uterus is still within the pelvic area. On the 12th week, the uterus and placenta have grown, expanding into the abdominal cavity. On the 18th week, the uterus has already risen out of the pelvis and is expanding into the abdominal area. 4. (A) frequency. Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence and burning are symptoms associated with urinary tract infection. 5. (B) 25-35 lbs. A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently recommended as an average weight gain in pregnancy. This weight gain consists of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb; uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7 lb. 6. (B) Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth. A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available. 7. (D) convulsions. Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsia—an obstetrical emergency. 8. (C) Should be restricted because it may stimulate uterine activity.. Coitus is restricted when there is watery discharge, uterine contraction and vaginal bleeding. Also those women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of pregnancy when a previous miscarriage occurred. 9. (D) assume Sim’s position. When the woman is in Sim’s position, this puts the weight of the fetus on bed, not on the woman and allows good circulation in the lower extremities. 10. (A) The anterior is large in shape when compared to the posterior fontanel.. The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped closes at 18 month, whereas the posterior fontanel, which is triangular in shape closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increases ICP or sunken, which may indicate hydration. 11. (A) 13 -14 lbs. The birth weight of an infant is doubled at 6 months and is tripled at 12 months. 12. (B) To promote uterine contraction. Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions, helping to promote uterine involution. 13. (B) 100 beats per minute. The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute. 14. (D) Trust vs. Mistrust. The child with Down syndrome will go through the same first stage, trust vs. mistrust, only at a slow rate. Therefore, the nurse should concentrate on developing on bond between the primary caregiver and the child. 15. (A) Irreversible brain damage. The child with PKU must maintain a strict low phenylalanine diet to prevent central nervous system damage, seizures and eventual death. 16. (B) Preschool. During preschool, this is the time when children do imitative play, imaginative play—the occurrence of imaginative playmates, dramatic play where children like to act, dance and sing. 17. (D) Saying “mama” or “dada” for the first time at 18 months of age.. A child should say “mama” or “dada” during 10 to 12 months of age. Options A, B and C are all normal assessments of language development of a child. 18. (C) Ignore her behavior as long as she does not hurt herself and others.. If a child is trying to get attention or trying to get something through tantrums—ignore his/her behavior. 19. (B) 4 inches. From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. From 6 to 12 months, the infant grows ½ inch (1.25 cm) per month. 20. (D) Status Asthmaticus. Status asthmaticus leads to respiratory distress and bronchospasm despite of treatment and interventions. Mechanical ventilation maybe needed due to respiratory failure. 21. (D) Abdominal mass and weakness. Nephroblastoma or Wilm’s tumor is caused by chromosomal abnormalities, most common kidney cancer among children characterized by abdominal mass, hematuria, hypertension and fever. 22. (A) blurred vision. Danger signs that require prompt reporting are leaking of amniotic fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated blood pressure. Nasal stuffiness, breast tenderness, and constipation are common discomforts associated with pregnancy. 23. (B) irritability, purulent drainage in middle ear, nasal congestion and cough. Irritability, purulent drainage in middle ear, nasal congestion and cough, fever, loss of appetite, vomiting and diarrhea are clinical manifestations of otitis media. Acute otitis media is common in children 6 months to 3 years old and 8 years old and above. Breast fed infants have higher resistance due to protection of Eustachian tubes and middle ear from breast milk. 24. (D) Kangaroo care. Kangaroo care is the use of skin-to-skin contact to maintain body heat. This method of care not only supplies heat but also encourages parent-child interaction. 25. (B) Use of a high-SPF sunblock. Without melanin production, the child with albinism is at risk for severe sunburns. Maximum sun protection should be taken, including use of hats, long sleeves, minimal time in the sun and high-SPF sunblock, to prevent any problems. Maternal and Child Health Nursing Exam 2 1. Nurse Bella explains to a 28 year old pregnant woman undergoing a non-stress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with: A. Fetal lie B. Fetal movement C. Maternal blood pressure D. Maternal uterine contractions 2. During a 2 hour childbirth focusing on labor and delivery process for primigravida. The nurse describes the second maneuver that the fetus goes through during labor progress when the head is the presenting part as which of the following: A. Flexion B. Internal rotation C. Descent D. External rotation 3. Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-fetoprotein. The nurse informed her about the result of the elevation of serum AFP. The patient asked her what was the test for: A. Congenital Adrenal Hyperplasia B. PKU C. Down Syndrome D. Neural tube defects 4. Fetal heart rate can be auscultated with a fetoscope as early as: A. 5 weeks of gestation B. 10 weeks of gestation C. 15 weeks of gestation D. 20 weeks of gestation 5. Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The nurse would explain that this is most probably the result of which of the following: A. Thrombophlebitis B. PIH C. Pressure on blood vessels from the enlarging uterus D. The force of gravity pulling down on the uterus 6. Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart disease lesion. Her pregnancy has just been diagnosed. Her heart disease has not caused her to limit physical activity in the past. Her cardiac disease and functional capacity classification is: A. Class I B. Class II C. Class III D. class IV 7. The client asks the nurse, “When will this soft spot at the top of the head of my baby will close?” The nurse should instruct the mother that the neonate’s anterior fontanel will normally close by age: A. 2-3 months B. 6-8 months C. 10-12 months D. 12-18 months 8. When a mother bleeds and the uterus is relaxed, soft and non- tender, you can account the cause to: A. Atony of the uterus B. Presence of uterine scar C. Laceration of the birth canal D. Presence of retained placenta fragments 9. Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD should be which of the following: A. February 11, 2011 B. January 11, 20111 C. December 12, 2010 D. Nowember 14, 2010 10. Which of the following prenatal laboratory test values would the nurse consider as significant? A. Hematocrit 33.5% B. WBC 8,000/mm3 C. Rubella titer less than 1:8 D. One hour glucose challenge test 110 g/dL 11. Aling Patricia is a patient with preeclampsia. You advise her about her condition, which would tell you that she has not really understood your instructions? A. “I will restrict my fat in my diet.” B. “I will limit my activities and rest more frequently throughout the day.” C. “I will avoid salty foods in my diet.” D. “I will come more regularly for check-up.” 12. Mrs. Grace Evangelista is admitted with severe preeclampsia. What type of room should the nurse select this patient? A. A room next to the elevator. B. The room farthest from the nursing station. C. The quietest room on the floor. D. The labor suite. 13. During a prenatal check-up, the nurse explains to a client who is Rh negative that RhoGAM will be given: A. Weekly during the 8th month because this is her third pregnancy. B. During the second trimester, if amniocentesis indicates a problem. C. To her infant immediately after delivery if the Coomb’s test is positive. D. Within 72 hours after delivery if infant is found to be Rh positive. 14. A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm. She has a weak cry, irregular respiration. She was moving all extremities and only her hands and feet were still slightly blue. The nurse should enter the APGAR score as: A. 5 B. 6 C. 7 D. 8 15. Billy is a 4 year old boy who has an IQ of 140 which means: A. average normal B. very superior C. above average D. genius 16. A newborn is brought to the nursery. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip. Based on this data, the nurse suspects that the newborn is MOST likely showing the effects of: A. Chronic toxoplasmosis B. Lead poisoning C. Congenital anomalies D. Fetal alcohol syndrome 17. A priority nursing intervention for the infant with cleft lip is which of the following: A. Monitoring for adequate nutritional intake B. Teaching high-risk newborn care C. Assessing for respiratory distress D. Preventing injury 18. Nurse Jacob is assessing a 12 year old who has hemophilia A. Which of the following assessment findings would the nurse anticipate? A. an excess of RBC B. an excess of WBC C. a deficiency of clotting factor VIII D. a deficiency of clotting factor IX 19. Celine, a mother of a 2 year old tells the nurse that her child “cries and has a fit when I have to leave him with a sitter or someone else.” Which of the following statements would be the nurse’s most accurate analysis of the mother’s comment? A. The child has not experienced limit-setting or structure. B. The child is expressing a physical need, such as hunger. C. The mother has nurtured overdependence in the child. D. The mother is describing her child’s separation anxiety. 20. Mylene Lopez, a 16 year old girl with scoliosis has recently received an invitation to a pool party. She asks the nurse how she can disguise her impairment when dressed in a bathing suit. Which nursing diagnosis can be justified by Mylene’s statement? A. Anxiety B. Body image disturbance C. Ineffective individual coping D. Social isolation 21. The foul-smelling, frothy characteristic of the stool in cystic fibrosis results from the presence of large amounts of which of the following: A. sodium and chloride B. undigested fat C. semi-digested carbohydrates D. lipase, trypsin and amylase 22. Which of the following would be a disadvantage of breast feeding? A. involution occurs rapidly B. the incidence of allergies increases due to maternal antibodies C. the father may resent the infant’s demands on the mother’s body D. there is a greater chance of error during preparation 23. A client is noted to have lymphedema, webbed neck and low posterior hairline. Which of the following diagnoses is most appropriate? A. Turner’s syndrome B. Down’s syndrome C. Marfan’s syndrome D. Klinefelter’s syndrome 24. A 4 year old boy most likely perceives death in which way: A. An insignificant event unless taught otherwise B. Punishment for something the individual did C. Something that just happens to older people D. Temporary separation from the loved one. 25. Catherine Diaz is a 14 year old patient on a hematology unit who is being treated for sickle cell crisis. During a crisis such as that seen in sickle cell anemia, aldosterone release is stimulated. In what way might this influence Catherine’s fluid and electrolyte balance? A. sodium loss, water loss and potassium retention B. sodium loss, water los and potassium loss C. sodium retention, water loss and potassium retention D. sodium retention, water retention and potassium loss Answers and Rationales 1. (B) Fetal movement. Non-stress test measures response of the FHR to the fetal movement. With fetal movement, FHR increase by 15 beats and remain for 15 seconds then decrease to average rate. No increase means poor oxygenation perfusion to fetus. 2. (A) Flexion. The 6 cardinal movements of labor are descent, flexion, internal rotation, extension, external rotation and expulsion. 3. (D) Neural tube defects. Alpha-fetoprotein is a substance produces by the fetal liver that is present in amniotic fluid and maternal serum. The level is abnormally high in the maternal serum if the fetus has an open spinal or abdominal defect because the open defect allows more AFP to appear. 4. (D) 20 weeks of gestation. The FHR can be auscultated with a fetoscope at about 20 weeks of gestation. FHR is usually auscultated at the midline suprapubic region with Doppler ultrasound at 10 to 12 weeks of gestation. FHR cannot be heard any earlier than 10 weeks of gestation. 5. (C) Pressure on blood vessels from the enlarging uterus. Pressure of the growing fetus on blood vessels results in an increase risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. 6. (A) Class I. Clients under class I has no physical activity limitation. There is a slight limitation of physical activity in class II, ordinary activity causes fatigue, palpitation, dyspnea or angina. Class III is moderate limitation of physical activity; less than ordinary activity causes fatigue. Unable to carry on any activity without experiencing discomfort is under class IV. 7. (D) 12-18 months. Anterior fontanel closes at 12-18 months while posterior fontanel closes at birth until 2 months. 8. (A) Atony of the uterus. Uterine atony, or relaxation of the uterus is the most frequent cause of postpartal hemorrhage. It is the inability to maintain the uterus in contracted state. 9. (B) January 11, 20111. Using the Nagel’s rule, he use this formula ( -3 calendar months + 7 days). 10. (C) Rubella titer less than 1:8. A rubella titer should be 1:8 or greater. Thus, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5%, WBC of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dL are within normal parameters. 11. (B) “I will limit my activities and rest more frequently throughout the day.”Pregnant woman with preeclampsia should be in a complete bed rest. When body is in recumbent position, sodium tends to be excreted at a faster rate. It is the best method of aiding increased excretion of sodium and encouraging diuresis. Rest should always be in a lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension. 12. (C) The quietest room on the floor.A loud noise such as a crying baby, or a dropped tray of equipment may be sufficient to trigger a seizure initiating eclampsia, a woman with severe preeclampsia should be admiotted to a private room so she can rest as undisturbed as possible. Darken the room if possible because bright light can trigger seizures. 13. (D) Within 72 hours after delivery if infant is found to be Rh positive. RhoGAM is given to Rh-negative mothers within 72 hours after birth of Rh-positive baby to prevent development of antibodies in the maternal blood stream, which will be fata to succeeding Rh-positive offspring. 14. (B) 6. Heart rate of 99 bpm-1; weak cry-1; irregular respiration- 1; moving all extremities-2; extremities are slightly blue-1; with a total score of 6. 15. (D) genius. IQ= mental age/chronological age x 100. Mental age refers to the typical intelligence level found for people at a give chronological age. OQ of 140 and above is considered genius. 16. (D) Fetal alcohol syndrome. The newborn with fetal alcohol syndrome has a number of possible problems at birth. Characteristics that mark the syndrome include pre and postnatal growth retardation; CNS involvement such as cognitive challenge, microcephally and cerebral palsy; and a distinctive facial feature of a short palpebral fissure and thin upper lip. 17. (A) Monitoring for adequate nutritional intake. The infant with cleft lip is unable to create an adequate seal for sucking. The child is at risk for inadequate nutritional intake as well as aspiration. 18. (C) a deficiency of clotting factor VIII. Hemophillia A (classic hemophilia) is a deficiency in factor VIII (an alpha globulin that stabilizes fibrin clots). 19. (D) The mother is describing her child’s separation anxiety. Before coming to any conclusion, the nurse should ask the mother focused questions; however, based on initial information, the analysis of separation anxiety would be most valid. Separation anxiety is a normal toddler response. When the child senses he is being sent away from those who most provide him with love and security. Crying is one way a child expresses a physical need; however, the nurse would be hasty in drawing this as first conclusion based on what the mother has said. Nurturing overdependence or not providing structure for the toddler are inaccurate conclusions based on the information provided. 20. (B) Body image disturbance. Mylene is experiencing uneasiness about the curvative of her spine, which will be more evident when she wears a bathing suit. This data suggests a body image disturbance. There is no evidence of anxiety or ineffective coping. The fact that Mylene is planning to attend a pool party dispels a diagnosis of social isolation. 21. (B) undigested fat. The client with cystic fibrosis absorbs fat poorly because of the think secretions blocking the pancreatic duct. The lack of natural pancreatic enzyme leads to poor absorption of predominantly fats in the duodenum. Foul- smelling, frothy stool is termed steatorrhea. 22. (C) the father may resent the infant’s demands on the mother’s body. With breast feeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation required for breast feeding. 23. (A) Turner’s syndrome. Lymphedema, webbed neck and low posterior hairline, these are the 3 key assessment features in Turner’s syndrome. If the child is diagnosed early in age, proper treatment can be offered to the family. All newborns should be screened for possible congenital defects. 24. (D) Temporary separation from the loved one. The predominant perception of death by preschool age children is that death is temporary separation. Because that child is losing someone significant and will not see that person again, it’s inaccurate to infer death is insignificant, regardless of the child’s response. 25. (D) sodium retention, water retention and potassium loss. Stress stimulates the adrenal cortex to increase the release of aldosterone. Aldosterone promotes the resorption of sodium, the retention of water and the loss of potassium. Maternal and Child Health Nursing Exam 3 1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time? A. Timing and recording length of contractions. B. Monitoring. C. Preparing for an emergency cesarean birth. D. Checking the perineum for bulging. 2. A client who hallucinates is not in touch with reality. It is important for the nurse to: A. Isolate the client from other patients. B. Maintain a safe environment. C. Orient the client to time, place, and person. D. Establish a trusting relationship. 3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child? A. Cola with ice B. Yellow noncitrus Jello C. Cool cherry Kool-Aid D. A glass of milk 4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of: A. Increased nasal congestion. B. Nasal polyps. C. Bleeding tendencies. D. Tinnitus and diplopia. 5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should: A. Place the client in a private room. B. Wear an N 95 respirator when caring for the client. C. Put on a gown every time when entering the room. D. Don a surgical mask with a face shield when entering the room. 6. Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma? A. The frequent nausea and vomiting accompanying use of miotic drug. B. Loss of mobility due to severe driving restrictions. C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine. D. The painful and insidious progression of this type of glaucoma. 7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What would be the initial nursing action? A. Apply pressure directly over the incision site. B. Clamp the chest tube near the incision site. C. Clamp the chest tube closer to the drainage system. D. Reconnect the chest tube to the Pleurovac. 8. Which of the following complications during a breech birth the nurse needs to be alarmed? A. Abruption placenta. B. Caput succedaneum. C. Pathological hyperbilirubinemia. D. Umbilical cord prolapse. 9. The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression? A. Protect the client against harm to others. B. Provide the client with motor outlets for aggressive, hostile feelings. C. Reduce interpersonal contacts. D. Deemphasizing preoccupation with elimination, nourishment, and sleep. 10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not: A. Sit up. B. Pick up and hold a rattle. C. Roll over. D. Hold the head up. 11. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not knowthe physician or the client to whom the order pertains. The nurse should: A. Ask the physician to call back after the nurse has read the hospital policy manual. B. Take the telephone order. C. Refuse to take the telephone order. D. Ask the charge nurse or one of the other senior staff nurses to take the telephone order. 12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial actionof the nurse? A. Accept the new assignment and complete an incident report describing a shortage of nursing staff. B. Report the incident to the nursing supervisor and request to be floated. C. Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment. D. Accept the new assignment and provide the best care. 13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the: A. 40 years of age. B. 20 years of age. C. 35 years of age. D. 20 years of age. 14. The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions? A. The float staff nurse will be informed of the situation before the shift begins. B. The staff nurse will be able to negotiate the assignments in the emergency department. C. Cross training will be available for the staff nurse. D. Client assignments will be equally divided among the nurses. 15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the child in order to assess the client’s risk for digoxin toxicity? A. “Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?” B. “Has he been taking diuretics at home?” C. “Do any of his brothers and sisters have history of cardiac problems?” D. “Has he been going to school regularly?” 16. The nurse noticed that the signed consent form has an error. The form states, “Amputation of the right leg” instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do? A. Call the physician to reschedule the surgery. B. Call the nearest relative to come in to sign a new form. C. Cross out the error and initial the form. D. Have the client sign another form. 17. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would: A. Vigorously strip the tube to dislodge a clot. B. Raise the apparatus above the chest to move fluid. C. Increase wall suction above 20 cm H2O pressure. D. Ask the client to cough and take a deep breath. 18. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to: A. Determine who is responsible for the mistake and terminate his or her employment. B. Record the event in an incident/variance report and notify the nursing supervisor. C. Reassure both mothers, report to the charge nurse, and do not record. D. Record detailed notes of the event on the mother’s medical record. 19. Before the administration of digoxin, the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant sign of digoxin toxicity? A. Tinnitus B. Nausea and vomiting C. Vision problem D. Slowing in the heart rate 20. Which of the following treatment modality is appropriate for a client with paranoid tendency? A. Activity therapy. B. Individual therapy. C. Group therapy. D. Family therapy. 21. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to: A. Wear sunglasses if exposed to bright light for an extended period of time. B. Take oral preparations of prednisone before meals. C. Have periodic complete blood counts while on the medication. D. Never stop or change the amount of the medication without medical advice. 22. A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response? A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife. B. “Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.” C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.” D. “Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L.” 23. Which of the following will help the nurse determine that the expression of hostility is useful? A. Expression of anger dissipates the energy. B. Energy from anger is used to accomplish what needs to be done. C. Expression intimidates others. D. Degree of hostility is less than the provocation. 24. The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management? A. Main objective is a written plan that combines discipline- specific processes used to measure outcomes of care. B. Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis. C. Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost. D. Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems. 25. The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct? A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome. B. Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy. C. Plan to give phenytoin over 30-60 minutes, using an in-line filter. D. Flush the IV tubing with normal saline before starting phenytoin. 26. The pregnant woman visits the clinic for check –up. Which assessment findings will help the nurse determine that the client is in 8-week gestation? A. Leopold maneuvers. B. Fundal height. C. Positive radioimmunoassay test (RIA test). D. Auscultation of fetal heart tones. 27. Which of the following nursing intervention is essential for the client who had pneumonectomy? A. Medicate for pain only when needed. B. Connect the chest tube to water-seal drainage. C. Notify the physician if the chest drainage exceeds 100mL/hr. D. Encourage deep breathing and coughing. 28. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause: A. Discoloration of baby and adult teeth. B. Pneumonia in the newborn. C. Snuffles and rhagades in the newborn. D. Central hearing defects in infancy. 29. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the nurse would be: A. “Yes, once I tried grass.” B. “No, I don’t think so.” C. “Why do you want to know that?” D. “How will my answer help you?” 30. Which of the following describes a health care team with the principles of participative leadership? A. Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members. B. The physician makes most of the decisions regarding the client’s care. C. The team uses the expertise of its members to influence the decisions regarding the client’s care. D. Nurses decide nursing care; physicians decide medical and other treatment for the client. 31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution? A. Oxytocin. B. Estrogen. C. Progesterone. D. Relaxin. 32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the: A. Primary nursing method. B. Case method. C. Functional method. D. Team method. 33. The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for: A. Gas exchange impairment. B. Hypoglycemia. C. Hyperthermia. D. Fluid volume excess. 34. Most couples are using “natural” family planning methods. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period? A. Ovum viability. B. Tubal motility. C. Spermatozoal viability. D. Secretory endometrium. 35. An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s station saying, “I am having difficulty in sleeping.” What is the best nursing response to the client? A. “I’ll give you a sleeping pill to help you get more sleep now.” B. “Perhaps you’d like to sit here at the nurse’s station for a while.” C. “Would you like me to show you where the bathroom is?” D. “What woke you up?” 36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to: A. Start oxygen by mask to reduce fetal distress. B. Examine the woman for signs of a prolapsed cord. C. Turn the woman on her left side to increase placental perfusion. D. Take the woman’s radial pulse while still auscultating the FHR. 37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like: A. Antihistamines. B. NSAIDs. C. Antacids. D. Salicylates. 38. A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when: A. Client is oriented when aroused from sleep, and goes back to sleep immediately. B. Blood pressure is decreased from 160/90 to 110/70. C. Client refuses dinner because of anorexia. D. Pulse is increased from 88-96 with occasional skipped beat. 39. The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct? A. “The spouse, but not the rest of the family, may override the advance directive.” B. “An advance directive is required for a “do not resuscitate” order.” C. “A durable power of attorney, a form of advance directive, may only be held by a blood relative.” D. “The advance directive may be enforced even in the face of opposition by the spouse.” 40. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, “I need to go to an appointment.” What is the appropriate nursing intervention? A. Tell the client that he cannot bang on the door. B. Ignore this behavior. C. Escort the client going back into the room. D. Ask the client to move away from the door. 41. Which of the following action is an accurate tracheal suctioning technique? A. 25 seconds of continuous suction during catheter insertion. B. 20 seconds of continuous suction during catheter insertion. C. 10 seconds of intermittent suction during catheter withdrawal. D. 15 seconds of intermittent suction during catheter withdrawal. 42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is: A. Suture set. B. Tracheostomy set. C. Suction equipment. D. Wire cutters. 43. A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation? A. The uterus becomes globular. B. The umbilical cord is shortened. C. The fundus appears at the introitus. D. Mucoid discharge is increased. 44. After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the physician? A. 3+ peripheral pulses. B. Change in level of consciousness and headache. C. Occasional dysrhythmias. D. Heart rate of 100/bpm. 45. A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing? A. Push fluid administration to loosen respiratory secretions. B. Have the client lie on the unaffected side. C. Maintain the client in high Fowler’s position. D. Coordinate breathing and coughing exercise with administration of analgesics. 46. The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the “fertile” period of the menstrual cycle? A. Absence of ferning. B. Thin, clear, good spinnbarkeit. C. Thick, cloudy. D. Yellow and sticky. 47. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to: A. Facilitate movement and reduce complications from immobility. B. Fully aerate the lungs. C. Splint the wound. D. Promote drainage and prevent subdiaphragmatic abscesses. 48. Which of the following will best describe a management function? A. Writing a letter to the editor of a nursing journal. B. Negotiating labor contracts. C. Directing and evaluating nursing staff members. D. Explaining medication side effects to a client. 49. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops: A. In the middle of the lower conjunctival sac of the infant’s eye. B. Directly onto the infant’s sclera. C. In the outer canthus of the infant’s eye. D. In the inner canthus of the infant’s eye. 50. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding? A. Frank blood on the clothing. B. Thirst and restlessness. C. Abdominal pain. D. Confusion and altered of consciousness. 51. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse charts this as: A. Icterus neonatorum B. Multiple hemangiomas C. Erythema toxicum D. Milia 52. The client is brought to the emergency department because of serious vehicle accident. After an hour, the client has been declared brain dead. The nurse who has been with the client must now talk to the family about organ donation. Which of the following consideration is necessary? A. Include as many family members as possible. B. Take the family to the chapel. C. Discuss life support systems. D. Clarify the family’s understanding of brain death. 53. The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. Which of the following should the nurse exclude in the exercise program? A. Stand with legs apart and touch hands to floor three times per day. B. Ten minutes of walking per day with an emphasis on good posture. C. Ten minutes of swimming or leg kicking in pool per day. D. Pelvic rock exercise and squats three times a day. 54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to: A. Provide distraction. B. Support but limit the behavior. C. Prohibit the behavior. D. Point out the behavior. 55. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma: A. When the client is able to begin self-care procedures. B. 24 hours later, when the swelling subsided. C. In the operating room after the ileostomy procedure. D. After the ileostomy begins to function. 56. A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response? A. It is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile. B. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day 15. C. In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. The fertile period would be approximately between day 13 and 17. D. In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The fertile period is between day 20 and the beginning of the next period. 57. Which of the following statement describes the role of a nurse as a client advocate? A. A nurse may override clients’ wishes for their own good. B. A nurse has the moral obligation to prevent harm and do well for clients. C. A nurse helps clients gain greater independence and self- determination. D. A nurse measures the risk and benefits of various health situations while factoring in cost. 58. A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2? A. “Abstain from intercourse until lesions heal.” B. “Therapy is curative.” C. “Penicillin is the drug of choice for treatment.” D. “The organism is associated with later development of hydatidiform mole. 59. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client? A. Depression underlines ritualistic behavior. B. Fear and tensions are often expressed in disguised form through symbolic processes. C. Ritualistic behavior makes others uncomfortable. D. Unmet needs are discharged through ritualistic behavior. 60. The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism? A. Intellectualization. B. Suppression. C. Repression. D. Denial. 61. Which of the following situations cannot be delegated by the registered nurse to the nursing assistant? A. A postoperative client who is stable needs to ambulate. B. Client in soft restraint who is very agitated and crying. C. A confused elderly woman who needs assistance with eating. D. Routine temperature check that must be done for a client at end of shift. 62. In the admission care unit, which of the following client would the nurse give immediate attention? A. A client who is 3 days postoperative with left calf pain. B. A client who is postoperative hip pinning who is complaining of pain. C. New admitted client with chest pain. D. A client with diabetes who has a glucoscan reading of 180. 63. A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen? A. Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately. B. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours. C. Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately. D. Collect specimen at night, refrigerate, and bring to clinic the next morning. 64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will: A. Treat infection. B. Suppress labor contraction. C. Stimulate the production of surfactant. D. Reduce the risk of hypertension. 65. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures? A. Suction the trachea and mouth. B. Have the obdurator available. C. Encourage deep breathing and coughing. D. Do a pulse oximetry reading. 66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that: A. Gloves are worn when handling the client’s tissue, excretions, and linen. B. Both client and attending nurse must wear masks at all times. C. Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques. D. Full isolation; that is, caps and gowns are required during the period of contagion. 67. A client with lung cancer is admitted in the nursing care unit. The husband wants to know the condition of his wife. How should the nurse respond to the husband? A. Find out what information he already has. B. Suggest that he discuss it with his wife. C. Refer him to the doctor. D. Refer him to the nurse in charge. 68. A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Which is the most therapeutic approach to this client? A. Divert the client’s attention. B. Listen without reinforcing the client’s belief. C. Inject humor to defuse the intensity. D. Logically point out that the client is jumping to conclusions. 69. After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the instruction to empty the urine pouch: A. Every 3-4 hours. B. Every hour. C. Twice a day. D. Once before bedtime. 70. Which telephone call from a student’s mother should the school nurse take care of at once? A. A telephone call notifying the school nurse that the child’ pediatrician has informed the mother that the child will need cardiac repair surgery within the next few weeks. B. A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice. C. A telephone call notifying the school nurse that a child has a temperature of 102ºF and a rash covering the trunk and upper extremities of the body. D. A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night. 71. Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy? A. Severe abdominal pain or fluid discharge from the vagina. B. Excessive saliva, “bumps around the areolae, and increased vaginal mucus. C. Fatigue, nausea, and urinary frequency at any time during pregnancy. D. Ankle edema, enlarging varicosities, and heartburn. 72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes slightly cyanotic. What is the initial nursing action? A. Elevate his head to promote gravity drainage of secretions. B. Wrap him in another blanket, to reduce heat loss. C. Stimulate him to cry,, to increase oxygenation. D. Aspirate his mouth and nose with bulb syringe. 73. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle? A. The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings. B. The major fundamental mechanism is regression. C. The client’s symptoms are imaginary and the suffering is faked. D. An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love. 74. An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should: A. Be drawn in the same syringe and given in one injection. B. Be mixed and inject in the same sites. C. Not be mixed and the nurse must give three injections in three sites. D. Be mixed and the nurse must give the injection in three sites. 75. A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client: A. Flat in bed. B. On the side only. C. With the foot of the bed elevated. D. With the head elevated 45-degrees (semi-Fowler’s). 76. The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. Which of the following statement will help the nurse to know that the mother needs additional teaching? A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.” B. “I’ll give the medicine if my child gets into some aspirin.” C. “I’ll give the medicine if my child gets into some plant bulbs.” D. “I’ll give the medicine if my child gets into some vitamin pills.” 77. To assess if the cranial nerve VII of the client was damaged, which changes would not be expected? A. Drooling and drooping of the mouth. B. Inability to open eyelids on operative side. C. Sagging of the face on the operative side. D. Inability to close eyelid on operative side. 78. The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation? A. Assess the child’s injuries. B. Report the incident to protective agencies. C. Refer the family to appropriate support group. D. Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents. 79. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant: A. Always, as a representative of the institution. B. Always, because nurses who supervise less-trained individuals are responsible for their mistakes. C. If the nurse failed to determine whether the nursing assistant was competent to take care of the client. D. Only if the nurse agreed that the newborn could be fed formula. 80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged to the client. the primary reason for this is to: A. Reduce the size of existing stones. B. Prevent crystalline irritation to the ureter. C. Reduce the size of existing stones D. Increase the hydrostatic pressure in the urinary tract. 81. The nurse is counseling a couple in their mid 30’s who have been unable to conceive for about 6 months. They are concerned that one or both of them may be infertile. What is the best advice the nurse could give to the couple? A. “it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress.” B. “Start planning adoption. Many couples get pregnant when they are trying to adopt.” C. “Consult a fertility specialist and start testing before you get any older.” D. “Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy.” 82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine clearance is to be done. The client tells the nurse, “I can’t remember what this test is for.” The best response by the nurse is: A. “It provides a way to see if you are passing any protein in your urine.” B. “It tells how well the kidneys filter wastes from the blood.” C. “It tells if your renal insufficiency has affected your heart.” D. “The test measures the number of particles the kidney filters.” 83. The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night because of fear of dying.” What is the best initial nursing response? A. “It must be frightening for you to feel that way. Tell me more about it.” B. “Don’t worry, you won’t die. You are just here for some test.” C. “Why are you afraid of dying?” D. “Try to sleep. You need the rest before tomorrow’s test.” 84. In the hospital lobby, the registered nurse overhears a two staff members discussing about the health condition of her client. What would be the appropriate action for the registered nurse to take? A. Join in the conversation, giving her input about the case. B. Ignore them, because they have the right to discuss anything they want to. C. Tell them it is not appropriate to discuss such things. D. Report this incident to the nursing supervisor. 85. The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer? A. Weakened (L) side of the cient next to bed. B. Weakened (R) side of the client next to bed. C. Weakened (L) side of the client away from bed. D. Weakened (R) side of the cient away from bed. 86. The child client has undergone hip surgery and is in a spica cast. Which of the following toy should be avoided to be in the child’s bed? A. A toy gun. B. A stuffed animal. C. A ball. D. Legos. 87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) mu