DIAGNOSTIC EXAM - SET 3

14. A hospitalized male adolescent flirts with and is sexually

1. A client with a history of schizophrenia has been admitted provocative toward a female nurse. The nurse can respond
for suicidal ideation. The client states “God is telling me to kill MOST therapeutically by doing which of the following?
myself right now.” The nurse’s best response is: a. telling him she is married and too old for him
a. I understand that God’s voice is real to you, but I don’t b. introducing him to female clients his own age
hear anything. I will stay with you. c. encouraging him to watch TV in his room.
b. The voices are part of your illness; it will stop if you take d. Ignoring his flirtations and provocative behaviors.
medication.
c. The voices are all in your imagination, think of something 15. A young adult male is unable to stay put in one job and
else and it will go away. has no commitment in his relationship is having difficulty in
d. Don’t think of anything right now, just go and relax. achieving a sense of:
a. autonomy b. trust
2. The nurse should know that the normal therapeutic level of c. industry d. intimacy
lithium is:
a. 0.5 to 1.5 mEq/L b. 0.5 to 15 mEq/L 16. the most advantageous therapy for a preschool-aged
c. 0.5 to 0.15 cc/L d. 0.5 to 1.6 mEq/mL child with history of physical and sexual abuse would be:
a. Play therapy b. Psychodrama
3. A client has been taking lithium carbonate (Lithane) for c. Group therapy d. Family therapy
hyperactivity, as prescribed y his physician. While the client
is taking this drug, the nurse should ensure that he has an 17. Neuroleptics are the drugs of choice to relieve symptoms
adequate intake of: of:
a. Sodium b. Iron a. Psychosis b. Depression
c. Iodine d. Calcium c. Hyperkinesis d. Narcotic withdrawal

4. A level of anxiety in which the person has narrowing of 18. An extrapyramidal symptom that is potentially irreversible
perceptual field, has selective inattention with some physical side effect of antipsychotic drugs is
signs and symptoms. a. torticollis b. oculogyric crisis
a. Mild b. Moderate c. tardive dyskinesia d. pseudoparkinsonism
c. Severe d. Panic
19. Another term for the superego is:
5. All of the following are examples of Benzodiazepines a. Self b. Ideal self
except: c. Narcissism d. Conscience
a. Clonazepam (Klonopin) b. Diazepam (Valium)
c. Buspirone (Buspar) d. Chlordiazepoxide (Librium) 20. The level of anxiety that best enhances an individual’s
power of perception is:
6. A client’s husband was found dead after a robbery a. Mild Anxiety b. Panic Anxiety
incident, this is what type of crisis? c. Severe Anxiety d. Moderate Anxiety
a. maturational crisis b. developmental crisis
c. situational crisis d. adventitious crisis 21.Autism can usually be diagnosed when the child is about:
a. 2 years of age b. 6 years of age
7. Which of the following situation is an example of c. 6 months of age d. 1- 3 months of age
maturational crisis?
a. death of a loved one b. volcanic eruption 22. Attention-deficit hyperactivity disorder in children is
c. marriage d. suicide usually treated with:
a. Lorazepam (Ativan)
8. It is a negative symptom of Schizophrenia which means b. Haloperidol (Haldol)
lack/poor motivation in achieving something. c. Methocarbamol (Robaxin)
a. anergia b. avolition d. Methyphenidate HCl (Ritalin)
c. anhedonia d. alogia
23. The best approach in helping a very confused, elderly
9. It is a major type of schizophrenia which is marked by client is to provide an environment with:
stupor in which the client is unresponsive to his or her a. a specific routine b. group involvement
surroundings and displays a lack of spontaneous c. a trusting relationship d. activities that are varied
psychomotor activity.
a. catatonic type b. undifferentiated type 24. The CAGE screening questionnaire is best used by the
b. paranoid type d. disorganized type nurse with the client who is abusing:
a. alcohol b. multiple drugs
10. The client ward states to the nurse “I can control you with c. hallucinogens d. opiates / depressants
my thoughts.” This is an example of what type of delusion?
a. delusion of reference b. delusion of influence 25. A recovering alcoholic joins Alcoholic Anonymous (AA) to
b. paranoid delusions d. grandiose delusions help maintain sobriety. AA is classified as:
a. social group b. self-help group
11. Which of the following is an example of Monoamine c. resocialization group d. psychotherapeutic group
Oxidase Inhibitor?
a. Fluvoxamine (Luvox) b. Clomipramine (Anafranil) 26. A disturbed client starts to repeat phrases that others
c. Phelzine (Nardil) d. Bupropion (Welbutrin) have just said. This type of speech is known as:
a. autism b. echolalia
12. When the client has unstable and intense interpersonal c. neologism d. Echopraxia
relationships and has a self-mutilating behavior, the client
has what type of personality disorder? 27. One evening the nurse finds a client who has been
a. Borderline PD b. Schizoid PD experiencing persecutory delusions trying to get out the door.
c. Anti-social PD d. Avoidant PD The client states, “Please let me go. I trust you. The Mafia
are going to kill me tonight.” The nurse should respond:
13. An approach which utilizes the environment is which of a. “You are frightened. Come with me to your room and we
the following? can talk about it.”
a. Milieu therapy b. somatic therapy b. ‘Nobody here wants to harm you, you know that. I’ll come
c. behavioral therapy d. psycho therapy with you to your room.”
c. “Come with me to your room. I’ll lock the door and no one 39. A nursing student becoming a critical care nurse because
will get in to harm you.” this is the specialty of an instructor she admires.
d. “Thank you for trusting me. Maybe you can trust me when a. Intellectualization b. Repression
I tell you no one can kill you while you’re here.” c. Identification d. Introjection

28. A delusional client refuses to eat because of a belief that 40. A child scores between 55 and 68 on a standardized
the food is poisoned. One of the most appropriate ways for intelligent quotient (IQ) assessment test. The nurse is aware
the nurse to initially intervene is to: that this degree of intellectual impairment would be
a. taste the food in the client’s presence considered:
b. simply state that the food is not poisoned a. mild b. severe
c. suggest that food be brought in from home c. profound d. moderate
d. tell the client that tube feedings will be started if eating
does not begin. 41. The nurse recognizes that dementia of the Alzheimer’s
type is characterized by:
29. A client is placed on suicide precautions. The most a. aggressive acting-out behavior
therapeutic way to provide these precautions would be to: b. periodic remissions and exacerbations
a. remove all sharp and cutting objects c. hypoxia of selected areas of brain tissue
b. not allow the client to leave his/her room d. areas of brain destruction called senile plaques
c. give client the opportunity to ventilate feelings
d. assign a staff member to be with the client at all times 42. A regressed, emotionally disturbed client who has been
watching the nurse for a few days suddenly walks up and
30. The action by the nurse that would be most therapeutic shouts, “You think you’re so damned perfect and good. I
when a depressed client states “I am no good. I’m better off think you stink!!!” The most appropriate response for the
dead,” would be: nurse to make would be:
a. Stating, “I think you’re good; you should think of living.” a. “You seem angry with me.”
b. Stating, “I will stay with you until you are less depressed.” b. “Stink? I don’t understand.”
c. Alerting the staff to provide 24 hour observation of the c. “Boy, you’re in a bad mood.”
client d. “I can’t be all that bad, can I?”
d. Unobtrusively removing those articles that could be used
in a suicide attempt 43. The activity would be the least therapeutic for severely
depressed clients would be:
31. A positive nursing action when caring for a middle-aged, a. specific, simple instructions to be followed
depressed client is to: b. simple, easily completed, short-term projects
a. play a game of chess with the client c. monotonous, repetitive projects and activities
b. allow the client to make personal decisions d. allowing the clients to plan their own activities
c. sit down next to the client as often as possible
d. provide the client with frequent periods of thinking time 44. A person who habitually expresses anxiety through
physical symptom is using:
32. One day, while shaving, a male client with the diagnosis a. projection b. regression
of bipolar disorder states to the nurse, “I have hidden a razor c. conversion d. Hypochondriasis
blade and tonight I am going to kill myself. “ The nurse’s best
reply would be: 45. A person who deliberately pretends an illness is usually
a. “You’re going to kill yourself?” thought to be:
b. “Things can’t really be that bad.” a. neurotic b. malingering
c. “I’m sure you don’t really mean that.” c. out of contact with reality d. conversion defenses
d. “You’d better finish shaving; its time for lunch.”
46. It is a stage in which a person has the capacity to be
33. A side effect of electroconvulsive therapy that a client involved in true intimacy
may experience is: a. anal stage b. phallic stage
a. loss of appetite c. latency stage d. genital stage
b. postural hypotension
c. confusion for a time after treatment 47. Late Adulthood has what central task?
d. complete loss of memory for a time a. Identity vs. role confusion b. Intimacy vs. isolation
c. Generativity vs. stagnation d. Integrity vs. despair
34. A client is receiving lithium carbonate. While this
medication is being administered, it is important that the 48. It is the association of words by sound rather than
nurse: meaning after resulting in a non-sensical rhymes and puns.
a. test the client’s urine weekly a. associative looseness b. circumstantiality
b. restrict the client’s sodium intake c. clang association d. tangentiality
c. monitor the client’s blood level regularly
d. withhold the client’s other medications for 1 week 49. Digressions that divert the speaker from his goal, which
he/she never reaches.
35. A nurse with low self-esteem works double shifts so her a. associative looseness b. circumstantiality
supervisor will like her. c. clang association d. tangentiality
a. Conversion b. Displacement
c. Compensation d. Denial 50. It is termed as motor restlessness ranging from a feeling
of inner disquiet. Characterized by inability to sit still or lie
36. A teenager forbidden to see X-rated movies is tempted to quietly.
do so by friends and develops blindness, and the teenager is a. delirium b. akinesia
unconcerned about the loss of sight. c. akathisia d. catatonia
a. Introjection b. Conversion
c. Regression d. Projection 51. The nurse should plan to include which initial exercise for
breast cancer.
37. A child who is harassed by a bully at school mistreats his a. abduction and external rotation of the affected arm
younger brother. b. weight-lifting
a. Sublimation b. Projection c. squeeze ball
c. Displacement d. Conversion d. isotonic exercise

38. A diabetic client eats lots of chocolates and candies. 52. A nurse has received an order to transfuse a client with
a. Denial b. Suppression a unit of packed red blood cells. Before explaining the
c. Rationalization d. Introjection procedure to the client, the nurse asks which initial
question?
a. “why do you think that you need the transfusion?”
b. “do you know the complications and risks of a b. Ask Mr. Norman’s likes and dislikes
transfusion?” c. Assess Mr. Norman’s willingness to learn
c. “have you ever had a transfusion before?” d. Ask Mr. Norman’s beliefs and traditions
d. “have you ever gone into shock for any reason in the
past?” 65. The foundation of Nurse-patient relationship is:
a. trust b. rapport
53. A mother calls the home care nurse and tells the nurse c. consistency d. honesty
that her 3-year old child has just ingested liquid furniture
polish. The home care nurse would direct the mother 66. The most effective communication technique is:
immediately to: a. silence b. listening
a. induce vomiting c. reflecting d. consistency
b. bring the child to the emergency room
c. call an ambulance 67. Before blood transfusion in an adult, the appropriate
d. call the Poison Control Center needle size is:
a. G 22-24 b. G 16-18
54. A nurse is developing a plan of care for a preoperative c. G 20-22 d. G 18-20
client who has a latex allergy. Which of the following
interventions would be included in the plan? 68. A client who is using cane should carry it on:
a. apply a cloth barrier cuff when taking the blood pressure a. affected leg b. unaffected leg
b. use medications that are from ampules with rubber
stoppers. 69. In the event of fire, the nurse should first:
c. avoid using medications from glass ampules. a. remove the client in the room
d. avoid using IV tubing that is made of polyvinyl chloride. b. call the fire department
c. attempt to contain the fire
55. A client with Sengstaken-Blakemore tube should be d. extinguish the fire
placed on a:
a. supine position b. semi-fowler’s position 70. To avoid false result, before taking oral temperature in an
c. prone position d. lithotomy position adult client, he/she hasn’t taken hot and cold foods for the
past:
56. While performing Sigmoidoscopy, the nurse should place a. 1 hour b. 45 minutes
the client on what position? c. 30 minutes d. 2 hours
a. Semi-fowler b. moderate high back rest
c. prone d. knee-chest position 71. If instilling eye ointment and eyedrops at the same time,
the nurse should consider the following, except:
57. Nurse Tanya, was about to give liquid Iron supplement to a. instill the eyedrops first.
Mr. Reyes with IDA. In identifying client’s identity, Nurse b. instill the ointment from inner to outer canthus
Tanya would: c. instill the eyedrops at the lower conjunctival sac
a. Ask client’s name d. instill the eye ointment first
b. Ask client if he is Mr. Reyes.
c. Check the IV tag 72. A client with hearing aid complains “my aid is not
d. Check identification band working”, the nurse should:
a. check the aid if it is switched on
58. In giving Iron liquid preparation, Nurse Tanya should b. check the batteries
consider that: c. purchase a new one
a. it should be taken through a straw d. refer the client to an EENT expert
b. it should be taken on an empty stomach
c. it can’t cause staining of the teeth 73. It is a method of determining whether nursing actions and
d. it should be taken before meal. practices meet established standards:
a. quality improvement b. quality assurance
59. Iron dextran (Inferon) is given Z-track IM injection, Nurse c. health care development d. nursing process
Tanya knows that the reasons for giving Z-track injection are,
except: 74. Patient can’t void, she should:
a. it seals medication deep into the muscle a. ask the client to stand and go to the CR immediately
b. it minimizes skin irritation b. catheterize the client as ordered
c. it delivers medication efficiently c. palpate the bladder for bladder distention
d. it causes staining d. give Lasix as prescribed

60. Client undergone infratentorial craniotomy, he/she should 75. Client has a purple discoloration on the skin, she notes
be placed on what position? this as:
a. flat b. semi-fowlers a. petechiae b. purpura
c. prone d. fowlers c. Mongolian spots d. milia

61. Client undergone supratentorial craniotomy, he/she 76. The client is bedridden, in order to prevent bedsores, the
should be placed on what position? nurse should:
a. flat b. semi-fowlers a. ask client to ambulate every am
c. prone d. supine b. turn client to sides every shift
c. turn client to sides every 2 hours
62. Nurse Bem knows that descending colostomy drains d. increase oral fluid intake
what fecal matter?
a. liquid product 77. A.U means
b. mushy a. both eyes b. left ear
c. solid/formed c. both ears d. right eye

63. While cleaning the colostomy stoma, nurse Bem should 78. O.D means
consider which of the following? a. both eyes b. left ear
a. use alcohol and soap for cleaning c. both ears d. right eye
b. use mild soap and water for cleaning
c. a normal saline solution is needed 79. A patient is admitted to the emergency department with
d. mild soap can be irritating and shouldn’t be used complaints of pain to her surgical incision. The doctor
diagnoses the patient with wound dehiscence. The nurse
64. Upon discharge, Nurse Bem is providing health education understands that wound dehiscence is:
to Mr. Norman, Nurse Bem should first: a. a normal post operative occurrence
a. Assess Mr. Norman’s knowledge on colostomy b. a ruptured organ
c. an opening of the wound edges
d. the protrusion of internal organs at a wound site
80. An oncologist is evaluating a patient diagnosed with
breast cancer. Further diagnostic studies are ordered to
determine if the cancer has spread. The nurse understands
that the ability of cancer to spread to other parts of the body
is called:
a. dysplasia b. hyperplasia
c. metaplasia d. metastasis
81. A key element of Florence Nightingale’s nursing practice
was:
a. maintaining a maximal level of wellness
b. promoting the patient’s self-care needs
c. recognizing nutrition as an important part of nursing care.
d. addressing the patient’s adaptation to health problems
82. Maslow’s hierarchy of basic needs is a common theory
that nursing education incorporates to explain the basic
needs of people. What need must be met before the person
can focus on safety and security?
a. love and belonging b. physiological
c. self-actualization d. self-esteem
83. The nurse performs many roles in the practice of nursing.
Which role is defined as “the protection of human or legal
rights and the securing of quality care for each patient”?
a. advocator b. communicator
c. counselor d. leader
84. All registered nurses may function in all of the following
capacities, except:
a. participate in gathering data for nursing research
b. provide health teaching at time of discharge from the
hospital
c. work in the operating room assisting the doctor
d. write prescriptions for common ailments
85. A nurse caring for a two-year old patient leaves the
bedside without raising the side rails and the patient falls to
the floor. What type of legal action could be used in a
lawsuit?
a. battery b. malpractice
c. negligence d. slander
86. The theorist who believes that adaptation and
manipulation of stressors are needed to foster change is:
a. Betty Neuman b. Dorothea Orem
c. Martha Rogers d. Sister Callista Roy
87. A theorist whose major theme is the idea of transcultural
nursing and caring nursing is:
a. Dorothea Orem b. Madeleine Leininger
c. Sister Callista Roy d. Virginia Henderson
88. The most accurate measurement of fluid status is:
a. anthropometric measurement
b. blood pressure
c. input and output
d. body weight
89. Cardiac output is defined as:
a. blood pressure plus heart rate
b. blood pressure times heart rate
c. stroke volume times heart rate
d. stroke volume plus heart rate
90. The nurse understands that surgical asepsis means:
a. free of most pathogenic organisms.
b. free of all pathogenic organisms
c. having pathogenic organisms
d. removing pathogenic organisms
91. When applying wrist restraints to a combative patient, the
restraints should be fastened to the:
a. side rail on the opposite of the bed
b. side rail on the same side of the bed
c. bed frame on the same side of the bed
d. bed frame on the opposite side of the bed.
92. A client has been diagnosed with gout. In developing a
dietary plan for the client, a nurse plans to include which item
on a list of foods to be avoided.
a. liver b. chocolate
c. carrots d. broccoli
93. A client is recovering from abdominal surgery and has a
large abdominal wound. A nurse encourages the client to eat
which food item that promotes wound healing.
a. milk b. egg
c. broccoli d. banana
94. A physician has written an order to discontinue an
intravenous line. A nurse obtains which of the following
supplies from the unit supply area for use in applying
pressure to the site after removing the intravenous catheter?
a. adhesive bandage b. sterile 2x2 gauze
c. alcohol swab d. betadine swab
95. A nurse determines that a client is having transfusion
reaction. As the nurse is stopping the unit of packed red
blood cells that currently is infusing, the nurse plans to take
which of the following actions next?
a. run normal saline at a keep vein open rate
b. change the solution to 5% dextrose in water
c. remove the IV line
d. obtain a culture of the tip of the catheter device removed
from the client.
96. A nurse assesses a client’s surgical incision for signs of
infection. Which finding by the nurse would be interpreted as
a normal finding at the surgical site?
a. red, hard skin b. purulent drainage
c. serous drainage d. warm, tender skin
97. A nurse is monitoring the status of a postoperative client.
The nurse would become most concerned with which of the
following signs that could indicate an evolving complication?
a. blood pressure of 110/70 mmHg and a pulse of 86
beats/minute
b. increasing restlessness
c. hypoactive bowel sounds in all four quadrants
d. a negative Homan’s sign
98. A nurse is reviewing a physician’s order sheet for a
preoperative client that states that the client must be NPO
after midnight. The nurse would telephone the physician to
clarify whether which of the following medications should be
given to the client and not withheld?
a. Conjugated estrogen (Premarin)
b. Prednisone (Deltasone)
c. Cyclobenzaprine (Flexeril)
d. Ferrous sulfate
99. A client has just returned to a nursing unit after an above-
knee amputation of the right leg. A nurse places the client in
which of the following most appropriate positions?
a. supine with the stump flat on the bed
b. supine with the stump supported with pillows
c. reverse trendelenburg
d. prone
100. A nurse is providing instructions to a client and the
family regarding home care after right eye cataract removal.
Which statement by the client would indicate an
understanding of the instructions?
a. “I will not sleep on my right side”
b. “I will not sleep on my left side”
c. “I will not sleep with my head elevated”
d. “I will not wear my glasses until my physician says it is
okay”