INSTRUCTIONS: Select the correct answer for each of the following questions. Mark only one answer for each item by making the
box corresponding to the letter of your choice on the answer sheet provided.
Situation: Mrs. de Vera, an 89-year-old widow, is admitted to a hospital because of Dehydration brought about by 2-day-history of
LBM and occasional vomiting. She needs to be in bed because of her generalized weakness and occasional confusion and
disorientation.
1. From the knowledge of temperature regulation in the elderly, the nurse should:
A. make sure that the environmental temperature is adequately controlled
B. palpate the client’s skin periodically to assess for warmth
C. place extra blanket at bedside in case she becomes cold especially at night
D. do all of the above
2. Mrs. De Vera is on diaper for urinary incontinence:
A. necessitates frequent changes of diaper to preserve skin integrity
B. prompts the nurse to request catheterization of the patient
C. brings the body toxins out of the gastrointestinal system
D. all of the above conditions are probable
3. The nurse initiates a 2-hourly-turning schedule based on the knowledge that the underlying cause of bedsore formation is:
A. altered skin turgor
B. nutritional deficiency
C. pressure
D. vasoconstriction
4. On diaper change, the nurse noted blister formation on an erythematous background of the sacral area; this is stage
____________of bedsore formation:
A. ONE
B. TWO
C. THREE
D. FOUR
Situation: Mr. Castro, a 67-year-old retired carpenter is admitted to the hospital because of anorexia and afternoon fever.
5. Mr. Castro’s PPD tuberculin test yields an induration of 10mm that indicates that:
A. an active disease is present
B. he has been exposed to M. tuberculosis
C. preventive treatment should be initiated
D. reaction is doubtful, a repeat test is necessary
6. Mr. Castro’s PPD tuberculin test result is confirmed by:
A. a chest X-ray
B. (+) AFB in sputum smears indurations
C. repeat PPD test that yields>10mm
D. (+) blood culture for M. tuberculosis
7. Mr. Castro is started on quadruple drug regimen. Nursing management includes observing for ototoxicity and nephrotoxicity
when _____is used:
A. ETHAMBUTOL
B. ISONIAZID
C. RIFAMPICIN
D. STREPTOMYCIN
8. Mr. Castro is informed that he will no longer be considered infectious after:
A. 1 week of treatment
B. 2-3 weeks of treatment
C. 2 months of treatment
D. complete 6-9 treatment
Situation: Miko, a 19-year-old student nurse, is admitted to the hospital with a possible diagnosis of appendicitis. He has been
vomiting every after meal.
9. On assessment, the nurse is looking for positive indicators of appendicitis, which includes all of the following except:
A. a low grade fever
B. abdominal tenderness on palpation
C. leukocytosis
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