Continue from 11 to 100.

Please provide ALL

QUESTIONS WITH RATIONALE.
Below are questions 11 to 100 for PNLE Nursing Practice V, each with answer and rationale. The
questions are constructed to reflect the scope and competencies set by the PRC for Nursing
Practice V-Care of Clients with Physiologic and Psychosocial Alterations (Part C) [1] [2] [3] [4] .
These questions draw from standard PNLE test bank models and integrate best practices in test
construction for local board exams [3] [4] [2] [5] [6] .

PNLE Nursing Practice V: Questions 11–100 with Rationales

11. A client with congestive heart failure is prescribed a low-sodium diet. Which food should the
nurse advise the client to avoid?
A. Fresh fruits
B. Canned soups
C. Steamed vegetables
D. Grilled chicken
Answer: B
Rationale: Canned soups are high in sodium, which can worsen fluid retention in heart failure.
12. Which is the priority nursing action for a client with suspected stroke?
A. Administer anticoagulants
B. Assess airway, breathing, and circulation
C. Encourage oral fluids
D. Perform neurological assessment
Answer: B
Rationale: ABCs (airway, breathing, circulation) are always the first priority in emergencies.
13. A client with major depressive disorder is prescribed sertraline. What should the nurse teach
about this medication?
A. It works immediately
B. Avoid foods high in tyramine
C. It may take several weeks to see effects
D. Stop the medication if feeling better
Answer: C
Rationale: SSRIs like sertraline may take several weeks to achieve therapeutic effect.
14. Which intervention is appropriate for a client experiencing a panic attack?
A. Encourage deep, slow breathing
B. Leave the client alone
C. Provide detailed explanations
D. Administer sedatives immediately
Answer: A
Rationale: Deep breathing helps control hyperventilation and anxiety.
15. What is the most important nursing consideration for a client with a tracheostomy?
A. Maintain cuff pressure to prevent aspiration
B. Encourage oral intake
C. Keep client supine
D. Avoid suctioning
Answer: A
Rationale: Maintaining cuff pressure prevents aspiration and maintains airway patency.
16. A diabetic client complains of numbness and tingling in the feet. What is the nurse’s best
action?
A. Assess blood glucose
B. Check for infection
C. Educate about foot care and inspect feet
D. Encourage increased activity
Answer: C
Rationale: Neuropathy increases risk for injury; foot care prevents complications.
17. Which electrolyte imbalance is common in chronic kidney disease?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypercalcemia
Answer: B
Rationale: Kidneys cannot excrete potassium efficiently, leading to hyperkalemia.
18. A client with schizophrenia is disorganized and refuses medication. What is the nurse’s best
approach?
A. Force medication
B. Use simple, clear communication and build trust
C. Ignore refusal
D. Restrain the client
Answer: B
Rationale: Simple communication and rapport can improve cooperation.
19. Which is a sign of fluid overload in heart failure?
A. Dry mucous membranes
B. Weight loss
C. Jugular vein distention
D. Hypotension
Answer: C
Rationale: JVD is a classic sign of right-sided heart failure and fluid overload.
20. What is the priority nursing action for a client with suicidal ideation?
A. Provide one-on-one supervision
B. Encourage verbalization
C. Administer antidepressants
D. Inform family
Answer: A
Rationale: Safety is the priority; constant supervision prevents self-harm.
21. A client with asthma is wheezing and dyspneic. Which medication should the nurse
administer first?
A. Corticosteroids
B. Bronchodilators
C. Antibiotics
D. Antihistamines
Answer: B
Rationale: Bronchodilators relieve bronchospasm rapidly.
22. Which nursing diagnosis applies to a Parkinson’s client with difficulty swallowing?
A. Risk for aspiration
B. Impaired mobility
C. Chronic pain
D. Ineffective airway clearance
Answer: A
Rationale: Dysphagia increases aspiration risk.
23. What is the priority when caring for a client with a seizure disorder?
A. Restrain during seizure
B. Place tongue blade in mouth
C. Protect from injury
D. Administer sedatives
Answer: C
Rationale: Preventing injury is the immediate concern during a seizure.
24. A client with bipolar disorder is in a manic phase. Which behavior is expected?
A. Social withdrawal
B. Increased energy and rapid speech
C. Depressed mood
D. Excessive sleeping
Answer: B
Rationale: Mania is marked by increased activity and pressured speech.
25. What is the best intervention to prevent pressure ulcers in an immobile client?
A. Use heat packs
B. Reposition every 2 hours
C. Limit fluids
D. Encourage high-protein diet only
Answer: B
Rationale: Frequent repositioning relieves pressure and prevents skin breakdown.
26. Which lab value is most important to monitor for a client on warfarin?
A. Blood glucose
B. PT/INR
C. Serum potassium
D. Hemoglobin
Answer: B
Rationale: PT/INR monitors anticoagulation and bleeding risk.
27. A client with tuberculosis is on isoniazid. What teaching is essential?
A. Avoid alcohol
B. Stop when symptoms improve
C. No need for labs
D. Take only when sick
Answer: A
Rationale: Alcohol increases risk of liver toxicity with isoniazid.
28. Which symptom is characteristic of hyperthyroidism?
A. Weight gain
B. Cold intolerance
C. Tachycardia
D. Constipation
Answer: C
Rationale: Hyperthyroidism increases metabolism, causing tachycardia.
29. Priority action when a client develops sudden chest pain and SOB?
A. Obtain vital signs and administer oxygen
B. Encourage ambulation
C. Provide pain medication only
D. Prepare for discharge
Answer: A
Rationale: Assessing and stabilizing ABCs is critical in chest pain.
30. A CKD client has hyperphosphatemia. Which diet change is best?
A. Increase dairy
B. Limit phosphorus-rich foods
C. Increase protein
D. Increase potassium
Answer: B
Rationale: Limiting phosphorus helps manage hyperphosphatemia.
31. Early sign of increased intracranial pressure (ICP)?
A. Bradycardia
B. Vomiting without nausea
C. Pupillary dilation
D. Decreased consciousness
Answer: B
Rationale: Sudden vomiting is an early ICP sign; others are late.
32. Paranoid schizophrenic refuses to eat. Best action?
A. Force-feed
B. Provide food from trusted source
C. Ignore refusal
D. Restrain
Answer: B
Rationale: Trusted food reduces paranoia and encourages eating.
33. Best intervention for anxiety disorder?
A. Encourage avoidance
B. Teach relaxation and coping skills
C. Administer sedatives routinely
D. Limit social interaction
Answer: B
Rationale: Coping skills empower clients to manage anxiety.
34. Heart failure client gains 3 kg in 2 days. What to do?
A. Notify physician
B. Encourage fluids
C. Document and continue
D. Restrict sodium
Answer: A
Rationale: Rapid weight gain = fluid overload; needs prompt intervention.
35. Appropriate care for a client with NG tube?
A. Check placement before feeding
B. Flush once a day
C. Leave open to air
D. Supine during feeding
Answer: A
Rationale: Checking placement prevents aspiration.
36. Schizophrenic with delusions. Best response?
A. Argue
B. Acknowledge feelings, don’t reinforce delusion
C. Ignore
D. Encourage acting on delusion
Answer: B
Rationale: Validate feelings, don’t reinforce false beliefs.
37. Priority diagnosis for pneumonia?
A. Ineffective airway clearance
B. Risk for injury
C. Impaired skin integrity
D. Deficient knowledge
Answer: A
Rationale: Pneumonia impairs airway clearance.
38. Bipolar client on lithium. Essential teaching?
A. Maintain consistent fluid and salt intake
B. Avoid dairy
C. Stop if feeling well
D. Take only when symptomatic
Answer: A
Rationale: Fluid/salt changes affect lithium levels and toxicity.
39. Sign of hypoxia in respiratory distress?
A. Bradycardia
B. Cyanosis
C. Hypotension
D. Hyperthermia
Answer: B
Rationale: Cyanosis means poor tissue oxygenation.
40. Stroke client with aphasia. Best communication?
A. Speak loudly and quickly
B. Use simple sentences and gestures
C. Avoid talking
D. Use medical jargon
Answer: B
Rationale: Simple language and gestures aid comprehension.
41. Priority for diabetic ketoacidosis (DKA)?
A. Administer insulin
B. Restrict fluids
C. High carb diet
D. Encourage exercise
Answer: A
Rationale: Insulin corrects hyperglycemia and acidosis.
42. Schizophrenic is socially withdrawn, flat affect. Diagnosis?
A. Risk for violence
B. Impaired social interaction
C. Acute pain
D. Ineffective airway clearance
Answer: B
Rationale: Social withdrawal = impaired social interaction.
43. Appropriate intervention for anxiety?
A. Stimulating environment
B. Encourage verbalization
C. Avoid discussing feelings
D. Sedatives without assessment
Answer: B
Rationale: Verbalization helps reduce anxiety.
44. CHF client with leg edema. Best intervention?
A. Elevate legs
B. Encourage standing
C. Restrict fluids completely
D. Massage swollen areas
Answer: A
Rationale: Elevation reduces edema by promoting venous return.
45. Key sign of hypoglycemia?
A. Fruity breath
B. Confusion
C. Polyuria
D. Hyperventilation
Answer: B
Rationale: Confusion is a CNS sign of hypoglycemia.
46. Priority for suspected pulmonary embolism?
A. Administer anticoagulants
B. Encourage deep breathing
C. Monitor for infection
D. High-protein diet
Answer: A
Rationale: Anticoagulants prevent clot progression.
47. Parkinson’s with swallowing difficulty. Best intervention?
A. Provide thickened liquids
B. Encourage thin liquids
C. Feed quickly
D. Avoid oral hygiene
Answer: A
Rationale: Thickened liquids reduce aspiration risk.
48. Priority diagnosis for acute pancreatitis?
A. Acute pain
B. Risk for infection
C. Deficient knowledge
D. Impaired skin integrity
Answer: A
Rationale: Pain is the most urgent problem.
49. Schizophrenic with auditory hallucinations. Best response?
A. Voices not real
B. Ask to describe voices and feelings
C. Ignore
D. Restrain
Answer: B
Rationale: Understanding experience builds trust and guides care.
50. Common side effect of antipsychotics?
A. Hypotension
B. Extrapyramidal symptoms
C. Hyperglycemia
D. Bradycardia
Answer: B
Rationale: EPS (tremors, rigidity) are common with antipsychotics.

51. A client with COPD is at risk for which acid-base imbalance?

A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B
Rationale: COPD causes CO₂ retention, leading to respiratory acidosis.
52. Which is a priority nursing intervention for a client post-ECT (electroconvulsive therapy)?
A. Monitor for memory loss
B. Assess gag reflex before oral intake
C. Encourage ambulation
D. Provide high-calorie diet
Answer: B
Rationale: Anesthesia may impair gag reflex, increasing aspiration risk.
53. A client with schizophrenia is mute and withdrawn. Which is the best nursing approach?
A. Sit with the client in silence
B. Force conversation
C. Ignore the client
D. Leave the client alone
Answer: A
Rationale: Presence without pressure conveys support.
54. A client with heart failure is prescribed furosemide. What is the most important assessment?
A. Blood glucose
B. Serum potassium
C. Hemoglobin
D. Blood pressure
Answer: B
Rationale: Furosemide can cause hypokalemia.
55. Which is the best method to assess for edema in a client with heart failure?
A. Weigh daily
B. Measure abdominal girth
C. Check capillary refill
D. Assess urine output
Answer: A
Rationale: Daily weights are the most sensitive indicator of fluid status.
56. What is the most appropriate nursing action for a client with a panic attack?
A. Stay with the client and remain calm
B. Leave the client alone
C. Give detailed explanations
D. Administer sedative without assessment
Answer: A
Rationale: Presence and calmness help reduce anxiety.
57. Which is an expected finding in a client with major depressive disorder?
A. Flight of ideas
B. Anhedonia
C. Delusions of grandeur
D. Hyperactivity
Answer: B
Rationale: Anhedonia (loss of interest/pleasure) is a core symptom.
58. Which is a priority nursing action for a client with acute mania?
A. Provide a quiet environment
B. Encourage group activities
C. Allow unlimited choices
D. Encourage caffeine intake
Answer: A
Rationale: Reducing stimuli helps control manic behavior.
59. What is the best dietary advice for a client on lithium therapy?
A. Restrict sodium
B. Maintain consistent sodium intake
C. Increase sodium intake
D. Avoid all salt
Answer: B
Rationale: Fluctuations in sodium affect lithium levels.
60. A client with schizophrenia is suspicious and hostile. What is the best nursing intervention?
A. Set clear, consistent limits
B. Ignore the behavior
C. Argue with the client
D. Avoid all interaction
Answer: A
Rationale: Consistency and limits provide structure and safety.

61. Which is a common side effect of benzodiazepines?

A. Insomnia
B. Drowsiness
C. Hypertension
D. Tachycardia
Answer: B
Rationale: Benzodiazepines cause CNS depression and sedation.
62. What is the priority nursing action for a client with a history of suicide attempt?
A. Remove all potentially harmful objects
B. Assign to a private room
C. Encourage group therapy
D. Allow unsupervised walks
Answer: A
Rationale: Removing hazards ensures safety.
63. Which is a therapeutic communication technique?
A. Giving advice
B. Active listening
C. Changing the subject
D. Making value judgments
Answer: B
Rationale: Active listening builds trust and rapport.
64. A client with schizophrenia is experiencing command hallucinations. What is the nurse’s
priority?
A. Assess what the voices are telling the client
B. Ignore the hallucinations
C. Tell the client to stop listening
D. Restrain the client
Answer: A
Rationale: Command hallucinations may direct self-harm; assessment is urgent.
65. Which is an early sign of lithium toxicity?
A. Seizures
B. Nausea and vomiting
C. Coma
D. Arrhythmias
Answer: B
Rationale: GI upset is an early sign of lithium toxicity.
66. What is the best intervention for a client with insomnia?
A. Encourage daytime napping
B. Promote a regular bedtime routine
C. Provide caffeine at bedtime
D. Allow unlimited screen time
Answer: B
Rationale: Consistent routines promote sleep hygiene.
67. Which is a priority nursing diagnosis for a client with schizophrenia?
A. Disturbed thought processes
B. Risk for impaired skin integrity
C. Deficient fluid volume
D. Risk for constipation
Answer: A
Rationale: Schizophrenia involves disordered thinking.
68. Which is a priority for a client with acute psychosis?
A. Maintain safety
B. Encourage insight
C. Promote independence
D. Provide detailed explanations
Answer: A
Rationale: Safety is always the priority in acute psychosis.
69. A client with depression is refusing to eat. What is the best nursing intervention?
A. Offer small, frequent meals
B. Force feed
C. Ignore refusal
D. Restrict fluids
Answer: A
Rationale: Small meals are less overwhelming and encourage intake.
70. Which is a side effect of tricyclic antidepressants?
A. Diarrhea
B. Dry mouth
C. Hypotension
D. Polyuria
Answer: B
Rationale: TCAs have anticholinergic effects like dry mouth.

71. What is the best nursing action for a client with schizophrenia who is pacing and agitated?
A. Offer a quiet area to calm down
B. Restrain the client immediately
C. Ignore the behavior
D. Encourage group activities
Answer: A
Rationale: Reducing stimuli can help de-escalate agitation.
72. Which is a priority for a client with panic disorder?
A. Ensure safety during attacks
B. Encourage caffeine intake
C. Provide detailed explanations
D. Promote social isolation
Answer: A
Rationale: Safety is the first concern during panic attacks.
73. Which is an expected finding in a client with schizophrenia?
A. Hallucinations
B. Hyperactivity
C. Elevated mood
D. Increased appetite
Answer: A
Rationale: Hallucinations are a positive symptom of schizophrenia.
74. Which is a priority nursing diagnosis for a client with bipolar disorder in the depressive
phase?
A. Risk for suicide
B. Risk for infection
C. Impaired skin integrity
D. Deficient fluid volume
Answer: A
Rationale: Suicide risk is elevated in depression.
75. What is the best intervention for a client with obsessive-compulsive disorder (OCD)?
A. Allow time for rituals
B. Forbid all rituals
C. Ignore compulsions
D. Encourage group therapy only
Answer: A
Rationale: Allowing rituals initially reduces anxiety; then gradually limit.
76. Which is a priority for a client with acute mania?
A. Provide finger foods
B. Encourage long meals
C. Allow unlimited choices
D. Promote group therapy
Answer: A
Rationale: Finger foods are easy to eat for hyperactive clients.
77. Which is a side effect of antipsychotic medications?
A. Weight loss
B. Weight gain
C. Insomnia
D. Hyperactivity
Answer: B
Rationale: Many antipsychotics cause weight gain.
78. What is the best nursing intervention for a client with delusions?
A. Do not argue; focus on reality
B. Argue with the client
C. Ignore the client
D. Encourage acting on delusions
Answer: A
Rationale: Do not reinforce false beliefs; gently focus on reality.
79. Which is a priority for a client with suicidal ideation?
A. Maintain close observation
B. Assign to a room alone
C. Encourage isolation
D. Allow access to sharp objects
Answer: A
Rationale: Close observation prevents self-harm.
80. Which is a common side effect of SSRIs?
A. Sexual dysfunction
B. Hypertension
C. Constipation
D. Weight loss
Answer: A
Rationale: Sexual dysfunction is common with SSRIs.

81. Which is a priority for a client with schizophrenia experiencing command hallucinations?
A. Ensure client safety
B. Encourage acting on commands
C. Ignore hallucinations
D. Provide group therapy
Answer: A
Rationale: Command hallucinations may direct self-harm.
82. What is a priority intervention for a client with severe anxiety?
A. Stay with the client
B. Leave the client alone
C. Provide detailed explanations
D. Encourage caffeine
Answer: A
Rationale: Presence is calming and reassuring.
83. Which is a priority for a client with acute psychosis?
A. Maintain a safe environment
B. Encourage reality testing
C. Promote independence
D. Provide complex tasks
Answer: A
Rationale: Safety is the first concern.
84. Which is an appropriate intervention for a client with depression?
A. Encourage participation in activities
B. Allow isolation
C. Ignore the client
D. Discourage all activity
Answer: A
Rationale: Activity helps improve mood and socialization.
85. Which is a priority for a client with schizophrenia and poor self-care?
A. Assist with ADLs as needed
B. Encourage independence only
C. Ignore hygiene
D. Restrict all activities
Answer: A
Rationale: Assistance ensures needs are met and prevents neglect.
86. Which is a priority for a client with bipolar disorder in mania?
A. Set limits on inappropriate behavior
B. Allow unlimited spending
C. Encourage long discussions
D. Promote group therapy
Answer: A
Rationale: Limits maintain safety and structure.
87. Which is a priority for a client with depression and insomnia?
A. Promote sleep hygiene
B. Encourage caffeine
C. Allow daytime naps
D. Ignore sleep complaints
Answer: A
Rationale: Good sleep habits improve rest and recovery.
88. Which is a priority for a client with schizophrenia and social isolation?
A. Encourage social interaction gradually
B. Force group participation
C. Ignore isolation
D. Assign to a private room
Answer: A
Rationale: Gradual exposure builds confidence.
89. Which is a priority for a client with anxiety and hyperventilation?
A. Encourage slow, deep breathing
B. Encourage rapid breathing
C. Ignore symptoms
D. Promote strenuous activity
Answer: A
Rationale: Slow breathing reduces hyperventilation.
90. Which is a priority for a client with schizophrenia and poor nutrition?
A. Offer small, frequent meals
B. Restrict food choices
C. Ignore intake
D. Provide only liquid diet
Answer: A
Rationale: Small meals are more manageable.

91. Which is a priority for a client with depression and suicidal thoughts?
A. Maintain constant observation
B. Assign to a private room
C. Encourage isolation
D. Allow access to medications
Answer: A
Rationale: Observation prevents self-harm.
92. Which is a priority for a client with acute mania and aggressive behavior?
A. Remove other clients from the area
B. Ignore aggression
C. Encourage confrontation
D. Provide stimulating environment
Answer: A
Rationale: Removing others prevents harm.
93. Which is a priority for a client with schizophrenia and poor reality testing?
A. Provide reality-based activities
B. Encourage acting on delusions
C. Ignore client
D. Promote isolation
Answer: A
Rationale: Reality-based activities reinforce orientation.
94. Which is a priority for a client with depression and poor appetite?
A. Offer favorite foods
B. Restrict food choices
C. Ignore intake
D. Encourage fasting
Answer: A
Rationale: Favorite foods may encourage eating.
95. Which is a priority for a client with anxiety and insomnia?
A. Promote relaxation techniques
B. Encourage caffeine
C. Allow unlimited screen time
D. Ignore complaints
Answer: A
Rationale: Relaxation promotes sleep.
96. Which is a priority for a client with schizophrenia and suspiciousness?
A. Establish trust
B. Ignore client
C. Argue with client
D. Encourage confrontation
Answer: A
Rationale: Trust is essential for effective care.
97. Which is a priority for a client with depression and lack of energy?
A. Encourage rest and gradual activity
B. Force strenuous exercise
C. Ignore fatigue
D. Restrict all activity
Answer: A
Rationale: Gradual activity improves energy and mood.
98. Which is a priority for a client with bipolar disorder and impulsivity?
A. Set clear limits
B. Allow unlimited choices
C. Ignore behavior
D. Encourage risk-taking
Answer: A
Rationale: Limits maintain safety.
99. Which is a priority for a client with schizophrenia and poor hygiene?
A. Assist with hygiene
B. Ignore hygiene
C. Restrict all activity
D. Assign to a private room
Answer: A
Rationale: Assistance ensures needs are met.
100. Which is a priority for a client with anxiety and restlessness?
A. Provide a calm environment
B. Encourage stimulating activities
C. Ignore restlessness
D. Promote confrontation
Answer: A
Rationale: Calm environment reduces anxiety and restlessness.

These questions and rationales are modeled after standard PNLE and NCLEX test banks, and
are consistent with the PRC's official guidelines and expected competencies for Nursing Practice
V [3] [4] [2] [1] [5] [6] .
⁂

1. https://www.prc.gov.ph/sites/default/files/exam progam may 2024 pnle (nursing) v2 signed.pdf

2. https://www.rnpedia.com/practice-exams/philippine-nursing-licensure-exam-pnle/pnle-v-nursing-prac
tice/
3. https://www.rnpedia.com/practice-exams/philippine-nursing-licensure-exam-pnle/
4. https://nurseslabs.com/nursing-test-bank/
5. https://www.youtube.com/watch?v=At_L4AOjnLA
6. https://www.1nurse.com/blog/2024/06/10/free-pnle-practice-questions-palmer/