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Nursing state exams > State exams 2 > Flashcards

State exams 2 Flashcards

1
Q

STATE EXAMS 9

  1. Angina is

a) Caused by a sudden blockage of one of the coronary arteries
b) Caused by anaerobic metabolism exciting pain receptors
c) Causes cardiac tissue necrosis and scaring
d) Interferes with cardiac contractility

A

a) Caused by a sudden blockage of one of the coronary arteries

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2
Q
  1. Myocardial infarction (MI)

a) Causes irreversible tissue damage
b) The final extent of the damage depends on the ability of the surrounding tissue to
recruit collateral circulation
c) 15% of all MIs are silent
d) All the above

A

d) All the above

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3
Q
  1. MIs may be caused by

a) A formation of a thrombus in a coronary artery
b) Sudden progression of atherosclerotic changes
c) Prolong constriction of the arteries
d) All of the above

A

d) All of the above

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4
Q
  1. Manifestations of an MI are

a) Bradycardia
b) Necrosis of a portion of the myocardium
c) Treated only by bypass surgery
d) Not seen on an ECG for 24 hours

A

b) Necrosis of a portion of the myocardium

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5
Q
  1. Medications which are of the utmost importance for a patient following an MI are

a) 02
b) Stool softeners
c) Morphine
d) All of the above

A

a) 02

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6
Q
  1. ACE inhibitors include

a) Catopril, enalapril
b) Propranolol, atenolol
c) Niphedipine, diltiazem
d) Frusemide

A

a) Catopril, enalapril

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7
Q
  1. Antidiuretic hormone is

a) Secreted by the posterior pituitary
b) Increases glomerular filtration rate
c) Increases urinary output
d) Secreted by the hypothalamus

A

a) Secreted by the posterior pituitary

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8
Q
  1. The renal system maintains homeostasis by

a) Maintaining electrolyte balances
b) Maintenance of blood volume
c) Conversion of vitamin D for calcium reabsorption
d) All of the above

A

d) All of the above

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9
Q
  1. Prerenal failure may be caused by

a) Burns
b) Nephrotoxic drugs
c) Multiple transfusions
d) Renal calculi

A

a) Burns

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10
Q
  1. Acute renal failure (ARF) is

a) Incurable
b) Only curable by kidney transplantation
c) Occurs suddenly and may be reversible
d) Characterised by polyuria

A

c) Occurs suddenly and may be reversible

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11
Q
  1. Chronic renal failure (CRF)

a) Occurs suddenly and is reversible
b) Occurs over a long period of time and is reversible
c) Occurs over a long period of time and is irreversible
d) Is a nuisance by not fatal

A

c) Occurs over a long period of time and is irreversible

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12
Q
  1. Chronic renal failure may be characterised by

a) Lethargy, mental confusion
b) Headaches, GI symptoms
c) General weakness and bleeding tendencies
d) All of the above

A

d) All of the above

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13
Q
  1. Problems associated with CRF are

a) Polycythemia
b) Metabolic alkalosis
c) Accentuated sex drive
d) Reduced healing, susceptibility to infections

A

d) Reduced healing, susceptibility to infections

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14
Q
  1. Nursing interventions with a client with renal failure includes

a) Increase dietary protein
b) Increase fluid intake
c) Increase potassium intake
d) Maintain adequate nutritional status and decrease the metabolic demands

A

d) Maintain adequate nutritional status and decrease the metabolic demands

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15
Q
  1. Malignant tumours have

a) Irregular shapes with poorly defined borders
b) Cells similar to their parent cells
c) Expansive growth
d) Fibrous capsule

A

a) Irregular shapes with poorly defined borders

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16
Q
  1. Which of the following are not malignant

a) Sarcoma
b) Metastases
c) Neoplasm
d) Benign

A

d) Benign

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17
Q
  1. Side effects of radiotherapy include

a) Burns, lethargy
b) Alopecia
c) Increased rate of cell division
d) Increased WBC production

A

a) Burns, lethargy

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18
Q
  1. Cytotoxic therapy

a) Is used only as a last resort – a palliative care
b) May be used in conjunction with radiotherapy
c) Not to be given if radiotherapy is anticipated
d) Is used if surgery is impossible

A

b) May be used in conjunction with radiotherapy

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19
Q
  1. Chemotherapy acts by

a) Attacking existing malignant cells and kills tumours
b) Decreases the blood supply to the tumour
c) Interferes with the cell division
d) Increases the clients feelings of wellness therefore giving a boost to cancer
patients

A

c) Interferes with the cell division

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20
Q
  1. Cancer clients pain is assessed by

a) The doctor
b) The health care team
c) The client
d) The family

A

b) The health care team

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21
Q
  1. If paracetamol is no longer effective in the treatment of malignant pain

a) Strong opioids are prescribed
b) The end is near
c) Weak opioids and/or NSAIDS may be prescribed
d) The client needs hospitalisation for pain control

A

c) Weak opioids and/or NSAIDS may be prescribed

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22
Q
  1. Important components of pain assessment include

a) Site of pain
b) Onset and patterns
c) Current therapy and effect
d) All of the above

A

d) All of the above

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23
Q
  1. The world health organisations (WHO) analgesia ladder is

a) A systematic tool used for the identification of medications to prescribe for
patients with cancer pain
b) Initial treatment includes simple analgesics, to progression of mild opioids to
strong opioids
c) Opioids may be used in conjunction with anticonvulsant and antidepressant drugs
to promote effectiveness
d) All of the above

A

d) All of the above

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24
Q
  1. If your client is experiencing break through pain

a) They are not administering their medications correctly
b) Morphine should only be taken when pain is experienced
c) They may require a quick release morphine titrated to alleviate their pain
d) Start an IV and double the dose of morphine

A

c) They may require a quick release morphine titrated to alleviate their pain

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25
Q
  1. Potential side effects of morphine administration for the alleviation of malignant pain
    are

a) Addiction
b) Constipation, nausea and vomiting
c) Antisocial behaviour
d) Once the maximum dose of morphine is reached, the pain may no longer be
controlled

A

b) Constipation, nausea and vomiting

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26
Q
  1. When an arterial blood gas (ABG) sample is taken, the initial nursing intervention
    should be

a) Assessing the movement of the extremity
b) Applying pressure to prevent an arterial bleed
c) Calming and educating the client to alleviate anxiety
d) All the above

A

b) Applying pressure to prevent an arterial bleed

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27
Q
  1. Normal oxygen saturation values are

a) 80-100% saturation
b) 70-90% saturation
c) 90-100% saturation
d) 100% saturation

A

c) 90-100% saturation

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28
Q
  1. Which patient is at highest risk for pulmonary embolus

a) A 25 year old man with a history of alcohol abuse recuperating from a gastric
ulcer
b) A 36 year old woman on a liquid diet beginning an exercise programme
c) A 40 year old, obese, pregnant woman place on bed rest
d) A 90 year old man with no identified health problems

A

c) A 40 year old, obese, pregnant woman place on bed rest

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29
Q
  1. James has sustained a fracture of his left lower leg in a car accident. Classical signs of
    a fracture may include

a) Intermittent pain, flushing of surrounding tissues and vascular spasm
b) Local bone tenderness, soft tissue swelling and inability to use extremity
c) Neural compromise, sharp stabbing pain and obvious ischaemia of the extremity
d) Blanching, hyperextension and parasthesia

A

b) Local bone tenderness, soft tissue swelling and inability to use extremity

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30
Q
  1. Monitoring for compartment syndrome is done by checking for

a) Active movement of the limb
b) Colour, warmth, sensation and movement of the extremity
c) Pulse and blood pressure changes
d) The rightness of the plaster cast

A

b) Colour, warmth, sensation and movement of the extremity

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31
Q
  1. On assessment, the nurse suspects that James is developing compartment syndrome
    because he complains of

a) Severe pain, motor compromise and a ‘pins and needles’ sensation
b) A radiating pain and loss of two point discrimination
c) Swelling, muscle atrophy and intermittent parasthesia
d) Dull aching, spasms and lack of fine co ordination

A

a) Severe pain, motor compromise and a ‘pins and needles’ sensation

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32
Q
  1. Uraemia is a clinical syndrome associated with

a) Retention of urea and other nitrogenous wastes
b) The presence of urine in the blood
c) The presence of blood in the urine
d) High ammonia excretion

A

a) Retention of urea and other nitrogenous wastes

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33
Q
  1. Spinal anaesthesia is inserted into the

a) Intravenous space
b) Sacral canal
c) Dural membrane
d) Subarachnoid space

A

d) Subarachnoid space

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34
Q
  1. To monitor abdominal distension, you would

a) Assess bowel sounds every shift
b) Measure abdominal girth at the umbilicus every 24 hours
c) Measure abdominal girth every shift, using two fixed points
d) Weigh the patient every shift

A

c) Measure abdominal girth every shift, using two fixed points

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35
Q
  1. The fluid outside the vascular system, which surrounds tissue cells, and which
    includes lymph is called

a) Interstitial fluid
b) Extracellular fluid
c) Intravascular fluid
d) Intracellular fluid

A

a) Interstitial fluid

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36
Q
  1. When there is a decrease in blood volume (as in dehydration or blood loss), the body
    reacts by retaining sodium and thus water. This occurs mainly as a result of adrenal
    gland secretion of

a) Aldosterone
b) Antidiuretic hormone (ADH)
c) Cortisol
d) Parathyroid hormone

A

a) Aldosterone

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37
Q
  1. Which of the following is a defining characteristic for a nursing diagnosis of ‘fluid
    volume deficit’

a) Distended neck veins
b) Weak, rapid pulse
c) Moist rales in lungs
d) Bounding, full pulse

A

b) Weak, rapid pulse

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38
Q
  1. The nurse should assess carefully for hypervolaemia, (fluid volume excess) when
    working with the client with

a) Nausea and vomiting
b) Kidney failure
c) Decreased fluid intake
d) Blood loss

A

b) Kidney failure

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39
Q
  1. Which is probably the most accurate indication of a clients fluid balance status

a) Intake and output record
b) Skin turgor
c) Daily weight
d) Complete blood count

A

a) Intake and output record

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40
Q
  1. When you check the time tape on your clients IV bag, you note that the proper
    amount has not been infused. The prescribed rate is 200 ml/hour, but in the past hour
    only 100 mls have infused. Your first action should be to

a) Call the physician for a new order
b) Adjust the roller clamp and increase the rate to 300 ml/hour to ‘catch up’
c) Restart the IV at a different site
d) Count the drops per minute to be sure it is running at a rate of 200 ml/hour

A

d) Count the drops per minute to be sure it is running at a rate of 200 ml/hour

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41
Q
  1. In evaluating for complications of IV therapy, which of the following are evidence
    that the IV has infiltrated

a) In the past hour, only 50 ml of fluid have infused
b) The insertion site is red, hot and swollen
c) The clients temperature has gone up to 38.oC
d) The site is pale, cool, swollen and painful

A

d) The site is pale, cool, swollen and painful

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42
Q
  1. Swelling and paleness of the skin at the venipuncture site could be indicative of

a) Infiltration
b) Phlebitis
c) Infection
d) Air embolism

A

a) Infiltration

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43
Q
  1. Mr Smith is to have one litre of normal saline IV over 6 hours. The giving set has a
    drop factor of 10. The correct flow rate would be

a) 14 dpm
b) 28 dpm
c) 140 dpm
d) 280 dpm

A

b) 28 dpm

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44
Q
  1. John has been prescribed dextrose/saline 125 mls per hour IV. The giving set has a
    drop factor of 60. The correct flow rate would be

a) 125 dpm
b) 120 dpm
c) 60 dpm
d) 65 dpm

A

a) 125 dpm

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45
Q
  1. Hone has been prescribed plasmolyte 500 mls over 2 hours IV. The giving set has a
    drop factor of 10. The correct flow rate would be

a) 24 dpm
b) 42 dpm
c) 84 dpm
d) 48 dpm

A

b) 42 dpm

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46
Q
  1. The optimal position for the comatose patient is

a) Prone
b) Supine
c) Semi fowlers
d) Side lying
e) High semi fowlers

A

d) Side lying

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47
Q
  1. Which of the following would a nurse be testing if she asked a 65 year old patient
    questions like, ‘what day is it’, ‘what time is it’, ‘what month is it’

a) Intelligence
b) Perception
c) Orientation
d) Personality

A

c) Orientation

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48
Q
  1. When a person experiences loss or decreased sensation of pain, temperature and touch,
    the major nursing concern will be meeting their need for

a) Communication
b) Nutrition
c) Safety
d) Belonging

A

c) Safety

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49
Q
  1. When caring for a patient with aphasia, you should

a) Talk loudly so she can hear you
b) Refrain from giving explanations about procedures
c) Provide as much environmental stimuli as possible to prevent feelings of isolation
d) Consider the type that the person has and adapt communications methods
accordingly

A

d) Consider the type that the person has and adapt communications methods
accordingly

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50
Q
  1. Narcotics are given as pre-anaesthetic medications to

a) Decrease oral secretions
b) Reduce the risk of intra operation DUT
c) Decrease postoperative pain
d) Reduce postoperative nausea and vomiting

A

c) Decrease postoperative pain

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51
Q
  1. Clinical manifestations of hypovolemic shock include all except

a) A fall in blood pressure
b) A decreased urinary output
c) A weak, rapid, thread pulse
d) Warm, moist skin

A

d) Warm, moist skin

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52
Q
  1. Your clients physician writes an order for antibiotics stat that you feel are too high a
    dosage for that client. What should your reaction to this order be

a) Administer the drug as prescribed since the physician is legally responsible for
any mistakes in the order
b) Check with the prescribing physician before administering the drug
c) Administer the drug first since it is a stat drug, and then check with the physician
d) Check with the client about dosages administered to him in the past and compare
this response to the ordered dosage

A

b) Check with the prescribing physician before administering the drug

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53
Q
  1. Miss Blake has suddenly had a cardiac arrest. What is the critical time period that the
    nurse must keep in mind before irreversible brain damage occurs

a) 1-3 minutes
b) 8-10 minutes
c) 2-4 minutes
d) 4-6 minutes

A

d) 4-6 minutes

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54
Q
  1. David white is in the hospital with a medical diagnosis of viral pneumonia. He is
    getting oxygen via a simple face mask. Why must it fit snugly over the clients face

a) Prevents mask movement and consequent skin breakdown
b) Helps the client feel secure
c) Maintains carbon dioxide retention
d) Aids in maintaining expected oxygen delivery

A

d) Aids in maintaining expected oxygen delivery

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55
Q
  1. The Heimlich manoeuvre is described in which of the following statements

a) Arms encircling persons waist from behind with firm abdominal thrusts
b) Quick, forceful blow with fist on clients sternum
c) Sweeping out foreign objects from clients mouth with fingers
d) Sharp blow on centre of clients back

A

a) Arms encircling persons waist from behind with firm abdominal thrusts

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56
Q
  1. In teaching a patient about foods that affect his fluid balance, the nurse will keep in
    mind that the electrolyte which primarily controls water distribution throughout the
    body is

a) Sodium
b) Potassium
c) Calcium
d) Magnesium

A

a) Sodium

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57
Q
  1. Mrs Zikes is receiving frequent medication. Which of the following would be the
    correct identification procedure

a) Check the identification bracelet and call Mrs. Zikes by name
b) Check the name on the foot of the bed, and check the identification bracelet
c) Call Mrs. Zikes by name, this is all that is needed
d) Ask Mrs. Zikes her name, and check her identification bracele

A

d) Ask Mrs. Zikes her name, and check her identification bracelet

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58
Q
  1. When you answer the clients call light, you note that he has suffered a wound
    evisceration. Your response will be to

a) Call the physician immediately for offers. Do not touch the wound
b) Cover the wound with sterile dressing, call the lab to do a culture and then call the
physician
c) Cover the wound with sterile, saline soaked towels and immediately notify the
physician
d) Take the clients vital signs, cover the wound with a sterile towel and call the
physician

A

c) Cover the wound with sterile, saline soaked towels and immediately notify the
physician

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59
Q
  1. Which surgical consent would NOT be considered legal

a) Consent signed by a 36 year old lady one hour after receiving her preoperative
medication of morphine
b) Consent signed by 21 year old man who has fractured leg due to an auto accident
c) Telephone consent from the father to perform an emergency surgery on a 17 year
old girl
d) Consent signed by a 60 year old man the evening prior to surgery and prior to his
evening sedative

A

a) Consent signed by a 36 year old lady one hour after receiving her preoperative
medication of morphine

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60
Q
  1. Which statement by the nurse would be most therapeutic when the client says ‘ my
    friend has a terrible scar from her surgery’

a) Don’t worry, your surgeon is very good
b) You need the surgery, and a little scarring is okay
c) Are you concerned about how your surgical scar will look
d) I wouldn’t worry about that right now, all people are different

A

c) Are you concerned about how your surgical scar will look

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61
Q
  1. Several screening tests are performed on clients preoperatively. Which test
    demonstrates the presence of bleeding or anaemia

a) An elevated white blood cell count
b) Decreased haemoglobin and hematocrit
c) Elevated blood urea nitrogen
d) Hypokalemia

A

b) Decreased haemoglobin and hematocrit

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62
Q
  1. Leg exercises are taught to clients in order to increase venous return and prevent
    thrombophylebitis. Which step of this procedure is incorrect

a) Alternately dorsiflex and plantar flex toes
b) Flex and extend the knee
c) Raise and lower each leg
d) Repeat exercise every one to two hours

A

b) Flex and extend the knee

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63
Q
  1. Two days post surgery ms D continues to complain of pain. There are a number of
    interventions available for pain relief. Which comfort measure has the potential of
    increasing ms Daniels risk for cardiovascular complications

a) Turn ms D every two hours
b) Place pillows under ms Ds knees
c) Splint ms Ds abdomen when she coughs
d) Encourage ambulation as tolerated

A

d) Encourage ambulation as tolerated

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64
Q
  1. Your client develops a fever and complaints of calf pain over an area that is red and
    swollen. Nursing interventions for thrombophlebitis will include all except

a) Elevate the affected leg to heart level
b) Maintain bed rest as ordered
c) Measure bilateral calf circumference every shift
d) Massage the affected calf

A

d) Massage the affected calf

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65
Q
  1. Which of the following is an autonomic nervous system response to acute pain

a) Decreased heart rate
b) Decreased depth of respiration
c) Pupil constriction
d) Increased blood pressure

A

d) Increased blood pressure

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66
Q
  1. Which of the following is a natural opiate of the brain involved in the analgesic
    system

a) Endorphins
b) Histamine
c) Collagenase
d) Neurotensin

A

a) Endorphins

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67
Q
  1. Judgement and caution must be used when nonpharmacologic interventions are
    applied in the treatment of acute pain because

a) No proof exists that they work
b) They are very expensive to implement
c) They are outside the scope of nursing practice
d) They do not guarantee pain relief

A

d) They do not guarantee pain relief

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68
Q
  1. If morphine is given intravenously, regularly as post operative analgesia for 10 days
    to a multiple trauma patient, what is the possibility that this patient would become
    addicted to the narcotic

a) Almost never
b) Sometimes
c) Often
d) Almost always

A

c) Often

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69
Q
  1. A malignant neoplasm

a) Grows very slowly
b) Is usually surrounded by a well defined capsule
c) Consists of cells that only form tissues in a very disorganised manner
d) Is composed of goblet cells

A

c) Consists of cells that only form tissues in a very disorganised manner

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70
Q
  1. Which of the following characteristics generally differentiate malignant tumours from
    benign tumours

1 lack of a capsule
2 more rapid growth
3 infiltrates normal tissues
4 respects other cells boundaries

a) 1, 2 and 3
b) 1, 2 and 4
c) 1, 3 and 4
d) 2, 3 and 4

A

a) 1, 2 and 3

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71
Q
  1. Malignant tumours and leukaemias may be treated with chemotherapy. The primary
    aims of this therapy is to

1 attack newly developing cancer cells
2 reduce the size of a tumour
3 build up a person’s defence system
4 reduce the oxygen bearing capacity of the blood
5 destroy cancer cells and leave normal cells

a) 1, 2 and 3
b) 1, 2 and 5
c) 2, 3 and 4
d) 2, 3 and 5

A

b) 1, 2 and 5

72
Q
  1. During chemotherapy, soreness of the mouth and anus may develop because

a) The effects of the chemotherapeutic agents concentrate in these body areas
b) These tissues normally divide rapidly and are damaged by chemotherapeutic
agents
c) The entire GI tract is involved because of the direct irritating effects of
chemotherapy
d) The tissues have become damaged from prolonged vomiting and diarrhoea

A

b) These tissues normally divide rapidly and are damaged by chemotherapeutic
agents

73
Q
  1. Which of the following should be considered in order to avoid skin reactions
    following radiotherapy

1 not to apply ointments or lotions
2 not to vigorously dry the skin
3 to apply powder p.r.n
4 to keep the skin area dry and open to air
5 to avoid exposure to sunlight

a) 1, 2 and 3
b) 2, 3 and 5
c) 3, 4 and 5
d) 1, 2, 4 and 5
e) 2, 3, 4 and 5

A

d) 1, 2, 4 and 5

74
Q
  1. A common problem after open cholecystectomy is shallow breathing. This is mainly
    due to

a) The site of the incision making breathing painful
b) Damage to the phrenic nerves during surgery
c) The obese state of most patients pre operatively
d) Inadequate pre operative instruction

A

a) The site of the incision making breathing painful

75
Q
  1. Chest problems may best be prevented after cholecystectomy by

1 giving the patient oxygen
2 regular deep breathing and coughing
3 keeping the patients pain minimised
4 prophylactic antibiotic therapy
5 keeping the patient rested and warm

a) 1 and 3
b) 1 and 4
c) 2 and 3
d) 2 and 4

A

d) 2 and 4

76
Q
  1. Your client suffers from nausea and vomiting in the early post operative period.
    Vomiting at this time is most likely due to

a) Volvulus
b) Phrenic irritation
Page 77 of 203
c) Effect of anaesthetic
d) Paralytic ileus

A

c) Effect of anaesthetic

77
Q
  1. Mrs S is scheduled for a cholecystectomy and asks you how she will manage without
    a gallbladder. Your best reply is

a) Dilute bile will still pass into your digestive tract but will be less efficient at
digesting fat
b) Your liver will no longer produce bile now so you must stay strictly off fatty
foods
c) Your gallbladder was not a very important organ and you will not miss it
d) You can take a bile supplement in your diet to compensate

A

a) Dilute bile will still pass into your digestive tract but will be less efficient at
digesting fat

78
Q
  1. An intravenous infusion of 500 ml dextrose/saline through a metriset infusion set (60
    drops per ml) is ordered to run over 6 hours. Calculate the drops per minute

a) 137
b) 36
c) 60
d) 83

A

d) 83

79
Q
  1. An injection of morphine 7.5 mg is required – on hand are ampoules containing 10
    mg per ml. Calculate the volume to be drawn up

a) 0.5 ml
b) 0.6 ml
c) 0.65 ml
d) 0.7 ml
e) 0.75 ml

A

e) 0.75 ml

80
Q
  1. Your patient is charted 1 L normal saline 12 hourly via an IV line (drop factor 10).
    Calculate the correct drops per minute (d.p.m)

a) 8
b) 12
c) 14
d) 20
e) 24

A

c) 14

81
Q
  1. If the drop factor is 15, how fast should an infusion of 1000 ml normal saline run over
    10 hours

a) 15 dpm
b) 20 dpm
c) 25 dpm
d) 40 dpm

A

c) 25 dpm

82
Q
  1. Mrs Graham is an active, retired 62 year old. She has been admitted for investigation
    of possible renal calculi. Which of the following investigations would be most useful
    in confirming Mrs G’s provisional diagnosis of renal calculi

a) Cystoscopy
b) Intravenous pyelogram
c) Renal biopsy
d) Urinary electrolytes

A

b) Intravenous pyelogram

83
Q
  1. Mrs S, aged 56, has undergone elective abdominal surgery. In the evening of the day
    of surgery she feels that she wants to pass urine but is unable to do so. The nurse
    could best assist her to micturate by

1 applying manual pressure to the suprapubic region
2 assisting her to sit at the edge of the bed and use a pan
3 encouraging her to increase her fluid intake
4 changing her position, ensuring comfort and giving pain relief
5 emptying her bladder to give relief by use of a urinary catheter

a) 1 and 3
b) 1 and 4
c) 2 and 3
d) 2 and 4

A

a) 1 and 3

84
Q

STATE EXAMS 10

  1. Critical thinking skills that assist the nurse in appropriately setting priorities are which
    type of nursing skill

a) Intellectual
b) Interpersonal
c) Technical
d) Mechanical

A

a) Intellectual

85
Q
  1. Which of the following peripheral pulses is the most common site for obtaining a
    pulse in an emergency

a) Carotid artery
b) Radial artery
c) Brachial artery
d) Temporal artery

A

a) Carotid artery

86
Q
  1. Culturally safe nursing practice involves

a) Relating to all clients in a neutral manner regardless of their cultural heritage
b) Asking clients about knowledge of their own cultural heritage
c) Ensuring clients are nursed by nurses from their own culture
d) Using appropriate resources to meet clients identified needs

A

d) Using appropriate resources to meet clients identified needs

87
Q
  1. The nurse notifies the physician when it is determined that an adult male clients pulse
    is 52 beats per minute because the client is experiencing

a) Cardiovascular collapse
b) Bradycardia
c) Tachycardia
d) Dysrhythmia

A

b) Bradycardia

88
Q
  1. Potential sources of client data useful to the nurse for a comprehensive assessment
    include

a) client
b) family
c) medical records
d) all of the above

A

d) all of the above

89
Q
  1. vital signs are measured in order to

a) regulate the clients condition within a narrow range
b) provide clues to the physiologic functioning of the body
c) comply with the doctors order for vital signs to be taken at prescribed intervals
d) assess the psychological status of the client

A

b) provide clues to the physiologic functioning of the body

90
Q
  1. In effective communication, the course sends a message to the receiver. Which of the
    following describes the process by which reception and comprehension of the
    message are verified

a) noise
b) feedback
c) channel
d) decoder

A

b) feedback

91
Q
  1. the frequency of assessing vital signs depends upon the

a) doctors orders
b) nurses discretion
c) availability of personnel
d) patients condition

A

d) patients condition

92
Q
  1. where should the stethoscope be placed upon the auscultation of apical beat

a) fifth intercostals space at left midclavicular line
b) the epigastric area at the tip of the sternum
c) third intercostals space over the right ventricle
d) between the aortic and tricuspid areas

A

a) fifth intercostals space at left midclavicular line

93
Q
  1. which of the following best indicates good blood circulation to the extremities

a) blood pressure in normal range
b) dorsalis pedis pulses strong and equal bilaterally
c) mucous membranes pink and moist
d) venous patterns readily identifiable

A

b) dorsalis pedis pulses strong and equal bilaterally

94
Q
  1. measuring the clients response to nursing interventions and the clients progress
    toward achieving goals is done during which phase of the nursing process

a) planning
b) nursing diagnosis
c) evaluation
d) assessment

A

c) evaluation

95
Q
  1. the primary source of data for evaluation is the

a) physician
b) client
c) nurse
d) medical record

A

b) client

96
Q
  1. the criteria for determining the effectiveness of nursing actions are based on the

a) nursing diagnosis
b) expected outcome
c) clients satisfaction
d) nursing interventions

A

c) clients satisfaction

97
Q
  1. the planning step of the nursing process includes which of the following activities

a) assessing and diagnosing
b) evaluating goal achievement
c) performing nursing actions and documenting them
d) setting goals and selecting interventions

A

d) setting goals and selecting interventions

97
Q
  1. the nursing care plan is
    a) a written guideline for implementation and evaluation
    b) a documentation of client care
    c) a projection of potential alterations in client behaviours
    d) a tool to set goals and project outcomes
A

a) a written guideline for implementation and evaluation

98
Q
  1. the nurses act is administered by the

a) new Zealand nurses organisation
b) nursing council of new Zealand
c) division of nursing (department of health)
d) all of the above

A

b) nursing council of new Zealand

99
Q
  1. the registrar of nurses is employed in the

a) department of health
b) nursing council
c) nurses organisation
d) hospital boards association

A

b) nursing council

100
Q
  1. the nursing council is

a) bureau in the department of health
b) a subcommittee of the nurses organisation
c) an incorporated society
d) a statutory body

A

d) a statutory body

101
Q
  1. the nursing council does all of the following except

a) administer the nurses act
b) administer the hospitals act
c) approve schools of nursing
d) issue practising certificate

A

b) administer the hospitals act

102
Q
  1. the act which provides for the nursing council to have disciplinary jurisdiction over
    the conduct of registered and enrolled nurses is

a) the nurses act of 1977
b) the nurses regulation act of 1977
c) the hospital act of 1951
d) the area health board act of 1989

A

a) the nurses act of 1977

103
Q
  1. Nurses employed in any setting can be formal complaint is made against them. By
    law to whom should these complaints be addressed

a) the medical superintendent
b) the registrar of the nursing council
c) the medical officer of health
d) the executive director of the nurses organisation

A

b) the registrar of the nursing council

104
Q
  1. the maintenance of standards, discipline, examinations are administered by the
    nursing council under which act of parliament

a) crimes act 1961
b) nurses act 1977
c) accident rehabilitation and compensation insurance act
d) official information act 1982

A

b) nurses act 1977

105
Q
  1. As you prepare a client for surgery she states that although she has signed her consent
    form she doesn’t really understand what the doctor told her. She asks what sort of
    operation is she to have. You respond with

a) I’ll just give you your pre medication and soon you’ll be alright
b) you seem worried about your operation, would you like to stay
c) I can see you are upset. I’ll get the doctor to explain the operation again to clarify
if for you
d) You don’t have to worry, the doctors do this operation all time

A

c) I can see you are upset. I’ll get the doctor to explain the operation again to clarify
if for you

106
Q
  1. If a client is admitted and dies within 24 hours following surgery must be notified by
    law

a) Significant others
b) Doctor
c) Medical superintendent
d) Coroner

A

d) Coroner

107
Q
  1. All of the following are a coroners case except

a) An unexpected death of client 24 hours after admission
b) Death of a client with an infectious disease
c) An unexpected death 24 hours after surgery
d) No established cause of death

A

b) Death of a client with an infectious disease

108
Q
  1. Richard a 25 year old mildly retarded person was admitted to accident and emergency
    due to multiple fractures after a motor bike accident. Richard is to have an emergency
    laparotomy due to internal bleeding. The crimes act states that consent in the above
    case is

a) Implied from the circumstances surrounding the case and the need to take
immediate action for the welfare of the individual
b) Written and must be freely given and fully understood if major surgery was to be
performed
c) Mentally ill and demented clients must have a consent of a parent or a guardian or
significant others representing them
d) Valid only if the client is 16 years and over or if married

A

a) Implied from the circumstances surrounding the case and the need to take
immediate action for the welfare of the individual

109
Q
  1. Whilst in theatre, a friend who knew Richard very well, rings to inquire about the
    client’s condition. You are the staff nurse on duty. The official secrets act of 1951
    allows you to

a) Give the full information as he is a very close friend of the client
b) Give him the information as he is a member of the health profession
c) Give him information in general terms concerning the condition of the client
d) None of the above

A

d) None of the above

110
Q
  1. After surgery Richard is taken to the intensive care unit but dies shortly thereafter. A
    legal responsibility in cases of unexplained death up to 24 hours after surgery is to

a) Lay the body out so that the family and friends can see the client
b) Send a coroners referral for investigation
c) Make sure the clients name and address and the circumstances surrounding the
death are written in the 24 hours census book
d) Ensure that personal belonging are inspected and signed for by the family

A

b) Send a coroners referral for investigation

111
Q
  1. Debbie a 16 year old student, is admitted in a semi conscious state with a history of a
    58 pound weight loss in 3 months. Preliminary diagnosis is acute anorexia nervosa.
    Which of the following admissions lab values should the nurse caring for Debbie
    consider to most critical

a) Glucose 8.0
b) Potassium 3.0
c) Sodium 144
d) Haemoglobin 10

A

d) Haemoglobin 10

112
Q
  1. Which vital sign would provide the most essential information in light of Debbie’s
    current lab values

a) Temperature
b) Pulse
c) Respirations
d) Blood pressure

A

c) Respirations

113
Q
  1. Claire aged 30 and single, is brought to the mental health unit by her brother, who
    tells the nurse that she has become increasingly overactive and out of control over the
    past 2 months. She begins tasks but doesn’t complete them, takes little time to eat and
    sleep and spends large amounts of money and is now in debt. Which approach would
    be most therapeutic in working with Claire?

a) Teaching the patient about banking procedures, then extending this approach to
everyday issues
b) Confronting the patient about all her inappropriate behaviour
c) Kindly but firmly guiding the patient into such activities such as bathing and
eating
d) Showing the patient that she is in a controlled environment so that no difficulties
arise later

A

c) Kindly but firmly guiding the patient into such activities such as bathing and
eating

114
Q
  1. Claire lost 15lb last week and now weights 100lb. the nurse formulates a nursing
    diagnosis based on the diagnostic category altered nutrition: less than body
    requirements. Which goal is most appropriate initially

a) The patient will consume an adequate diet
b) The patient will maintain her current weight of 100lb
c) The patient will gain 1lb per week
d) The patient will remain adequately hydrated

A

d) The patient will remain adequately hydrated

115
Q
  1. Claire’s hydration and nutrition needs would be to

a) Leave finger foods and liquids in her room and let her eat and drink as she moves
about
b) Bring her to the dining room and encourage her to sit and eat with calm, quiet
companions
c) Explain meal time routines and allow her to make own decisions about eating
d) Provide essential nutrition through high calorie gavage (naso gastric) feedings

A

b) Bring her to the dining room and encourage her to sit and eat with calm, quiet
companions

116
Q
  1. The physician decides to start Claire on lithium therapy. Which of the following best
    describes her dietary requirements while she is receiving this medication

a) A high calorie diet with reduced sodium and adequate fluid intake
b) A regular diet with normal sodium and adequate intake
c) A low calorie diet with reduced sodium and increased fluid intake
d) A regular diet with reduced sodium and adequate fluid intake

A

b) A regular diet with normal sodium and adequate intake

117
Q
  1. Michelle aged 25 is found sitting on the floor of the bathroom in treatment clinic with
    moderate lacerations to both wrists. Accompanied with broken glass she sits staring
    blankly at her bleeding wrists while staff members call for an ambulance. How should
    the nurse approach Michelle initially

a) Enter the room quietly and move beside Michelle to assess her injuries
b) Call for staff backup before entering the room and restraining Michelle
c) Move as much glass away from Michelle as possible and quietly sit next to her
d) Approach Michelle slowly while speaking in a calm voice, calling her name and
telling her that the nurse is here to help her

A

d) Approach Michelle slowly while speaking in a calm voice, calling her name and
telling her that the nurse is here to help her

118
Q
  1. Michelle is taken to the hospital and admitted on an emergency basis for 5 days
    compulsory assessment and treatment. Michelle says to the admitting nurse. I’m not
    staying here. I was a little upset and did a stupid thing. I want to leave. Which
    response is most appropriate

a) Unfortunately, you have no right to leave at this time. You must be evaluated
further
b) Cutting your wrists certainly was a stupid thing to do. What were you trying to
accomplish anyway
c) You have been admitted on an emergency basis and can be held you have the right
to consult a lawyer about your admission
d) I can see you’re upset. Why don’t you try to relax. You can explain to the doctor
what upset you. If what you say is true, you’ll be released sooner

A

c) You have been admitted on an emergency basis and can be held you have the right
to consult a lawyer about your admission

119
Q
  1. Determining michelles suicide potential during the mental status examination,
    involves assessing several factors, the most significant of which is her

a) History of previous suicide attempts
b) Suicide plan
c) Emotional state
d) Self esteem

A

b) Suicide plan

120
Q
  1. Michelle is placed on suicide precautions, which include constant observation. When
    the nurse accompanies her to the bathroom. Michelle complains, I can’t believe this. I
    can’t even go to the bathroom without being watched. How would you like to have
    me watching you go to the toilet. Which response by the nurse is best

a) I’m sure I wouldn’t like it very much, but then I didn’t try to hurt myself
b) I’m sorry but these are the rules. Someone must be with you at all times
c) If it’s more comfortable for you, I can stand right outside as long as the door is
open. Would you agree to that
d) I would probably feel uncomfortable too, but ensuring your safety is my first
priority. I must stay in the room with you

A

c) If it’s more comfortable for you, I can stand right outside as long as the door is
open. Would you agree to that

121
Q
  1. 5 days of hospitalization. Michelle is to be discharged and an outpatient basis at the
    day of treatment clinic. During discharge planning, the nurse should set as a priority
    short term goals Michelle will

a) Identify support systems to help manage stress
b) Verbalise feelings of shame regarding her suicide attempt
c) Demonstrate an uplifted mood and optimism about the future
d) Admit that her wrist slashing was an attention seeking behaviour and not a true
suicide attempt

A

a) Identify support systems to help manage stress

122
Q
  1. Upon transfer to the psychiatric unit Megan is informed by the admitting nurse that it
    will be necessary to check her belongings for any unsafe or banned items. She begins
    to scream angrily. What’s the matter with you. I’m upset. Get away from me. The
    nurse should first

a) Administer emergency tranquillizers as ordered
b) Place Megan in seclusion and restraints
c) Eliminate the belongings search so as to avoid upsetting her
d) Set verbal limits on her behaviour

A

d) Set verbal limits on her behaviour

123
Q
  1. Megan requests a weekend pass two days after transfer to the psychiatric unit. Her
    primary nurse informs her following the treatment team meeting that the pass has not
    been approved. Megan responds angrily. They all hate me, they’re so mean. I know
    you’d have let me go. You’re the only decent nurse here. The nurses best response is

a) I would have approved it, but you’re right I’m only one voice
b) I don’t think the others realise how hard you’ve been trying
c) Megan you’ll never get a pass behaving this way
d) This was the teams’ decision. Let’s talk about why we feel it’s not appropriate
now

A

d) This was the teams’ decision. Let’s talk about why we feel it’s not appropriate
now

124
Q
  1. Megan’s behaviour in this situation illustrates the use of which defence mechanism

a) Splitting
b) Reaction formation
c) Conversion
d) Repression

A

a) Splitting

125
Q
  1. Megan’s doctor resumes her regular dosage of amitriptyline. Which effect of this
    medication might the staff and patient expect to see first

a) Elevated mood
b) Improved reality testing
c) Improved sleep pattern
d) Fewer hallucinations and delusions

A

c) Improved sleep pattern

126
Q
  1. Wilfred a 42 year old executive, is admitted for treatment of his alcoholism. The most
    important factor in Wilfred’s rehabilitation is

a) His emotional or motivational readiness
b) The qualitative level of his physical state
c) His familys’ accepting attitude
d) The availability of community resources

A

a) His emotional or motivational readiness

127
Q
  1. Which one of the following remarks of Wilfred, made prior to discharge from hospital
    would show the most realistic assessment of his situation in relation to avoiding future
    drinking problems

a) I promise I’ll never get drunk again
b) I will cut down my drinking so I drink only socially
c) I can stop drinking providing my wife keeps off my back
d) I’m going to try hard to stay away from that first drink

A

d) I’m going to try hard to stay away from that first drink

128
Q
  1. John is a 32 year old man with a 5 year history of psychiatric admissions. He is
    escorted to the mental health unit by the police. He is dishevelled, confused and his
    records state that he has been diagnosed as chronic undifferentiated schizophrenic.
    The nurse observes john sitting in the hall looking frightened. He is curled up in a
    corner of the bench with his arms over his head and covering his face. How should the
    nurse approach the patient

a) Walk over to the bench, sit beside him quietly, and place an arm around his
shoulders, then say I’m the nurse and wait for a response
b) Allow him to remain alone on the bench, where he can observe the unit for a half
hour or so until he is more comfortable
c) Greet him warmly saying hi I’m the nurse. This is a very nice unit. I think you’ll
like it here. Let me show you around
d) Sit about 3 or 4 feet from him on the bench and say hello john I’m a nurse on this
unit. You appear frightened then wait for a response

A

d) Sit about 3 or 4 feet from him on the bench and say hello john I’m a nurse on this
unit. You appear frightened then wait for a response

129
Q
  1. John responds to the nurse by curling up on the bench even tighter. His arms still
    cover his head and his hands are clasped tightly over his ears. The nurse should

a) Show acceptance of johns behaviour by remaining with him and reassuring him,
gently stroking his arms and shoulders
b) Tell john that she will leave him for a while and will return later when he feels
more relaxed
c) Say gently john ill just sit here quietly with you for a while then remain seated
nearby
d) Say john, most people feel uncomfortable in hospitals. You shouldn’t be afraid.
I’m here to help you

A

c) Say gently john ill just sit here quietly with you for a while then remain seated
nearby

130
Q
  1. Later that evening, the nurse finds john crouched in the corner of his room, with a
    curtain covering him. His roommate is sitting on the bed laughing and saying this guy
    is really a nut. He should be in a padded cell. How should the nurse respond to the
    roommate

a) Say I’m sure John’s behaviour is frightening to you. I understand that you are
trying to cover up how you really feel by laughing
b) Say id appreciate it if you’d step outside for awhile. I’d like to talk with you after I
help john
c) Say nothing and attend to john
d) Say in a neutral tone. I think your laughing is making john feel worse. How would
you feel if you were john

A

b) Say id appreciate it if you’d step outside for awhile. I’d like to talk with you after I
help john

131
Q
  1. What is the least threatening approach to john while he sits huddled under the curtain

a) Sit next to him on the floor without speaking, and wait for him to acknowledge the
nurse
b) Gently remove the curtain and say, john this is the nurse. What happened
c) Approach john slowly and say. John this is the nurse. You appear to be very
frightened. Can you tell me what you are experiencing
d) Call for assistance and do not approach john until at least two other staff members
are present

A

c) Approach john slowly and say. John this is the nurse. You appear to be very
frightened. Can you tell me what you are experiencing

132
Q
  1. Because john has previously responded well to treatment with haloperidol (serenace),
    the doctor orders haloperidol 10mg orally twice a day. Which adverse effect is most
    common with this medication

a) Extrapyramidal symptoms
b) Hypotension
c) Drowsiness
d) Tardive dyskinesia

A

a) Extrapyramidal symptoms

133
Q
  1. During the next several days, john is observed laughing, yelling and talking to himself.
    His behaviour is characteristic of

a) Delusion
b) Looseness of association
c) Illusion
d) Hallucination

A

d) Hallucination

134
Q
  1. John tells the nurse, the earth is doomed, you know. The ozone is being destroyed by
    hair spray. You should get away before you die. John appears frightened as he say this.
    The most helpful response is to

a) Say john I think you are overreacting. I know that some concern about the earth’s
ozone layer, but there is no immediate danger to anyone
b) Say I’ve heard about the destruction of the ozone and its effect on the earth. Why
don’t you tell me more about it
c) Ignore johns statement and redirect his attention to activity on the unit
d) Say john are you saying you feel as though sometimes will happen to you. I don’t
believe we are in danger right now

A

d) Say john are you saying you feel as though sometimes will happen to you. I don’t
believe we are in danger right now

135
Q
  1. After a half hour, john continues to ramble about the ozone layer being doomed to die.
    He paces in an increasingly agitated mood he begins to speak more loudly. At this
    time, the nurse should

a) Check to see whether the doctor ordered haloperidol
b) Allow john to continue pacing but observe him closely
c) Try to involve john in a current events discussion group that is about to start
d) Tell john to go to his room for a while

A

a) Check to see whether the doctor ordered haloperidol

136
Q
  1. Henry is brought to the mental health unit by his wife who states for the past week her
    husband has refused all meals and accused her of poisoning him, he has become
    withdrawn, forgetful and inattentive and has frequent mood swings. Henry appears
    suspicious. His speech which is only partly comprehensible reveals that his thoughts
    are controlled by delusions of possession by the devil. He claims the devil told him
    that people around him are trying to destroy him. The doctor diagnoses paranoid
    schizophrenia. Schizophrenia is best described as a disorder characterised by

a) Disturbed relationships related to an inability to communicate and think clearly
b) Severe mood swings and periods of low to high activity
c) Multiple personalities, one of which is more destructive than the others
d) Auditory and visual hallucinations

A

d) Auditory and visual hallucinations

137
Q
  1. The nursing assessment of Henry should include careful observation of his

a) Thinking, perceiving and decisions making skills
b) Verbal and nonverbal communication processes
c) Affect and behaviour
d) Psychomotor activity

A

a) Thinking, perceiving and decisions making skills

138
Q
  1. When communicating with Henry the nurse should initially

a) Remain silent and wait for Henry to speak first
b) Talk with Henry as one would talk with a healthy person
c) Allow Henry to do all the talking
d) Speak to Henry using simple, concrete language

A

b) Talk with Henry as one would talk with a healthy person

139
Q
  1. The patients thought content can be evaluated on the basis of which assessment area

a) Presence or absence of delusions
b) Unbiased information from the patients psychiatric history
c) Degree of orientation to person, place and time
d) Ability to think abstractly

A

a) Presence or absence of delusions

140
Q
  1. Henry mentions that voices are telling him that he is in danger and that he will be safe
    only if he stays in his room and avoids ‘zoids’. How should the nurse respond

a) I understand that these voices are real to you, but I want you to know that I do not
here them
b) Don’t worry. I won’t let anything happen to you here
c) What else can you tell me about the voices
d) Many patients hear voices when they come here. The voices will go away when
you get better

A

c) What else can you tell me about the voices

141
Q
  1. The innermost layer of the eye is

a) Sclera
b) Retina
c) Choroid
d) Conjunctive

A

b) Retina

142
Q
  1. The nurse observes Henry pacing in his room. He is alone but in an angry tone. When
    asked what he was experiencing he replies the devil is yelling in my ear. He say
    people here want to live. The nurses best response is

a) Can you tell me more about what the devil is saying
b) How do you feel when the devil says such things to you
c) I don’t hear any voice. Henry are you feeling afraid now
d) Henry the devil cannot talk to you

A

c) I don’t hear any voice. Henry are you feeling afraid now

143
Q
  1. Mary is admitted under section 11 of the mental health (compulsory assessment and
    treatment act 1992). The definition of mental disorder under the act includes all of the
    following except

a) A seriously diminished ability to care for yourself
b) Mental handicap and substance abuse
c) An abnormal state of mind
d) A serious danger to self or others

A

b) Mental handicap and substance abuse

144
Q
  1. Marys rights under the act include, the right

a) To information about her status, to respect of her culture identity, to seek legal
representation
b) To respect as a human being, to respect of her cultural values, to receive visitors
and make phone calls
c) To information about her status, to receive treatment to health care, to change her
treatment at her request
d) To receive visitors and make telephone calls, to refuse seclusion on cultural
grounds, to seek a judicial inquiry

A

b) To respect as a human being, to respect of her cultural values, to receive visitors
and make phone calls

145
Q
  1. Mary asks for review of her legal status. Your action would be

a) Explain that her status will be reviewed by the responsible clinician before the end
of five days
b) Reassure her that you understand how frustrating it must to be in hospital against
her will
c) Offer to phone the client advocate on Marys behalf
d) Explain section 16 to Mary and allow her to phone the district inspector

A

a) Explain that her status will be reviewed by the responsible clinician before the end
of five days

146
Q
  1. Under section 30 of the mental health act (1992), the inpatient treatment order lasts
    for

a) 2 months
b) 4 months
c) 6 months
d) 12 months

A

c) 6 months

147
Q
  1. Under section 111 of the mental health act (1992) a person admitted to hospital, not
    already subject to any assessment and treatment can be detained, for how long, if
    considered mentally disordered

a) 24 hours
b) 12 hours
c) 6 hours
d) 3 hours

A

c) 6 hours

148
Q
  1. Lisa tell the nurse that she has gained 2kg in a month and plans to diet by skipping
    lunches. Which of the following responses would be the most appropriate

a) Have you noticed that your hands and feet have become swollen
b) You should cut down on high calorie foods like cake and candy, but you shouldn’t
skip lunch
c) Your weight gain is just right for you for this period of your pregnancy. You are
doing fine
d) You’re supposed to gain a lot of weight its good for the baby. You’ll lose it after
the baby is born

A

b) You should cut down on high calorie foods like cake and candy, but you shouldn’t
skip lunch

149
Q
  1. 50mg is equal to

a) 0.5 gram
b) 5 grams
c) 5000 micrograms
d) 50,000 micrograms

A

d) 50,000 micrograms

150
Q
  1. The drugs used to treat Parkinson’s disease act by

a) Increasing cholinergic activity and increasing dopamine
b) Reducing cholinergic activity and increasing dopamine
c) Increasing cholinergic activity and reducing dopamine
d) Reducing cholinergic activity and reducing dopamine

A

b) Reducing cholinergic activity and increasing dopamine

151
Q
  1. Recent research indicates that arthritis may be an autoimmune disease. Which of the
    following statements most accurately describes the process of autoimmunity

a) A rare complication of vaccination when the body reacts to the vaccine by
producing symptoms of the disease
b) An inherent factor in the blood which renders the person susceptible to certain
diseases
c) Lack of antitoxins in the blood which render the person susceptible to the certain
diseases
d) Formation of antibodies in the blood which destroy certain healthy cells in the
individual

A

b) An inherent factor in the blood which renders the person susceptible to certain
diseases

152
Q
  1. Patients with rheumatoid arthritis commonly have a raised ESR (erythrocyte
    sedimentation rate). This is because

a) Arthritic patients usually have a degree of anaemia
b) Rheumatoid factor decreases the viscosity of the cells
c) Protein changes result in the erythrocytes becoming heavier
d) There is an increase in leukocyte numbers

A

c) Protein changes result in the erythrocytes becoming heavier

153
Q
  1. Before administering a dose of digoxin the patients pulse (apex beat) should be taken.
    Which is the correct action for the nurse to take if the pulse is found to be under 60
    beats per minute

a) Give the drug and take the pulse again an hour later
b) Give the drug and notify the staff nurse that the pulse is slow
c) Do not give the drug and report the slow pulse to the doctor
d) Omit the drug and make a note on the nursing care plan

A

c) Do not give the drug and report the slow pulse to the doctor

154
Q
  1. Which of the following can be causes of anaemia in the elderly
  2. Apathy and depression
  3. Ill fitting dentures
  4. A physiological inability to utilize food properly

a) 3 only
b) 1 and 2
c) 1 and 3
d) 1, 2 and 3

A

a) 3 only

155
Q
  1. Old people are inevitably a burden on the community (assertion) because old people
    cannot work because they are slow and cannot be relied on (reason). With reference to
    the above statement which of the following is true

a) Both assertion and reason are true statements but the reason is not a correct
explanation of assertion
b) The assertion is true but the reason is a false statement
c) The assertion is false but the reason is a true statement
d) Both the assertion and reason are false statements

A

d) Both the assertion and reason are false statements

156
Q
  1. A common problem with the elderly is their reluctance to drink adequate amounts of
    fluid. The most probable reason for this is that they are

a) Frightened of being incontinent
b) More likely to sweat than younger people
c) Unable to afford adequate fluids
d) Afraid of developing diarrhoea

A

a) Frightened of being incontinent

157
Q
  1. Haemorrhage into the anterior chamber of the eye following a cataract extraction is
    called

a) Hyaemia
b) Hyphaema
c) Hayfever
d) Hyena

A

b) Hyphaema

158
Q
  1. Mrs Adams suffers from dementia and requires a dressing to a shin wound. The nurse
    suspects the wound is the result of a non accidental injury. What is the main cause of
    non accidental injury in an elderly person suffering from dementia

a) A dependent person being more prone to injury
b) A long standing pattern of domestic violence
c) The home not being a suitable place for a dependent person
d) The increased stress in caring for a dependent person at home

A

a) A dependent person being more prone to injury

159
Q
  1. When dressing the shin wound the nurses most appropriate remark is

a) How did you scrape your shin Mrs. Adams
b) How did you scrape your wife’s shin Mr. Adams
c) This shin must hurt. Was it really an accident
d) A shin is easy to hurt. How did this injury happen

A

d) A shin is easy to hurt. How did this injury happen

160
Q
  1. The most appropriate way to help Mr. and Mrs. Adams at the first visit is to

a) Express professional concern at the cause of the injury
b) Conceal feelings about the possible cause of the injury
c) Reassure Mrs. Adams that this injury will not occur again
d) Acknowledge the stress of Mr. Adams in caring for his wife

A

a) Express professional concern at the cause of the injury

161
Q
  1. An increased incidence of vaginal infections occurs when contraceptive pills are taken
    because there is

a) A shift in the vaginal pH
b) Drying of the vagina mucosa
c) An increase in vaginal fluids
d) A reduction in white cell numbers

A

a) A shift in the vaginal pH

162
Q
  1. What action should the nurse take when on three home visits the mother of a nine
    months old baby prevents him from being seen as ‘he is sleeping’

a) Notify the social welfare of the situation
b) Notify the family doctor in writing of this occurrence
c) Insist on seeing the child and refuse to leave the home
d) Respect the patients right to accept or refuse treatment

A

a) Notify the social welfare of the situation

163
Q
  1. Which is the major pathophysiological abnormality occurring in asthma

a) Cardiac arrhythmias
b) Bronchiole dysplasia
c) Spasm of the smooth muscles of the bronchi
d) Inflammation of the alveoli

A

c) Spasm of the smooth muscles of the bronchi

164
Q
  1. Which of the following sings/symptoms would indicate mumps

a) Swelling of the lymph nodes
b) Tenderness of the parotid gland
c) Enlargement of the prostate gland
d) Ulceration of vesicular stomatitis

A

a) Swelling of the lymph nodes

165
Q
  1. Which option is important for the nurse to know with regard to prevention of the
    spread of mumps

a) Safe disposal of all bodily excretions
b) No specific isolation measures are needed
c) Control of all food stuffs prepared for sale
d) Isolation for ten days after the last notified case

A

d) Isolation for ten days after the last notified case

166
Q
  1. Which of the following is the best description of a vaccine

a) Dead modified bacilli
b) Live attenuated virus
c) Dead virus given orally
d) Antibodies suspended in serum

A

b) Live attenuated virus

167
Q
  1. Mrs Shaw brings her 8 year old daughter Jane to the clinic. Jane has eczema. Jane’s
    eczema is most likely the result of

a) Inadequate skin care and hygiene
b) Excretion of acids through sweat pores
c) An inherited predisposition to skin infections
d) Sensitivity to a substance in her external environment

A

d) Sensitivity to a substance in her external environment

168
Q
  1. Eczema is the term used to describe a (n)

a) Acute, contagious inflammation of the skin
b) Non contagious inflammatory response of the skin
c) Fungal infection more commonly seen in childhood
d) Condition marked by the appearance of erythematous wheals

A

b) Non contagious inflammatory response of the skin

169
Q
  1. Which statement best describes ‘vesicle’

a) Reddened, pinprick like rash
b) Small round area of discolouration
c) Small area of swelling on the skin
d) Small blister filled with serous fluid

A

d) Small blister filled with serous fluid

170
Q
  1. You are employed as a practice nurse. A friend telephones and asks if her boyfriend
    has been to see the doctor this week. Your most appropriate response is

a) I don’t know
b) I’ll have to ask the doctor
c) I am not able to tell you that
d) Just a moment, ill check the files

A

c) I am not able to tell you that

171
Q
  1. Aminophylline 350mg is prescribed. Each ampoule contains 250mg in 10ml. how
    much should be added to the intravenous solution

a) 12ml
b) 14ml
c) 16ml
d) 35ml

A

b) 14ml

172
Q
  1. Jillian’s intravenous infusion of 300ml normal saline is due to run over 4 hours. The
    drop factor is 60. How many drops per minute must be given for the IV to be
    completed on time

a) 60 dpm
b) 75 dpm
c) 100 dpm
d) 47 dpm

A

b) 75 dpm

173
Q
  1. A client is charted nitrazepam (mogadon) tablets to sleep. She refuses to take them at
    9pm. She tells you that the other nurses always leave the tablets on the locker and she
    takes them when she is ready. What should you do

a) Put them back in the container
b) Give her the tablets and let her take them later
c) Tell the patient to ring when she is ready for them
d) Tell her if she doesn’t take them now she may not get them later

A

c) Tell the patient to ring when she is ready for them

174
Q
  1. Hyperventilation may initially cause

a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis

A

d) Respiratory alkalosis

175
Q
  1. Your neurologic assessment indicates increased ICP (intracranial pressure), so you
    raise the head of the bed 15 to 30 degrees in order to

a) Improve arterial flow to the brain
b) Promote venous drainage from the brain
c) Improve respirations
d) Increase cardiac output

A

c) Improve respirations

Nursing state exams (5 decks)

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