LORMA COLLEGES

COLLEGE OF NURSING
Carlatan, San Fernando City, La Union
DIAGNOSTIC EXAMINATION
COMPETENCY APPRAISAL 1
NURSING PRACTICE I
SITUATION 1. Health teaching is always integrated in nursing practice that should result in
improved health, enhanced functional ability and better quality of life.
1. A nurse is providing instructions to a client and the family regarding home care after right
eye cataract surgery would indicate understanding of the instructions if she says?
A. I should not sleep on my left side.
B. I should not sleep on my right side.
C. I should not sleep with my head elevated.
D. I should not wear my glasses at any time.
2. A nursing student is preaparing a prenatal class on the process of fetal circulation. The
nursing instructor askes the student specifically to describe the processthrough the umbilical
cord. Which of the following statements from the student is correct?
A. The one artery carries freshly oxygenated blood and nutrient-rich blood back from
the placenta to the fetus.
B. The two arteries carry freshly oxygenated blood and nutrient-rich blood back from
the placenta to the fetus.
C. The two arteries in the umbilical cord carry deoxygenated blood and waste
products away from the fetus to the placenta.
D. The two veins in the umbilical cord carry blood that is high in carbon dioxide and
other waste products away from the fetus to the placenta.
3. A registered nurse who works in the preoperative area of the operating room notices that a
client is scheduled for a partial mastectomy and axillary lymph node removal the following
week. The nurse should make sure that the client is well educated about her surgery by:
A. Talking with the nursing staff at the physicians office to find out what the
client has been taught and her level of understanding
B. Making sure that the post-anesthesia care unit nurses know what to teach the client
before discharge
C. Providing all of the preoperative teaching before surgery
D. Having the post-operative nurses teach the client because shell be too anxious
before surgery
4. The home care nurse is making an initial visit to a mother and baby as routine follow up for
maternal/child assessment. The client was discharged from the hospital 24 hours ago after
birth of her first child. The client is 17 years old, single in the 11th grade, and staying at
home with her parents and younger siblings until she make alternative living arrangements.
The client is uncertain about keeping the baby because she doesnt kmnow whether she
wants to commit to the responsibilities of single parenthood at such a young age. Based on
this information, which primary obstacle that may interfere with the clients potential for
learning?
A. Low literacy
C. Lack of social support

B. Knowledge deficit
D. Lack of readiness to learn
5. The nurse is preparing a client for gallbladder surgery. The client has signed the cosnent
document. Which action should the nurse carry out to verify the client understands the
procedure?
A. Check whether the clients reading level is equivalent to the level of the consent form
B. Talk to a family member or the nurse who witnessed the clients signature on the
consent form
C. Ask the client to explain the procedure in his own words
D. Discuss with the clients physician what the client was told about the procedure
Situation 2. The ability to progress to each of the developmental phase influences the holistic
health of the individual.
6. A clinic nurse is preparing to discuss the concepts of moral development with a mother. The
nurse understands that according to Kohlbergs Theory of Moral Development, in the
preconventional level, moral development is thought to be motivated by which of the
following?
A. Peer pressure
C. Parents behavior
B. Social pressure
D. Punishment and reward
7. A maternity nurse is providing instructions to a new mother regarding the psychosocial
development of the newborn. Using Ericksons psychosocial development theory, the nurse
instructs the mother to:
A. Allow the newborn infant to signal a need
B. Anticipate all the needs of the newborn
C. Attend to the newborn immediately when crying
D. Avoid the newborn during the first 10 minutes of crying
8. A mother of 3 year old tells a clinic nurse that the child is rebelling constantly and having
temper tantrums. Using Ericksons psychosocial development theory, the nurse tells the
mother to:
A. Set limits on the childs behavior
B. Ignore the child when this behavior occurs
C. Allow the behavior because this is normal at this age period
D. Punish the child every time the child says no to change the behavior
9. The mother of an 8 year old child tells the clinic nurse that she is concerned about the child
because the child seems to be more attentive to friends than anything else. Using
Ericksons psychosocial development theory, the appropriate nursing response is which of
the following?
A. You need to be concerned.
B. You need to monitor the childs behavior closely.
C. At this age, the child is developing his own personality.
D. You need to provide more praise to the child to stop this behavior.
10. The mother of 4 year old child calls the clinic nurse and expresses concern because the
child has been masturbating. Using Freuds psychosexual stages of development, the
appropriate response by the nurse is which of the following?
A. This is a normal behavior at this age.
B. Children usually begin this behavior at age 8 years.
C. This is not normal behavior, and the child should be seen by the physician.
D. The child is very young to begin this behavior and should be brought to the clinic.

Situation 3. Nurse Allan conducts health assessment in a variety of setting seeking information
about health status to detect clients with high probabilities of having a disease.
11. Nurse Allan is instructing a client how to perform a testicular self examination (TSE). The
nurse explains that the best time to perform this exam is:
A. After a shower or bath
C. After having a bowel movement
B. While standing to void
D. While lying in bed before arising
12. Nurse Allan is also assessing to a client with menigeal irritation and elicits positive
Brudzinskis sign. Which finding did the nurse observe?
A. The client rigidly extends the arms with pronated forearms and plantar flexion of the
feet
B. The client flexes a leg at the hip and knee and reports pain in the vertebral column
when the leg is extended
C. The client passively flexes the hip and knee in response to neck flexion and
reports pain in the vertebral column
D. The clientsupper armsare flexed and held tightly to the sides of the body and the
legs are extended and internally rotated
13. The nurse is auscultating the clients lung fields. The systematic pattern used for
comparison is:
A. Side to side
C. Anterior to posterior
B. Top to bottom
D. Interspace to intraspace
14. The nurse is conducting a general survey on an adult client. The general survey includes:
A. Appearance and behavior
C. Observing specific body system
B. Measurement of vital signs
D. Conducting a detailed health history
Situation 4. A safe environment is essential for clients survival and well being. A nurse obtains
a prescription from a Physician to restrain a client by using a jacket safety device and instructs a
nursing assistant to apply the safety device to the client.
15. Which observation by the nurse indicates unsafe application of the safety device by the
nrusing assistant?
A. A safety knot in the safety device straps
B. Safety device straps that are safely secured to the side rails
C. Safety device straps that do not tighten when force is applied against them
D. Safety device secured so that two fingers can slide easily between the safety device
and the clients skin
16. A nurse is giving a report to a nursing assitant who will be caring for a client who has
restraints. The nurse instructs the nursing assistant to check the skin integrity of the
restrained hands every:
A. 2 hours
C. 1 hour
B. 3 hours
D. 30 minutes
17. A nurse is administering a cleansing enema to a client with a fecal impaction. Before
adminstering the enema, the nurse places the client in which position?
A. Left sims position
C. On the left side of the body, with HOB at 45
B. Right sims position
D. On the right side of the bosy, with HOB at 45
18. The Nurse Preceptor askes nurse trainees to describe the formal operations stage of
Piagets Cognitive Developmental Theory. The appropriate response by the nurse is:
A. The child has the ability to think abstractly.

B. The child begins to understand the environment.

C. The child is able to classify, order and sort facts.
D. The child learns to think in terms of past, present and future.
19. A nurse is evaluating the developmental level of a 2 year old. Which of the following does
the nurse expect to observe in this child?
A. Uses a fork to eat
C. Pours own milk into a cup
B. Uses a cup to drink
D. Uses a knife for cutting food
20. The nurse teaches parents how to have their children learn impulse control and cooperative
behaviors. This would be during Ericksons stage of development:
A. Trust versus Mistrust
C. Initiative versus Guilt
B. Autonomy versus Shame and Doubt
D. Industry versus Inferiority
NURSING PRACTICE II
Situation 5. Christina, an 18 years old woman, thinks she is 24 weeks pregnant. Today at clinic
vist, she tells you she helt her fetus move for the first time. She states, Feeling the baby move
made me realize for the first time theres someone inside me, you know what I mean. It made
me know its time I started being more careful with what I do. The client consents to sonogram
and for other diagnostic procedures needed to assess her baby.
21. Which of the following instructions to Christina would be included for her abdominal
ultrasound?
A. Bathing with an antibacterial soap to remove bacteria from the skin
B. Drinking a quart or more fluids 2 hours before the procedure and not voiding
C. Remaining in a fasting state from midnight until after the test is completed
D. Taking 2 ounces of mineral oil to facilitate bowel evacuation
22. After teaching the client about the purpose of the routine ultrasound, which of the following
Christinas statements would indicate to the nurse that the client needs instruction?
A. The ultrasound will help to locate the placenta
B. The ultrasound identifies blood flow through the umbilical cord
C. The test will determine where to insert the needle
D. The ultrasound locates a pool of amniotic fluid
23. Christina is also scheduled to have an amniocentesis to test for fetal maturity. What
instruction should the nurse give before the procedure?
A. Void immediately before the procedure to reduce your bladder size
B. The xray used to reveal the position of your fetus
C. The IV fluid that will be infused will dilate your uterus but will not harm the fetus
D. No more amniotic fluid forms afterwards which is why only a small amount is
removed
24. The nurse notes early decelerations of the fetal heart rate. Which of the following would the
nurse anticipate as the most likely cause of this fetal heart rate pattern?
A. Cord compression
C. Fetal head compression
B. Fetal bradycardia
D. Inadequate uteroplacental perfusion
Situation 6. Nurses play vital roles in providing prenatal care.
25. During a pre-natal visit, the nurse evaluates the fundal height of the uterus to be at the
umbilicus. The nurse estimates the gestation of the client at:
A. 16 weeks
C. 20 weeks
B. 24 weeks
D. 28 weeks

26. Which of the following is the appropriate obstetrical history or pregnancy classification for
Mrs. Annie, pregnant for the third time, whose first pregnancy ended in miscarriage at 9
weeks and second pregnancy was a vaginal delivery at 39 weeks of gestation and the child
is 2 years old now?
A. G3P1011
C. G2P2110
B. G3P3201
D. G2P2100
Situation 7. Mrs. Martinez, a 31 year old client, Gravida II, Para 0, 32 weeks gestation, is
admitted to the hospital with contractions of moderate intensity occurring every 3 4 minutes.
Mrs. Martinez who has previously delivered two nonviable fetuses at 30 weeks gestation, is
crying on admission. She asks, what causes preterm labor?
27. After giving instruction about various risks for preterm labor, the nurse determines the
additional explanation is needed when the client says that preterm labor is often associated
with which of the following?
A. Age older than 30 years
C. Chronic hypertension
B. Polyhydramnios
D. Multifetal gestation
28. Mrs. Martinez asks the nnurse, Why is God punishing me? I go to church every Sunday.
What did I do wrong to cause this? Which of the following would be the priority nursing
diagnosis?
A. Risk for impaired parenting related to hospitalization
B. Spiritual distress related to feelings of guilt and preterm labor
C. Risk for infection related to possible chorioamnionitis
D. Disturbed body image related to pregnancy and hospitalization
29. Mrs. Martinez is experiencing preterm labor. The nurses first intervention is to:
A. Obtain a complete history and update the physician
B. Initiate IV hydration an begin the tocolytic medication
C. Obtain a fetal fibronectin and CBC
D. Monitor for contractions and fetal well-being
30. Mrs. Martinez is being treated with indomethacin to halt preterm labor. If Mrs. Martinez
should deliver a preterm infant, the nurse would notify the nursery personnel about this
therapy because of the possibility for which of the following?
A. Pulmonary hypertension
C. Hyperbilirubinemia
B. Respiratory distress syndrome D. Cardiomyopathy
Situation 8. Boy Ted is a child diagnosed with Tetralogy of Fallot. He becomes upset, crying and
trashing around when a blood speciemn is obtained. The childs color becomes blue and the
respiratory rate increases to 44BPM. As a nurse of Boy Ted, you should have knowledge about
the different congenital heart diseases.
31. Which of the following actions would the nurse do first?
A. Obtain an order for sedation for the child
B. Assess for an irregular heart rate and rhythm
C. Explain to the child that it will only hurt for a short time
D. Place the child in a knee-to-chest position
32. These are the following anomalies in Tetralogy of Fallot except:
A. Pulmonary stenosis
C. Ventricular spetal defect
B. Atrial septal defect
D. Right ventricular hypertrophy

33. When teaching Boy Ted how to perform coughing and deep breathing exercises before
corrective surgery for Tetralogy of Fallot, which of the following teaching and learning
principles would the nurse address first?
A. Organizing information to be taught in a logical sequence
B. Arranging to use actual equipment for demonstrations
C. Building the teaching on the childs current level of knowledge
D. Presenting the information in order from simplest to most complex
34. When planning care for Boy Ted before corrective surgery for Tetralogy of Fallot, which of
the following would the nurse identify as the priority nursing diagnosis?
A. Ineffective coping related to upcoming surgery and complications
B. Pain related to surgical incision required to correct the defect
C. Deficient knowledge related to upcoming surgery and postoperative events
D. Impaired gas exchange related to structural cardiac defect
35. When assessing Boy Ted after heart surgery, which of the following would alert the nurse to
suspect a low cardiac output?
A. Bounding pulses and mottled skin
B. Altered level of consciousness and thready pulse
C. Capillary refill of 2 seconds and blood pressure of 96/67mmHg
D. Extremities warm to touch and pale skin
Situation 9. Dan is 9 months old. He weighs 9.5 kg. His temperature is 39.5C. His mother
says he has had diarrhea for 1 week now. Dan does not have any general danger sign. He
does not have cough or DOB.
36. Dan has had diarrhea for 1 week. There is no blood in his stool. He is not restless or
irritable and he is not lethargic or unconscious either. He has sunken eyes, thirsty and
drinks eagerly when offered a drink. When his skin was pinched, it went back to its original
state slowly. What is the category of this child?
A. Some dehydration
C. No dehydration
B. Severe dehydration
D. Persistent diarrhea
37. In Dans classification, the nurse will give initial treatment such as fluids and food. For Dans
weight, what is the appropriate fluid replacement the nurse should give?
A. 200 400 ml
C. 700 900 ml
B. 400 700 ml
D. 900 1400 ml
38. After how many hours of fluid replacement the nurse should reassess Dan?
A. 2
B. 3
C. 4
D. 5
39. The nurse assesses Dan for additional signs related to fever. Dans mother says he has felt
hot for about 2 days now. The risk of malaria is high. He has not had measles in the last 3
months. He does not have a stiff neck or runny nose. The nurse can classify Dan in:
A. Fever: Malaria Unlikely
C. Very Severe Febrile Disease
B. Malaria
D. Fever: No Malaria
40. The nurse should give one dose of paracetamol in the health center for his fever, she would
advice the mother regarding when to return immediately to the health center. If fever has
been present everyday, for more than how many days the child must be referred to a
hospital for assessment?
A. 3 days
B. 5 days
C. 7 days
D. 10 days
NURSING PRACTICE III

Situation 10. David, 57 years old, is admitted in the medical unit with a diagnosis of Chronic
Obstructive Pulmonary Disease (COPD).
41. The nurse is collecting data regarding Davids cigarette smoking habit. David admits to
smoking one and half packs per day for the last 15 years. The nurse would determine that
the client has a smoking history of how many pack years?
A. 20
B. 22.5
C. 25
D. 30
42. David has had an anterial blood gas drawn from the radial artery and the nurse is asked to
hold pressure on the site. The nurse would apply the pressure for at least:
A. 1 minute
B. 5 minutes
C. 10 minutes
D. 15 minutes
43. Davids ABG values were obtained and the report is as follows: pH 7.35, PO2 85, PCO2 55,
HCO3 25. The nurse interprets these values as:
A. Compensated respiratory acidosis
C. Uncompensated respiratory acidosis
B. Compensated metabolic acidosis
D. Uncompensated metabolic acidosis
44. The nurse instructs David to use a metered dose inhaler. It would be essential for the nurse
to include which of the following?
A. Hold the breath for 3 seconds after using the inhaler
B. Take a quick deep breath after activating the inhaler
C. Place the canister six inches in front of an open mouth
D. Activate the canister at the beginning of a slow deep breath
45. The nurse teaches David about positions that help breathing during dyspneic episodes.
Which statement by the client indicates the need for further instruction?
A. I should sit up and lean on the table
B. I should lie on my back with a pillow
C. I should sit up with my elbows resting on my knees
D. I should stand and lean against a wall
Situation 11. Nurse Bambi is a staff nurse in the surgical ward of a tertiary hospital. She is in
charge of preoperative teaching and assessment.
46. Nurse Bambi reads the clients chart and a surgery was scheduled. The surgery was
classified as urgent. This means that surgery is performed:
A. Without delay
C. Within few weeks or months
B. Within 24-30 hours
D. Based on personal preference
47. Which of the following is not true regarding obese clients who udergo surgery?
A. Obesity increases the risk of severity of complications
B. During surgery, fatty tissues are susceptible to infection
C. Wound dehiscence is less common
D. Obese clients tend to breathe poorly when supine adding risk for pulmonary
complications
48. Spauldings Classification System is used to determine the appropriate method to attain the
desired level of disinfection required for patient care items. This system was adopted and
later modified by the Center for Disease Control and Prevention (CDC).
A. Critical items
C. Moderate-critical items
B. Semi-critical items
D. Non-critical items
49. As a nurse caring for patients in pain, you should evaluate for opioid common side effects
which include the following except:
A. Physical dependence
C. Respiratory depression
B. Pruritus
D. Constipation

50. The patient has been on morphine on a regular basis for several weeks. He is now
complaining that the usual dose he has been receiving is no longer relieving his pain as
effectively. Assuming that nothing has changed in his condition, you would suspect that the
patient is:
A. Becoming psychologically dependent
B. Needing to have the morphine discontinued
C. Developing tolerance to the morphine
D. Exaggerating his level of pain
Situation 12. A 48 years old foreman comes to the hospital complaining of severe substernal
chest pain radiating down his left arm. He is admitted to the CCU with a diagnosis of
Myocardial Infarction (MI).
51. Which of the following nursing assessment activities is a priority on admission to the CCU?
A. Begin ECG monitoring
B. Obtain information about family history of heart diseases
C. Auscultate lung fields
D. Determine if the client smokes
52. Which of the following blood tests is most indicative of cardiac damage?
A. Myoglobin
C. Troponin I
B. Creatinin Kinase
D. Lactate Dehydrogenase
53. When preparing to administer thrombolytic therapy to this client, the nurse is aware that
which situation would be an absolute contraindication to its use?
A. A history of hemorrhagic stroke
B. Onset of chest pain less than 24 hours ago
C. ST segment elevation in two leads facing same heart area
D. Unrelieved chest pain lasting longer than 20 minutes
54. Which of the following classes of medications protects the ischemic myocardium by blocking
catecholamine and sympathetic nerve stimulation?
A. Beta adrenergic blockers
C. Narcotics
B. Calcium channel blockers
D. Nitrates
55. The nurse notes on the ECG monitor, that the client with sinus rhythm has premature
ventricular contraction (PVC) that falls on the T wave of the preceding beat. The clients
rhythm suddenly changed to one with no P waves or definable QRS complexes. Instead,
there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be
which of the following?
A. Asytole
C. Ventricular fibrillation
B. Atril fibrillation
D. Ventricular tachycardia
Situation 13. Mr. Paras was admitted into the hospital with symptoms of sore throat, headache
and lower back pain. He was diagnosed to have acute glomerulonephritis.
56. On initial assessment, the nurse detects one of the classic signs of acute glomerulonephritis
of acute onset. Such signs include:
A. Generalized edema
C. Moderate to severe hypotension
B. Green-tinged urine
D. Polyuria
57. The physician prescribed Hydralazine for Mr. Paras. Which finding indicates that the drug is
having its desired effect?
A. UO is brown in color
C. Creatinine levels return to normal

B. The clients appetite has improved

D. The clients BP has decreased
58. Which of the following treatment regimen would not be effective for Mr. Paras?
A. Antibiotics
C. Decrease potassium in the diet
B. Increased potassium in the diet
D. Dialysis
59. When teaching a client how to prevent recurrences of AGN, which instruction should the
nurse include?
A. Avoid physical activity
C. Seek early treatment for respiratory infection
B. Strain all urine
D. Monitor urine specific gravity every day
60. The nurse initiates the clients first hemodialysis treatment. After the treatment, the client
develops headache, confusion and nausea. These symptoms indicate which of the
following potential complications?
A. Disequilibrium syndrome
C. Air embolism
B. Myocardial infarction
D. Peritonitis
NURSING PRACTICE IV
Situation 14. Oncology nurses are engaged in a collaborative practice with all members of the
team to provide optimal mangement of patients with cancer. Their professional practice
requires detailed knowledge of the biologic and psychosocial dimensions of the cancer problem.
61. Which of these terms describes any abnormal growth of new tissue?
A. Malignancy
B. Neoplasm
C. Vesicant
D. Leukemia
62. Nurse Fred is correct when he identify a cancer that occurs in epithelial tissue such as skin
as:
A. Carcinoma
B. Leukemia
C. Lymphoma
D. Sarcoma
63. The nurse is caring for a client with leukemia. The nurse is aware that this type of cancer
originates in the:
A. Blood-forming organs
C. Epithelial tissue
B. Connective tissue
D. Infection-fighting organs
64. When teaching a client about the risk factors for cancer, the nurse is aware that which risk
factor cannot be modified?
A. Alcohol consumption
C. Overexposure to UV rays
B. Family heredity
D. Smoking
65. The nurse is reviewung these statements related to cancer risks. Which is not true?
A. Exposure to coar tar constitutes a risk factor for lung cancer
B. Melanoma can develop with even limited exposure to UV rays
C. Smokeless tobacco poses less risk for cancer than cigarettes
D. Heavy alcohol consumption primarily increases risk for lung cancer
Situation 15. Care of clients in Emergency and Disaster situations.
66. When dealing with the family of a patient in critical care, the nurse should:
A. Consider them an integral part of the team
B. Allow them to visit only during posted visiting times
C. Refer them to the patients practitioner for all information
D. Tell them not to touch the patient
67. Your patient has second and third degree burn injuries to his anterior chest, anterior
abdomen, and entire right arm. Using the rule of nine, the percent of total BSA involved can
be estimated at:
A. 18%
B. 27%
C. 45%
D. 50%

68. A patient is admitted to a burn intensive care unit with extensive full-thickness burns. The
nurse is most concerned about the patients:
A. Fluid and electrolytes status C. Body image
B. Risk of infection
D. Level of pain
69. After the initial phase of a burn injury, the primary focus of a patients cure is:
A. Enhancing self esteem
C. Reducing anxiety
B. Promoting hygiene
D. Preventing infection
70. The nurse is applying Mafenide Acetate (Sulfamylon) to a clients burn on the right lower
extremity. Which assessment data would require immediate attention by the nurse?
A. The client complains of pain when the medication is administered
B. The clients potassium level is 4.2mEq/L and sodium level is 139mEq/L
C. The clients ABG are pH 7.38, PaCO2 98, HCO3 24
D. The client reports tingling and numbness of the right foot
71. A client presents to the emergency department expectorating pink-tinged, frothy respiratory
secretions.The nurse would immediately gather additional assessmet data related to the
possibility of which order?
A. Cardiac tamponade
C. Pulmonary edema
B. Pulmonary tuberculosis
D. Bacterial pneumonia
72. A middle-aged man collapses in the emergency department waiting room. The triage nurse
should first:
A. Gently shake the victim and ask him to state his name
B. Perform the chin-tilt to open the victims airway
C. Feel for any air movement from the victims nose or mouth
D. Watch the victims chest for respirations
73. Proper hand placement for chest compression during CPR is essential to reduce the risk of
which complication?
A. Gastrointestinal bleeding
C. Emesis
B. Myocardial infarction
D. Rib fracture
74. There has been an increase in medication errors and errors in ordering laboratory studies in
the emergency department. The nurse manager is conducting a staff education session on
when to use read back procedures. Read back procedures should be performed in
which of the following situations? Select all that apply.
1. When a medication order or critical lab result is received verbally or over the telephone
2. When any verbal or phone order is received
3. Whenever a written order or printed critical result is received
4. When the unit secretary takes a phone order
5. When the agency uses computerized health care records
A. 1 and 2
B. 1, 2, 4
C. all except 3
D. all of the above
75. A Severe Acute Respiratory Syndrome (SARS) epidemic is suspected in a community of
10,000 people. As clients with SARS are admitted to the hospital, what type of precautions
should the nurse institute?
A. Enteric precautions
C. Reverse isolation
B. Hand-washing precautions
D. Standard precautions
76. There has been an industrial explosion near the hospital and many victims are brought to
the ER for treatment of their injuries. A young male is brought in complaining of severe
chest pain. His pulse is 120 beats/min. BP is 100/60mmHg and RR is 28BPM. He is short
of breath and diaphoretic. Which color tag should be used to identify this client?
A. Red
B. Yellow
C. Green
D. Black

77. While on a camping trip, the nurse cares for a camper who was bitten by a poisonous
spider. What is the priority action of the nurse?
A. Applies ice to the site of the bite
C. Give ibuprofen from the first aid kit
B. Apply loose tourniquet to the limb
D. covers the camper with a blanket
78. A client presents to the ER after prolonged exposure to the cold. The client is shivering, has
slurred speech and is slow to respond to questins. Which treatment will the nurse prepare
for this client?
A. Dry clothing and warm blankets
C. Peritoneal lavage with warmed saline
B. Administrtation of warmed IV fluids
D. Continuous AV rewarming
79. Then nurse service office is requiring emergency room nurses to obtain certification in
advanced cardiac life support. Its major purpose is:
A. It demonstrates basic first aid skills
B. To learn the concepts of multitasking
C. To become an expert in pediatric resuscitation
D. It demonstrates competence in adult emergency situations
80. The hospital is overwhlemed when caring for victims after an earthquake that occurred 48
hours ago. Which responsibility of the nurse supervisor is most important at this time?
A. Assuming leadership for implementation of the hospital emergency plan
B. Making sure that the nursing staff takes time periodically to sleep and eat
C. Releasing updates of client conditions to the media
D. Converting the physical therapy clinic into a treatment area for the injured
NURSING PRACTICE V
Situation 16. Nurses in many types of practice ettings encounter patients with altered neurologic
function. Disorders of the NS can occur at any time during the life span and can vary from mild
to self limiting symptoms.
81. When helping the client who has had CVA learn self care skills, the nurse should use which
of the following interventions to help him learn to dress himself?
A. Encourage the client to wear clothing designed especially for people who have had a
CVA
B. Dress the client explaining each step of the process as it is completed
C. Teach the client to put on clothing on the affected side first
D. Encourage the clien to ask his wif for help when dressing
82. Where would the nurse place the call light for a client with a right-sided brain attack and left
homonymous hemianopsia?
A. On the clients right side
C. Directly in front of the client
B. On the clients lef side
D. Where the client prefers
83. The client has a neurological deficit involving the limbic system. Specific to this type of
deficit, the nurse would document which of the following information related to the clients
behavior?
A. Is disoriented to person, place and time
B. Affect is flat, with periods of emotional lability
C. Cannot recall what was eaten for breakfast today
D. Demosntrates inability to add and substract, does not know who is the president
84. The client with a closed head injury is obtunded with a GCS of 3. His pupils are fixed and
dilated, his BP has gone from 140/94 to 170/62, and his HR has gone from 84 to 42. Based
on the findings given, the client is exhibitng which of the following conditions?
A. Cerebral edema
C. Cushings triad

B. Curlings Syndrome
D. Impaired cerebral perfusion
85. The nurse is caring for a client who has cerebral edema following a CVA. The nurse should
understand that the client is to receive Mannitol IV for which of the following purposes?
A. Decrease ICP
C. Perfusion of occluded intracranial arteries
B. Prevent platelet aggregation
D. Inhibit prothrombin formation
Situation 17. A 30 year old male client was diagnosed with right tibial fracture following a
motorcycle accident.
86. The client has a long leg cast on his right tibia. Which statement made by the client
indicates a lack of understanding of long leg cast and extremity care?
A. Ill keel the cast dry
B. If a foreing object drops to the cast, Ill attempt to retrieve it before calling the
nurse
C. Ill wiggle my toes at least once each hour
D. Ill keep my leg elevated above the level of my heart for the next 24 hours
87. The nurse teaches the client hoe to transfer and ambulate safely by using a cane. Which of
the following is the correct position for a patient who is wallking with a cane?
A. The client should put the cane far from the body
B. The patient should lean forward at the cane
C. The client should put the cane on the side of the affected extremity
D. The hand piece should allow for 30 degrees of flexion at the elbow
88. The client askes the nurse how to use the cane when going up the stairs. The nurse
appropriate response is:
A. Step up the stairs usign the affected extremity, place the cane and the unaffected
extremity up on the step
B. Step up the stairs using the affected extremity, place the cane forward and then put
the unaffected extremity up the stairs
C. Place the cane forward then step both affected and unaffected extremity up the step
D. Step up the stairs using the unaffected extremity, place the cane and affected
extremity up on the step
89. The nurse is performing discharge teaching to another client with a fracture of the left leg.
Which instruction should the nurse give about how to use a crutch using three point gait?
A. Advance right crutch, advance left foot, advance left crutch then advance the right
foot
B. Using one movement, advance your left foot and both crutches and then bright
your right leg forward
C. Advance left foot and right crutch and then advance right foot and left crutch
D. Advance both crutches and then lift both feet next to the crutches
Situation 18. There are only two nurses in the unit attending to several patients. The other
nurse, being overworked, reports to be suffering from a severe headache.
90. Emotional or physical stress causes this type of headache?
A. Migrain
B. Cluster
C. Tension
D. Cranial neuralgia
91. Nurse experiencing tension headache should do which of the following?
A. Attend stress management programs
B. Be advised to see the doctor
C. Take a day off

D. No longer continue working in the hospital

92. Tension headache results from:
A. Contraction of the muscles of the neck and scalp
B. Decreased oxygen supply to an area of the brain
C. Dilation of cerebral arteries
D. Vascular injury and inflammation
Situation 19. The nurse should be aware about the proper nurisng management of clients
experiencing seizure attacks.
93. The nurse enters the room of a client who is in the clonic phase of a tonic-clonic seizure.
The initial nursing action should be to:
A. Insert a padded mouth gag
C. Gently restrain the limbs
B. Place some padding under the head D. Obtain equipment for suctioning
94. The nurse knows that tonic-clonic seizure is:
A. Sustained contractions of muscles with alternating contraction-relaxation of
opposing muscle group
B. Unsustained contractions of muscles with alternating contraction-relaxation of
opposing muscle group
C. Sustained contractions of muscles with continuous contraction-relaxation of opposing
muscle group
D. Sutained contractions of intraocular msucles with continuous contraction-relaxation
of opposing muscle group
95. The nurse has orders to administer Phenytoin (Dilantin) 100mg IV. Dilantin was properly
administered to the client if it was:
A. Combined with plain NSS
C. Combined with D5LR
B. Combined with D5W
D. Combined with Distilled Water
96. Phenytoin (Dilantin) has been prescribed for the client. Based on an understanding of this
medication, the nurse caring for the client should:
A. Give the drug IM
C. Administer good oral hygiene
B. Dilute IV Dilantin with 5% Dextrose
D. Maintain Dilantin level of 30-50mcg/ml
97. Nursing implications with diphenylhydantoin given during treatment of status epilepticus
include giving of the intravenous injection slowly and in small increments to prevent:
A. Respiratory depression and arrest
B. Vasodepression and circulatory shock
C. Irritation and necrosis of the vein and the surrounding tissue
D. Vasomotor stimulation with a sudden, malignant increase in BP
98. While working in the ICU, the nurse is assigned to care for a client with a seizure disorder.
Which of the following nursing actions will the nurse implement first if the client has a
seizure?
A. Administer prescribed Lorazepam (Ativan) 1mg IV
B. Assess the LOC during and immediately after a seizure
C. Place the client on a non-rebreather mask with O2 at 15LPM
D. Turn the patient to the side and protect the airway
99. Which of the following pathophysiologic processes are involved in multiple sclerosis?
A. Destruction of the brain stem and basal gnaglia in the brain
B. Degeneration of the nucleus pulposus, causing pressure on the spinal cord
C. Chronic inflammation of rhizomes just outside the nervous system

100.

D. Development of demyelination of the myelin sheath, interfering with nerve

transmission
Which of the following symptoms usually occurs early in multiple sclerosis?
A. Diplopia
B. Grief
C. Hemiparesis
D. Recent memory loss