Title PNLE MAY 2023 -DIAGNOSTIC EXAM - ANSWER KEY.docx.pdf ✅

REFRESHER PHASE DIAGNOSTIC EXAMINATION MAY 2023 Philippine Nurse Licensure Examination Review 1. A client is admitted with paranoid schizophrenia. Recognizing the common behaviors exhibited by a client with schizophrenia, the nurse can anticipate which of the following? a. Grandiosity, arrogance, and distractibility b. Slumped posture and feelings of despondency c. Disorientation, anxiety, and panic reactions d. Withdrawal, regressed behavior, and problems with social skills 2. A nurse visited a child with a newly dried cast. While assessing the child, the nurse understands that which of the following observation necessitates the removal of the cast before the fracture has healed? a. If the patient can’t seem to get used of using crutches b. If the nurse detects the formation of pressure ulcer c. If the patient complains of itching under the cast d. If pain is still present the day after the injury 3. A client has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessment should the nurse make? a. Observing the fingers for change in color b. Palpating the radial pulse for pulselessness c. Checking the cast for presence of foul odor and drainage d. Evaluate client’s response to analgesic 4. Which of the following is not an indicative of neuromuscular compromise in a patient with a shoulder dislocation? a. Numbness of the extremity b. Intense pain with movement of the joint c. Inability to move the extremity d. Paresthesia of the extremity 5. A patient presents in the ED after an assault and complains of an injury in the left femur. The nurse observes an obvious deformity to the middle of the thigh and a protruding bone. The patient’s left foot is pale and cool and palpable pulses are absent. Which of the following is the priority intervention for the patient? a. Applying a firm in-line traction to the left leg, reassessing distal neurovascular status, and anticipating the placement of a traction splint b. Administering oxygen at 2 liters per minute via nasal cannula c. Attempting to push the bone back and covering with sterile dressing d. Applying pneumatic antishock trousers to the patient and inflating the left leg compartment 6. A 19-year-old patient is about to be delivered in the operating room for repair of a midshaft femur fracture after a vehicular accident. The nurse is aware that a possible lethal complication of femur fracture after surgery is fat embolism syndrome (FES) that usually occurs a. 24-48 hours after injury b. 24-72 hours after surgery c. 24-36 hours after injury d. 6-8 hours after injury 7. While caring for a client diagnosed with schizophrenia, the nurse know that the client may have trouble with a. Staff who are cheerful b. Simple direct sentences c. Multistage command d. Violent behaviors 8. A 26-year-old woman on a psychiatric unit is brought to the emergency department by police. She is on four-point restraints. The patient was reportedly observed running through the street naked, smashing windows and screaming. She is now calm, nonverbal, and diaphoretic and has both vertical and horizontal nystagmus. He is noted to have a 2-inch laceration to her arm. What is the priority of the nurse when assessing this patient? a. Evaluating his mental status and obtaining a full set of vital signs b. Performing a primary assessment and rule out other sign of trauma c. Determining if the patient can cooperate so that restraints can be removed d. Sending urine specimen for toxicology screening 9. When writing an assessment of a client with mood disorder, the nurse should specify a. How flat the client’s affect is b. How suicidal the client is TOP RANK REVIEW ACADEMY, INC. Page 1 | 22
c. How grandiose the client is d. How the client is behaving 10. Which nursing diagnosis is most likely to be associated to person with a medical diagnosis of schizophrenia, paranoid type? a. Impaired social skills related to inadequately developed superego b. Social isolation related to impaired ability to trust c. Fear of being alone related to suspiciousness d. perceptual disturbance related to delusions of persecution 11. A client has been very despondent, withdrawn, and apathetic for about 6 months. Recently, the client began to attend outpatient clinic for treatment of depressive disorder. Fluoxetine HCL (Prozac) is prescribed, and after 3 days the client shows improvement. What is the most appropriate nursing intervention at this time? a. Encourage the client to interact with other clients b. Assess the client’s knowledge about the medication c. Evaluate the potential for self-destructive behavior d. Discuss long term plan for discharge and follow-up 12. A 35-year-old male arrives in the ED by private vehicle after an industrial accident that resulted in a mid forearm amputation. The patient has a tourniquet in place, bleeding is minimal, and the amputated part is wrapped in a towel. Which of the following is a priority intervention by the emergency nurse? a. Preparing the patient for reimplantation b. Caring for the severed part c. Removing the tourniquet and controlling the bleeding part with another method d. Obtaining an X-ray of the extremity to rule out a fracture proximal to the point of amputation. 13. Which of the following is an appropriate intervention for the preservation of the amputated part? a. Discard the amputated part if it has been severed for longer than 30 minutes b. Wrap the amputated part in a towel and moisten with cool tap water c. Immerse the amputated part directly into a bath of ice and water d. Anticipate the need to x-ray the severed part before reimplantation 14. Which of the following intervention is appropriate for a nurse to perform to control the bleeding associated with an extremity injury? a. Applying a warm compress to cause vasoconstriction b. Placing tourniquet 3 to 4 inches above the site of hemorrhage c. Applying pressure dressing to the site of bleeding d. Holding the extremity low and applying a direct pressure 15. A nurse is caring for a patient with newly applied cast because of sustaining a fall from the second floor of their house. Upon assessing the patient that nurse is aware compartment syndrome would likely to develop in which body part? a. Upper arm b. Lower arm c. Upper leg d. Joint spaces 16. While caring for a client with newly applied plaster of Paris cast, the nurse makes note all of the following conditions. Which assessment finding requires an immediate notification of the physician? a. Presence of moderate pain b. A report of heat felt under the cast c. Onset of paralysis in the toes of the casted foot d. Presence of slight edema of the toes of the casted foot 17. A patient with acute myocardial infarction was brought to the ED. The nurse caring for the patient is aware that the most common lethal arrhythmia in the first hour of an acute myocardial infarction (AMI) is a. Asystole b. Atrial fibrillation c. Ventricular fibrillation d. Third-degree heart block 18. Mrs. F., age 45 is admitted with a diagnosis of thrombophlebitis of the leg. As the nurse inspects the patient, which finding should the nurse report immediately when assessing Mrs. F.? a. Calf tenderness b. Shortness of breath c. Reddened skin d. Increased skin temperature of the affected leg 19. Mr. A., a 56-year-old diabetic patient with arterial insufficiency in the legs, complains that his feet are cold. Which nursing measure is contraindicated? a. Applying a warm socks b. Applying a heating pad to the client’s feet c. Increasing the room temperature slightly d. Encouraging exercise 20. A 67-year-old client was rushed to the hospital and was later diagnosed of congestive heart failure (CHF). The patient is in the acute phase of ventricular heart failure. To alleviate his symptoms, the nurse should place him in a. Left lateral Sim’s position b. Dorsal recumbent position with elevated feet c. Low Fowler’s position with elevated knees d. An upright position 21. A 68-year-old patient is admitted with a diagnosis of arteriosclerosis obliterans. Which statement of the patient would indicate a need for further instructions? a. “I will start quitting from smoking” b. “I am trying to lose weight because I’m too heavy” c. I haven’t taken a walk for a week” d. I will make sure to dry my feet thoroughly” TOP RANK REVIEW ACADEMY, INC. Page 2 | 22
22. Mr. R. a 50-year-old banker, is admitted to the emergency department (ED) with severe chest and arm pain of 4 hours duration that radiates to his jaw, accompanied by sweating and weakness. While assessing Mr.S. the nurse should first relieve his discomfort by: a. Checking his arterial blood gas b. Administering 4 mg of morphine IV c. Instructing him in guided imagery d. Starting oxygen by nasal cannula at 2 liters/min 23. Mr.R. exhibits signs and symptoms of cardiogenic shock during the cardiac catheterization procedure. The nurse is aware that characteristics of cardiogenic shock includes all of the following, except a. ECG showing ST-segment elevations in leads II, III, and aVF b. Pain in the distal, left lower extremity c. Disorientation to time and place d. Narrowed pulse pressure and thready pulse 24. A male arrives in the emergency department after a scuba diving trip with friends. He is complaining of shortness of breath, chest pain, and vertigo. He is coughing up pink, frothy sputum. The emergency nurse should assess the patient while placing him in what position? a. Right lateral decubitus b. High Fowler’s position c. Semi Fowler’s position d. Left lateral trendelenburg 25. A 52-year-old patient comes to the hospital complaining of severe “tearing” chest pain that radiates to the back. The nurse would probably suspect that the patient is experiencing a. Acute myocardial infarction b. Pericarditis c. Dissecting abdominal aneurysm d. Ruptured appendicitis 26. A trauma patient with a diagnosis of ruptured bladder has two large bore IV lines, oxygen, a nasogastric tube, and an indwelling urinary catheter in place. Initial vital signs were blood pressure 120/54 mmHg, pulse 120 beats/minute, respirations 20 breaths/minute, pulse oximetry 95% (room air), and temperature 98.20 F. Which of the following might indicate an impending hypovolemic shock? a. Pulse of 120 beats/minute b. Pain that is unrelieved c. Restlessness d. Blood pressure of 100/80 mmHg 27. Mr. D., a client with chronic emphysema is admitted in the unit with acute respiratory failure. Endotracheal intubation and mechanical ventilation with high peak respiratory pressures are attached. After several days in the hospital, which physiologic parameter indicates that weaning Mr. D., from the ventilator is already feasible? a. An increase in shunt function b. Vital capacity of less than 10 ml/kg of body weight c. Negative peak inspiratory pressure greater than―20 cmH2O d. PaO2 of 100 mmHg on 100% oxygen 28. A 19-year-old college student who sustained a fractured ribs on the right side of his chest after a football game is taken to the emergency department. To promote pulmonary ventilation, the nurse plans to include all of the following, except a. Encouraging coughing and deep breathing b. Providing hydration c. Positioning the client on his right side d. Encouraging the use of an incentive spirometer 29. A 29-year-old patient with multiple trauma and hemothorax arrives in the emergency department. A chest tube is placed. Initially 500 mL of blood drains from the tube. The patient’s vital signs are blood pressure 140/70 mmHg and a heart rate of 138 beats/minutes. Respirations are controlled by mechanical ventilation at a rate of 16 breaths/minute. Which assessment parameter should be closely monitored over the next hour? a. Central venous pressure b. Vital signs c. Chest tube drainage d. Urine output 30. An elderly with chronic obstructive pulmonary disease (COPD) is given discharge instructions regarding nutritional support. Which of the following statements identifies the need for further teaching? a. “I should rest for 30 minutes before each meal.” b. “I will limit my fluid intake at meal time.” c. “I should eat five or six small meals each day.” d. “I should select most of my foods from the carbohydrate group.” 31. The goals of successful asthma management include the measurement of lung function. This can be accomplished with peak expiratory flow rate (PEFR). The nurse understands that the optimal PERF is a. PERF variability of less than 30 % b. PERF less than 50% of predicted or personal best c. PERF variability of 80% to 90% d. PERF greater than 80% of predicted or personal best 32. Mr. A., a 65-year-old tailor, is admitted to the hospital, complaining of difficulty holding objects. He states that his condition has progressively worsened. The physician suspects amyotrophic lateral sclerosis (ALS). In order to confirm the diagnosis, the physician would order which of the following? a. Romberg's test b. Lumbar Puncture c. Creatine phosphokinase (CPK) test d. Skeletal muscle biopsy 33. Mr. P., a 68-year-old retired assembly-line worker, is admitted to the hospital with a diagnosis of Parkinson’s disease. Which clinical features of the disease should the nurse expect to observe during admission assessment? TOP RANK REVIEW ACADEMY, INC. Page 3 | 22