1.
May arrives at the health care clinic and tells the nurse that
her last menstrual period was 9 weeks ago. She also tells the nurse
that a home pregnancy test was positive but she began to have mild
cramps and is now having moderate vaginal bleeding. During the physical
examination of the client, the nurse notes that May has a dilated
cervix. The nurse determines that May is experiencing which type of
abortion?
Correct Answer
A. Inevitable
Explanation
An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion.
2.
Nurse Reese is reviewing the record of a pregnant client for her
first prenatal visit. Which of the following data, if noted on the
client’s record, would alert the nurse that the client is at risk for a
spontaneous abortion?
Correct Answer
B. History of sypHilis
Explanation
Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion.
3.
Nurse Hazel is preparing to care for a client who is newly
admitted to the hospital with a possible diagnosis of ectopic
pregnancy. Nurse Hazel develops a plan of care for the client and
determines that which of the following nursing actions is the priority?
Correct Answer
C. Monitoring apical pulse
Explanation
Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock.
4.
Nurse Oliver is teaching a diabetic pregnant client about nutrition
and insulin needs during pregnancy. The nurse determines that the
client understands dietary and insulin needs if the client states that
the second half of pregnancy require:
Correct Answer
B. Increased caloric intake
Explanation
Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mother’s demand for insulin and is referred to as the diabetogenic effect of pregnancy.
5.
Nurse Michelle is assessing a 24 year old client with a diagnosis of
hydatidiform mole. She is aware that one of the following is
unassociated with this condition?
Correct Answer
A. Excessive fetal activity.
Explanation
The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted.
6.
A pregnant client is receiving magnesium sulfate for severe
pregnancy induced hypertension (PIH). The clinical findings that would
warrant use of the antidote , calcium gluconate is:
Correct Answer
B. Absent patellar reflexes.
Explanation
Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.
7.
During vaginal examination of Janah who is in labor, the presenting
part is at station plus two. Nurse, correctly interprets it as:
Correct Answer
C. Presenting part in 2 cm below the plane of the ischial spines.
Explanation
Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines.
8.
A pregnant client is receiving oxytocin (Pitocin) for induction of
labor. A condition that warrant the nurse in-charge to discontinue I.V.
infusion of Pitocin is:
Correct Answer
A. Contractions every 1 ½ minutes lasting 70-80 seconds.
Explanation
Contractions every 1 ½ minutes lasting 70-80 seconds, is indicative of hyperstimulation of the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued.
9.
Calcium gluconate is being administered to a client with pregnancy
induced hypertension (PIH). A nursing action that must be initiated as
the plan of care throughout injection of the drug is:
Correct Answer
C. EKG tracings
Explanation
A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care.
10.
A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:
Correct Answer
D. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.
Explanation
This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery.
11.
Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is:
Correct Answer
A. Talk to the mother first and then to the toddler.
Explanation
When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse.
12.
Baby Tina a 3 month old infant just had a cleft lip and palate
repair. What should the nurse do to prevent trauma to operative site?
Correct Answer
D. Place the infant’s arms in soft elbow restraints.
Explanation
Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such as objects as pacifiers, suction catheters, and small spoons shouldn’t be placed in a baby’s mouth after cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair.
13.
Which action should nurse Marian include in the care plan for a 2 month old with heart failure?
Correct Answer
B. Allow the infant to rest before feeding.
Explanation
Because feeding requires so much energy, an infant with heart failure should rest before feeding.
14.
Nurse Hazel is teaching a mother who plans to discontinue breast
feeding after 5 months. The nurse should advise her to include which
foods in her infant’s diet?
Correct Answer
C. Iron-rich formula only.
Explanation
The infants at age 5 months should receive iron-rich formula and that they shouldn’t receive solid food, even baby food until age 6 months.
15.
Mommy Linda is playing with her infant, who is sitting securely
alone on the floor of the clinic. The mother hides a toy behind her
back and the infant looks for it. The nurse is aware that estimated age
of the infant would be:
Correct Answer
D. 10 months
Explanation
A 10 month old infant can sit alone and understands object permanence, so he would look for the hidden toy. At age 4 to 6 months, infants can’t sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects.
16.
Which of the following is the most prominent feature of public health nursing?
Correct Answer
D. Public health nursing focuses on preventive, not curative, services.
Explanation
The catchments area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services.
17.
When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating
Correct Answer
B. Efficiency
Explanation
Efficiency is determining whether the goals were attained at the least possible cost.
18.
Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she apply?
Correct Answer
D. Rural Health Unit
Explanation
R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU.
19.
Tony is aware the Chairman of the Municipal Health Board is:
Correct Answer
A. Mayor
Explanation
The local executive serves as the chairman of the Municipal Health Board.
20.
Myra is the public health nurse in a municipality with a total
population of about 20,000. There are 3 rural health midwives among the
RHU personnel. How many more midwife items will the RHU need?
Correct Answer
A. 1
Explanation
Each rural health midwife is given a population assignment of about 5,000.
21.
According to Freeman and Heinrich, community health nursing is a
developmental service. Which of the following best illustrates this
statement?
Correct Answer
B. Health education and community organizing are necessary in providing community health services.
Explanation
The community health nurse develops the health capability of people through health education and community organizing activities.
22.
Nurse Tina is aware that the disease declared through
Presidential Proclamation No. 4 as a target for eradication in the
Philippines is?
Correct Answer
B. Measles
Explanation
Presidential Proclamation No. 4 is on the Ligtas Tigdas Program.
23.
May knows that the step in community organizing that involves training of potential leaders in the community is:
Correct Answer
D. Core group formation
Explanation
In core group formation, the nurse is able to transfer the technology of community organizing to the potential or informal community leaders through a training program.
24.
Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing?
Correct Answer
D. To maximize the community’s resources in dealing with health problems.
Explanation
Community organizing is a developmental service, with the goal of developing the people’s self-reliance in dealing with community health problems. A, B and C are objectives of contributory objectives to this goal.
25.
Tertiary prevention is needed in which stage of the natural history of disease?
Correct Answer
D. Terminal
Explanation
Tertiary prevention involves rehabilitation, prevention of permanent disability and disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally ill (those in the terminal stage of a disease).
26.
The nurse is caring for a primigravid client in the labor and
delivery area. Which condition would place the client at risk for
disseminated intravascular coagulation (DIC)?
Correct Answer
A. Intrauterine fetal death.
Explanation
Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the membranes aren't associated with DIC.
27.
A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:
Correct Answer
C. 120 to 160 beats/minute
Explanation
A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with blood and pumping it out to the system.
28.
The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to:
Correct Answer
A. Change the diaper more often.
Explanation
Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the irritation.
29.
Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy 21) is:
Correct Answer
D. Endocardial cushion defect
Explanation
Endocardial cushion defects are seen most in children with Down syndrome, asplenia, or polysplenia.
30.
Malou was diagnosed with severe preeclampsia is now receiving I.V.
magnesium sulfate. The adverse effects associated with magnesium
sulfate is:
Correct Answer
B. Decreased urine output
Explanation
Decreased urine output may occur in clients receiving I.V. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily accumulate to toxic levels.
31.
A 23 year old client is having her menstrual period every 2 weeks
that last for 1 week. This type of menstrual pattern is bets defined by:
Correct Answer
A. Menorrhagia
Explanation
Menorrhagia is an excessive menstrual period.
32.
Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be:
Correct Answer
C. Blood typing
Explanation
Blood type would be a critical value to have because the risk of blood loss is always a potential complication during the labor and delivery process. Approximately 40% of a woman’s cardiac output is delivered to the uterus, therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding.
33.
Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is:
Correct Answer
D. pHysiologic anemia
Explanation
Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production.
34.
Nurse Lynette is working in the triage area of an emergency
department. She sees that several pediatric clients arrive
simultaneously. The client who needs to be treated first is:
Correct Answer
D. A 2 year old infant with stridorous breath sounds, sitting up in his
mother’s arms and drooling.
Explanation
The infant with the airway emergency should be treated first, because of the risk of epiglottitis.
35.
Maureen in her third trimester arrives at the emergency room with
painless vaginal bleeding. Which of the following conditions is
suspected?
Correct Answer
A. Placenta previa
Explanation
Placenta previa with painless vaginal bleeding.
36.
A young child named Richard is suspected of having pinworms.
The community nurse collects a stool specimen to confirm the diagnosis.
The nurse should schedule the collection of this specimen for:
Correct Answer
D. Early in the morning
Explanation
Based on the nurse’s knowledge of microbiology, the specimen should be collected early in the morning. The rationale for this timing is that, because the female worm lays eggs at night around the perineal area, the first bowel movement of the day will yield the best results. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test.
37.
In doing a child’s admission assessment, Nurse Betty should be alert
to note which signs or symptoms of chronic lead poisoning?
Correct Answer
A. Irritability and seizures
Explanation
Lead poisoning primarily affects the CNS, causing increased intracranial pressure. This condition results in irritability and changes in level of consciousness, as well as seizure disorders, hyperactivity, and learning disabilities.
38.
To evaluate a woman’s understanding about the use of diaphragm for
family planning, Nurse Trish asks her to explain how she will use the
appliance. Which response indicates a need for further health teaching?
Correct Answer
D. “I really need to use the diapHragm and jelly most during the middle of my menstrual cycle”.
Explanation
The woman must understand that, although the “fertile” period is approximately mid-cycle, hormonal variations do occur and can result in early or late ovulation. To be effective, the diaphragm should be inserted before every intercourse.
39.
Hypoxia is a common complication of laryngotracheobronchitis. Nurse
Oliver should frequently assess a child with laryngotracheobronchitis
for:
Correct Answer
C. Restlessness
Explanation
In a child, restlessness is the earliest sign of hypoxia. Late signs of hypoxia in a child are associated with a change in color, such as pallor or cyanosis.
40.
How should Nurse Michelle guide a child who is blind to walk to the playroom?
Correct Answer
B. Walk one step ahead, with the child’s hand on the nurse’s elbow.
Explanation
This procedure is generally recommended to follow in guiding a person who is blind.
41.
When assessing a newborn diagnosed with ductus arteriosus,
Nurse Olivia should expect that the child most likely would have an:
Correct Answer
A. Loud, machinery-like murmur.
Explanation
A loud, machinery-like murmur is a characteristic finding associated with patent ductus arteriosus.
42.
The reason nurse May keeps the neonate in a neutral thermal
environment is that when a newborn becomes too cool, the neonate
requires:
Correct Answer
C. More oxygen, and the newborn’s metabolic rate increases.
Explanation
When cold, the infant requires more oxygen and there is an increase in metabolic rate. Non-shievering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption, therefore, the newborn increase heat production.
43.
Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant has:
Correct Answer
D. Voided
Explanation
Before administering potassium I.V. to any client, the nurse must first check that the client’s kidneys are functioning and that the client is voiding. If the client is not voiding, the nurse should withhold the potassium and notify the physician.
44.
Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is:
Correct Answer
C. Laundry detergent
Explanation
Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. The topical allergen that is the most common causative factor is laundry detergent.
45.
During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with formula?
Correct Answer
A. 6 inches
Explanation
This distance allows for easy flow of the formula by gravity, but the flow will be slow enough not to overload the stomach too rapidly.
46.
In a mothers’ class, Nurse Lhynnete discussed childhood diseases
such as chicken pox. Which of the following statements about chicken
pox is correct?
Correct Answer
A. The older one gets, the more susceptible he becomes to the complications of chicken pox.
Explanation
Chicken pox is usually more severe in adults than in children. Complications, such as pneumonia, are higher in incidence in adults.
47.
Barangay Pinoy had an outbreak of German measles. To prevent
congenital rubella, what is the BEST advice that you can give to women
in the first trimester of pregnancy in the barangay Pinoy?
Correct Answer
D. Consult a pHysician who may give them rubella immunoglobulin.
Explanation
Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated in pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to pregnant women.
48.
Myrna a public health nurse knows that to determine possible sources
of sexually transmitted infections, the BEST method that may be
undertaken is:
Correct Answer
A. Contact tracing
Explanation
Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections, such as sexually transmitted diseases.
49.
A 33-year old female client came for consultation at the health
center with the chief complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise. A week after the start of
fever, the client noted yellowish discoloration of his sclera. History
showed that he waded in flood waters about 2 weeks before the onset of
symptoms. Based on her history, which disease condition will you
suspect?
Correct Answer
D. Leptospirosis
Explanation
Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals, like rats.
50.
Mickey a 3-year old client was brought to the health center
with the chief complaint of severe diarrhea and the passage of “rice
water” stools. The client is most probably suffering from which
condition?
Correct Answer
B. Cholera
Explanation
Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary dysentery are characterized by the presence of blood and/or mucus in the stools. Giardiasis is characterized by fat malabsorption and, therefore, steatorrhea.