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Situation 1 - The nurse should be aware of legal principles associated with 9. The nurse is planning a teaching session for an adult about
nursing practice. It is very important to equip ourselves with these so we prescribed medication regimen. An issue of major concern for the nurse is
can provide quality care, prevent ourselves from legal constraints, prevent that older adults:
injury to our clients, and protect the institution we are in. A. Experience an increase in absorptionof drugs from the
gastrointestinal tract
1. The nurse says, ³If you do not let me do this dressing change, I B. Often use alcohol to cope with the multiple stressor of aging
will not let you eat dinner with the other residents in the dining room.´ This C. Are less motivated to follow a prescribed regimen
is an example of: D. Have a decreased risk for adverse reaction to drugs
A. Assault
B. Battery 10. A resident in a nursing home reminisces about past-life events.
C. Negligence The nurse identifies that according to Erik Erikson the patient is in which
D. Malpractice stage of psychosocial development?
A. Autonomy vs. Shame and doubt
2. A patient falls while getting out of bed unassisted. When B. Identity vs. Role confusion
completing an Incident Report, the nurse understands that its main C. Generativity vs. Stagnation
purpose is to: D. Ego integrity vs. despair
A. Ensure that all parties have an opportunity to document what
happened
B. Help establish who is responsible for the incident Situation 3 - Communication is a vital sign component in fostering a
C. Make data available for quality control analysis therapeutic relationship with a patient.
D. Document the incident on the patient¶s chart
11. Which nursing action best reflects the concept of therapeutic
3. When the nurse administering a medication to a confused communication?
patient, the patients says, ³This pill looks different from the one I had A. Using interviewing skills to discuss the patients concern
before.´ What should the nurse do? B. Letting the patient control the focus of conversation
A. Ask what the other pill look like C. Setting time aside to talk with the patient
B. Check the original medication order D. Agreeing with a patient¶s statement
C. Explain the purpose of the medication
D. Encourage the patient to take the medication 12. What is the best response by the nurse when the patient¶s
husband says, ³I just don¶t know what to say to my wife if she asks how I
4. The nurse administers an incorrect dose of a medication to a feel about her breast cancer.´
patient. The nurse understands that the primary purpose of documenting A. ³How do you feel about your wife¶s diagnosis?´
this event in an Incident Report is to: B. ³This is a difficult topic. However, let¶s talk about it.´
A. Record the event for future litigation C. ³Do you think you could be as supportive as you can possibly
B. Provide a basis for designing new policies be?´
C. Prevent similar situations from happening again D. ³Men don¶t always understand what women are going through.
D. Ensure accountability for the cause of the accident Ask her about how she feels.´

5. If you harm a patient by administering a medication (wrong drug, 13. An agitated 80-year-old patient states ³I¶m having trouble with
wrong dose, etc.) ordered by a physician, which of the following is TRUE? my bowels.´ Which response by the nurse incorporates the interviewing
A. You are not responsible, since you were merely following skill of reflection?
doctors¶ order A. ³You seemed distressed about your bowels´
B. Only you are responsible, since he or she actually ordered the B. ³You¶re having trouble with your bowels?´
drug C. ³It¶s common to have problems with the bowels at your age´
C. Only the physician is responsible, since he or she actually D. ³When did you first notice having trouble with your bowels?´
ordered the drug.
D. Both you and the physician are responsible for your respective 14. The patient is upset and crying and mentions something about
actions her job that the nurse cannot understand. The nurse¶s best response is:
A. ³It¶s natural to be worried about your job.´
B. ³Your job must be very important to you´
Situation 2 - Nurse Belinda is assign to care of elderly patients in the C. ³Calm down so that I can understand what you are saying.´
medical unit. D. ³I¶m not quite sure I heard what you were saying about your job.´

6. Which of the following nursing diagnoses would be appropriate 15. The patient¶s states, ³ I can¶t believe that I couldn¶t even eat
for the middle adult: breakfast.´ Which statement by the nurse uses the interviewing skill for
A. Risk for Imbalanced Nutrition: More than body requirements reflection?
B. Delayed Growth and Development A. ³Let¶s talk about your inability to eat.´
C. Self-Care Deficit B. ³What part of your breakfast were you able to eat?´
D. Disturbed Thought Process C. ³How long have you been unable to eat your breakfast?´
D. ³You seem surprised that you were unable to eat all your
7. The nurse is assessing the skin of an older adult. Which breakfast?´
changes in the patient¶s skin should the nurse anticipate?
A. Increased tone B. decrease dryness C. Increased
elasticity D. Decreased thickness Situation 4 - Jerry is admitted and he is to receive 1 unit of packed red
cells. He has a hemoglobin level of 8g/dl and a diagnosis of
8. Which comment most demonstrates ageism? ³He is 75 years old gastrointestinal bleeding.
and:
A. Has outlived his usefulness 16. Before initiating the transfusion, the nurse need to check:
B. Reads the newspaper with fully difficulty A. For the abnormal presence of gas bubbles and cloudiness in the
C. Reminisces about his past work experience blood bag.
D. Is most happy when working in his home workshop B. That the blood has been typed and cross-matched
C. That the recipient¶s blood numbers match the donor¶s blood
numbers
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D. D. all of the above C. Determine the mothers¶ level of pain immediately postpartum
D. observe for signs of maternal hypotension
17. The nurse is aware of a transfusion reaction, if it occurs, will
probably happen:
A. 1 to 2 minutes after infusing begins SITUATION 6 - Two children were brought to you. One with chest in-
B. During the first 15 to 30 minutes of the transfusion drawing and the other has diarrhea. Apply the Integrated Management
C. After half the solution has been infused and the Childhood illness (IMCI) approach.
D. Several hours after the infusion, when the body has assimilated
the new blood components into the general circulation. 26. The 1st child who is 13 months has fast breathing, he has:
A. 60 breaths per minute
18. If a transfusion reaction occurs, the nurse should: B. 50 breaths per minute
A. Call the physician and wait for directions based on the specific C. 30 breaths per minute or more
type of reaction D. 40 breaths per minute or more
B. Stop the transfusion immediately and keep the vein patient with
saline or dextrose solution. 27. How would you classify the illness of the 1st child?
C. Slow the transfusion rate and observe for an increase in the A. Pneumonia
severity of the reaction B. Bronchopneumonia
D. Slow the infusion and request a venipuncture for retyping to start C. No pneumonia: cough and cold
a second transfusion D. Severe pneumonia

19. Prior to hanging the blood, the nurse will prime the blood tubing 28. Gwen, the 2nd child has diarrhea for 5 days, there is no blood in
with which of the following solutions? the stool. She is irritable; her eyes are sunken. The nurse offer fluids, the
A. 5% dextrose in water child drinks eagerly. How would you classify Gwen¶s illness?
B. Lactated Ringers solution A. No dehydration
C. 0.9% sodium chloride B. Dysentery
D. 5% dextrose in 0.45% sodium chloride C. Some dehydration
D. Severe dehydration
20. A client has just had a blood transfusion started. The nurse
suspects a possible hemolytic reaction to the blood. After stopping the 29. Gwen¶s treatment should include the following EXCEPT:
transfusion, which nursing intervention would NOT be carried out? A. Do not give any other foods to the child for home treatment
A. Return the blood bag to the laboratory B. Reassess the child and classify her for dehydration
B. Obtain frequent urine specimen C. Give in the health center the recommended amount of ORS for 4
C. Send a blood specimen to the laboratory for detection of hours
intravascular hemolysis D. For infants under 6 months old who not breastfed, give 100-200
D. Start another unit of blood to prevent further hemolysis. ml clean water as well during this period

30. While on treatment, Gwen who is 18 months old weight 18kgs.

Situation 5 - You have been doing follow up care for Bendita and she has And her temperature registered at 37°C. Her mother says she developed
developed trust in you as her nurse. cough for 3 days. Gwen has no general danger signs. She has 45
breaths/minute, no chest in-drawing; no stridor. How will you classify
21. Bendita tells you that she has been feeling contractions, but they Gwen¶s manifestation?
stop when she walks around. These contraction are called A. Bronchopneumonia
A. Tetanic B. Severe pneumonia
B. Braxton hicks C. Pneumonia
C. Premature labor D. No pneumonia
D. Dysfunctional

22. Later on her pregnancy, you notice that Bendita¶s blood SITUATION 7 - As a field of nursing practice, CHN synthesize nursing
pressure is lower when she rests on her back than she is on her side. You practice with the public health. The following questions apply.
explain that this is because:
A. There is pressure on her arteries in the side-lying position 31. Which of the following is NOT the application of the public health
B. The fetus may compress the major vessels when she is supine principles?
C. She is in early labor A. Nursing care is mainly directed to sick population who seek
D. She is having back labor consultation in the health center
B. The nurse utilizes vital and health statistics to describe the
23. You are planning care for Bendita whose membranes have community health status.
ruptured; you recognize that the client¶s risk is increased for C. The nurse analyses the determinants of health needs and
A. Cervical laceration problems as basis in developing community health programs
B. Supine hypotension D. In preventing and controlling disease transmission in the
C. Precipitous labor community, the nurse¶s priority is to protect the healthy population by
D. Intrauterine infection instituting specific protection measures against a disease.

24. When caring for laboring client with epidural anesthesia, you 32. The community health nurse as a manager, leader and
should be alert for which complication? supervisor best performs all these roles, EXCEPT:
A. Hypovolemia A. Performs surgical and dental procedures during medical
B. Hypotension missions.
C. Hyperemia B. Plans, Enhances and Evaluates health skills of midwives and
D. Hyponatremia auxiliary health workers in the performance of their jobs.
C. Organizes and mobilizes the community in a campaign to
25. Bendita receives a narcotic pain medication 45 minutes prior to prevent and control endemic diseases.
giving birth. What action by the nurse is appropriate? D. Assumes the municipal health officer¶s role in his/her absence.
A. Observe for signs of hypothermia in the newborn
B. Evaluate the newborn¶s respiratory effort
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33. Which among the following best describe the unit of care in D. Promoting rest.
community health nursing?
A. The Reyes Family who just recently moved into the Barangay Situation 10 - Nurse Sam was assigned to 5 clients who are for surgery.
Welferville after their house was demolished Barangay Puting Bato.
B. Children attending the Day care center. 46. Which of the following would be Nurse Sam¶s priority in nursing
C. Sitio Maasim where the igorots have traditionally live for years. assessment of her 5 clients pre-operatively?
D. Mang Ben, a PTB patient enrolled in the D.OT.S. program. A. Determining history of allergies. C. Identifying
anesthesia preference.
34. Which best describes community health nursing practice? B. Checking of client¶s identification. D. Marking of
A. Prioritized health-promotive and diseased preventive strategies. surgical site.
B. It is population focused.
C. Setting of practiced is situated in the natural environment of the 47. Which of the following assessment for a client who is to undergo
people. surgery under general anesthesia should Nurse Sam promptly report?
D. A Synthesis of nursing practice and public health practice. A. The client had French fries 2 hour prior to scheduled surgery.
B. The client smokes 1 pack of cigarettes a day.
35. ³Community health nursing is aggregate-focused´. Which best C. A history of hypertension controlled by diet.
demonstrate this concept? D. The client has full dentures.
A. The provision of nursing care in the natural environment of the
people. 48. Nurse Sam will do all of the following before administering the
B. The provision of service at an affordable cost. pre-medication EXCEPT:
C. The performance of community diagnosis. A. Make sure that the client observed NPO (nothing by mouth) at
D. The coordination of serviced by different members of all health least 6 hours prior to surgery.
team. B. Ascertain that the consent has been signed.
C. Instruct the client to empty his/her bladder.
D. Ascertain that the client has sufficient hospital deposit for the
SITUATION 8: Research surgery.

49. One client who was on NPO starting midnight asked Nurse Sam
Situation 9 - The highly subjective nature of pain makes assessment and what she should do if she feels thirsty. She will be instructed to:
management a constant challenge to health care workers including the A. Wet a cotton ball and place it on her lips.
nurse. B. Take sips of water.
C. Gargle but not swallow any amount of water.
41. During assessment of a confused client, which of the following D. Chew gums.
can be considered as ³proxy indicator´ of pain?
A. Hunger 50. Nurse Sam wanted to evaluate her pre-op teaching among her 5
B. Thirst clients. What would be the MOST effective way of evaluating her
C. Anger clients¶/significant others¶ understanding of her previous teaching?
D. Restlessness A. Offer to answer any questions that the client and family ask
before discharge.
42. Many factors influence the client¶s response to pain. Which B. Ask the family caregiver to demonstrate the procedure before
statement is TRUE among older adults? discharge.
A. Pain perception is diminished among older adults. C. Discuss it with the family when ready.
B. Older adults are fearful of addiction. D. Reinforce the teaching as the procedure or need arises.
C. Small doses of analgesic agents may be sufficient to relieve pain
among older adults. Situation 11 - A nurse participate in a Barangay-wide screening to identify
D. Older adults require a higher dosage of pain medication. adults who may have undiagnosed diabetes mellitus.

43. In rare occasions, administration of placebo among clients who 51. If the screening includes a measurement of postprandial blood
are chronically in pain is resorted to. The following principles should guide glucose, the nurse is correct in explaining that blood will be draw at which
the nurse EXCEPT: approximate time?
A. A placebo effect is not an indication that the client does not A. 2 hours after fasting.
experience the pain. B. 2 hours after meal.
B. A placebo should be used to test the client¶s truthfulness about C. 2 hours before exercise.
pain. D. 2 hours after sleep.
C. A client should never be on a placebo as a substitute for an
analgesic. 52. Which statement indicates that a client with elevated 2-hours
D. Placebo should never be used as a first line of therapy. post- prandial blood glucose level understands the significance of the
screening?
44. The chronic pain of arthritis illustrates the usefulness of A. ³I need to eat less frequent.´
determining between time and intensity. Arthritic clients usually report that B. ³My doctor must teach me how to diet.´
pain worsens during what time of the day? C. ³I need to stop eating sweets right away.´
A. Morning. D. ³I need to consult my doctor.´
B. Night.
C. Afternoon. 53. When the client expresses shock to the news of elevated blood
D. Midday. glucose, which nursing action is MOST appropriate at this time?
A. Reassuring that a number of people live a long life with diabetes.
45. Essential in pain assessment are the aggravating and alleviating B. Emphasizing that the modern technology is affordable for
factors as a basis of health education. As a nurse in charge of the client everyone.
with gastritis, you will consider the following factors to alleviate pain and C. Reassuring the client that modern science has a variety of
discomfort EXCEPT: effective treatment.
A. Reducing stress. D. Listening as she expresses her feeling of concern.
B. Small frequent feeding of bland diet.
C. Administering NSAID (Non Steroidal Anti-Inflammatory Drugs).
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54. The diabetic client states that she never taken breakfast. Which Blood Count revealed immature white blood cells. The diagnosis of
response of the nurse is CORRECT? Leukemia was confirmed by the bone marrow biopsy. As his nurse you
A. ³If you miss breakfast, make sure to have a heavy morning have a good working knowledge about the disease process and its
snacks.´ management.
B. ³If you take a glass of milk, it is a sufficient substitute for
breakfast.´ 61. Which type of large number of immature cells would most
C. ³Wait to take your medication until you breakfast.´ strongly support a diagnosis of acute leukemia?
D. ³You should start eating each meal and in between meal at A. Lymphocytes. C. Thrombocytes.
regular hours.´ B. Reticulocytes. D. Leukocytes.

55. The nurse knows that the diabetic client understands that ³lite´ 62. Induction, a component of antileukemic therapy, is primary
or ³light´ is labeling term that means which of the following? designed to:
A. A food item has reduced water content. A. Eradicate and achieve complete remission.
B. The product is compressed to lesser weight but the same caloric B. Prevent relapse.
content. C. Minimize symptoms.
C. The item contains one third fewer calories than a similar D. Achieve optimal comfort.
unaltered item.
D. The product is calculated specially for diabetic client 63. Complete remission of the leukemic patient means:
assumption. A. No signs and symptoms of the disease.
B. Respiratory and gastrointestinal symptoms relieved.
SITUATION 12 - The health instruction received by the family for the sick C. Bone marrow shows evidence of adequate function.
member of the family can significantly improve the client¶s recovery and D. Presence of less than 5% abnormal blast cells in the blood.
well being.
64. Risk for infection is one of the nursing diagnoses identified with
56. Nurse Camille is instructing the family of the client who just had Yvan. Which of the following about the risk of infection is INCORRECT?
pacemaker insertion. The nurse emphasized particularly to AVOID which A. Risk of infection is proportional to severity and duration of
of the following activity? neutropenia.
A. Keeping the insertion site dry until the next check-up B. Increased protein stores leads to decreased immune and
B. Raising the arm on the side of the peacemaker above the energy.
shoulder C. Antibiotic therapy increases the risk for fungal superinfection.
C. Staying in bed more than 3 hours D. Breaks in skin integrity increase opportunity for organisms to
D. Using electric razor to shave enter blood systems.

57. Rowena¶s husband is under your care and he is recovering from 65. Myelo ± suppression is a side effect of leukemia or its treatment.
myocardial infarction. Rowena is concerned about food, exercise and As a nurse you have to know its consequences which include the
when her husband asks about sexual activity, which is the appropriate following:
response of the nurse? 1. Erythrocytosis and risk of circulatory overload.
A. ³The doctor should be consulted´ 2. Neutropenia and risk of infection.
B. ³The next cardiac test will tell you when is the time to resume 3. Thrombocytopenia and risk of bleeding.
sexual activity´ 4. Leukostasis and risk of microcirculation obstruction.
C. ³Usually sexual activity can be resumed when your husband is A. 1 and 2. C. 3 and 4.
able to climb to flight of stairs comfortably´ B. 2 and 3. D. All except 4.
D. ³Continue with the sexual practice when you can both more
comfortable´ Situation 14 - As a nurse you should be equipped with decision making
skills. It is your responsibility to empower your clients to make critical
58. Joyce asks the nurse some instruction regarding oral iron decisions about their health conditions
supplement administration for her grandmother who has iron deficiency
anemia. The nurse would advise the mother to: 66. Eugenio who had previously signed consent for liver biopsy has
A. Administer the iron supplement at meal time a changed mind and no longer wants the procedure. Your best initial
B. Mix with ice cream or yoghurt response would be:
C. Add the iron supplement to the formula A. ³Can you tell me why you decided to refuse the procedure?´
D. Administer the iron with dropper B. ³You are obviously afraid about something concerning the
procedure.´
59. A new friend of yours who is to give birth in month¶s time asks C. ³Although the procedure is important, I understand that you
how to prevent ³sudden infant death syndrome´ of newborn. You will teach changed your mind.´
the appropriate position of the newborn which is: D. ³Why did you originally signed the consent?´
A. Lying on the abdomen with the face turn to either side
B. Back to prone 67. The decision not to use advance clinical technology to sustain
C. Supine life should be made:
D. Side to prone A. By the healthcare provider
B. When the patient is transferred to the ICU
60. You validated your instruction about Ethambutol to your client C. Before emergency situation
with pulmonary tuberculosis who is for discharge. Which of the following D. By community standards
answers will indicate that your client understood your instruction on what
sign is need to be reported? 68. You are assigned with a newly hired staff nurse and a nursing
A. Impaired speech attendant to take care of cardiac patients. As head of the team, which
B. Colored body secretion client you should address first:
C. Difficulty to distinguish from red and green A. Ador, who is admitted for an unstable angina, wants to be
D. Constipation discharged.
B. Buddy, who has pacemaker inserted yesterday and is
Situation 13 - Yvan, 25 years old, sought medical consult because of a complaining of incisional pain.
history of a history of extreme fatigue and swollen glands in his neck. He C. Pat, who has call light on
has been experiencing spontaneous nose bleeding recently. Complete
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D. Tony, who suffered an acute MI and who is complaining of 76. The nurse recognizes that nephrotic syndrome is an
constipation. autoimmune response responsible for which of the following?
A. Bacterial infection of the nephron.
69. Clara, with mitral valve prolapsed, is advised to have an elective B. Decreased glomerular filtration.
mitral valve replacement. Because Clara is Jehova¶s Witness, she C. Extensive nephron destruction.
declared in her advance directive that no blood products are to be D. Increased glomerular permeability
administered. As a result the consulting surgeon refuses to care for Clara.
It would be most appropriate for you who is caring for Clara: 77. The mother of Dennis asked the nurse, ³Why is Dennis gaining
A. That she has the right to refuse the care from the surgeon so much weight?´ Which of the following is the MOST appropriate
B. To look for another cardiac surgeon response of the nurse?
C. To inform Clara that her decision can shorten the life A. Dennis has retained so much fluid in his body , thus his weight is
D. To tell Clara that she can donate her own blood for the increased.
procedure. B. Dennis has been losing protein because his kidneys could not
control this.
70. Which Nursing diagnosis is most appropriate for Wanda who C. He is not voiding enough urine because his kidneys are
has coronary artery disease (CAD) and who is manifesting the following defective
signs: easy fatigability, irregular heartbeat and chest pain? D. He should not be drinking too much water to avoid fluid to be
A. Decreased cardiac output retained
B. Risk for injury
C. Impaired gas exchange 78. The therapy of choice for Dennis is Prednisone. Which of the
D. Ineffective thermoregulation following is the correct information given by the nurse to the mother of
Dennis regarding purpose of therapy?
Situation 15 - You are caring for Selina, who is 58 years old with Chronic A. Reduce inflammation of nephron
Renal disease. Your significant assessment findings are: B. Reduce proteinuria
‡ Vital signs: Temperature 37.2 degrees Celsius, BP 120/80, C. Promote dieresis
Respiratory Rate 32 rapid vigorous D. Decreased blood volume
‡ She is restless
‡ Her urine pH is 4.5 and urine output is decreased 79. While Dennis is on Prednisone therapy, the nurse makes the
‡ ABG results: pH ± 7.32, PaO2-88 mmHg, PaCO2 ± 37 mmHg, mother understand that the most important intervention is to:
HCO3 ± 16 mEq/L A. Maintain high protein diet
B. Promote activity and exercise
71. Which of your assessment findings would indicate Selina has C. Avoid exposure to infection
acid base imbalance? D. Keep skin clean and dry
1. Temperature ± 37.2 deg C
2. Respiratory rate ± 32/min rapid vigorous 80. The nurse explained to the mother that Prednisone therapy
3. Restlessness should not be stopped abruptly. The mother understood that if she
4. Urine pH 4.5 and decreased urine output discontinue the therapy:
A. All except 1 A. Congestive heart failure will develop
B. All of these B. Liver will be inflamed
C. 3 and 4 C. Kidneys will shut down
D. 1 and 2 D. Adrenal glands will be affected

72. You would interpret Selina¶s ABG result as: Situation 17 - Communication is the means for demonstrating compassion
A. Metabolic acidosis and care. It is essential to the nurse client interaction as it serves as a
B. Respiratory alkalosis vehicle in establishing a therapeutic relationship. The following situations
C. Metabolic alkalosis require the deliberate planning for effective therapeutic relationship.
D. Respiratory acidosis
81. Zeus is waiting for the result of MRI that will describe the extent
73. Which of the following statements is correct rationale regarding of the disease in the brain. He says to the nurse, ³I think it¶s taking a long
Selina¶s acid base imbalance? time to get the results. Something must be wrong.´ Which of the following
A. Cellular catabolism and acid accumulation should be the appropriate response of the nurse?
B. Excessive loss of bicarbonate ions A. ³Perhaps would you like to talk about it?´
C. Increased catabolism of fatty acids B. ³Oh, don¶t worry; everything¶s going to be fine!´
D. Retention and build up of nonvolatile acids. C. ³What do you think would be helpful?´
D. ³Sounds like you are worried about how the procedure turns
74. As Selina¶s nurse you know that the body compensate acid base out.´
imbalance by the following mechanisms except:
A. Hepatic compensation 82. Artemis 15 years old is being treated in the emergency room for
B. Excretion of bicarbonate treatment of minor injuries from a motor vehicle accident. She is anxious
C. Respiratory compensation and hysterical. She tells the nurse, I can¶t go home. My father will surely
D. Buffering kill me. It¶s my fault.´ In this situation the nurses appropriate action is to:
A .Tell her to calm down and say, ³Your mother is coming to take you
75. Knowing Selina¶s condition, which collaborative intervention will home.´
you anticipate to be implemented first? B. Hold his hands and say, ³Slow down. Take a deep breath.´
A. Oxygen at 2 -10 liters per minute C. ³Stop worrying. Your father loves you and understands it was an
B. IV Lorazepam (Ativan) 1 mg accident.´
C. Respiratory compensation D. Reassure and say, ³It¶s not your fault.´
D. Buffering
83. Virgil a young successful businessman sustained spinal cord
Situation 16 - Dennis, 4 years old is admitted to the hospital because of injury leaving him paralyzed from waist down. While the nurse is giving a
marked ascites and edema. The physician¶s diagnosis is Nephrotic morning care, she notices him to be staring blankly. He states, ³I think, I
Syndrome. am better off dead.´ The best response of the nurse is:
A. ³Do you have thoughts of committing suicide?´
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B. ³I don¶t think you are serious about these feelings.´ 92. Rhea alleges that people are unfair and unreasonable towards
C. ³When did this feeling start?´ her though she claims she is patient, calm, fair and kind. She expressed
D. ³There still hope or you to recover.´ that she needs someone to talk to her problems. Rhea would benefit
MOST from a:
84. Aphrodite a budding young artist was confined to the hospital A. Support group
and diagnosed with multiple sclerosis. The nurse enters the clients room B. Relationship therapy
found her crying. Which of the following is the appropriate response of the C. Crisis counseling intervention
nurse? D. Behavior modification program
A. ³Do you want me to call your mother?´
B. ³Tell me what is bothering you?´ 93. Failure to develop intimate relationships and inability to hold on
C. ³Its okay. You will be fine.´ to a job is a carryover of an unresolved problem of:
D. ³Here is a tissue paper. I would like to stay with you for a while.´ A. Despair
B. Isolation
85. The nurse is teaching the mother of a 10 month old infant in hip C. Stagnation
spica. She judges that the mother understands how to feed infant when D. Role diffusion
she states which of the following?
A. ³I¶ll position my baby flat on bed and will feed her the formula.´ 94. A basic principle that the nurse must observed during the early
B. ³I¶ll elevate the head of the bed to prevent regurgitation of milk.´ phase of nursing intervention is:
C. ³I¶ll look for a modified high chair or special feeding table to use.´ A. Control
D. ³I¶ll ask somebody to assist me in feeding my baby.´ B. Consistency
C. Transparency
Situation 18 - Galatea, a 27 year old woman was admitted to an adult D. Acceptance
inpatient psychiatric unit with symptoms of excessive hand washing. She
believed numerous stimuli like door knobs, toilets are ³unclean´ individuals 95. Being a devil¶s advocate and challenging almost everything that
contaminated with chemicals and toxins that could contribute to her people say is a pattern of:
development of brain tumor. These resulted to inability to work, crying A. Aggression
daily, not eating well and staying in bed a lot. B. Anxiety
C. Manipulation
86. Galatea¶s condition indicate a symptomatology of: D. Projection
A. Agoraphobia
B. Personality disorder Situation 20 - Helen, 16 years old was brought to the University Hospital
C. Obsessive- compulsive disorder by her classmate after fainting in class. She is a part time model 5¶8´ tall
D. Panic anxiety disorder and weighs 105 lbs. She was admitted with a diagnosis of anorexia
nervosa.
87. Galatea¶s hospitalization lasted 2 weeks during which she
started on Fluoxetine which is an? 96. To determine Helen¶s caloric intake, the nurse should:
A. Antidyskinetic A. Ask Helen what she has eaten in the past 24 hours
B. Mood stabilizer B. Have Helen list her favorite foods
C. Neuroleptic C. Observe what Helen eats
D. Antidepressant D. Ask Helen¶s roommate what she usually eats.

88. The nurse interprets Galatea¶s handwashing rituals as attempt to 97. Helen requests a mild milk shake. When the nurse brings it,
reduce her: Helen says that she Is too busy to drink it. The best interpretation of this
A. Mania behavior is that it is:
B. Immobility A. A means of avoiding the responsibility of making decision
C. Isolation B. An expression of an acknowledged internal conflicts
D. Anxiety C. An indication of fear of being poisoned
D. Evidence of an easily distracted attention
89. The nursing staff in the unit supported interventions for cognitive
therapy which include the following except: 98. Which of these recreational activities would be therapeutic for
A. Restructuring inaccurate thoughts. Helen?
B. Refraining from engaging in rituals A. Reading
C. Recognizing deep seated unconscious conflicts B. Playing bored games with other patients
D. Thought stoppage C. Playing volleyball
D. Taking exercise class
90. Cognitive therapy is a treatment based on principles of:
A. Learning theory 99. Which of these occurrences would suggest an improvement in
B. Phenomenological theory Helen¶s condition?
C. Psychoneuroimmunology A. She has menstrual period
D. Psychodynamic theory B. She gains 2 lbs in 24 hours
C. She frequently looks at herself in the mirror
SITUATION 19 - Rhea, age 30 years, is in her 4th job and fears that she D. She volunteers to prepare snacks for the patient group.
will be terminated again; she consulted the outpatient clinic and asks for
medicine to ³calm her nerves´. She claims she likes to be the devil¶s 100. Helen says to the nurse, ³Look at my thighs. I can¶t believe how
advocate and challenges almost everything people say. big they are.´A therapeutic response is:
A. ³I wish my legs look like yours.´
91. The nurse assesses the client¶s difficulty in relating with others is B. ³They don¶t look fat to me.´
primarily due to her: C. ³You look all right to me.´
A. Lack of adequate communication skills D. ³No one will see them unless you wear a bathing suit.´
B. Fear of intimacy
C. Inability to develop rapport 101. According to Benner¶s stages of nursing expertise, a nurse with
D. Negative perception of others 2-3 years of experience who can coordinate multiple complex nursing care
demands is at which stage?
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a. Advanced beginner 110. If a client fails to follow the information of teaching provided, how
b. Competent should the nurse respond?
c. Proficient a. Develop a tough approach
d. Expert b. Give up, as the client doesn¶t want to change
c. Reteach the information, as the nurse is the expert
102. Which activity is an example of health promotion by the nurse? d. Reassess the client¶s importance given to the behavior and
a. Administering immunization readiness to change it
b. Giving a bath
c. Preventing accidents at home 111. In doing an abdominal assessment, how should you correctly
d. Performing diagnostic procedures sequence the following actions?
i. Palpation
103. Which of the following is an example of continuing education for ii. Auscultation
nurses? iii. Inspection
a. Attending the hospital¶s fire safety program iv. Percussion
b. Talking with a competent representative about a new piece of a. i ii iii iv
equipment b. i iii iv ii
c. Receiving a certificate of completion for a workshop on legal c. iii ii iv i
aspects of nursing d. ii iii iv i
d. Obtaining information about the facility¶s new computer charting
system 112. Mr. F is admitted to hospital with extensive carcinoma of the
descending colon with metastasis to the lymph nodes. The operative
104. Which of the following is based on quantitative research? procedure that would probably be performed to Mr. F is a/an:
a. A study measuring the effects of sleep deprivation on wound a. Ileostomy
healing b. Colecomy
b. Study examining the bereavement process in spouses of clients c. Colostomy
c. A study exploring factors influencing weight control behavior d. Cecostomy
d. Study examining client¶s feelings before and after a bone
marrow aspiration 113. When teaching Mr. F for a new stoma, the nurse should advice
him that irrigations be done at the same time everyday. The time selected
105. An 85-year-old client in a nursing home tells a nurse ³I signed should be:
the papers for that research study because the doctor was so insistent and a. An hour before breakfast
I want him to continue taking care of me.´ Which client right is being b. Approximate to Mr. F¶s usual daily time for elimination
violated? c. Provide ample uninterrupted bathroom use at home
a. Right not to be harmed d. Halfway between 2 large meals
b. Right to full disclosure
c. Right of privacy and confidentiality 114. When performing colostomy irrigation, the nurse inserts the
d. Right of self-determination catheter into the stoma:
a. 5 cm
106. Cost-effective health care emphasizes primary level of b. 10 cm
prevention. Which of the following isa example of primary preventive c. 15 cm
activity? d. 20 cm
a. Antibiotic treatment of a suspected UTI
b. Occupational therapy to assist a client in adapting to his 115. Mr. F should follow a diet that is:
environment following a stroke a. Rich in protein
c. Nutrition counseling for young adults with strong history of high b. Low in fiber content
cholesterol c. High in CHO
d. Removal of tonsil for a client with recurrent tonsillitis d. As close to normal as possible

107. What would be the primary goal of therapy for a client with 116. Joselito is an OFW presents at the admission with an A:P
pulmonary edema and heart failure? diameter ration of 2:1. Which of the following associated findings should
a. Enhance comfort the nurse expect?
b. Increase cardiac output a. Pancytopenia
c. Improve respiratory status b. Anemia
d. Peripheral edema decreased c. Fingers are club-like
d. Hct is decreased
108. Discharge planning is the process of preparing a client to leave
one level of care for another within or outside the current health care 117. Which of the following statement by a client with prolonged
agency. When does discharge planning start? vomiting indicates the initial onset of hypokalemia?
a. Upon admission a. My arm feels so weak
b. During hospitalization b. I felt my heartbeat just right now
c. After surgery c. My face muscle is twitching
d. One day before client leaves the hospital d. My legs are cramping

109. Change in the behavior of the client is one important goal of 118. Nurse Pat has seen Mr. John for the first time. She establishes a
health education. During what stage of health behavior change (according contract about the frequency of meeting and expected termination. Started
to Prochaska, etc) does the client acknowledges having the problem, talking about baseline assessment and set interventions and outcomes.
seriously considers changing a specific behavior and actively gathers On what phase of the NPR does the nurse and patient belong?
information but may not be ready to commit? a. Preorientation
a. Precontemplation b. Orientation
b. Contemplation c. Working
c. Preparation d. Termination
d. Action

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119. Nurse Keith knows that taking the rectal temperature of a patient d. Needs of patient should be considered in the choice of games
with MI is contraindicated. What cranial nerve will stimulate the SNS to
cause bradycardia? 128. To encourage active participation among patients, it is BEST to
a. Vagus plan activities they can engage in through a:
b. Facial a. One to one interaction
c. Olfactory b. Community meeting
d. Optic c. Checklist
d. Feedback evaluation forum
120. Nurse Keith is going to take the vital signs of Mr. Chiu. Upon
entrance in his room, he found Mr. Chiu to be breathing deeply and 129. In planning activities for the patients, it is essential to consider
rapidly. Based on this, what acid-base imbalance might have occurred? FOREMOST:
a. Metabolic acidosis a. Safety and security
b. Metabolic alkalosis b. Variety and fun
c. Respiratory acidosis c. Novelty and creativity
d. Respiratory alkalosis d. Excitement and challenge

130. Adults, ³ singing and acting like children´ is a form of:

121. Situation - A group of adult chronic schizophrenic patients were a. Displacement
recommended to undergo social skills training. The following are the b. Regression
objectives of a social skills training program EXCEPT: c. Sublimation
a. Explore deep seated intrapsychic conflicts d. Compensation
b. Practice skills in relating with people
c. Help build self esteem and self confidence 131. A flat plate radiograph of the abdomen is ordered. The nurse
d. Develop and practice general coping skills recognizes that the client should receive:
a. No special preparation
122. Social skills training is NOT primarily indicated for psychiatric b. Low soap-suds solution
patients who are: c. NPO for 8 house
a. In acute stage of illness d. Laxative the evening before the examination
b. Having difficulties starting and maintaining interpersonal
relationships 132. The sport that should be avoided by a client with an ilestomy is:
c. Having chronic episodes of stress and anxiety while interacting a. Skiing
with others b. Football
d. Experiencing recurrence of symptoms in front of particular c. Swimming
people or among people in general d. Track events

123. The focus of the group interaction is ³here and now´. An 133. The nurse should visit which of the following clients first?
appropriate topic would be: a. Client with diabetes with a blood glucose of 95 mg/dl
a. Ways to celebrate Valentine¶s Day in February b. Client with hypertension being maintained on captopril
b. How to spend the summer vacation c. Client with chest pain and history of angina
c. An unforgettable experience as a child d. Client with Raynaud¶s disease
d. How to tell a joke
134. Which laboratory test is the most accurate indicator of a client¶s
124. An appropriate technique for the participants to practice how to renal function?
communicate effectively is through/a: a. BUN
a. Lecture b. Creatinine clearance
b. Seminar c. Serum creatinine
c. Role play d. Urinalysis
d. Psychodrama
135. A gradually developing opacity of the lens can be found when
125. Considering that it is BEST to learn by example, it is MOST the patient has:
practical to: a. Cataract
a. Model good social skills throughout the session b. Glaucoma
b. Relate successful past experiences c. Corneal abrasion
c. Invite a resource person d. Retinal detachment
d. Watch a movie
136. A client with seizure disorder has been prescribed phenytoin
126. Situation - The nurse observed that Marie, age 28 years old had (Dilantin). Which of the following facts should the nurse include in the
not been participating in activity therapies. Which of the following remarks teaching plan?
from the nursing attendants indicates a need for further teaching and a. Use of phenytoin can lead to the development of diabetes
observation? mellitus
a. Marie made no response to an invitation to play b. It is appropriate to substitute various brands of phenytoin as long
b. Marie preferred to sit at the bench and watch the ballgame as the dose is the same
c. Marie is aloof and indifferent to co-patients c. It will be necessary for the client to take potassium supplements
d. Marie read a book while other patients played a ballgame to prevent hypokalemia
d. The client should use a soft toothbrush and floss teeth everyday
127. Marie said ³I don¶t like to be a part of it. Look, they are being
laughed at because they are singing and acting like children´. The nurse 137. A client rates pain as 8 in a scale of 10 (highest). The client is
notes that in order for the activity therapy to be therapeutic: sitting in his bed calmly watching TV. How should the nurse interpret the
a. The staff should decide solely what activities to be done and situation?
what rules apply a. Ignore the client¶s pain as he must be exaggerating
b. Patients should be allowed solely to decide what they want to do b. Recognize the client is in pain and administer medications as
on their own ordered
c. Ballgames should be limited to male patients only
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c. The nurse must clarify with the client the meaning of 8 as it is a 146. Joselito is an OFW presents at the admission with an A:P
serious condition diameter ration of 2:1. Which of the following associated findings should
d. Increase the dosage the nurse expect?
a. Pancytopenia
138. The nurse is assessing the client before he enters the OR. What b. Anemia
is the value of a thorough preoperative assessment? c. Fingers are club-like
a. To identify and correct problems before surgery and establish a d. Hct is decreased
baseline for post-op complications
b. To save time doing an assessment after the client returns from 147. Which of the following statement by a client with prolonged
surgery vomiting indicates the initial onset of hypokalemia?
c. To provide the doctor with information that may have been a. My arm feels so weak
missed during the preadmission assessment b. I felt my heartbeat just right now
d. To ensure that post-op complications don¶t occur c. My face muscle is twitching
d. My legs are cramping
139. A client with moderate persistent asthma is admitted for a minor
surgical procedure. On admission the peak flow meter is measure at 480 148. Nurse Pat has seen Mr. John for the first time. She establishes a
L/min. Postoperatively, the client is complaining of chest tightness. The contract about the frequency of meeting and expected termination. Started
peak flow has dropped to 200 L/min. What should the nurse do first? talking about baseline assessment and set interventions and outcomes.
a. Notify physician On what phase of the NPR does the nurse and patient belong?
b. Administer prescribed dose of albuterol a. Preorientation
c. Apply oxygen at 2 L/min per nasal cannula b. Orientation
d. Repeat peak flow reading in 30 minutes c. Working
d. Termination
140. What is the most important nursing action when the client
provides information that is pertinent to care? 149. Nurse Keith knows that taking the rectal temperature of a patient
a. Disclose the information to everyone in the nunit with MI is contraindicated. What cranial nerve will stimulate the SNS to
b. Disclose the information only to nurses in the unit cause bradycardia?
c. Disclose the information with those needing to know for plan of a. Vagus
care b. Facial
d. Document the information in the chart only c. Olfactory
d. Optic
141. A client diagnosed with cerebral thrombosis is scheduled for
cerebral angiography. Nursing care of the client includes the following 150. Nurse Keith is going to take the vital signs of Mr. Chiu. Upon
EXCEPT entrance in his room, he found Mr. Chiu to be breathing deeply and
a. Inform the client that a warm, flushed feeling and a salty taste rapidly. Based on this, what acid-base imbalance might have occurred?
may be a. Metabolic acidosis
b. Maintain pressure dressing over the site of puncture and check b. Metabolic alkalosis
for c. Respiratory acidosis
c. Check pulse, color and temperature of the extremity distal to the d. Respiratory alkalosis
site of
d. Kept the extremity used as puncture site flexed to prevent
bleeding

142. The meal pattern that would probably be most appropriate for a
client recovering from GI bleeding is:
a. Three large meals large enough to supply adequate energy
b. Regular meals and snacks to limit gastric discomfort
c. Limited food and fluid intake when he has pain
d. A flexible plan according to his appetite

143. The sign/symptom that would be most likely to occur for patients
with duodenal ulcer would be:
a. Pain relieved by vomiting
b. Pain relieved by food
c. Pain relieved by NSAIDs
d. Pain relieved by not eating

144. Louis develops peritonitis and sepsis after surgical repair of

ruptures diverticulum. The nurse in charge should expect an assessment
of the client to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds

145. What instructions should the client be given before undergoing a

paracentesis?
a. NPO 12 hours before procedure
b. Empty bladder before procedure
c. Strict bed rest following procedure
d. Empty bowel before procedure

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