#1. Answer: D
It does not occur in retinal detachment.
b. Severe eye pain
Retinal detachment is painless.
c. Sudden blindness
It does not occur in the early stage.
d. Bright flashes of light
Bright flashes of light or photopsia is a common symptom of retinal detachment. It results from mechanical stimulation of the retina through the vitreoretinal traction.
#2. Answer: D
It is not a predisposing factor.
b. Cranial tumors
It is not a predisposing factor.
It is not a predisposing factor.
Near-sightedness or myopia is a predisposing factor for retinal tear people with moderate to severe myopia have thinner retinas that are more prone to detaching.
#3. Answer: D
a. A labyrinthectomy is the preferred treatment for relieving symptoms and restoring hearing.
Labyrinthotomy and labyrinthectomy are considered destructive surgical interventions for vestibular system dysfunction. It involves removal of the vestibular nerve or the labyrinth, thereby relieving vertigo at the expense of causing deafness.
b. During an acute attack, the client’s room should be brightly lit, and the side rails must be raised to provide safety.
The room must be darkened with side rails up because brightly lit rooms may trigger exacerbation of clinical manifestations.
c. Turning the head rapidly will provide comfort when the client is suffering from acute attacks and vertigo.
To prevent vertigo from worsening, client must be instructed to avoid any rapid or sudden movements.
d. This disease is managed well by giving diuretics to the client and maintaining the client in a low-sodium diet.
Limiting the sodium in the diet and giving diuretics will decrease the overall fluid level in the body, eventually decreasing the endolymphatic fluid or the fluid insider the inner ear. Meniere’s disease is caused by increased endolymphatic fluid as shown in autopsies.
#4. Answer: D
a. Is a unilateral inflammation of the 9th cranial nerve.
The nerve involved is the 7th cranial nerve
b. Is a consequence of stroke or transient ischemic attack.
There is no sufficient evidence or studies which state that it is caused by either stroke or TIA.
c. Will present as spastic paralysis of the client’s facial muscles.
The client will present with a flaccid paralysis of the facial muscles.
d. Is due to a lower motor neuron lesion to the 7th cranial nerve.
Bell’s Palsy affects the 7th cranial nerve, which is also called the facial nerve. It causes a unilateral facial paralysis, manifested as loss of taste, inability to raise the eyebrows, smile, close the eyelids, or puff out cheeks.
#5. Answer: A
a. Place the client in supine position.
It is better to elevate the head of bed to minimize the cerebral edema.
b. Keep the head in neutral position.
Maintaining the head in a neutral position promotes proper venous drainage.
c. Avoid neck and hip flexion.
Strict care should be maintained in these areas to prevent venous obstruction.
d. All are correct nursing interventions.
Placing the client in supine is not a correct intervention in this situation.
#6. Answer: B
a. Continue administering the pain medication.
The nurse must first assess the client before giving any medications. Pain medications may alter initial assessment results especially the Glasgow Coma Scale.
b. Ask if the client is feeling lethargic.
Lethargy is considered as the first sign of increased intracranial pressure which is an emergency situation.
c. Increase the Intravenous Fluid flow rate.
The nurse is not permitted to change the IVF flow rate without the physician’s order unless there are some protocols instituted in the healthcare facility.
d. Call the significant others for a stand-by assistance.
Maybe a necessity, but it is not the priority at this time.
#7. Answer: A
a. Light flashes and black spots or floaters.
Floaters and flashes indicate severe problems like retinal detachment. Floaters or black spots may appear as small specks or clouds moving in front of one’s vision which may indicate signs of bleeding. Flashes are brief sensation of bright lights at the edge of one’s vision.
b. Decreased vision and abnormal color perception.
This assessment finding is consistent with Cataract.
c. Diminished accommodation and increased intraocular pressure.
This assessment finding suggests Glaucoma.
d. Presence of Scotomas and drusen in the fundus.
Scotomas are shimmering island in the field of vision, and drusen is the yellowish exudate in the fundus. These suggest that the client has Macular degeneration.
#8. Answer: B
a. Family history of Diabetes
A family history of Diabetes is not directly associated with the development of gallstones.
b. High waist circumference
Gallstone formation is more prevalent in clients with a high body mass index or waist circumference. The nurse should be aware that obesity is the major risk factor for gallstone formation.
c. Enzyme deficiency
Presence of enzyme deficiency does not influence the formation of gallstones.
d. Medication intake
Client’s use of medications does not directly influence the formation of gallstones.
#9. Answer: C
a. Related to an allergic reaction
IgE is the immunoglobulin specific for allergic reactions.
b. Parasitic in nature
IgE is the immunoglobulin that is involved in parasitic infections.
c. In the acute phase
IgM is responsible for primary immune response and is activated during the acute phase of the infection.
d. Chronic in duration
When the infection is chronic in duration, there will be an increased concentration of IgG and not IgM.
#10. Answer: D
a. Twin pregnancy
The hematologic adaptation occurring during pregnancy is a normal process to deliver nutrients to the mother and the baby.
b. Early onset of menarche
Early menarche does not produce a hematologic disorder.
c. Severe vomiting and diarrhea
These symptoms are not related with hematologic disorders.
d. Duodenum surgery
Surgery of the duodenum can produce a hematologic condition because it is where iron absorption occurs.
#11. Answer: C
a. Administer nitroglycerin.
Nitroglycerin is a drug given to clients suffering from angina pectoris. The signs and symptoms mentioned are more likely to be pericarditis.
b. Prepare for test tube insertion.
Test tube insertion is a management for pneumothorax. However, the pathognomonic sign for this is deviated trachea which is absent from the signs and symptoms mentioned. Therefore, test tube insertion is not advised.
c. Assist client in sitting position leaning slightly forward.
The client is possibly suffering from pericarditis, and leaning forward may ease the discomfort and pain.
d. Call the physician.
Nursing management for pain and further assessment must be instituted first before endorsing the client to the physician for further medical management and diagnosis.
#12. Answer: D
a. Maintain adequate hydration of the client.
Adequate hydration helps prevent formation of the thrombus. However, the most important nursing action when the catheter is in place is to ensure proper functioning of the catheter and prevent rupture of the balloon.
b. If bleeding occurs, notify the physician.
If bleeding occurs, the nurse must place direct pressure on the site and ask somebody else to call the physician.
c. Encourage active ROM exercises for the unaffected side of the body every 4 hours after the catheter is removed.
After the procedure and the catheter is taken out, the nurse must encourage active ROM exercises every 2 hours for the arms, the unaffected leg, and the affected ankle
d. Inform the client not to sit upright, flex hip or bend knee.
Sitting upright, flexing hips or bending knees may cause blood pressure fluctuations. It is important to avoid fluctuations in blood pressure after intra-aortic balloon pump counterpulsation to prevent complications. Balloon deflation and inflation is carefully timed in order to coincide with the arterial waveform.
Fundamentals of Nursing
#13. Answer: C, E
Options C and E are caused by low airway pressure alarms and not by high pressure alarms.
#14. Answer: A
a. Difficulty breathing
This needs immediate attention because it may indicate lung collapse, which is the primary complication of loss of the normal negative pressure in the thoracic cavity.
b. Continuous bubbling in the water seal chamber
Continuous bubbling means there is bubbling in the water seal bottle both upon inspiration and expiration. This is an inappropriate finding since the expected outcome should be bubbling only upon inspiration. Bubbling upon expiration may result from a leak between the atmosphere and the water seal bottle or between the pleura and the alveoli. This condition can result to an inability to restore the normal negative pressure in the thoracic or pleural cavity and may lead to lung collapse.
c. Fluctuation of fluid in the water seal chamber
This is an expected outcome when the pressure in the thoracic cavity is not equal to the pressure in the water seal bottle.
d. Presence of fluid in the chest tube
This is the chief indication for the drainage system and therefore does not warrant immediate attention of the physician.
#15. Answer: B, E
a. Explain to the client that sensations of shortness of breath and coughing are not normal.
These sensations are expected but any discomfort will be very brief.
b. Check suction source, occlude the suction source and adjust the dial between 80 to 120 mmHg.
This is done to prevent hypoxemia and trauma to the mucosa.
c. Preoxygenate the client with 100% oxygen for 30 secs, with at least two hyperinflations.
Preoxygenate the client with 100% oxygen for 30 seconds to 3 minutes (at least three hyperinflations) to prevent hypoxemia. Keep hyperinflations synchronized with inhalation.
d. While applying suction, quickly insert the suction catheter until resistance is met
Do not apply suction during insertion of catheter.
e. Use intermittent suction and a twirling motion of the catheter during withdrawal.
Withdraw the catheter 0.4 to 0.8 inch (1 to 2 cm) and begin to apply suction to prevent trauma to the mucosa.
f. Never suction longer than 40 to 60 seconds.
To prevent hypoxemia, never suction longer than 10 to 15 seconds.
#16. Answer: A, B, E
a. Resonance is low pitch, moderate to loud intensity, hollow and has long duration
Resonance is the characteristic of the normal lung tissue.
b. Hyperresonance is higher than resonance in pitch, very loud intensity, booming and longer than resonance in duration
Indicates the presence of trapped air, commonly heard over an emphysematous or asthmatic lung and ocassionally over pneumothorax.
c. Flatness is low pitch, loud intensity, extremely dull, and short duration
Flatness is high pitch, soft intensity, extremely dull and short duration. Flatness percussed over the lung field may indicate massive pleural effusion.
d. Dullness is low pitch, medium intensity, thud-like and moderate duration
Dullness is medium pitch, medium intensity, thud-like, and moderate duration. An example location is over the liver and the kidneys. Dullness can be percussed over an atelectatic lung or consolidated lung.
e. Tymphany is high pitch, loud intensity, musical or drum like and short duration
Examples are the cheek filled air and the abdomen distended with air. Over the lung, a tympanic note usually indicates a large pneumothorax.
f. Dullness is the characteristic of the normal lung tissue
Resonance is the characteristic of the normal lung tissue.
#17. Answer: A
a. Reflective question
A reflective comment is used to describe and explore the feelings of the client. The technique encourages the client to elaborate thoughts and feelings.
b. Open-ended question
The open-ended technique is more appropriate to use when the nurse is expecting a wide range of client response and not limited to the feelings alone.
c. Closed question
This is incorrect because it provides limited response to the client.
d. Clarifying question
A clarifying question allows the nurse to gain an understanding of a client’s comment regarding symptoms, disease, and medications.
#18. Answer: D
Assessment is the initial phase in the nursing process which involves gathering data from the client and making a thorough physical examination.
Planning is a phase in the nursing process wherein goals and objectives are prioritized. Nursing interventions are carefully selected to accomplish outcomes or goals.
The implementation phase deals with the activation of the plan by actively performing nursing interventions.
Formulating the nursing diagnosis needs analysis of the available data in order to identify the client’s problem.
#19. Answer: A
a. Laryngeal trauma
The nurse should first assess for presence of neck and cervical spine injury before performing the head tilt-chin lift maneuver because doing so can lead to further injury.
b. Facial trauma
Presence of facial trauma is not contraindicated for the nursing maneuver.
Upper airway obstruction due to anaphylaxis can be initially managed with the head tilt-chin lit maneuver.
The maneuver can be performed in near-drowning for as long as the health care provider is sure that there is no injury to the neck and cervical spine.
#20. Answer: D
a. Radial pulse
The radial pulse is peripherally located and may be absent in severe blood loss.
b. Brachial pulse
Severe hemorrhage would likely cause diminished peripheral pulses.
c. Popliteal pulse
Vasoconstriction occurs in severe hemorrhage as an adaptive mechanism in distributing blood to the vital organs of the body. Taking the pulse rate from the popliteal area is not best for the situation.
d. Carotid pulse
A central pulse should be considered first in the situation so that an accurate assessment of the rate and quality of the pulse can be obtained.
#21. Answer: A
a. Intravenous rehydration with normal saline
Intravenous rehydration is based on clinical and laboratory parameters, therefore laboratory tests should be taken first. It is initiated when oral rehydration is not tolerated by the client.
b. Removal of client’s constrictive clothing
The removal of constrictive clothing is an initial treatment to avoid breathing difficulties.
c. Placing the client in a cool area
Exposing the client in a cool area marks the start of treatment with the goal of decreasing core temperature.
d. Oral fluid and electrolyte replacement
Oral fluid and electrolyte replacement is initially started while waiting for further assessment results. There is no contraindication in the case like nausea and vomiting so it is an immediate nursing intervention for heat exhaustion.
#22. Answers: A, C, D, E
a. Jaundice within 24 hours appears after birth.
This occurs because of increased bilirubin in the newborn’s blood and is caused by blood antigen incompatibility.
b. Increased WBC in CBC result.
This does not indicate Hemolytic Disease in newborns, rather it indicates infection or sepsis.
c. The newborn’s serum bilirubin level elevates rapidly.
There is an increase in bilirubin level because it is a byproduct of hemolysis which occurs when there is a blood incompatibility problems.
d. There is a positive Coombs test result.
Coombs test is performed on cord blood sample. A positive Coombs test indicates Hemolytic disease.
e. There is decreased hematocrit level.
This is indicative of hemolysis of large number of erythrocytes.
f. The newborn manifest cyanosis when crying.
Cyanosis when a newborn is crying is not indicative of hemolytic disease. It may indicate congenital heart problems.
#23. Answers: A, B, D
A 7 month old infant can normally sit for a short period of time. The infant can also grasp a toy using one hand and can vocalize 1 to 2 words.
#24. Answers: A, C, D, E
a. Foot-to-floor ride-on toys
These are recommended for 12 months old because it helps develop their gross motor skills, balance and coordination.
b. Cradle gym
These are for 2 months old to 4 months old infants.
c. Push and pull toys
These are appropriate for 12 months old because it also helps in the development of gross motor skills, balance and coordination.
d. Books with large pictures
These toys stimulate a 12-month old’s curiosity and learning ability and help develop cognitive skills.
e. Building blocks
These toys stimulate a 1-year old’s thinking and problem solving skills and help develop fine motor skills.
These are appropriate for infant aging 2 – 4 months old, and it won’t challenge a 12-month old’s developmental skills.
#25. Answers: B, C, D, E, F
a. The normal head circumference of a newborn ranges from 33cm – 35cm. 37 cm is not a normal finding and needs further assessment and referral to the physician.
b. APGAR scoring is an assessment tool performed at 1 and 5 minutes after the neonate is born. Interpretations:
Therefore, an APGAR score of 8 is a normal assessment at 5 minutes after birth.
c. The anterior fontanel is diamond shape, measures 2.5-4cm, and is easily palpated. It is soft and flat. Moderate bulging is considered normal when the newborn is crying or defecating.
d. The presence of tiny, white, pinpoint papules sound in the forehead, nose, cheeks and chin of neonates are normal distended sebaceous gland known as Milia.
e. Bluish gray pigmentation over the buttocks or the lower is known as Mongolian spot, it is a normal finding in newborns and common to a non-Caucasian.
f. The normal apical range in new born is 120 -140 bpm when awake, 180 bpm when crying and 100bpm when sleeping. Auscultation should be done for full minute when the infant is not crying for accurate assessment.
#26. Answer: A, D, F
a. This statement is true because the anterior fontanel is diamond in shape and normally measures approximately 2.5-4cm.
b. The anterior fontanel closes by 18 months of age; on the other hand the posterior fontanel closes between 8-12 weeks of the newborn’s life.
c. The anterior fontanel is easily palpated but the posterior fontanel is not.
d. Bulging of the anterior fontanel indicates increased intracranial pressure that needs further assessment and referral to the physician.
e. It is not the anterior fontanel that is triangular in shape and measures 0.5-1cm but the posterior fontanel.
f. Depression of the anterior fontanel indicates dehydration which needs prompt medical and nursing interventions.