Community Health Nursing,Maternal And Child Nursing Practice Test

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Community Health Nursing,Maternal And Child Nursing Practice Test - Quiz


Questions and Answers
  • 1. 

    Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is: 

    • A.

      Ventilator assistance

    • B.

      CVP readings

    • C.

      EKG tracings

    • D.

      Continuous CPR

    Correct Answer
    C. EKG tracings
    Explanation
    Answer: (C) EKG tracings
    Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care.

    Rate this question:

  • 2. 

    A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is: 

    • A.

      Contractions every 1 ½ minutes lasting 70-80 seconds.

    • B.

      Maternal temperature 101.2

    • C.

      Early decelerations in the fetal heart rate.

    • D.

      Fetal heart rate baseline 140-160 bpm.

    Correct Answer
    A. Contractions every 1 ½ minutes lasting 70-80 seconds.
    Explanation
    Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds.
    Rationale: Contractions every 1 ½ minutes lasting 70-80 seconds, is indicative of hyperstimulation of the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued.

    Rate this question:

  • 3. 

    During vaginal examination of Janah who is in labor, the presenting part is at station plus two.Nurse, correctly interprets it as: 

    • A.

      Presenting part is 2 cm above the plane of the ischial spines.

    • B.

      Biparietal diameter is at the level of the ischial spines.

    • C.

      Presenting part in 2 cm below the plane of the ischial spines.

    • D.

      Biparietal diameter is 2 cm above the ischial spines.

    Correct Answer
    C. Presenting part in 2 cm below the plane of the ischial spines.
    Explanation
    Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
    Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines.

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  • 4. 

    A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension(PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: 

    • A.

      Urinary output 90 cc in 2 hours.

    • B.

      Absent patellar reflexes.

    • C.

      Rapid respiratory rate above 40/min.

    • D.

      Rapid rise in blood pressure.

    Correct Answer
    B. Absent patellar reflexes.
    Explanation
    Answer: (B) Absent patellar reflexes
    Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.

    Rate this question:

  • 5. 

    Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?  

    • A.

      Excessive fetal activity.

    • B.

      Larger than normal uterus for gestational age.

    • C.

      Vaginal bleeding

    • D.

      Elevated levels of human chorionic gonadotropin(HCG).

    Correct Answer
    A. Excessive fetal activity.
    Explanation
    Answer: (A) Excessive fetal activity.
    Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to
    detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted.

    Rate this question:

  • 6. 

    May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion? 

    • A.

      Inevitable

    • B.

      Incomplete

    • C.

      Threatened

    • D.

      Septic

    Correct Answer
    A. Inevitable
    Explanation
    Answer: (A) Inevitable
    Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion.

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  • 7. 

    Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is:

    • A.

      Talk to the mother first and then to the toddler.

    • B.

      Bring extra help so it can be done quickly.

    • C.

      Encourage the mother to hold the child.

    • D.

      Ignore the crying and screaming.

    Correct Answer
    A. Talk to the mother first and then to the toddler.
    Explanation
    Answer: (A) Talk to the mother first and then to the toddler.
    Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse.

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  • 8. 

    Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?

    • A.

      Avoid touching the suture line, even when cleaning.

    • B.

      Place the baby in prone position.

    • C.

      Give the baby a pacifier.

    • D.

      Place the infant’s arms in soft elbow restraints.

    Correct Answer
    D. Place the infant’s arms in soft elbow restraints.
    Explanation
    Answer: (D) Place the infant’s arms in soft
    elbow restraints.
    Rationale: Soft restraints from the upper arm to
    the wrist prevent the infant from touching her
    lip but allow him to hold a favorite item such as
    a blanket. Because they could damage the
    operative site, such as objects as pacifiers,
    suction catheters, and small spoons shouldn’t
    be placed in a baby’s mouth after cleft repair. A
    baby in a prone position may rub her face on
    the sheets and traumatize the operative site.
    The suture line should be cleaned gently to
    prevent infection, which could interfere with
    healing and damage the cosmetic appearance
    of the repair.

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  • 9. 

    Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need?

    • A.

      1

    • B.

      2

    • C.

      3

    • D.

      The RHU does not need any more midwife item.

    Correct Answer
    A. 1
    Explanation
    Answer: (A) 1
    Rationale: Each rural health midwife is given a
    population assignment of about 5,000.

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  • 10. 

    Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she apply?

    • A.

      Department of Health

    • B.

      Provincial Health Office

    • C.

      Regional Health Office

    • D.

      Rural Health Unit

    Correct Answer
    D. Rural Health Unit
    Explanation
    Answer: (D) Rural Health Unit
    Rationale: R.A. 7160 devolved basic health
    services to local government units (LGU’s ). The
    public health nurse is an employee of the LGU.

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  • 11. 

    When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating

    • A.

      Effectiveness

    • B.

      Efficiency

    • C.

      Adequacy

    • D.

      Appropriateness

    Correct Answer
    B. Efficiency
    Explanation
    Answer: (B) Efficiency
    Rationale: Efficiency is determining whether the
    goals were attained at the least possible cost.

    Rate this question:

  • 12. 

    Which of the following is the most prominent feature of public health nursing?

    • A.

      It involves providing home care to sick people who are not confined in the hospital.

    • B.

      Services are provided free of charge to people within the catchments area.

    • C.

      The public health nurse functions as part of a team providing a public health nursing services.

    • D.

      Public health nursing focuses on preventive, not curative, services.

    Correct Answer
    D. Public health nursing focuses on preventive, not curative, services.
    Explanation
    Answer: (D) Public health nursing focuses on
    preventive, not curative, services.
    Rationale: The catchments area in PHN consists
    of a residential community, many of whom are
    well individuals who have greater need for
    preventive rather than curative services.

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  • 13. 

    Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back, and the infant looks for it. The nurse is aware that the estimated age of the infant would be:

    • A.

      6 months

    • B.

      4 months

    • C.

      8 months

    • D.

      10 months

    Correct Answer
    D. 10 months
    Explanation
    Answer: (D) 10 months Rationale: A 10 month old infant can sit alone and understands object permanence, so he would look for the hidden toy. At age 4 to 6 months, infants can’t sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects.

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  • 14. 

    Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?

    • A.

      Skim milk and baby food.

    • B.

      Whole milk and baby food.

    • C.

      Iron-rich formula only.

    • D.

      Iron-rich formula and baby food.

    Correct Answer
    C. Iron-rich formula only.
    Explanation
    Answer: (C) Iron-rich formula only.
    Rationale: The infants at age 5 months should
    receive iron-rich formula and that they
    shouldn’t receive solid food, even baby food
    until age 6 months.

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  • 15. 

    Which action should nurse Marian include in the care plan for a 2 month old with heart failure?

    • A.

      Feed the infant when he cries.

    • B.

      Allow the infant to rest before feeding.

    • C.

      Bathe the infant and administer medications before feeding.

    • D.

      Weigh and bathe the infant before feeding.

    Correct Answer
    B. Allow the infant to rest before feeding.
    Explanation
    Answer: (B) Allow the infant to rest before
    feeding.
    Rationale: Because feeding requires so much
    energy, an infant with heart failure should rest
    before feeding.

    Rate this question:

  • 16. 

    According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following best illustrates this statement?

    • A.

      The community health nurse continuously develops himself personally and professionally.

    • B.

      Health education and community organizing are necessary in providing community health services.

    • C.

      Community health nursing is intended primarily for health promotion and prevention and treatment of disease.

    • D.

      The goal of community health nursing is to provide nursing services to people in their own places of residence.

    Correct Answer
    B. Health education and community organizing are necessary in providing community health services.
    Explanation
    Answer: (B) Health education and community
    organizing are necessary in providing
    community health services. Rationale: The
    community health nurse develops the health
    capability of people through health education
    and community organizing activities.

    Rate this question:

  • 17. 

    Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing?

    • A.

      To educate the people regarding community health problems

    • B.

      To mobilize the people to resolve community health problems

    • C.

      To maximize the community’s resources in dealing with health problems.

    • D.

      To maximize the community’s resources in dealing with health problems.

    Correct Answer
    D. To maximize the community’s resources in dealing with health problems.
    Explanation
    Answer: (D) To maximize the community’s
    resources in dealing with health problems.
    Rationale: Community organizing is a
    developmental service, with the goal of
    developing the people’s self-reliance in dealing
    with community health problems. A, B and C
    are objectives of contributory objectives to this
    goal.

    Rate this question:

  • 18. 

    The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)?

    • A.

      Intrauterine fetal death.

    • B.

      Placenta accreta.

    • C.

      Dysfunctional labor.

    • D.

      Premature rupture of the membranes.

    Correct Answer
    A. Intrauterine fetal death.
    Explanation
    Answer: (A) Intrauterine fetal death.
    Rationale: Intrauterine fetal death, abruptio
    placentae, septic shock, and amniotic fluid
    embolism may trigger normal clotting
    mechanisms; if clotting factors are depleted,
    DIC may occur. Placenta accreta, dysfunctional
    labor, and premature rupture of the
    membranes aren't associated with DIC.

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  • 19. 

    A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:

    • A.

      80 to 100 beats/minute

    • B.

      100 to 120 beats/minute

    • C.

      120 to 160 beats/minute

    • D.

      160 to 180 beats/minute

    Correct Answer
    C. 120 to 160 beats/minute
    Explanation
    Answer: (C) 120 to 160 beats/minute
    Rationale: A rate of 120 to 160 beats/minute in
    the fetal heart appropriate for filling the heart
    with blood and pumping it out to the system.

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  • 20. 

    The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to:

    • A.

      Change the diaper more often.

    • B.

      Apply talc powder with diaper changes.

    • C.

      Wash the area vigorously with each diaper change.

    • D.

      Decrease the infant’s fluid intake to decrease saturating diapers.

    Correct Answer
    A. Change the diaper more often.
    Explanation
    Answer: (A) Change the diaper more often.
    Rationale: Decreasing the amount of time the
    skin comes contact with wet soiled diapers will
    help heal the irritation.

    Rate this question:

  • 21. 

    Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (trisomy 21) is:

    • A.

      Atrial septal defect

    • B.

      Pulmonic stenosis

    • C.

      Ventricular septal defect

    • D.

      Endocardial cushion defect

    Correct Answer
    D. Endocardial cushion defect
    Explanation
    Answer: (D) Endocardial cushion defect
    Rationale: Endocardial cushion defects are seen
    most in children with Down syndrome,
    asplenia, or polysplenia.

    Rate this question:

  • 22. 

    Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is:

    • A.

      Anemia

    • B.

      Decreased urine output

    • C.

      Hyperreflexia

    • D.

      Increased respiratory rate

    Correct Answer
    B. Decreased urine output
    Explanation
    Answer: (B) Decreased urine output
    Rationale: Decreased urine output may occur in
    clients receiving I.V. magnesium and should be
    monitored closely to keep urine output at
    greater than 30 ml/hour, because magnesium is
    excreted through the kidneys and can easily
    accumulate to toxic levels.

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  • 23. 

     A 23 year old client is having her menstrual  period every 2 weeks that last for 1 week. This type of menstrual pattern is bets defined by:

    • A.

      Menorrhagia

    • B.

      Metrorrhagia

    • C.

      Dyspareunia

    • D.

      Amenorrhea

    Correct Answer
    A. Menorrhagia
    Explanation
    Answer: (A) Menorrhagia
    Rationale: Menorrhagia is an excessive
    menstrual period.

    Rate this question:

  • 24. 

    Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is:

    • A.

      Metabolic alkalosis

    • B.

      Respiratory acidosis

    • C.

      Mastitis

    • D.

      Physiologic anemia

    Correct Answer
    D. Physiologic anemia
    Explanation
    Answer: (D) Physiologic anemia
    Rationale: Hemoglobin values and hematocrit
    decrease during pregnancy as the increase in
    plasma volume exceeds the increase in red
    blood cell production.

    Rate this question:

  • 25. 

    Nurse Lynette is working in the triage area of an emergency department. She sees that several pediatric clients arrive simultaneously. The client who needs to be treated first is:

    • A.

      A crying 5 year old child with a laceration on his scalp.

    • B.

      A 4 year old child with a barking coughs and flushed appearance.

    • C.

      A 3 year old child with Down syndrome who is pale and asleep in his mother’s arms.

    • D.

      A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling.

    Correct Answer
    D. A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling.
    Explanation
    Answer: (D) A 2 year old infant with stridorous
    breath sounds, sitting up in his mother’s arms
    and drooling.
    Rationale: The infant with the airway
    emergency should be treated first, because of
    the risk of epiglottitis.

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  • 26. 

    Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected?

    • A.

      Placenta previa

    • B.

      Abruptio placentae

    • C.

      Premature labor

    • D.

      Sexually transmitted disease

    Correct Answer
    A. Placenta previa
    Explanation
    Answer: (A) Placenta previa
    Rationale: Placenta previa with painless vaginal
    bleeding.

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  • 27. 

    A young child named Richard is suspected of having pinworms. The community nurse collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for:

    • A.

      Just before bedtime

    • B.

      After the child has been bathe

    • C.

      Any time during the day

    • D.

      Early in the morning

    Correct Answer
    D. Early in the morning
    Explanation
    Answer: (D) Early in the morning
    Rationale: Based on the nurse’s knowledge of
    microbiology, the specimen should be collected
    early in the morning. The rationale for this
    timing is that, because the female worm lays
    eggs at night around the perineal area, the first
    bowel movement of the day will yield the best
    results. The specific type of stool specimen
    used in the diagnosis of pinworms is called the
    tape test.

    Rate this question:

  • 28. 

    In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or symptoms of chronic lead poisoning?

    • A.

      Irritability and seizures

    • B.

      Dehydration and diarrhea

    • C.

      Bradycardia and hypotension

    • D.

      Petechiae and hematuria

    Correct Answer
    A. Irritability and seizures
    Explanation
    Answer: (A) Irritability and seizures
    Rationale: Lead poisoning primarily affects the
    CNS, causing increased intracranial pressure.
    This condition results in irritability and changes
    in level of consciousness, as well as seizure
    disorders, hyperactivity, and learning
    disabilities.

    Rate this question:

  • 29. 

    To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish asks her to explain how she will use the appliance. Which response indicates a need for further health teaching?

    • A.

      “I should check the diaphragm carefully for holes every time I use it”

    • B.

      “I may need a different size of diaphragm if I gain or lose weight more than 20 pounds”

    • C.

      “The diaphragm must be left in place for atleast 6 hours after intercourse”

    • D.

      “The diaphragm must be left in place for atleast 6 hours after intercourse” d. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”.

    Correct Answer
    D. “The diaphragm must be left in place for atleast 6 hours after intercourse” d. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”.
    Explanation
    Answer: (D) “I really need to use the diaphragm
    and jelly most during the middle of my
    menstrual cycle”.
    Rationale: The woman must understand that,
    although the “fertile” period is approximately
    mid-cycle, hormonal variations do occur and
    can result in early or late ovulation. To be
    effective, the diaphragm should be inserted
    before every intercourse.

    Rate this question:

  • 30. 

    How should Nurse Michelle guide a child who is blind to walk to the playroom?

    • A.

      . Without touching the child, talk continuously as the child walks down the hall.

    • B.

      Walk one step ahead, with the child’s hand on the nurse’s elbow.

    • C.

      Walk slightly behind, gently guiding the child forward.

    • D.

      Walk next to the child, holding the child’s hand.

    Correct Answer
    B. Walk one step ahead, with the child’s hand on the nurse’s elbow.
    Explanation
    Answer: (B) Walk one step ahead, with the
    child’s hand on the nurse’s elbow.
    Rationale: This procedure is generally
    recommended to follow in guiding a person
    who is blind.

    Rate this question:

  • 31. 

    When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the child most likely would have an:

    • A.

      Loud, machinery-like murmur.

    • B.

      Bluish color to the lips.

    • C.

      Decreased BP reading in the upper extremities

    • D.

      Increased BP reading in the upper extremities.

    Correct Answer
    A. Loud, machinery-like murmur.
    Explanation
    Answer: (A) Loud, machinery-like murmur.
    Rationale: A loud, machinery-like murmur is a
    characteristic finding associated with patent
    ductus arteriosus.

    Rate this question:

  • 32. 

    Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant has:

    • A.

      Stable blood pressure

    • B.

      Patent fontanels

    • C.

      Moro’s reflex

    • D.

      Voided

    Correct Answer
    D. Voided
    Explanation
    Answer: (D) Voided
    Rationale: Before administering potassium I.V.
    to any client, the nurse must first check that the
    client’s kidneys are functioning and that the
    client is voiding. If the client is not voiding, the nurse should withhold the potassium and notify
    the physician.

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  • 33. 

    Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is:

    • A.

      Baby oil

    • B.

      Baby lotion

    • C.

      Laundry detergent

    • D.

      Powder with cornstarch

    Correct Answer
    C. Laundry detergent
    Explanation
    Answer: (c) Laundry detergent
    Rationale: Eczema or dermatitis is an allergic
    skin reaction caused by an offending allergen.
    The topical allergen that is the most common
    causative factor is laundry detergent.

    Rate this question:

  • 34. 

    In a health teaching class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the following statements about chicken pox is correct?

    • A.

      The older one gets, the more susceptible he becomes to the complications of chicken pox.

    • B.

      A single attack of chicken pox will prevent future episodes, including conditions such as shingles.

    • C.

      To prevent an outbreak in the community, quarantine may be imposed by health authorities.

    • D.

      Chicken pox vaccine is best given when there is an impending outbreak in the community.

    Correct Answer
    A. The older one gets, the more susceptible he becomes to the complications of chicken pox.
    Explanation
    Answer: (A) The older one gets, the more
    susceptible he becomes to the complications of
    chicken pox.
    Rationale: Chicken pox is usually more severe in
    adults than in children. Complications, such as
    pneumonia, are higher in incidence in adults.

    Rate this question:

  • 35. 

    Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST advice that you can give to women in the first trimester of pregnancy in the Barangay?

    • A.

      Advise them on the signs of German measles.

    • B.

      Avoid crowded places, such as markets and movie houses.

    • C.

      Consult at the health center where rubella vaccine may be given.

    • D.

      Consult a physician who may give them rubella immunoglobulin.

    Correct Answer
    D. Consult a physician who may give them rubella immunoglobulin.
    Explanation
    Answer: (D) Consult a physician who may give
    them rubella immunoglobulin.
    Rationale: Rubella vaccine is made up of
    attenuated German measles viruses. This is
    contraindicated in pregnancy. Immune globulin,
    a specific prophylactic against German measles,
    may be given to pregnant women.

    Rate this question:

  • 36. 

    Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertaken is:

    • A.

      Contact tracing

    • B.

      Community survey

    • C.

      Mass screening tests

    • D.

      Interview of suspects

    Correct Answer
    A. Contact tracing
    Explanation
    Answer: (A) Contact tracing
    Rationale: Contact tracing is the most practical
    and reliable method of finding possible sources
    of person-to-person transmitted infections,
    such as sexually transmitted diseases.

    Rate this question:

  • 37. 

    A 33-year old female client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will you suspect?

    • A.

      Hepatitis A

    • B.

      Hepatitis B

    • C.

      Tetanus

    • D.

      Leptospirosis

    Correct Answer
    D. Leptospirosis
    Explanation
    Answer: (D) Leptospirosis
    Rationale: Leptospirosis is transmitted through
    contact with the skin or mucous membrane
    with water or moist soil contaminated with
    urine of infected animals, like rats.

    Rate this question:

  • 38. 

    Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of “rice water” stools. The client is most probably suffering from which condition?

    • A.

      Giardiasis

    • B.

      Cholera

    • C.

      Ameobiasis

    • D.

      Dysentery

    Correct Answer
    B. Cholera
    Explanation
    Answer: (B) Cholera
    Rationale: Passage of profuse watery stools is
    the major symptom of cholera. Both amebic
    and bacillary dysentery are characterized by the
    presence of blood and/or mucus in the stools.
    Giardiasis is characterized by fat malabsorption
    and, therefore, steatorrhea.

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  • 39. 

    The student nurse is aware that the pathognomonic sign of measles is Koplik’s spot and you may see Koplik’s spot by inspecting the:

    • A.

      Nasal mucosa

    • B.

      Buccal mucosa

    • C.

      Skin on the abdomen

    • D.

      Skin on neck

    Correct Answer
    B. Buccal mucosa
    Explanation
    Answer: (B) Buccal mucosa
    Rationale: Koplik’s spot may be seen on the
    mucosa of the mouth or the throat.

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  • 40. 

    In Integrated Management of Childhood Illness, the nurse is aware that the severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital?

    • A.

      Mastoiditis

    • B.

      Severe dehydration

    • C.

      Pneumonia

    • D.

      Severe febrile disease

    Correct Answer
    B. Severe dehydration
    Explanation
    Answer: (B) Severe dehydration
    Rationale: The order of priority in the
    management of severe dehydration is as
    follows: intravenous fluid therapy, referral to a
    facility where IV fluids can be initiated within 30
    minutes, Oresol or nasogastric tube. When the
    foregoing measures are not possible or
    effective, then urgent referral to the hospital is
    done.

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  • 41. 

    Marie brought her 10 month old infant for consultation because of fever, started 4 days prior to consultation. In determining malaria risk, what will you do?

    • A.

      Perform a tourniquet test.

    • B.

      Ask where the family resides.

    • C.

      Get a specimen for blood smear.

    • D.

      Ask if the fever is present every day.

    Correct Answer
    B. Ask where the family resides.
    Explanation
    Answer: (B) Ask where the family resides.
    Rationale: Because malaria is endemic, the first
    question to determine malaria risk is where the
    client’s family resides. If the area of residence is
    not a known endemic area, ask if the child had
    traveled within the past 6 months, where she
    was brought and whether she stayed overnight
    in that area.

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  • 42. 

    Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?

    • A.

      Inability to drink

    • B.

      High grade fever

    • C.

      Signs of severe dehydration

    • D.

      Cough for more than 30 days

    Correct Answer
    A. Inability to drink
    Explanation
    Answer: (A) Inability to drink
    Rationale: A sick child aged 2 months to 5 years
    must be referred urgently to a hospital if
    he/she has one or more of the following signs:
    not able to feed or drink, vomits everything,
    convulsions, abnormally sleepy or difficult to
    awaken.

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  • 43. 

    Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guidelines, how will you manage Jimmy?

    • A.

      Refer the child urgently to a hospital for confinement.

    • B.

      Coordinate with the social worker to enroll the child in a feeding program.

    • C.

      Make a teaching plan for the mother, focusing on menu planning for her child.

    • D.

      Assess and treat the child for health problems like infections and intestinal parasitism.

    Correct Answer
    A. Refer the child urgently to a hospital for confinement.
    Explanation
    Answer: (A) Refer the child urgently to a
    hospital for confinement.
    Rationale: “Baggy pants” is a sign of severe
    marasmus. The best management is urgent
    referral to a hospital.

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  • 44. 

    Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. As a nurse you will tell her to:

    • A.

      Bring the child to the nearest hospital for further assessment.

    • B.

      Bring the child to the health center for intravenous fluid therapy.

    • C.

      Bring the child to the health center for assessment by the physician.

    • D.

      Let the child rest for 10 minutes then continue giving Oresol more slowly.

    Correct Answer
    D. Let the child rest for 10 minutes then continue giving Oresol more slowly.
    Explanation
    Answer: (D) Let the child rest for 10 minutes
    then continue giving Oresol more slowly.
    Rationale: If the child vomits persistently, that
    is, he vomits everything that he takes in, he has
    to be referred urgently to a hospital. Otherwise,
    vomiting is managed by letting the child rest for
    10 minutes and then continuing with Oresol
    administration. Teach the mother to give Oresol
    more slowly.

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  • 45. 

    Chris a 4-month old infant was brought by her mother to the health center because of cough. His respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, his breathing is considered as:

    • A.

      Fast

    • B.

      Slow

    • C.

      Normal

    • D.

      Insignificant

    Correct Answer
    C. Normal
    Explanation
    Answer: (C) Normal
    Rationale: In IMCI, a respiratory rate of
    50/minute or more is fast breathing for an
    infant aged 2 to 12 months.

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  • 46. 

    Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection against tetanus for

    • A.

      1 year

    • B.

      3 years

    • C.

      5 years

    • D.

      Lifetime

    Correct Answer
    A. 1 year
    Explanation
    Answer: (A) 1 year
    Rationale: The baby will have passive natural
    immunity by placental transfer of antibodies.
    The mother will have active artificial immunity
    lasting for about 10 years. 5 doses will give the
    mother lifetime protection.

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  • 47. 

    Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution?

    • A.

      2 hours

    • B.

      4 hours

    • C.

      8 hours

    • D.

      At the end of the day

    Correct Answer
    B. 4 hours
    Explanation
    Answer: (B) 4 hours
    Rationale: While the unused portion of other
    biologicals in EPI may be given until the end of
    the day, only BCG is discarded 4 hours after
    reconstitution. This is why BCG immunization is
    scheduled only in the morning.

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  • 48. 

    The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs only up to:

    • A.

      5 months

    • B.

      6 months

    • C.

      1 year

    • D.

      2 year

    Correct Answer
    B. 6 months
    Explanation
    Answer: (B) 6 months
    Rationale: After 6 months, the baby’s nutrient
    needs, especially the baby’s iron requirement,
    can no longer be provided by mother’s milk

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  • 49. 

    Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live outside the womb) is:

    • A.

      8 weeks

    • B.

      12 weeks

    • C.

      24 weeks

    • D.

      32 weeks

    Correct Answer
    C. 24 weeks
    Explanation
    Answer: (C) 24 weeks
    Rationale: At approximately 23 to 24 weeks’
    gestation, the lungs are developed enough to
    sometimes maintain extrauterine life. The lungs
    are the most immature system during the gestation period. Medical care for premature
    labor begins much earlier (aggressively at 21
    weeks’ gestation)

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  • 50. 

    Which finding might be seen in baby James a neonate suspected of having an infection?

    • A.

      Flushed cheeks

    • B.

      Increased temperature

    • C.

      Decreased temperature

    • D.

      Increased activity level

    Correct Answer
    C. Decreased temperature
    Explanation
    Answer: (C) Decreased temperature
    Rationale: Temperature instability, especially
    when it results in a low temperature in the
    neonate, may be a sign of infection. The
    neonate’s color often changes with an infection
    process but generally becomes ashen or
    mottled. The neonate with an infection will
    usually show a decrease in activity level or
    lethargy.

    Rate this question:

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Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Sep 11, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Jul 30, 2012
    Quiz Created by
    Posh0038
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