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SET A Seat No.____
NURSING PRACTICE 1: FOUNDATION OF PROFESSIONAL NURSING PRACTICE
Direction: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answer sheet provided. STRICTLY NO ERASURE! Situation 1: Mr. Martin, 71 years old was suddenly rushed to the hospital because of severe chest pain. On admission, he was diagnosed to have acute myocardial infarction and was placed in the ICU. 1. While in the ICU, he executes the document tat list the medical treatment he chooses to refuse in case his condition becomes severe to a point that he will be unable to make decisions for himself. This document is: A. living will C. last will and testament B. informed consent D. power of attorney 2. After one day, the patient’s condition worsened and feeling hopeless. He requested the nurse to remove the oxygen. The nurse should: A. follow the patient because it is his right to die gracefully B. follow the patient as it is his right to determine the medical regimen he needs C. refuse the patient and encourage him to verbalize hid feelings D. refuse the patient since euthanasia is not accepted in the Philippines 3. Euthanasia is an ethical dilemma which confronts nurses in the ICU because: A. the choices involved do not appear to be clearly right or wrong B. a clients legal right co-exist with the nurse’s professional obligation C. decisions has to be made based on societal norms. D. decisions has to be mad quickly, often under stressful conditions 4. A nurse who supports a patient and family’s need to make decisions that is right for them is practicing which of the following ethical principles? A. Autonomy B. confidentiality C. privacy d. truthfulness 5. Mr. Martin felt better after 5 days but recognizing the severity of his illness, he executes a document authorizing the wife to transact any form of business in his behalf in addition to all decisions relative to his confinement his document is referred to as: A. power f attorney C. informed consent B. living will D. medical records Situation 2: Miss Castro was recently appointed chief nurse of a 50-bed government hospital in Valenzuela. On her first day of duty, she tried to remember the elements of administration she learned from her basic nursing education. 6. One of the first things Ms. Castro did was to engage her until in objective writing, formulating goals and philosophy of nursing service. Which activities are MOST appropriately described to which elements of administration? A. planning B. controlling C. directing d. organizing
7. In recognizing the Department of Nursing, she comes up with the organizational structure defining the role and function of the different nursing positions and lineup the position with qualified people. This is included in which element of administration: A. monitoring B. evaluation C. organizing d. planning 8. After one month, she and her management committee assess the regulatory measures taken and correct whatever discrepancies are found. This is part of which element of administration: A. monitoring B. organizing C. evaluation d. planning 9. Revaluation and administrative process is BEST described as: A. a continuing process of seeing that performance meets goals and targets B. obtaining commitment of members to do better C. informing personnel how well and how much improvement has been made D. follow-up of activities that have been studied 10. In all of the various administrative functions, which of the following management skill is demanded efficiently and effectively of Ms. Castro? 1. Decision making skills 2. Forecasting skills 3. Auditing skills 4. Communications skills A. 2 & 3 B. 1 & 4 C. 1 & 2 D. 2 & 4 Situation 3: Meldy. 40 years old. is waiting for her doctor’s appointment at the clinic where you work. 11. You are to interview her as an initial nursing action so that you can. A. Document important data in her client records for health team to read. B. Gather data about her lifestyle, health needs, lifestyle, health needs and problems to develop plan of care C. provide solutions to her immediate health concern D. identify the most appropriate nurse diagnosis for her heath problem 12. During the interview, Meldy experiences a sharp abdominal pain on the right side of her abdomen. She further tells you that an hour ago, she ate fatty food and this had happened many times before. You will record this as: A. Client complains of intermittent abdominal pain an hour alter eating fatty foods B. After eating fatty food the client experienced severe abdominal pain C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain medication D. Client reported sharp abdominal pain on the right upper quadrant of abdomen an hour after ingestion of fatty foods. 13. Meldy tells you that she has been on a high protein / high fat / low carbohydrate diet order to lose weight and that she has successfully lost 8 lbs during the past two weeks. In planning a healthy balanced diet for her, you will: A. Encourage her to eat well-balanced diet with a variety of food from the major food groups and take plenty of fluids. B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates. C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular exercise. D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet.
14. You learn that Meldy drinks 5-8 cups o coffee a day plus cola drinks. Because she is in her premenopausal years, the nurse instructs her to decrease consumption of coffee and cola preparation because: A. these products increase calcium loss from the bones B. These products have stimulant effect n the body C. these products encourage increase in sugar consumption D. these products are addicting 15. Health education plan for Meldy stresses prevention of NCD or Non-communicable diseases that are influenced by lifestyle. These include the following EXCEPT: A. Cancer B. DM C. Osteoporosis D. Cardiovascular diseases Situation 4: Changes in technology, the nation’s economy and the increasing number of population have brought about changes in the Health Care System. 16. At present, government hospitals are expected to offer comprehensive health services to include illness prevention and health promotion. In which of the following unit of services are these services integrated? A. Wellness center C. Rehabilitation Center C. Intensive Care unit D. newborn screening unit 17. Which of the following is the MOST recent government initiative to help subsidize the cost of health services for both the employed and the unemployed? A. National Health Insurance Act C. Medicare Act B. Worker’s Compensation Act D. Magna Carta for Public Health Workers 18. The top ten morbidity cases in the Phil. Include TB, diarrhea among children to name a few. Many of these conditions are preventable and have implications are preventable and have implications in the development of which nursing competencies? A. Execution of nsg. procedure and technique B. Therapeutic use of self C. Administration of treatment and medication D. Health education 19. The cost of hospitalization is getting more expensive and unaffordable to many of our people. These facts will MOST LIKELY bring about development in which of the following? A. acute services C. home care services B. managed care services D. advance practice nursing 20. Which of the following latest trend has expanded health services based on prepaid fees with emphasis on health promotion and illness prevention? A. Government Insurance Plan C. Health Maintenance Organization B. Preferred Provider Organization D. Private Insurance Plan Situation 5: It is Safety Awareness Week in the Community and the nurse checks on the presence of hazards at home. The nurse plan is to have the residents themselves identify the physical hazards in their own homes. 21. Which of the following is NOT a physical hazard in the home? A. unstable and slippery stairway B. large windows that allow good ventilation C. obstacle people cam trip over like door mats, rugs, electric cords D. inadequate lighting in and out of the house 22. Risk factors exist for each of the different developmental levels. From infancy to preschool age, the most common
cause of death is injury rather than disease. To protect children from harm, that parents should be aware that MOST injuries for this age group are due to: A. Accidents at home caused by the swallowed poisonous materials, small objects, exploring electrical sockets B. Accidents from self inflicted wounds C. accidents from sports related activities at school or the neighborhood D. accidents in the Playground Park, school and presence of strangers who may abduct of molest the child. 23. To promote safety at home, the nurse identifies ways and means of “child proofing” the house. Which of the following is NOT safe? A. apply child proof caps and medicine bottles and chemicals B. covering electrical outlets, tying up long and loose electrical and telephone cords, securing cabinets or doors within reach o the child C. giving colorful grocery bags to play with or to store toys and materials D. removing objects that the child could easily dismantle and swallow like small parts of a mechanical toy, buttons, materials inside, stuffed animals, liquid chemicals. 24. The nurse knows that a person’s hygienic practices are influenced family customs and traditions. Which of the following is NOT part of Basic Hygienic Practices? A. bathing practices, frequency and time, care of eyes, ear and nose B. oral hygiene practices such as brushing and flossing teeth, gum care C. care of skin with lesions, cuts with infection D. hair and skin such as washing hair and face, feet, hand and nail care 25. Falls are the common home accident among elderly and these are due to physical limitations imposed by aging and some hazards in the home setting. The nurse reduces the risk of falling through the following EXCEPT: A. rearranging furniture frequently
B. having the bed or mattress close to the floor C. providing a nonskid and well fitted shoes or slippers D. having a call bell within the persons reach and answering call bells immediately Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C. 26. Given the above assessment data, the most immediate goal of the nurse would be which of the following? A. Prevent urinary complication B. maintains fluid and electrolytes C. Alleviate pain D. Alleviating nausea 27. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post operative order includes “daily urine specimen to be sent to the laboratory” . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container
ham and cheese sandwich. Mang Carlos will know about diabetes related to foot care and the techniques and equipments necessary to carry it out B. sandbag B. D. facilitate evaluation of the nurse’s performance C. dehydration B. Which of the following objectives is written in behavioral terms? A. using body weight to assist with the movement B. Major. ensure learning on the part of the nurse D. sensory alterations B. lowers blood glucose B. The importance of forcing fluids with an immobilized patient is to: A. 36. trapeze bar 45. Mang Carlos wife needs to understand the side effects of insulin D. standing with feet apart 43. prevent skin breakdown . empty a sample urine from the collecting bag into the specimen container C. flat on his of her back.B. hypertension C. developing of contractures C. The circulating nurse’s responsibilities. any unconscious patient should be positioned: A. to the patient’ B. standing with feet together D. prevent pneumonia C. Minor. closed reduction of a fracture C. to the patient lower abdomen 29. proper body alignment D. see to it that the drainage tubing touches the level of the urine B. Laryngospasm C. to the patient’s inner thigh C. D. to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand. because it: A. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container. An informed consent is required for: A. Mang Carlos daughter should learn about DM within the week C. patient’s position should be changed at least three or four times a day 6 44. trochanter roll D. Which of the following is the CORRECT guideline when positioning patients? A. hypoxemia and hypercapnea B. setting up the sterile tables B. accomplishes all of the above 35. 41. urethral catheterization 38. the nurse should observe certain principles of body mechanics for herself and her patients. frequent use of technical terms for familiarization B. hyperventilation D. instant noodles. decrease in activity tolerance 42. change he catheter every eight hours C. diagnosis C. ablative B. improves insulin utilization D. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. insertion of intravenous catheter D. position of the joint should be slightly extended C. urgent. to facilitate frequent turning and minimize pulmonary complications B. Which of the following are appropriate goals for client with positioning and mobility needs? A. emergency. and diet soda 30. put pillows above a joint to immobilize it B. side-rail C. urgent. She is beginning to write objectives of her teaching plan. drawing him into discussion about diabetes 5 C. loosely structured teaching session 34. major. which most closely stimulates a sitting position. potato salad. white chicken sandwich. palliative D. Mang Carlos sister will be able to determine in two days his insulin requirement based on blood glucose levels obtained from glucometer 32. fresh fruits and vegetables C. glucosuria Situation 8: Caring for the perioperative patient. canned soup. The chief life-threatening hazard for surgical patient with uncontrolled diabetes is: A. clean catheter may be used since urethral meatus is not a sterile area Situation 7: Miss Tingson is assigned to Mang Carlos. Unless contraindicated. Which for the following would MOST likely cause injury to the nurse when moving the patient from bed to the wheelchair? A. vegetable salad and tea D. document the quality of care 33. 31. hypoglycemia D. elective. Miss Tingson should encourage exercise in the management of diabetes. minor. fresh fruits and ice tea B. The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: A. in contrast to the scrub nurse’s responsibilities. Which of the following menu is appropriate for one with low sodium diet? A. pulmonary edema ad embolism 40. all of the above functions 39. Which of the following can be used by clients with problem of immobility to enable them raise their body from bed to wheelchair or perform some bed exercises? A. Howe will you prevent ascending infection to Eileen who has an indwelling catheter? A. decrease total triglyceride levels C. Which of the following behavior BEST contribute to the learning of Mang Carlos regarding his disease condition? A. irrigation of the external ear canal B. c. ensure communication among staff members B. 28. bending at the knees C. assisting the surgeon C. Which of the following is the BEST rationale for written objectives? A. in semi-fowlers position. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation? A. see to it that the drainage tubing does not touch the level of the urine D. detailed lengthy explanation about his condition D. to the patient’s lower thigh D. without elevation of the head. monitoring aseptic practices D. in fowler’s position. on his or her side without a pillow at the patient’s back and his or her chin extended to minimize the danger of aspirations Situation 9: To prevent further injury to patients with problems of immobility / mobility. a 60 year old newly diagnosed diabetic patient. thus facilitating reparatory as well as gastrointestinal functioning. An appendectomy during a hysterectomy would be classified as: A. joints of patient to be supported with pillow D. reconstructive 37. include: A.
One of the responsibilities of Mr. laboratory test C. 58. use of checklist 7 A. Which of the following statements do NOT contribute to the researchabilty of your proposed problem? A.4 & 5 C. big group of patients like 10-15 patients D.3. systemic review 47. 1. 3 & 4 B. A main function of the patient’s records is to: A. prepare the tool for collecting data 62. the nurse is responsible for which of the following group of patient? A. palpation 2. confirm and identify nursing diagnosis 3. narrative charting 2. SOAP charting 3.2.2 & 3 49. Which of the following should be given the HIGHEST PRIORITY before physical examination is done to a patient? A. act as the charge nurse. coordinator of comprehensive. 1 & 2 D. get the permission from the hospital director C. accountability is clearest since our nurse is responsible for the overall plan and implementation of care C. Which of the following is the least nursing activity in performing assessment of the patient? A. autonomy and authority for planning care are best delegated to a nurse B. physical therapist C. What is the function of the primary nurse in primary nursing? A. consult a complete expert B. maintain peristalsis 46. A study /research table should NOT contain which of the following ? A. gather baseline data about the client’s health 2. the nurse supervisor B. erase the erroneous material B. patient advocate in the health care team D. 1 & 3 D. preparation of the equipment C. Lata. ensure that the message is received 52. make clinical judgment of patients’ diagnosis A. preparation of the environment B. relevant rows and columns D. the whole unit 60. RN. consult a physician C. Which of the following actions will facilitate analysis of research data? A. percussion 4.3 & 5 D. She is able to communicate to the other member of the team by documenting the nursing care plan and the appropriate nursing intervention. 1 & 2 C. 1.2. inspection A. responsible for the over-all care of the patient during off days of primary nurse C. 1. As part of the assessment. Which of the following qualities are relevant in documenting patients care? 1. 1. consult an adviser D. categories of data collected C. 51. well-defined problem statement B. 2. categorize data collected . interpreting data B. auscultation 3. 53.4 & 5 B. thoroughness and currentness 3. 1. the whole ward B. an industrial nurse. specific title of table 8 B. find out from interview how many patients are willing to participate B. holistic patient care 59. During the assessment phase of the nursing process. establishing a data base D. names and sample of the selected 64.2 & 4 B. 3 &4 C. 1. use of locally accepted abbreviation A. speech therapist 54. the head nurse D. Which of the following are the purpose of performing a physical assessment? 1.2 & 3 B. properly dated and signed 5. 3 & 4 D. In primary nursing who among the following is needed to her leadership and quality control in the ward? A. 2 & 3 55. the patient B. draw a straight line through the error and initial it. physical examination D. Which is the role of the associate nurse in primary nursing? A. small group of patient like 3-5 patients C. over-all manager of the unit B. 1. evaluate physiological outcome of care 4. Primary nursing is MOST advantageous and satisfying to the patient and nurse because of which of the following principles? A. 61. readability of findings D. coordinates the care given to a group of patients by support staff 57. designing nursing strategies C. the chief nurse C. prepare the nurse for the shift worked B. review literature on the topic D. Which of the following persons cannot have the access to the patient record? A. serve as a record of financial charges C.3 & 4 48. 1. 3 & 4 C. physical preparation of the client 50. systematic and orderly 4. use of flow sheet 4 . measurability of variables 63. the nurse is concerned with: A. prevent urinary stasis D. carefully ink out the erroneous material C.3. which is the BEST approach? A. is to conduct physical head-to-toe assessment of a newly hired factory worker. psychological preparation of the client D. Health history B. continuity of patients care promotes efficient nursing care. In primary nursing. POMR charting is different from traditional method because of which of the following practices? 1. organizing staff assignments and help in solving problem in the unit C. legibly. he took the vital signs. Which of the four assessment techniques did he utilize? 1. Accuracy and consciousness 2. potential use of findings C.B. place as asterisk next to the statement. lawyer of the family D.3 & 4 Situation 12: The practice of primary nurse in primary nursing is preferred by many nurses because it supports professional autonomy and accountability of the nurses> 56. serve as a vehicle for communication D. When the nurse writes in the chart and discovers an error has been made. then footnote it D. plans and coordinate the patient care assigned to her from admission to discharge D. Which of the following research activities should you initially do? A. the service director Situation 13: Your nursing unit plans to conduct a study on the use of structured preoperative preparation in lessening the demand for post-operative pain medications. 2. acts as patient advocate and coordinate the health care team for specific group of patients B. comparing client responses with the anticipated outcome Situation 11: The nurse is responsible to accurately records and reports patient’s progress. the holistic approach provides fro a therapeutic relationship continuity of care and efficient nursing care D.
massage d. Seeing that his negative feelings for Mr. Principe asks the nurse to “leave me alone and stop bothering me and I don’t want your pity”. become a better family B. do a physical assessment 73. The research methodology that is appropriate for the above problem would be: A. quasi experimental Situation 14: The nurse meets a new client. One morning when the nurse enters the client’s room. the nurse has to be therapeutic at all times D. Ong You will: A. the nurse will not be able to accurately document that the patient actually took the medication d. 8981 82. “Why you are angry with me? What did I do anything to upset you? D. 10 b. Its functions include all . Ong is for admission to the medical unit and you are his nurse. The nurse understands that the nurse-client relationship is a therapeutic alliance when: A. take his BP before sleeping and upon waking up 9 C. “I understand and will leave you for a while” 70. cradle C. footboard B. relaxation techniques c. When gathering baseline data. A student nurse is observed putting a standard size cuff on an obese client. How does a nurse promote one’s well being? A. Mr. The nurse can be involved with health promotion as a significant person in helping the family: A. The nurse has to deal with his own thoughts and personal feelings about death and grieving in order to: A. the nurse talks about his personal feelings towards the client B. Non-pharmacologic pain management includes all the following EXCEPT: a. Principe reminds him of his strict disciplinarian father who abused him physically. stressful areas D.A.65. periodic travels for rest and recreation B. When assessing a client’s blood pressure. modify health promotive behaviors 78. the Philippine Nursing Act of 1991 or R. over fatigue nights 77. false low C. the nurse finds it necessary to recheck the reading. normative C. 79. bed board D. It specifies that independent practicing nurse is responsible for: a. the nurse uses his awareness and asks to be reassigned to another client D. get self out of the way while he assists the client and his family express their feelings of impending loss C. rehabilitative aspect of care d. the nurse uses self-awareness to manage his feelings and thoughts towards the client 68. the BEST way for you to check if the client has pedal edema is to: A. prevent self from being affected by the family’s grief and remain objective D. Collaborating with other healthcare providers for health restoration and alleviation of suffering 83. The MOST important initial nursing approach when admitting client is to: A. denial B. “You seem upset this morning” and remains with the client B. Shortly after. false high B. 30 c. The nurse is trained to promote well being of the people. “You are probably upset because you don’t feel well” C. control their symptoms D. avoid sleepless. Mr. 9173 b. prevent disease C. take V/S fro baseline assessment 72. introduce the client to the ward staff B. descriptive B. the nurse is a role model for a client B. it is convenient for the nurse c. use of herbal medicines b. The action would probably result in BP reading that is: A. The nurse should NOT leave medication at the bedside because: a. talk to the relatives C. the nurse begins to feel irritated towards the client.A. faithful and observance of healthy simple lifestyle C. The following response by the nurse would be MOST appropriate? A. undetectable Situation 16: Health is wealth specifically in this time of the century. interview the client D. observe his sleeping pattern over a period of time D. Mr. the patient may forget to take it. 7164 c. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure? a. do auscultation B. this law is : a. Principe. normal D. this is an essential part of the nursing process C. You want to know the sleeping pattern of Mr. 71. the nurse suppresses his feelings and continue to take care of the client C. Mr. The Philippine Nursing Act of 2002 or R. The Philippine Nursing Act delineates the scope of nursing. Principe is terminally ill and his family is coping with his impending death. perform physical assessment 74. 60 Situation 17: Safe nursing practice involves an understanding of the law. During the initial interview. how the nurse thinks and feels affects her actions and behavior towards her client and her work Situation 15: Mr. Republic Act No. 81. The nurse realizes the behavior and mannerism of Mr. 45 d. the bedside table is not sterile b. rolled pillows 75. The recognize that his feeling for the client is known as: A. 50 years old. administration of written prescription for treatment and therapies c. body movement 80. 76. experimental D. orient the client to the physical set up of the unit C. the nurse applies the concept of therapeutic use of self when: A. identify the most immediate needs of the client and implement the necessary intervention D. IRR or Resolution 425 of 2003 d. help the family plan for the funeral arrangement and burial services 69. health promotion and prevention of illness b. avoid sharing personal thought about their impending loss and feeling of grief since this is very subjective B. Which accessory device would be appropriate for his condition? A. 66. he becomes uncomfortable and politely leaves the room. Standards of care provide the legal basis for evaluation of nursing practice or malpractice. interview the clients and relatives B. counter transference C. Ong has severe pedal edema. Principe could affect his nursing care. In the Philippines. transference 67. run away from polluted. revenge D.
which of the following statements would be MOST APPROPRIATE? A.EXCEPT: a. maintain maximum functions C. used to measure or evaluate nursing conduct to determine if the nurse acted reasonably as any prudent nurse would under similar circumstances c. promote habits related to health care B. personal B. relatively recent in popularity and oftentimes focuses on maintenance of comfort and satisfactory lifestyle of clients in the terminal phase of illness? A. manage stress 88. intractable D. professional 95. which of the following nursing goals are MOST often overlooked by nurses and other members of the hospital team in the care of their clients in the hospital? A. double-bind communication D. community health center B. 86. In demonstrating the method for deep breathing exercises.____ ------------------------------------------------------------------------------------------------------------------------------- . which of the following is BEST for the patient? A. rehabilitation of patients 89. the same as that of the nurse 94. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting? A. the nurse places the hands on the client’s abdomen to explain diaphragmatic movement. Which of the following health care agencies is usually family-centered. meta communication 93. summarizing clients views 92. which of the following can decrease his chest pain? A. reduce risk factor D. the nurses should remember that a client’s personal space is: A. which of the following will help clients MOST? A. Which communication technique would be MOST effective in eliciting detailed information from the client? A. The ability to answer for and stand by one’s action refers to: a. chronic C. Beneficence b. He constantly complains of chest pain and has a standing order of Morphine SO4. appropriateness C. reduce the costs of health care D. channel B. acute B. supporting his rib cage when he coughs C. create better ways of providing nursing care and develop new nursing roles.A. identify disease symptoms 87. divert the attention by not limiting visitors 98. justice d. give instructions on relaxation technique to reduce frequency of pain sensation D. nonmalifecence 85. verbal communication C. social C. veracity d. accountability c. non-verbal communication B. 9173 C. In interacting with patients. advocacy b. In interpersonal communication is LEAST threatening during what type of relationship? A. Roy is constantly asking to be relieved from pain. encouraging him to breathe deeply 100. By experience. was diagnosed to have pneumonia. open-ended questioning C. Board of Nursing resolution adopting the Code of Ethics Situation 19: One of the professional 91. function and role of the nurse 10 d. As a standard in ethics. With regards to illness prevention activities as part of nursing care. teaching him B. health promotion D. change the clients perception of pain B. highly mobile depending upon certain situation C. administer morphine on a routine schedule as ordered C. Autonomy c. reduce the clients perception of pain C. responsibility Situation 18: An understanding of the factors influencing the health care delivery system will enable nurses to adjust to change. illness prevention C. promote health habits B. this represents an understanding and agreement to respect another person’s right to decide a course his or her own destiny: a. “Is it stubbing or radiating pain?” 99. “ Tell me what your pain feels like” D. Since morphine is an addicting drug. enumerate the source of pain 1 competencies that nurse must always demonstrate is in the area of communication: SET A Seat No. support group 90. change the clients reaction to pain D. used by nurse experts to define what appropriate nursing practice is in a given situation b. Bill of rights as provided in the Philippine Constitution B. the message and the listener? A. Which of the following is the nurse’s primary goal in caring for clients with chronic pain? A. that which revolves around the client B. “Have you taken something to relieve the pain?” B. feedback D. clearly visible to others D. The Code of Ethics refers to standards of behavior or ideals of conduct. Psychosomatic 97. Scope of nursing practice as defined in R. Which of the following MOST appropriately describe pain sensation that has periods of remission and exacerbation? A. advising him D. As the nurse assigned to Ray. Which of the following terms refer to the sender’s attitude towards the self. hospice D. message Situation 20: Roy. active listening B. maintain maximum function C. diagnosis and treatment B. This technique involves the use of which element of communication? A. Which of the following purposes LEAST helps clients in cases of these health promotion activities? A. intimate D. 96. use to measure or evaluate the conduct of nurse specialists who are certified in their own specialty fields 84. used to delineate the scope. “What cause you the pain?” C. administer morphine SO4 PRN B. an adolescent. Patient’s Bill of Rights ( as adopted by American Nurses Association ) D. non-government organization C. To get accurate information about the quality of pain the patient is experiencing. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate services. verbalizing observations D.
Amodia should: A. no dehydration 14. withdrawal C. The primary preventive measures against HIVAIDS is: A. a determination of the study’s feasibility could be extrapolated D. some dehydration D. On reporting to work. the intravenous fluid infused to dilate your uterus does not hurt the fetus D. existing knowledge about the identified problem can be found C. A child who is 13 months has fast breathing if he has: A. walk for at least half an hour daily to stimulate peristalsis 9. Fely has diarrhea for 2 days. health perception and health maintenance 10. convince victims to leave their abusers C. void immediately before the procedure to reduce your bladder size B. eat more frequent small meals instead of three large ones daily D. call her supervisor right away to report the findings 6. help clients become aware that they have control over their lives D. Which of the following is true about discharge planning? A. 40 breaths per minute or more D. drink 8 full glasses of fluid such as water daily B. She is not able to drink and there is no blood in the stool. severe dehydration B. If there develops severe pre-eclampsia. Wuchereria bancrofti B. social isolation C. Ms. chronic low self-esteem B. increased bleeding can occur from uterine pressure on leg veins 13. mycobacterium tubercle C. reading while resting in a trendelenburg position C. wake her son and ask him who would hurt his mother D. a non-steroidal inflammatory agent 7. What instructions would you give her before this procedure? A. complex referral includes interdisciplinary collaboration 3. the research design can be copied from another study 11. anxiety D. the vaccines have been stored at a temperature between 0 deg C and 8 deg C D. you have taken out the vaccine at the health center for some other reasons B. A bilateral amputee is assisted by his wife and children to the commode for bowel evacuation. The infectious agent that causes pulmonary tuberculosis is: A. Hansen’s bacillus D. mycobacterium diphtheria 15. Elimination C. sitting with her feet elevated while playing cards D. STRICTLY NO ERASURE! 1. Martina develops endometritis. the nurse should do which of the following? 2 . helpful information on demographic instrument development could be uncovered B. Maria is developing constipation from being on bed rest. lacerations can provoke allergic responses due to gonadotropic hormone release B. Amodia suspects that either abuse has occurred. When planning teaching strategy for a pregnant woman. a woman is less able to keep the laceration clean because of her fatigue C. Ms. She has sunken eyes. she observes numerous bruise and red marks on her patients face. foams and gels use B. 30 breaths per minute or more B. the vaccines have change its color 4. discharge plans involve referral to community resources C. As a community health nurse you always bear in mind that the purpose of empowering victims of violence is to: A. activity D. ineffective family coping 16. nutrition and metabolism B. Her patient seems upset. Based on this. is an adult survivor who states: “Why couldn’t I make him stop the abuse? If I were stronger person. healing is limited during pregnancy so these will not heal until after birth D. develop safety escape plans for them 8. Why are lacerations of lower extremities potentially more serious among pregnant women than other? A. persistent diarrhea C. Which of the following is the most important reason for doing a literature review for constructing a research study? A. basic discharge plans involve referral to community resources B. simple referral involves use of a discharge planner D. condom use 5. What would be the best activity for her? A. Maybe it was my fault to be abused”. that is why only a small amount is removed C. what would be the drug you would anticipate to be prescribed and that you would have to administer? A. virus killing drugs D. and she is drinking poorly and irritable. the expiry date has not passed C. Grace sustained a laceration on her leg from automobile accident. Maybelle is also scheduled to have an amniocentesis to test for fetal maturity. What measure would you suggest she take to help prevent this? A. 60 breaths per minute C. Amodia. How will you classify Fely’s illness? A. magnesium sulfate D. skin pinch goes back very slowly. who happens to be female resident of the barangay you are covering. no more amniotic fluid forms afterward. lying in bed with a cold cloth on her forehead B. 50 breaths per minute 2. tell them how to solve their problems B. Ms. I would have been able to make him stop. walking around her room listening to music 12.NURSING PRACTICE B: COMMUNITY HEALTH NURSING AND CARE OF MOTHER AND CHILD DIRECTION: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answer sheet provided. the x-ray used to reveal your fetus position has no long-term effects 17. This example best demonstrates the family’s assistance to meet which need? A. make an appointment with an elder adult counselor C. which would be your most appropriate nursing diagnosis? A. increased calcium intake prevents constipation C. RN works for a home health agency and cares for an older adult mental patient. contact the mobile police to investigate the abuse B. drink more milk. A nurse may keep opened vials of OPV for use in the next session if: A. ranitidine (zantac) B. Your client. a loop diuretic C.
Her temperature is 38. has no convulsion and not abnormally sleepy or difficult to awaken. The nurse should instruct her to do which of the following? A. how will you classify her illness? A. Why are small for gestational age newborns at risk for difficulty maintaining body temperature? 4 A. severe malnutrition 27. use plan C if there is bleeding from the nose or gums B. the chin should touch the breast while the mouth is wide open and while the lower lip is turned inward more areola is visible above than below B. Her mother says that Carol is not eating well and unable to breastfeed. a high choking voice B. if you were the nurse in charge of Carol. persistent vomiting. fetal activity stimulates the nerves of the legs and causes weakness C. and Mrs. Braxton Hicks’ Contractions 19. check for the general danger signs 31. they do not have as many fat stored as other infants D. they are more active than usual so they throw off comes 28. increase her intake of carbohydrates-breads and sweets to prevent protein metabolism C. vitamin K to avoid bleeding B. Which of the following could be included in the outcome criteria for a patient with a nursing diagnosis. prevent low blood sugar 30. limit intake of amino acids to prevent development of diabetic ketoacidosis 20. the chin should touch the breast while the mouth is wide open while the lower lip turned outward and more areola visible below than above D. fetal heart rate will remain between 120 and 160 beats a minute C. Which of the following supplies should be readily available for the infant immediately after birth? A. no specific treatments such as antibiotics C. g. additional weight from pregnancy may disturb balance when walking B. Pregnant women should be taught to be careful to avoid accidental injury. teach a woman the care measures necessary for health promotion throughout the pregnancy 18. abdominal bleeding and pain 29. Oxytocin is administered to Rita to augment labor. natural inquiry 26. maternal blood pressure maintained above 150 systolic 22. “Knowledge deficit related to potential for altered tissue perfusion in fetus or mother related to maternal cardiovascular disease”? A. headache and vomiting C. omit information related to minor pains of pregnancy to prevent the woman from developing hypochondria C. very severe febrile disease D. chills and fever D. has reported for her first prenatal visit. provide all information to the woman in a group session with other pregnant women so she can have someone to discuss it with D. the first thing that a nurse should do is to: A. give information about how the woman can manage the specific problems she identifies as relevant in her life B. give ORS if there is skin Petechiae. logical position B. ask what are the child’s problem C. and positive tourniquet test C. jugular vein distention is evident when lying at 45 degrees D. during the first prenatal visit. e. A child with diarrhea is observed for the following EXCEPT: . they are preterm so are born relatively small in size C. eat more dairy products and green leafy vegetables to provide an additional 300 calories each day B. Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever? A. check the patient’s level of consciousness D. quantitative research D. the IMCI chart uses illness classification. a child at a general danger sign C. no urgent measures 24. the chin should touch the breast. appropriate antibiotics B. Which type of research inquiry investigates the issues of human complexity ( e. the pink row needs: A.A. understanding the human expertise?) A. Using the integrated management of childhood illness or IMCI strategy. severe pneumonia B.5 kgs and it is her initial visit. What are the first symptoms of water intoxication to observe for during this procedure? A. 3 months pregnant. check for the four main symptoms B. Bonnie. the mouth is wide open while the lower lip turned outward and more areola visible above than below C. increased adrenalin released during pregnancy causes women to move faster than usual 23. mild soap without perfume so as not to irritate the skin C. frequency of urination C. They are prone to falls for which of the following reasons? A. high levels of hormones often impair judgment resulting in reckless behavior D. varicosities 3 B. the chin should touch the breast while the mouth is wide open and the lower lip turned inward. Which of the four signs of good attachment is true in this statement? A. their skin is more susceptible to conduction of cold B. In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy. urgent referral D. he has no vomiting. bulb syringe to suction fluid and mucous from the mouth D. give aspirin D.g. positivism C.9 deg C. bedrest is maintained at home after the 36th week of gestation B. When a nurse uses the IMCI model. Which of the following symptoms is LESS commonly noted in EARLY pregnancy? A. eat whenever she feels hungry because her body will let her know when she needs nutrients and extra calories D. heating lamp to avoid chilling from water evaporation 21. Carol is 15 months old and weighs 5. The nurse is assisting Mr. more areola is visible above than below 25. a swollen tender tongue D. Cruz to prepare for childbirth in the home setting.
A. Mr. justice and beneficence C. health perception and health maintenance B. Francis will probably deliver very quickly and without problems] B. fidelity and nonmaleficence D. The fetus is in the most common anterior fetal positions D. In asking the mother about her child’s problem the following communication skills should be used EXCEPT: A. While interviewing a woman in labor. Which of the following signs are present in the early stage? A. cognition and perception D. Ms. “Miss. take the baby away as soon as possible after birth to prevent bonding from occurring 45. ask checking questions 40. monitor the woman for shaking and complaints of chill sensations. the acceleration phase of labor can be a time of true discomfort and high anxiety 42. Tony. Such community action should positively influence Mr. monitoring for blood loss greater than 100 cc. and very painful B. coordinated. If a child with diarrhea has 2 or more signs in the IMCI pink row chart. presence of blood in the stool B. those with cavitary lung findings after two successive negative sputum examination C. early labor contractions are usually regular. moderate dehydration C. give the child more fluids B. no dehydration B. remove all coverings except a clean. the use of medications during pregnancy D. continue feeding the child D. the nurse would address which of the following? A. give drugs every 4 hours C. Jordan. cleanse the woman’s anal area. If the capillary refill takes more than 3 seconds it may mean: A. the classification will be: A. “Miss. The nurse locates fetal heart sounds in the upper left quadrant of the mother’s abdomen. If a woman will be placing her baby for adoption. the nurse may have which of the following responsibilities? A. The boys club in his hometown was renamed the Tony boys club. Which of the following conditions is not true about contraindication to immunization? . avoid discussing the baby during the historical assessment to minimize the woman’s anxiety B. This ethical principle that the patient referred to: A. Immediately following episiotomy repair. listen attentively B. they will require no pain medication to manage their pain C. this position is referred to as being left anteriopelvic 43. thickening or painful nerves 39. patients without having been given consent for anti-TB treatment D. All of these C. coping and stress tolerance 48. patients willing to undergo treatment 41. pain medication given during the latent phase of labor is not likely to impair contractions D. the child is alright 38. which may indicate an adverse reaction to medications C. if women are properly prepared. respect for person B. inform when to return to the health center 33. The child with no dehydration needs home treatment. Wash your hands first before getting the bread” 36. pushing down on the relaxed uterus to aid in the removal of the placenta 46. skin Petechiae D. the nurse must consider which of the following? A. the nurse would do which of the following? A. beneficence and nonmaleficence B. noting if the placenta makes a Schultz presentation. Francis is admitted in active labor. which is a sign of gross complication D. palpate the uterus fundus for size. Patients eligible under the short term chemotherapy (STC) are the following EXCEPT: A. autonomy 34. all newly discovered and reconfirmed sputum positive cases B. maternal concerns regarding fetal health B. Tony’s: A. the child is in shock C. the child is dehydrated D. protect the woman from visitors and family members who might try to change her mind D. self-perception and self concept C. it is better to use a pick up forceps/ bread tong” D. which would indicate gross hemorrhage C. the nurse advocate relies on the ethical principle of: A. When patients cannot make decisions for themselves. give time for the mother to answer the question D. severe dehydration 37. RN. you have the responsibility of participating in protecting the health of people. The nurse would recognize which of the following? A. Which of the following is NOT included in the care for home management at this case? A. and a parade is planned to honor Mr. Being a community health nurse. Leprosy is a chronic disease of the skin and peripheral nerves. which of the following nursing measures should be implemented during the labor stages? A. all of the above 44. During the third stage of labor. contractures 5 B. use words that the mother understand C. your hands are dirty. whether the pregnancy was planned C. support the woman as needed by accepting the decisions she makes regarding holding the baby C. loss of eyebrows C. administration of intramuscular Oxytocin to facilitate uterine contractility B. fidelity and justice 35. clawing of fingers D. Tony has been hospitalized for months following special spinal cord surgery. may I get the bread myself because you have not washed your hands” B. This indicates Francis will probably have a breech delivery C. signs of dehydration 32. how long the child has diarrhea C. beneficence C. You do not see them washing their hands. nonmaleficence D. Consider this situation: Vendors selling bread with their bare hands. light hospital gown to prevent the development of postpartal fever 47. believes that a patient should be treated as individual. some dehydration D. then perineum and vulva. to remove any fecal incontinence or vaginal secretions B. circulatory failure B. They receive money with these hands. consistency and position and take vital signs to obtain baseline data D.When planning comfort measures to help the woman in active labor to tolerate her pain. “Miss. What should you say/do? A.
Cavite. Side rails down. brief and limited C. 54. do not give DPT to a child who has recurrent convulsion or active neurologic disease D. How will the nurse explain the importance of immunizing the child with measles now? A. ignore the advance directive . if Arnie is placed in a cold bassinet B. “I was asleep and the next thing I knew I was on the floor”. medical and engineering practices to health services and effectiveness of workers may be termed as: A. B. A literature review should be: A. No complaints verbalized. transfusion and injection B. school health B. Queenie and Quency are twins 5. Tiangco fell out of bed while asleep. all persons of all ages above 1 year with symptoms indicative of tuberculosis C. To implement the case finding aspect of TB control. excessive risk to subject is required B. Barmonte’s lawyer C. With the current condition besetting the Santiago family. if there is a breeze from an open window 53. community health C. The child’s mother does not want her child to be immunized and instead they will just return as soon as the child is better. The side rails on the bed are down. Peter and the twins are enrolled in the day care. the research problem is based on untested nursing theories 50. 250 – 350 ml C. When you asked Mr.H. Rhean is 6. Rolled out of bed while asleep. the identified problem is covered in the literature D. Tiangco what happened. ask if the child has had no convulsion B. urine D. Mr.000. 300 – 500 ml 51. but the nurse is not sure that she can follow his wishes. assist Aling Rosa to be referred to the DSWD for livelihood assistance C. When asked what happened. do not give DPT2 or DPT3 to a child who has had convulsions within 3 days of DPT1 49. Which of the following examples of documentation is MOST APPROPRIATE for this situation? A. if the child is breastfed less than 8 times in 24 hours 59. applied C. What is the usual amount of blood loss with cesarean birth? A. 100 – 220 ml C.O. broad and theoretical D. if the child shows interest in semi solid foods C. the eldest son Rhio is 7 years old. the child will recover faster if the child will be immunized D. Marsha is concerned she may loose an excessive amount of blood with cesarean surgery. both side rails were left down. ask if the child is able to breastfeed D. children 0-9 years old with cough for 2 weeks or more B. Tanza. like all newborns. You have just entered Mr. When should the mother give complementary foods to a 5 months old infant? A. in order to gather data for the research. children below 10 years old with fever for 3-5 days D. The application of public health. all persons ages 10 years and over with progressive loss of weight 62. refer the children to a hospice care facility B. general and context 56. discuss with the interdisciplinary team in charge of Mr. Arnie.00 worth of capital for them to put a fishball stand D. Mr. The nurse should: A. systematic and exhaustive B. experimental B. Rhio and Rhean stopped studying to help their parents for their younger brothers and sisters. Composed of 8 members.500. ask if the child is eating well during illness C. sputum examination should be done to the following groups: A. Tiangco’s room and observed him lying on the floor next to the bed. he replies. Tiangco was found lying on the floor next to his bed. The nurse wants to immunize a 1 year old child for measles. The research typed used of this nature is: A. Barmonte was brought home with an advance directive. follow the directive even though the nurse is uncomfortable with the directives B. Under which conditions is this most apt to occur? A. call Mr. C. it is the child’s schedule to have the immunization 61. which of the following questions SHOULD NOT be included in checking the general danger signs? A. occupational health D. side rails down. can loose body heat by conduction. mental health 55. D. 500 – 1000 ml D. Lying on the floor.00 per day. Which of the following might prevent the conduct of a research study? A. he stated “ I was asleep and the next thing I knew I was on the floor”. Every year we discover new methods or gadgets to improve man’s life. if the nursery is cooled by air conditioning C. Aling Rosa works in a laundry earning Php 1. quantitative 7 58. fecal waste 60.6 A. the child has lower resistance and more prone to disease C. Lying on floor next to bed. ask if the child vomits everything 52. Appears to have fallen out of bed while asleep. Hepatitis A is differentiated from hepatitis B by their mode of transmission. The child has been classified as having pneumonia and no anemia and not very low weight.00 a month and husband Mang Sony works as fish vendor earning Php 150. costs for conducting the study are low compared to the potential benefits from the researcher C. Peter is 4 and the youngest is 6 months old named Oscar. insect bites C. do not give BCG if the child has known hepatitis B. which of the following interventions can lend assistance to them? A. Barmonte and the organization’s ethics committee D. B. if the child gives adequate weight for his age B. If the child is 4 months. The Santiago Family lives in a makeshift house in Julugan. supplementary foods should be given before breastfeeding D. Hepatitis B is transmitted through: A. Mr. developmental D. advise Aling Rosa to use contraceptive pills 57. if the infant is wet from amniotic fluid D. the child’s condition is not a hindrance to immunization according to W. give Aling Rosa’s family a Php 2. do not give BCG if the child has known AIDS C.
encourage each side to share their views with each other 72. What health risk should you warn the family? A. A home visit is a professional interaction between the community health nurse and his patient or the family. none of the above D. Which factor must be considered by the nurse as vital to determine frequency of the home visit? A. The nurse could suggest which of the following foods to increase protein content with little increase in food expenditure? A. The nurse manager wishes to implement a new way of determining the vacation schedule for the staff.” Mrs. When a child with persistent diarrhea returns for follow-up visit after 5 days. the child has 4 semi formed stool C. doctor’s office B. follow-up of medication and treatment B. one of the identified problems is unavailability of toilet facility for the residents. The senior staff opposes the change while the newer staff seems more accepting of the change. the mental status of family and friends 71. In planning a home visit. Gomez shrugs her shoulders and says. Mrs. validation C. Eating habits of the family has changed due to the existing fast food establishment in the area. A positive or negative feeling toward a person. the perceived health status and illness patterns of the family B. A term concerning body resistance which refers to protein present in the serum of the blood: A. 40 breaths per minute C. potatoes and rice D. increase weight B. past nursing services 81. available resources C. antibodies C. 38 breaths per minute B. The following are the concerns of the Public Health Nurse on the third trimester of pregnancy EXCEPT: A. merit C. records and reports D. 3 to 4 months C. the television shows that they watch C. document file C. 6 to 8 months B. Gomez’s reaction is described as: A. needs of all family members C. or idea is known as a/an: A. the nurse should ask the mother if the diarrhea has stopped when: A. clinic schedules after home visit 79. Gomez is unable to budget it over a 4-week period. leave to the BHW the responsibilities of educating the community B. provision of nursing care to the sick and well individuals C. indigestion D. 9 to 12 months 70. the family and all the relative’s statuses D. inquire about welfare and health condition of the client 80. advice for the mother to take oral contraceptive B.63. moral B. Which of the following statement SHOULD NOT be included? A. illness prevention D. The appropriate intervention is: A. the nurse considers the individual needs. food-borne infection C. An 8 month old has fast breathing if he has: A. place the infant in your most convenient position . greet the client or the household members B. type of feeding 75. discovery D. regardless of the staff’s preference B. A community health nurse (CHN) visits the Gomez family weekly. Which of the following is a priority? A. needs recognized by the family D. and a public education program begun is: A. peas and beans 69. one of not caring about her family’s needs C. proper timing in the separation of mother to other siblings D. provision of technical and administrative support to rural health midwives D. it will not be implemented C. explain that the change will occur as designed. this is an example of value: A. policy of the agency D. antigen B. conduct a community assembly and discuss the consequences of this problems 9 77. When the nurse assists the clients in understanding personal values. health promotion C. the child has less than 3 loose bowels per day B. Where could the nurse get available information about the patient or the family to be visited? A. antitoxin D. state the purpose or objective of the visit C. 4 to 5 months D. “Tomorrow may never come. The nurse would suggest the MOST APPROPRIATE age to begin vegetables is: A. A health care service in which risk factors are identified. rice and macaroni B. values. hand washing 82. ask help from local government C. Which of the following is the FIRST action of the nurse during a home visit? A. object. While doing a nutritional assessment of a lowincome family. indicating that her budget needs is a private matter 66. provide extensive and detailed rationale for the proposed change D. oranges and potatoes C. 45 breaths per minute 74. An effective strategy for resolving this difference in acceptance would be to: A. her belief that income may not be adequate as perceived by the CHN D. treatment facility B. value D. A new mother who is breast-feeding her baby asks the nurse when she should start her feeding baby vegetables. the child has 5 formed stools D. Assessment areas for the nurse is working with the family on health promotion strategies would include: A. choice 68. clarification 8 B. and time orientation B. 55 breaths per minute D. give necessary health teaching D. tell the staff that if they really do not want the change. conduct of pre and post consultation conference for clinic patients 73. Although family income seems adequate. occupational safety measures reduce. the community health nurse determines the family’s diet is inadequate in protein content. where to give birth C. In barangay Y. attitude 67. family health record 78. secure donations in the form of toilet bowls B. The following are the duties of the Public Health Nurse EXCEPT: A. the child has 3 loose stools/day 76. rehabilitation 65. allergen 64. To show a mother how to help her to have good attachment of the infant during breast feeding. reflecting her culture. The nurse asks what may be done to help Mrs. acceptance of the family B.
obesity B. what should the nurse do? A. work on its solutions with confidence in the spirit of cooperation. to be considered adequate? A. your supervisor makes masturbatory gestures every time you walk pass him C. administration of BCG vaccine for a 10 days old baby B. are legally binding in all states B. you can have medicine for pain for any contractions cause by the test 87. disengaged 85. and members are highly dependent on one another.____ ------------------------------------------------------------------------------------------------------------------------------NURSING PRACTICE 3A: NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS DIRECTION: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answer sheet provided. attention disorders D. AMV D. tolerance of various lifestyle D. touch the infant’s lips with her nipples C. Which among these activities is the concern of the Primary Level? A. you will need to drink at least 3 glasses of fluid before the procedure C. immobility B. increased rate of chronic disease 10 88. Which of the following is the best type of disease prevention? A. A group of nurses are studying the case of a 16year old nursing student who was accused of frustrated homicide. tertiary prevention C. secondary prevention D. remove the patient’s wound dressings from the home C. Ayuyao. . providing information and skills to maintain lifestyle changes 11 100. check for malnutrition 94. earaches C. Which of the following is a leading health problem of school-age children? A. As a license nurse. primary prevention B. regulate intravenous fluid drop rates 98. Mrs. check for ear drainage B. 77 year old. urgent pre-referral treatment and referral C. The nurse who is planning a health promotion program with clients in the community will have the LEAST focus on: A. community organizing B. check for tender swelling behind the ear C. has been admitted with pneumonia. leadership through traditional leaders 84. accepts death as an outcome of life 1 SET A Seat No. incorporates client perceptions of health when planning care B. community social events B. Tetanus Toxoid 99. simple advice on home management D. What instructions would you give her before her examination? A. how might the nurse best implement infection control? A. encourages behavior modification program C. immunization C. Nurses who deliver community-based care must have which of the following qualities? A. Her husband asks the nurse about the living will. the boss assures you of a big promotion if you go out on a couple of dates with him B. adaptability C. yearly physical exam D. reducing genetic risk factors for illness D. protection 91. enmeshed D. administer diuretics such as furosemide per doctors order D. void immediately before the procedure to reduce your bladder size D. OPV C. move the infant quickly onto her breast. immunization B. lack of information available to patients D. The process is: A. This service would be an example of which of the following types of health care? A. separated C. specific medical treatment 96. twice the width of the conjugate diameter 95. you remember that living wills: A. A holistic belief system by the nurse would be most evident if the nurse: A. government assistance D. connected B. cleanse the hands before and after giving direct patient care B. behavior that promotes health 89. What is the most common type of health problem seen in the health care system? A. Which of the following vaccine in the Expanded Program of Immunization have a 4 weeks interval? A. check for ear pain D. aiming the infant’s lips well below the nipple 83. In classifying the child’s illness using the IMCI color-coded triage. BCG B. the personnel manager hints that the job will be yours if you cooperate sexually with him D. poor prenatal care C. disinfect all work areas in the patient’s home 92. allow the individual to express his or her wishes regarding care D. got to diet question. insertion of a nasogastric tubes to patients C. allow health workers to withhold fluids and medications 86. dispose off patient’s syringes in the patient’s garbage D. organizing methods to achieve optimal mental health C. have the width of the symphysis pubis C. ability to be self-directed B. malnutrition 93. allow the court to decide when the care can be given C. When providing care in a home. You would document this as which level of cohesion: A. A nurse has scheduled a hypertension clinic. When members of the community identify needs. Maybelle is scheduled to have an ultrasound examination. In assessing the level of family cohesion. What size should the ischial tuberosity diameter be. your boss suggests that your “raise” is dependent upon having sex with him 97. 8 cm D. assisting the clients to make informed decisions B. STRICTLY NO ERASURE! 1. nurse’s professional effort C. you have determined that the family is very close and has very high loyalty. all of the above 90. Nona had her pelvic measurement taken. each illness is classified according to whether it requires the following EXCEPT: A. wait until the infant’s mouth is widely open D.B. If the child does not have ear problem. Which of the following is an example of hostile environment in terms of sexual harassment? A. 11 cm B. supports goal-directed learning to improve health D. The intravenous fluid infused to dilate your uterus does not hurt the fetus B.
presence of a neck injury b. apply direct pressure to the laceration to her head b. the nurse teaches the patient with a modified radical mastectomy to prevent lymphedema by: a. justifying circumstances c. The patient is scheduled for adrenalectomy. using an interpreter like a family member 6. One of the reasons why behavior in the OR is so tightly controlled is: a. Upon checking the chart. life and death prior to conception and birth d. De Leon is suffering from Bell’s palsy as indicated by a feeling of stiffness and a drawing sensation of the face. laboratory results and abstract only c. Venipuncture. no administrative support d. Drooling from an increase of saliva on the affected side may occur 11. There may be increased sensitivity to sound b. to prevent the cross-contamination of infection between OR staff and patient 14. accepting committee assignment c. gender choice for children 13. Postoperatively. intake and output d. a nurse at the PACU discovered that Luisa. urinary output c. the gastrointestinal part d. OR reports and patient’s abstract d. There is a heightened awareness of taste. selecting a. The perioperative nurse assumes responsibility and accountability for nursing judgments and actions exemplified by the following. the door of OR suite are closed c. everybody is busy doing their operation d. to Luisa c. Demerol I.” She understands that this type of fluid loss can occur through: a. restlessness d. blood urea nitrogen results 12. A most critical strategy in nursing communication is: a. the same day each month 3. He is transferred from Post Anesthesia Care Unit (PACU) to . Ms. wrapping the arm with elastic bandages during the night 3 b. aggravating circumstances d. ensure the patient has an open airway c. patients come back of their doctor’s advice 18.O. the skin b. shift only d. patency of airway 17. active listening 19. increase instrument inventory 15. urine for glucose and acetone b. spouse choice for children c. b. report to the nurse supervisor for opinion d. check the patient’s vital signs 16. prn for pain”. understaffing b. is found on the floor of her room. politics in the nursing department 8. Ms. treatment orders. In the hospital. so that foods must be bland c. verbal communication d. Mr. EXCEPT: a. symptoms b. it is hard to move around in a OR gown b. In the preoperative period. the nurse places the highest priority on assessment for: a. What should Fe do? a. she found out that Luisa had “Demerol 100 mg I. vital signs c. professional choice of children b. The nurse’s priority action would be: a. Jenny is reading the progress notes of her patient and reads that the physician had documented “insensible fluid loss of approximately 800 ml daily. the 26th day of the menstrual cycle b. T. In teaching her about the disease. accepting on-call assignment b. During admission of a patient with a severe head injury to the emergency department.g. laboratory results. Examples of non-verbal communication in patientnurse relationship are the following EXCEPT: a. 7 to 8 days after conclusion of the menstrual period c. Virtue ethics gives us a special prospective in the parent’s role to decide for their children including decision of: a. OR reports. inject 100 mg. patients come back with referral like their family and friends c. the priority nursing action would be to monitor: a. BP) to the arm on the operative side 10. She is unconscious and has a large laceration to the head that is bleeding profusely.M. x-ray result. patients demand more use of technology d. What one condition besetting the nursing service prevents the use of team approach? a.O. cerebrospinal fluid leakage from ears or nose d. maintaining basic nursing procedure 7.m. verify the order from the M.M. administer the recommended dose which is 50 mg because Luisa weighs 50 kilos 9. exempting circumstances b. giving stereotyped comments c. fast turn-around of nurses c. nurse’s notes 4. avoiding unnecessary trauma (e. laboratory results. The MOST appropriate reply by the nurse would be: a. The eye is susceptible to injury if the eyelid does not close d. notify the physician d. mitigating circumstances 2. exposing the arm to sunlight to increase circulation d. Communication can be verbal and non-verbal. what would be important to tell her? a. W. non-verbal communication 2 b. What is the appropriate approach to this happening? a. has undergone surgery for lyses of adhesions. She fell while crawling over the side rails of her bed. neurological status with the Glasgow Coma Scale c. and surgery technique b. E. is a 30-year old premenopausal female who is asking the nurse the most appropriate time of the month to do her self-examination of the breast. patients recover but spend more on supplies b. 50 kilos who is 3 hours post cholecystectomy was in severe pain. using a sling to keep arm flexed at the side c.M. Fe. install a flush sterilizer in the OR d. “a place for everything and everything in its place” c.D. One of the hidden dangers in the OR is missing instruments. Copies of certain portions of the chart maybe released at the discretion of the hospital but may be limited to: a. the best indicator of quality is: a.Benny can determine their understanding of circumstantial evidence if they can identify which of the following in the case? a. wound drainage 5. signs c. during her menstruation d. correct labeling b.
When questioned by the patient about these options. employed in state colleges and universities b. has about the same 10-year survival rate as the modified radical mastectomy c. cast syndrome b. the blood begins to coagulate c. Maalox and kayexalate d. public support and understanding 23. Mr. the lungs fill with fluid b. complaints of sharp. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a modified radical mastectomy. irreversible kidney failure develops 29. wet cloth to gently wipe away the pus c. compartment syndrome c. irrigate with normal saline for 1 to 15 minutes b. 20 minutes 20. He is very dyspneic and must sit up to breath. provides a shorter treatment period with a fewer long term complications d. Mr. 30. The nurse recognizes that the MOST common causative organism in pyelonephritis is: a. cover the eyes with a sterile gauze 24. deep.the Surgical floor. Hizon has had cataract surgery. the nurse informs the patient that the lumpectomy with radiation: a. glucose negative b. ph 6. special projects with hospitals with a fixed fee c. vanilla wafers and coffee with cream d. confidentiality d. Candida Albicans b. An abnormal condition in which there is discomfort in breathing in any bed or sitting position is: a. dyspnea 21. wearing eye patches for the first 72 hours b. c. 3 minutes c. The initial priority care following the chemical burn is to: a. Klebsiella d. 26. Is it cold inside the 33. K. reduces the fear and anxiety that accompany the diagnosis and treatment of cancer b. turbid d. The primary goal of nursing interventions after a craniotomy is: a. There is a global concern on AIDS. which of the following is MOST crucial? a. Endoscopic minimally invasive surgery has evolved from diagnostic modality to a widespread surgical technique. Who will be with me in the OR? b. Dyazide and carafate 36. employees by private hospitals d. squirt a small amount on the inside of the infected eye’s lower lid b. When reading the urinalysis report. has been admitted with the diagnosis of peptic ulcers.Coli c. medical mission whose services are free 25. Pseudomonas 22. the consent should offer a thorough explanation of the procedures to be done and the consequences of it. How is the post operative pain over the site like? c. pruritus and erythema of the conjunctiva 31. The nurse recognizes which drugs as those MOST commonly used in these patients to decrease acid secretions? a. ensuring patient comfort c. Mr. need for universal testing c. the nurse should obtain blood pressure. crackers with cheese and tea b. intermittent loss of vision c. WT is cleaning the garage and splashes a chemical to his eyes. Licensed nurses from foreign countries can practice nursing in the Philippines in the following condition: a. orthopnea d. Benny elaborated on the concept of informed consent. There are legal and ethical concerns specially: a. brain cells begin to die b. engineering department c. Salvo. assistant surgeon d. halos around lights b. a 35 year old male. The diabetic patient asks for a snack and something to drink. surgeon 28. Who does NOT belong to the sterile OR team? a. Another worthy study is the compliance to the principles of aseptic technique among the sterile OR team. the nurse recognizes this result as abnormal: a. bending at the knees and keeping the head straight d. What department should the nurse collaborate which is unusual in conventional surgery? a. Mr. is diagnosed with chronic bronchitis. x-ray technician b. Tagamet and zantac c. age 13. lifting light objects is acceptable 5 4 d. pulse and respiration every: a. fat embolism 27. The MOST appropriate choice for this client to meet nutritional needs would be which of the following: a. scrub nurse c. In teaching the mother the proper administration of tetracycline eye ointment. eupnea b. graham crackers and warm milk 32. wash hands before medication administration d. transport to a physician immediately c. Following a fracture of the forearm or tibia. erythromycin and flagyl b. Circulation must be restored within 4 minutes of cardiopulmonary arrest because: a. the consent should provide a description of alternative treatments or procedures 38. red blood cells 15-20 c. x-ray department d. Cheyne-stokes c. 30 minutes d. prevention of infection 35. avoiding need for secondary surgery b. duty siblings and spouse b.0 37. do not use other eye ointments or drops or put anything else in eyes. the consent should include the medical diagnosis and explanation of the patient’s condition d. Which of the assessment findings would indicate a need for possible glaucoma testing? a. preserves the normal appearance and sensitivity of the breast. The patient demonstrates knowledge of the psychological response to the operation and other invasive procedure when she asks about: a. use clean. bending at the waist acceptable if done slowly c. Will I be naked during the operation? d. 34. preventing increased intracranial pressure d. 15 minutes b. toast with peanut butter and cocoa c. blood bank services b. He determines that the nurses need more explanation if their response is one of the following: a. gangrene d. presence of floaters d. the consent should describe the prognosis if the recommended care is refused. Discharge teaching would include: a. unrelenting pain in the hand or foot unrelieved by analgesics or elevation of the extremity indicate which complication? a. irrigate with water for 15 minutes or longer d. E. linen section .
call to order d. clinical case b. refer urgently to the nearest hospital d. open system drainage d. determine the appropriate drug and dosage for the child’s age or weight b. The appropriate action of Cathy is: a.K. When the client is discharged from the hospital and is not capable of doing the needed care services. skin discoloration 48. checking the blood pressure and pulse rates each shift d. c. Christian Barnard of Soviet Union d. is surgically attached to the pancreas and infuses regular insulin into the pancreas. then will return as soon as possible c. which in turn releases the insulin into the bloodstream. demonstrate to the mother how to measure a dose d. A nursing intervention associated with this type of patient is: a. During surgery. observing vomitus for color. is being evaluated to rule out pulmonary tuberculosis. a young female executive admitted with bleeding peptic ulcer. the physical property of the hospital c. leg cramps b. age 45. chaplain d. the administration of the analgesic morphine may cause: a. C. and volume 58. b. In medical and nursing practice. advise the mother regarding follow-up after 5 days b. continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels d. A priority nursing assessment to be included in the plan regarding this medication is to assess for: a. c. The professional license of an RN is: a. Dr. Christian Barnard of U. ask the mother to give the first dose of the drug to her child c.S. the nurse focuses on nursing interventions. lifetime d. R. surgeon 46. Which of the following interventions would the nurse employ? a. Cover the client. respiratory effort c. is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals c. closed system drainage 42. frequently monitoring arterial blood levels b. signs of renal toxicity b. urinary output b. the patient owns the record b. code means a call for: a. a misrepresentation c. urinary retention d. tell the mother the reason for giving the drug to the child 53. responsible caregiver 40. A physician has prescribed propylthiouracil for a client with hyperthyroidism. consistency. has satisfactorily completed with the requirements to practice nursing as set by the state. has a baccalaureate degree in nursing c. monitored . Organ donation to save life was initially with the first transplant done by: a. personal 43. Dr. circulating nurse b.O. He bases the response on the information that the pump: a. just a title 41. It is the property of: a. transferable c. hanging system drainage b. addiction c. scrub nurse c. The OR team collaborates from the first to the last surgical procedure. Who is responsible in daily monitoring the standards of safe. Following a renal angiography. b. significant others b. finish the bed bath. The client asks Eddie about the function of the pump.A.N. gives a small continuous dose of regular insulin. signs and symptoms of hyperglycemia c. A nursing aide enters the patient’s room and informs her that another patient is in pain needs pain medication. EXCEPT: a. A nurse develops a plan of care for the client. In evaluating the care of Ms. signs and symptoms of hypothyroidism 56. The patient’s medical record is the best evidence of the care that is given to the patient. 57. green-colored sputum c. a valid signature 45. Cathy is giving bed bath to an assigned client. cardiopulmonary resuscitation 44. the doctor owns the record 54. give a tetracycline tablet c. kept to a minimum c. Dr. ask the nursing aide to stay with the other client while Cathy finishes the bed bath 52. relief of pain d. the following can assume the role. A thumb mark of a comatose patient in the informed consent is considered: a. surgeon c. the health team property d. denotes that a nurse: a. Who monitors the activities of each OR suite? a. a not valid signature b. OR nurse supervisor 6 b. and the client can self-bolus with an additional dosage from the pump prior to each meal. Edna classified the patient as having diarrhea with severe dehydration. Which finding is MOST closely associated with TB? a. Christian Barnard of the Union of South Africa b. chief nurse 51. can be revoked for reasons stipulated in RA 9173 b. Urinary tract infection is the most common site of nosocomial infection particularly with urinary catheterization. 47. intermittent drainage c. night sweats d. movement of personnel should be: a. In patients with acute pancreatitis. raise side rails. spasms of the sphincter of Oddi 50.39. It can be reduced significantly by through: a. “nothing” d. perioperative nurse d. anesthesiologist d. give vitamin A 55.. then administer the pain medication d. Which of the following health teachings by the nurse will be MOST appropriate in home medication administration? a. ask the nursing aide to continue the bed bath after asking the permission of the patient so Cathy can attend to the other client b. paralytic ileus b. puncture site 49. O. DNR state c. checking the patient’s low residue diet.. family members c. Dr. tell the client that Cathy has to administer the pain medication first. An external insulin pump is prescribed for a client with with diabetes mellitus. Ms. nursing practice in the operating suite? a.P. the patient assessment priority is the: a. blood pressure d. is professionally ready to practice nursing d. Christian of the U.
O. whole milk. prudence d. NPO 74. first case. pat dry. This right is achieved through: a. double effect 75. Which is a deterrent factor in written communications? a. Each has its own limitations. respirations 18 and regular 60. 72. Which of the following data from the nursing history indicates that the anemia is NOT currently managed effectively? a. A nurse is waiting for a report to be sent by fax. decreasing diameter d. or verbal response from the family. cut the photograph and throw it away. “I should eat a diet high in fiber and roughage to decrease my constipation. report swelling. Reusable supplies/instruments are still widely used in the Philippine OR setting. honesty 8 b. suicide tendencies b. perineal pad c. vaginal packing d.. Mr. it encourages the constructive use of the pleasure of the senses d. it refers to the quality of being righteous.” d. eliminated when possible 7 59. call the nursing supervisor and report the incident b. anesthesia b. F. will be a signal to the nurse that the instructions need to be reclarified? a. fax d. correct. F. Which of the following trays would be acceptable for her? a. A mother who is pregnant and has ovarian cancer has to undergo surgery to treat the cancer. fair and impartial 63. the nurse received a sexually oriented photograph.b. exception to the role b. restricted d.F. A clear advantage of single-use items is: a. transmission of infection during processing is avoided b. use hydrogen peroxide and rinse with water. informed consent c. Communication can take many forms. It is MOST important to assess the adolescent with acne for: a. liver. Which of the following would be MOST effective in promoting adequate respiratory function in an unconscious client recently admitted to the PACU with no contraindications to movement? a. OD d. Which of the following statements is NOT one of the strengths of nonexperimental designs? a. charting b. performing jaw thrust maneuver while client is supine 61. can be completed in a short span of time b. Monica shared with the interviewer her most recent experiences about a restless pediatric patient whom she puts up the side rails of the bed to prevent accidental falls. convenience c. change in weight c. not sterile. NNO b. Which of the following attributes is shown by Monica? a. The MOST appropriate nursing action is to: a. fried potatoes and avocado b. easier to gain cooperation of study subjects 71. dietary d. As the nurse in-charge for scheduling you will collaborate with the following departments EXCEPT: a. “If I miss an occasional dose of the medication. vaginal suppository b. age 52 had a laryngectomy due to cancer of the larynx. low self esteem d. turning the client from side to side at 10-minute interval c. smooth surface c. Dr. “I need to be sitting straight up and my chin slightly tucked so I won’t choke when I eat or drink. suicide tendencies b. pathology c. PRN c. it reflects the moral values and beliefs that are used as guides to personal behavior and actions c. Which response by written communication from Mr. less expensive c. anatomy d. extending client’s chin while on his side and pillow at the back b. c. Ms. It is important to teach the patient the warning signs for skin cancer. Dee is a 27-year-old housewife and mother of two children. e-mail c.X. placing the client prone to facilitate drainage of secretions d. thoughts and emotions in the face of difficulty b.” 67. and his family. mole symmetry 66. The doctrine that justifies the death of the fetus is: a. call the police d. pallor c. guaranteed first class quality d. She is being seen by the nurse at the health maintenance organization for signs of fatigue.” c. XP underwent D and C for dysfunctional bleeding. which response would indicate the need for further education? a. increase intake of fatty foods 68.O. it assists in the control of feelings. pain or excessive drainage d. She has the history of iron deficiency anemia.O.” b. Which of the following is a warning sign of cancer? a. The machine activates but instead of the report. Which statement about a person’s character is evident in the OR team? a. rice and pastry . In teaching the patient with Parkinson’s disease. preoperative visit d. “I need to exercise at least some everyday. poor skin turgor d. useful for predictive purposes d. 65. cleans skin around stoma BID. justice c. Mrs. E. surgery 73. Poe for a right breast mass incision with frozen section and possible mastectomy on Monday. Ms. Tuazon scheduled Mrs. What is inserted vaginally to prevent postoperative bleeding? a. border irregularity b. reliability 70. doctor’s rounds 62. it is not of much significance. Which of the following is NOT a standard abbreviation? a. monitored b. it is acceptable to take over-the-counter medications now that condition is stable b. so does non-experimental researches. call the unit who sent it and ask for the name of person who sent the photograph 76. integrity and functionality is assured. The patient has a right to information regarding the operation or other invasive procedure and potential effects. use of non-universal abbreviation 69. has been admitted with right upper quadrant pain and has been placed on a low fat diet. the suctioning at home must be a clean procedure. c. Charting should be legible and include only standard abbreviations. In the process the fetus died. As experimental research designs have their strengths. gelfoam 64. Discharge instructions are given to Mr. resourcefulness c.
the ophthalmologists administers phenylephrine 2. keeping patient NPO until gag reflex returns . A client with colostomy d. repeating the order message c. shelf life c. use of facemask b. but the patient must take medication for at least 10 years. Rita is assigned to care for group of patients. “Yes. ham. “No. skim milk. surgeon c. revocation of license by the DOH d. restructure OR scheduling system b. speaking distinctly using enough volume 9 79. At present. What is this procedure called? a. let the patient know that the family will be kept in formed c. surgical attire intended only for use within the surgical suite should be worn within the: a. In preparing the patient for endoscopic examinations of the upper GI tract. yes people. According to AORN recommended practices. “My husband and I have been using vaginal lubrication before my intercourse” c. improve instrument decontamination d. “My lips are dry an d cracking. pre-anesthetic drugs c. In providing general information and assessing the patients level of interest or reaction to surgery. pre-operative visit d. offer general information about the surgery 93. it has been found out that music can decreases anxiety. What other factors can reduce anxiety that is currently done among postoperative cases? a. revocation of license by the BON c. Que. 61 years of age is suffering from rheumatoid arthritis. S. but new drugs being developed can interfere with the body’s reaction to inflammation and better control the disease process. In the event of a fire. Nursing interventions for postendoscopic examination include: a. prone with the head turned to the side and supported by a pillow b. He asks if there is a cure for RA.” d. Maria is administering a cleansing enema to a patient with fecal impaction. This is researchable. run 94. Rest b. revocation of license by the Nursing Department 78. Mr. explain details of perioperative preparation with a tour and viewing of area and equipments d. we have to become one these and influence other: a. Rescue c. she should place the patient in which of the following positions? a. tapioca pudding 77. A research on “Surgical Instrument Availability” will help the surgical team: a. lean fish. on the right side of the body with the head of the bed elevated 45 degrees b. restricted area only c. most patients with RA also develop osteoarthritis. “I check my mouth and teeth after each meal” d. dilate the pupil d. removed any obstruction on the cornea 85.” 91. streamline instrument inventory c. bio-med technician d. Lying in bed on the unaffected side with the head of the bed elevated 45 degrees 84. integrity and functionality after each use and processing 90. restricted semi-restricted and unrestricted areas b. effective followers b. A client with decreased kidney function 92. A client receiving frequent wound irrigations c. Kelly identified five categories of followers in an organization: sheep. new drugs being developed offer a cure. “No. respond d. cream peas d. is the responsibility of the: a. cost b. a low platelet count and a hemoglobin measurement of 5.R. Maria will be preparing a patient for thoracentesis.” c. Sim’s position with the head of the bed flat d. handwashing c. which criterion is evaluated? a. alienated d. anesthetize the cornea c. revocation of license by the Ombudsman b. When a patient comes to the clinic for an eye examination.” b. One way of verifying that the right message/doctor’s order was communicated effectively is by: a.c. If we choose to be successful nursing professionals. “I’ve been very constipated and need an enema” 86. survivor and effective followers. shower prior to surgery b. “YES” people c. ensure efficient completion of surgical instrument 81. Negligence in the practice of nursing can be a ground for: a. The MOST appropriate response is: a. the patient’s pharynx is anesthesized with Xylocaine spray.O. brain washing 89. right Sim’s position 82. dilate retinal blood vessels b. which of the following nursing intervention will received priority? a.5% drops to: a. she determines that which patient is at risk for fluid volume deficit? a. What does R stand for? a. operating room only d. documenting d. Which of the following statements by Ms. reusability d. A client with CHF b. left Sim’s position c. phrasing intelligently b. OR staff are instructed to follow the international RACE. scrub nurse 83. I need some lubricant” b. sheep 80. alienated. To ensure quality of these instruments. lying in bed on the affected side with the head of the bed elevated 45 degrees c. Surgical instruments are expensive and are a lifetime investment of the O. on the left side of the body with the head of the bed elevated 45 degree d. restricted and semi-restricted areas 10 88. mashed potatoes. a chemotherapy patient with a low WBC count. The functionality and integrity of instruments and medical devices used in surgical procedure. On review of the patient’s medical record. She should assist the patient to which of the following positions for the procedure? a. A heavily researched topic in infection control is about the single most important procedure for preventing hospitalacquired infections. Before administering the enema. Patients undergoing surgery display different levels of anxiety. use of scrub suite d. “Yes. OR nurse b.6 g would indicate the need for further teaching? a. tell the patient when the surgery is scheduled b. presence of any members of the family 87.
avoid situations that involve physical activity D. use OTC vitamin D preparation b. Modern medicine has divided the human body into different systems/organs or the so called “specialty medicine practice”. facilitate lateral positioning of the breast Situation 2: Ensuring safety is one of your most important responsibilities. reinsert another tubing immediately C. seek early treatment for respiratory infections 1 rioSET A Seat No. you should instruct her to: A. balance the breast tissue more evenly on the chest wall D. multiple specialty c. prohibiting smoking before the test c. After pelvic surgery. LM has chest tube attached to a pleural drainage system. compartmentalized body 96. DILG d. Which of the following should NOT be included in the list? a. DOH b. clamp the chest tube when suctioning 7. STRICTLY NO ERASURE! 2 C. recognize that prompt closure of the tracheal opening . take showers instead of tub bath 9. the sign that would be indicative of a developing thrombophlebitis would be: A. When caring for LM you should: A. a physician conduct a breast clinical examination every 2 years 2. When preparing to examine the left breast in a reclining position. change in size and contour 5. use birth control to avoid pregnancy Situation 1: It is Cancer Consciousness Week and you are participating in an Early Cancer Detection Drive of the Department of Health. considerate and respectful ca re c. The purpose of performing the breast self examination (BSE) regularly is to discover: A. on the same day of each month C. If you are to instruct a postmenopausal woman about BSE. right after the menstrual period D. He would become MOST concerned with which of the following signs which could indicate an evolving complication? a. areas of thickness or fullness B. 11 98. To prevent recurrent attacks on FT who has glomerulonephritis. relevant current and understandable information concerning diagnosis. He is now for discharge. 6. pruritus on the calf and ankle D. when would you tell her to do BSE: A. MMDA 1. hypoactive bowel sounds in all four quadrants 99. The Patient’s Bill of rights helps practitioners provide more effective patient care. KN is monitoring the status of a postoperative patient. an annual hormone receptor assay C. a negative Homan’s sign b. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency? a. allowing fluids up to 4 hours before examination 95. be informed of administrative and policies and practices b. a tender.____ ------------------------------------------------------------------------------------------------------------------------------- NURSING PRACTICE 3B: NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS DIRECTION: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answer sheet provided. lumps in the breast tissue B. the mainstay for early detection method for breast cancer that is recommended for developing countries is: A. BP of 110/170 mmHg and a pulse of 80 beats per minute c. Collaboration of the specialists will in effect treat the client as: a. What would you teach him FIRST? A. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE) B. axillary D. supplement calcium intake d. multi-organ d. one whole human being b. on the first day of her menstruation B.b. palpate the surrounding areas for crepitus D. a pitting edema of the ankle B. avoid strenuous ex ercises c. An important nursing intervention goal to establish for Mang Carlos who has iron-deficiency anemia is: a. cancerous lumps D. You will need to provide instruction and information to your clients to prevent complications. alternate periods of rest and activity to balance oxygen supply and demand b. decrease fluids to prevent sickling of RBC’s d. During breast self-examination. specific procedures treatment and risks involved. an annual mammogram D. increase fluids to stimulate erythropoises c. a reddened area of the ankle 8. Discharge teaching for the client with hypoparathyroidism should include which of the following instructions: a. increasing restlessness d. continue to take the same restrictions on fluid intake B. bring the breast closer to the examiner’s right hand B. thickening of the tissue C. tense the pectoral muscle C. fibrocystic masses C. He verbalized his concern regarding his laryngectomy tube being dislodged. painful area on the leg C. withholding anticholinergic medications d. 100. change the dressing daily using aseptic technique B. the purpose of standing in front of the mirror it to observe the breast for: A. confidentiality of communications and records d. Records Management and Archives Office (RMAO) c. empty the drainage system at the end of the shift C. avoid diuretics to minimize calcium loss 97. GT had a laryngectomy. Based on the DOH and World Health Organization (WHO) guidelines. treatment diagnosis. the purpose of placing a small folded towel under the client’s left shoulder is to: A. changes from previous BSE 3. on the last day of her menstruation 4.
chest tube drainage C. 16. you must observe KJ for signs of rejection which includes: A. When caring for TU after an exploratory chest surgery and pneumonectomy. PET Scanning – may reveal information on cerebral metabolism and blood flow characteristics. Recently. second degree burn C. Which of the following is the MOST common cause of stroke or brain attack? A. 28 years old with chronic renal disease plans to receive a kidney transplant. burn shock B. it may be the results of a transient ischemic attack (TIA) 22. your PRIORITY would be to maintain: A. After the kidney transplant. edema provides a milieu for bacterial proliferation D. first degree or superficial burns 12. 21. To prepare for this assignment. severity of damage C. neurogenic shock D. avoid wearing canvas shoes C. Edema presents a significant problem in burn wounds because: A. Which statement by KP indicates a lack of understanding about his rights as a research study participant? A. treat transient ischemic attacks (TIA) early C. for the rest of my life 17. 11. 3 19. How would you respond to him? A. Which statement 26. KJ. intravenously 14. artery affected B. Which of the following statements can BEST describe/define stroke or brain attack? A. avoid use of cornstarch on the foot . DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators. Critically ill patients are at high risk for the following complication during the emergent phase: A. laryngeal spasms and swelling Situation 4: You are assigned to take care of four by DS indicates the need for further teaching before true informed consent can be obtained? A. When teaching a client with peripheral vascular disease about foot care. “a wire from the generator will be attached to my heart” B. cerebral arterial spasm B. subcutaneously D. you should be able to answer the following questions. FB tells you “I want to go off dialysis. the extent of collateral circulation 25. C. Several diagnostic tests may be ordered for proper evaluation. loss of protein prevents tissue repair B.B. painless. maintain serum cholesterol level between 220 and 180 mm/dL B. it is also important for you to remember that the clinical features of stroke vary with the following factors EXCEPT: A. “ I understand the risk associated in this study” C. You have been ready to provide holistic care for patients with severe burns. embolism C. drug abuse) to children of patients with stroke D. moon face and muscle atrophy 18. and leathery in texture describes a: A. orally B. take a sit next to him and sit quietly A. hemorrhage D. 23. screen for systolic hypertension Situation 6:Foot care among patients with peripheral vascular problems is very important. “this implanted defibrillator will protect me from those bad rhythms my heart goes into” 20. supplementary oxygen Situation 3: Severe burn is one of the most devastating kinds of injury one can experience. it occurs when circulation to a part of the brain is disrupted B. shock B. KP is participating in a cardiac study in which his physician is directly involved. hematuria and seizure D. until the supply is over B. Now. notify the physician at once emergency 10. intramuscularly C. edema impedes tissue perfusion/oxygenation C. who is to have a kidney transplant asks you how long will he take azathioprime (Imuran). “I can withdraw from the study anytime” D. FB. stress ulcers C. To guide you in your assessment. hemorrhage D. A burn that is white. alcoholism. such as focal slowing and assess amount of brain wave activity. “I wonder if there is another way to protect these bad rhythms” D. Cerebral Angiography – is used to identify collateral blood circulation and may reveal site of rupture or occlusion B. “the physician will make a small incision in my chest wall and place the generator there” C. you should include which instructions: A. during the preoperative period D. gender D. teach preventive health behaviors (consequences of smoking. The purpose of each of the following diagnostic examination is correct EXCEPT: patients with different conditions. until the anastomosis heals C. “My confidentiality will not be compromised in this study” B. hematoma and shift of brain structures D. deep partial thickness burns B. cyclosporine and prednisone? You recognized that KJ understood the teaching when he states. third degree or full thickness burn D. ECG – may reveal abnormal electrical activity. “ I’ll have to find a new physician if I don’t complete this study” Situation 5. edema can produce a tourniquet effect 15. The MOST effective method of delivering pain medication during the emergent phase is: A. thrombosis 24. tell FB that “ Treatments are only three times a week. it is caused by a cerebral hemorrhage D. blood replacement D. it is usually caused by abuse of prescribed medications C. fever and weight gain C. You are assigned in the neurology stroke unit. polyuria and jaundice B. obesity. ventilation exchange B. tell FB that “ We all have days when we don’t feel like going on” C. FB was told by his physician that he was a poor candidate for transplant because of his hypertension and diabetes mellitus. I’d rather not live than to be in this treatment the rest of my life”. It is important for you to also teach clients and their families who are at risk to observed primary prevention which includes the following EXCEPT: A. myocardial infarction C. you can live with that” D. MRI – may reveal the site of infarction. It can affect any group. contractures 13. keep calm because there is no immediate D. Which of the following can be a fatal complication of upper airway burns? A. “I must take these medications: A. leave the room and allow him to collect his thoughts B.
diabetes insipidus Situation 7: You are assigned to take care of a 36. avoid using a nail clipper to cut toe nails D. Shortly after being admitted to the CCU for acute MI. sense of control to life 5 38. TD with dry skin and dry mucous membranes has had a urine output of 600 m and a fluid intake of 800 ml. Inspection and palpation reveal absent pulses. TR has been on morphine on a regular basis for several weeks. keep the bedpan available so she does not have to get out of bed C. shave the affected leg in anticipation of surgery C. informed consent and treatment refusal? A. Nurses who work with critically ill patients should base their practice on all of the following EXCEPT: A. becoming psychologically dependent C. you should evaluate for opioid side effects which include the following EXCEPT: A. Nursing Practice Act D. effectiveness for patient C. placing the call light for easy access D. vitamin supplement B. Imbalanced nutrition: less than body requirement 42. decreasing environmental noise C. are most acceptable to burn out B. heart rate of 10 beats/min. comes to the emergency room complaining of sudden onset of lower leg pain. You are caring for GG with a history of falls. under treatment of pain is often due to a clinician’s failure or inability to evaluate or appreciate the severity of the client’s problem D. The guidelines for choosing appropriate nonpharmacologic intervention for pain include all of the following EXPECT: legal purposes. slightly diaphoretic. motor functions 29. you have important responsibilities to accurately document all nursing activities. experience greater stress 37. pruritus C. good glucose control C. As a nurse caring for patients in pain. recognition and appreciation of a person’s unique and social environmental relationships B. encouraging normal bowel movement D. needing to have the morphine discontinued B. You notice that JJ is restless. you would suspect that TR is: A. liver disease B. Which of the following statements about cancer pain is NOT true? A. specific pain management choices based on severity of pain B. The WHO analgesic ladder provides the health professional with: A. there is no slowing the process 30.B. Impaired urinary elimination C. Pain and urinary incontinence are their common concerns. general pain management choices based on level of pain C. Research study show that nurses who work with critically patients as opposed to nurses who work with less acute patient: A. thorough knowledge of the interrelatedness of body system D. appreciation of the collaborative role of all health team members 39. 41. developing tolerance to the morphine D. move a greater support system D. anti convulsants. optic functions B. pain problem identification D. For the past 24 hours. Common aspects of the critical care nursing role include: A. cadaverous left calf. delegated responsibility C. are more satisfied with their role C. steroid therapy D. a sense of control over the patient B. dimming light during normal sleeping time Situation 9: To ensure continuity of care and for group of elderly patients. Excessive fluid volume B. 31. who has no known history of peripheral vascular disease. While the physician determines the appropriate management. direct care provider B. paresthesia and a mottled. nothing. vascular functions D. Which document addresses the patient’s right to information. adjuvant medications such as steroids. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. staff liaison D. nonpharmacologic interventions based on level of pain 32. Which of the following interventions would support your patient’s circadian rhythm cycle? A. physical dependence 33. sensory functions C. avoid wearing cotton socks 27. constipation B. perception of change D. The FIRST PRIORITY when caring for GG who is at risk for falls is: A. respiratory depression D. . community referral 40. cold. Code for Nurses C. instruct GG not to get out of bed unassisted B. JJ reports midsternal chest pain radiating down the left arm. hyperthyroidism D. Deficient fluid volume D. You should be able to address their concerns in a holistic manner.. TD’s urine is dark amber. place a healing pad around the calf D. FT. Assuming that nothing has changed in his condition. Standard of Nursing Practice 43. pharmacologic and nonpharmacologic pain management choices D. opioids are drugs of choice for severe pain B. pain associated with cancer and the terminal phase of the disease occurs in majority of patients C. elevate the affected calf as high as possible 28. less commitment to work C. keep the bed at the lowest position ever 44. These assessments indicate which nursing diagnosis? A. nonsteroidal anti-inflammatory drugs enhance pain perception 34. putting a wall clock up on your patient’s room B. you should look into factors that will enhance your ability to provide quality nursing care. type of opioid being used Situation 8: To be able to provide care for patients in the critical areas. skill of the clinician health professional B. Peripheral neuropathies primarily affect: A. cyanotic.8 deg C. exaggerating his level of pain 35. Which of the components of HARDINESS has been linked to burnout? A. you should: A. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also develop in a client with: A. disaster management C. and has a temperature of 37. hypertension C. keep the affected leg level or slightly dependent A. Patient’s Bill of Rights B. Peripheral neuropathy can BEST be controlled by: A. 4 B.
The primary purpose of the endotracheal tube cuff is to: A. An endotracheal tube had to be inserted to correct the hypoxia. FF correctly identifies three potassium rich foods D. has a nursing diagnosis of “Risk for injury related to adverse effects of potassium-wasting diuretics”. retrograde bacterial contamination may occur c. who sustained 40% severe flame burn yesterday. FF knows all the complications of the disease process Situation 10: You are taking care of LC who develops acute respiratory distress. acute pain B. the length of the person’s airway 53. which among these interventions should be your PRIORITY? A. it seals off the nasopharynx from the oropharynx D. To assess her risk factors. aseptic wound care c. adequate wound healing Situation 12: Infection can cause debilitating consequences when host’s resistance is compromised and environmental factors are favorable. 6 48. wound healing c. Impaired urinary elimination related to fluid loss c. creating a stomal orifice from the ileum . EF was admitted to the hospital with a tentative diagnosis of acute pyelonephritis. keep skin test areas moist with mild lotion. keep the body parts in good alignment to prevent contractures C. discouraging pillows behind the head 54. Situation 13: TR attends a Health Education severe burns. What will be your PRIORITY nursing action? a. the internal diameter of the tube C. the length of the person’s airway D. it prevents stomach contents from getting into the lungs 49. 46. FG. the length of the tube D. In adults. Impaired body image related to physical appearance 55. management requires a multidisciplinary approach. Upon discharge. you observe for signs of systemic response. A colostomy can BEST be defined as: a. the internal diameter of the tube B. seal off the lower airway from the upper airway 47. cutting the colon and bringing the proximal end through the abdominal wall b. of reduced amounts of oxygen and nutrients are available 60. dead space and dead cells provide a culture medium b. Which action is MOST likely to cause a functional contracture? a. anxiety D. 51. FF states the importance of eating potassium rich foods daily B. Ineffective airway clearance related to edema d. When caring for DS. the circumference size of the tube C. encouraging self-care d. The following are taken up: types of ostomies. a febrile state due to release of pyrogens b. anorexia. Endotracheal tube size indicated on the tube reflects what measurements: A. it seals off the lower airway from the upper airway B. hourly hyperextension neck exercises b. One of the MOST effective nursing procedures for reducing nosocomial infection is: a. provide a calm. the circumference size of the tube B. Which nursing diagnosis takes HIGHEST PRIORITY? A. 61. These include all of the following EXCEPT: a. the length of the tube 50. come back on the specified date to have the skin tests read c. with a full thickness burns involving entire circumference of an extremity will require frequent peripheral vascular checks to detect: a. slightly labored respirations at 26 breaths/min and a blood pressure of 150/90 mmHg. loss of appetite and pain d. stay out of the sun until the skin tests are read b. assess the injury for signs of sepsis 52. Upon discharge.regular. efficient and safe environment B. proper handwashing technique b. What’s the correct written client outcome for this diagnosis? A. fluid resuscitation Class on colostomy care. and weakness c. seal off the oropharynx from the esophagus B. arteriosclerotic changes b. artificial airways must be secured directly to the patient B. ischemia d. what question should you ask? a. control of upper respiratory tract infection d. seal off the lower airway from the esophagus D. You are instructing EP regarding skin tests for hypersensitivity reactions. wash skin test areas with soap and water daily d. A wound that has hemorrhaged has increased risk for infection because: a. emotional support b. the inflated cuff provides sufficient securing Situation 11: Because of the serious effects of 56. Risk for infection related to epidermal disruption b. “Have you taken any analgesic recently?” b. FF knows which food sources are rich in potassium C. hypothermia c. risk for imbalanced body temperature 45. assess for airway. it prevents air from getting into the stomach C. You have important responsibilities as a nurse. CV who sustained upper torso and neck burns. indications and care. FF. 3 year old boy just sustained full thickness burns of the face. helping the patient to a position of comfort c. breathing and circulation problems D. Which of the following statements is TRUE about securing the artificial airway? A. reconstructive surgery d. administration of prophylactic antibiotic 59. “Have you had any sore throat lately?” 7 57. Your primary therapeutic goal for DS during the ACUTE PHASE is: a. AW. the tissue becomes less resilient d. While caring for a patient with an infected surgical incision. leukopenia due to increased WBC production 58. As a nurse you have important roles and responsibilities in infection control. “Do you hold your urine for a long time before voiding?” d. Endotracheal tube size indicated on the tube reflects what measurements: A. decreased cardiac output C. seal off the oropharynx from the nasopharynx C. an inflated E-T tube cuff is necessary for mechanical ventilation primarily because: A. chest and neck. the airway is generally sutured in place C. malaise. You should teach her to: a. “Do you have pain at your back?” c. a nasotracheal tube does not require securing D.
During the 24 hours. On the second day following abdominoperineal resection. risk for infection 77. corn and peanuts c. chewing gum and carbonated beverages 64. notify the physician b. your nursing diagnosis is: a. pale pink and with flushed skin d. prevent irritation of the intestinal mucosa b. Following thoracic surgery. As a nurse of BL which of the following nursing diagnosis will be your PRIORITY? be done when lung cancer is detected early. intermittent bubbling through the long tube of the suction control bottle. You are assigned to take care of a patient with such a condition. facilitation of coughing c. a presurgical decrease in fluid intake c. you anticipate that the colostomy stoma will appear: a. less than 25 ml drainage in the drainage bottle b. Several days prior to bowel surgery. the patient will not be able to tolerate coughing c. You explain to BC that this is necessary to: a. with renal stones. soften the stool by retaining water in the colon b. as the nurse should realize that this is a result of: a. dry. you should encourage BC to assume: a. moist. Before surgery. BL was brought to the Emergency Room for severe left flunk pain. imbalance nutrition: less than body requirements b. During the first post operative week. red and raised above the skin surface c. Based on the above data. a low residue diet is ordered. double-barreled 63. Her urine is dark amber. moist. When an abdominoperineal resection is done. clamp the tubing 75. knee-chest position 69. the bronchial suture line maybe traumatized 74. splinting the patient’s chest with both hands during the exercises b. reconnect the tube c. placing the patient on his/her operative side during exercises 73. removing the rectum and suturing the colon to the anus. excising a section of the colon and doing an endto-end anastomosis d. changing the dressing just prior to meals b. What should you do as a nurse when the chest tubing is accidentally disconnected? a. proper functioning of the nasogastric tube d. reduce the bacterial content of the colon c. promote rest of the bowel by minimizing peristalsis 68. the remaining normal lung needs minimal stimulation b. dry. You. cabbage and asparagus d. Which of the following observations indicates that the closed chest drainage system is functioning properly? a. transverse loop colostomy b. imbalance nutrition. the absence of intestinal motility b. To promote perineal wound healing after an abdominoperineal resection. The purpose of closed chest drainage following a lobectomy is: a.c. prevention of mediastinal shift d. fluid volume deficit . expansion of the remaining lung b. The physician gave a tentative diagnosis of right ureterolithiasis. mangoes and pineapples b. left or right side lying position d. encouraging the patient to observe the stoma and its care c. acute pain d. absence of bubbling in the suction-control bottle c. the patient should be informed he/she will have a. empty the bowel of solid waste d. deodorizing the room periodically with a spray can d. temporary colostomy c. intestinal edema following surgery 70. purple and depressed below the skin surface Situation 15: Specific surgical interventions may 71. dorsal recumbent position b. you can BEST help GM to reduce pian during the deep breathing and coughing exercises by: a. inserting an indwelling urinary catheter b. promotion of wound healing 72. nausea and vomiting. 9 Situation 16: Renal stones can cause one of the most excruciating pain experienced by a patient. 76. 30 year old business woman. 66. with flushed skin and painful when touched b. reduce the amount of stool in the large bowel c. providing rest for 6 hours before exercises d. deep tracheal suction should be done with extreme caution because: a. BC returns from surgery with a permanent colostomy. applying a large bulky dressing over the stoma to decrease odors Situation 14: These are gastrointestinal disease that can compromise life and that would necessitate extensive surgical management. change the tubing d. You have important perioperative responsibilities in caring for patients with lung cancer. the patient may be given sulfasuxidine and neomycin. permanent colostomy d. As the nurse of BL which of the following nursing diagnosis will be your PRIORITY? a. GM is scheduled to have lobectomy. the fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration d. the tracheobronchial tree are dry d. administering opioid analgesics preferably intravenously c. limit production of flatus in the intestines d. A colostomy patient who wishes to avoid flatulence should not eat the following EXCEPT: a. You are caring for YA. impaired urinary elimination c. primarily to: a. inserting a nasogastric tube (low suction) 78. administering intravenous solution at a keep vein open rate d. During the immediate post operative period following a pneumonectomy. 62. a. administering the prescribed analgesic immediately prior to exercises c. left or right Sim’s position c. Which of the following is the appropriate intervention for BL who has ureterolithiasis? a. the nurse can BEST help the patient with a colostomy to accept the change in body image by: a. Her skin and mucous membranes are dry and her 24 hour intake and output record reveal an oral intake of 900 ml and a urinary output of 700 ml. less than body requirements b. BC diagnosed with cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. the colostomy does not drain. lower the bacterial count in the GI tract 8 67. pink.
Why do you think you had a heart attack? b. add the total amount of blood to be transfused to the intake and output B. What . risk for injury C. impaired gas exchange D. discontinue the primary IV of Dextrose 5% Water C. What will be your PRIORITY intervention? a. check IV site and use appropriate BT set and needle D. immediately stop the BT. urticaria and wheezing D. increased urine output. As WQ’s nurse. risk for injury D. Which assessment parameter for kidney function will you use during the oliguric phase? A. verify physician’s order 88. cross matching results. chills. notify the blood bank D. fever 90. As you are caring for PL who has acute renal failure. What should you do FIRST before you administer blood transfusion? A. She is admitted for treatment of gastroenteritis. 91. Which question will be MOST HELPFUL for you to ask? a. kidneys in a state of suspension 92. 81. urine output of 30-60 ml/hour D. urine output directly related to the amount of IV fluid infused B. check the vital signs every 15 minutes D. WQ is undergoing blood transfusions of the first unit. As a nurse it is important that you understand the rationale behind the treatment regimen used. 86. hypertension and flushing B. expiration date with another nurse C. he demonstrates signs of dementia. what is the effect of the rennin-aldosterone-angiotensin system on renal function? A. what will be your PRIORITY intervention? A. increased absorption of sodium and water 10 A. An arteriovenous fistula was created for hemodialysis in his left arm. verify client identity and blood product. expiration date B. RR. 2 hours 87. dysfunctional grieving Situation 18: The physician has ordered 3 units 11 of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta. WW is blind. headache.c. Which nursing diagnosis is MOST appropriate? A. age 89. increased urine output. ineffective airway clearance 85. What seem you doing when the pain started? d. wipe the self-sealing aspiration port with antiseptic solution and aspirate urine with a sterile needle 80. The EARLIEST signs of transfusion reactions are: A. You are preparing the first unit of whole blood for transfusion. a 56 year old man who is dehydrated and with urinary incontinent. metabolic. KJ has an indwelling urinary catheter and she is suspected of having urinary infection. The period of oliguria usually lasts for about 10 days. decreased absorption of sodium and water D. blood type. Has anyone in your family been sick lately? 82. risk for infection related to anesthesia D. verify client identity and blood product serial number. offer the bed pan every 4 hours c. knowledge deficit regarding health 79. call the physician. impaired urinary elimination d. anxiety C. decreased absorption of sodium and water C. oliguria and jaundice C. How should you collect a urine specimen for culture and sensitivity? a. deficient fluid volume B. orient him to time. one of the collaborative interventions you are expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat: A. Which nursing diagnosis takes HIGHEST PRIORITY for WW? B. keep the perineal area clean. clump tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine b. You are obtaining a history of MR. ineffective cerebral tissue perfusion B. has terminal cancer. blood type. encourage oral fluid intake d. you noted perineal excoriation. which nursing diagnosis takes HIGHEST PRIORITY for BO? A. 4 hours B. The kidneys have very important excretory. You should give HIGHEST PRIORITY to which nursing diagnosis: A. Post-operatively. You are documenting your care for CC who has iron deficiency anemia. During the shock phase. acute pain related to surgery 83. what will you do AFTER the transfusion has started? A. person and place b. 40 year old with chronic renal failure. decrease fluid volume related to blood and fluid loss from surgery C. impaired physical mobility related to surgery B. decreased urine output. Do you need anything now? c. In case WQ will experience an acute hemolytic reaction. is admitted to the Nephrology Unit. hypercalcemia D. stop the blood transfusion and monitor the patient closely C. cross matching results. infuse NSS. how long should you infuse it? A. erythropoietic functions. BO who received general anesthesia returns from surgery. From the time you obtain it from the blood bank. PL. impaired physical mobility 84. immediately stop the blood transfusion. immediately stop the BT. and dry Situation 17: You are caring for several patients with various disease problems. Any disruptions in the kidney’s functions can cause disease. BN. increased absorption of sodium and water 93. 1 hour D. Upon physical examination. hypokalemia B. urine output is less than 400 ml/24 hours C. disconnect the tubing from the urinary catheter and let urine flow into a sterile container d. drain urine from the drainage bag into the sterile container c. ineffective breathing pattern C. notify the blood bank and administer antihistamines Situation 19. who is admitted with acute chest pain. hypernatremia 94. stay with WQ for 15 minutes to note for any possible BT reactions 89. hyperkalemia C. decreased urine output. activity intolerance B. bathing or hygiene self care deficit D. no urine output. 6 hours C. infuse Dextrose 5% in Water and call the physician B. You are caring for WE. who is in acute renal failure. serial number.
seedlings.____ ------------------------------------------------------------------------------------------------------------------------------- NURSING PRACTICE 3C: NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS DIRECTION: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answer sheet provided. women preparing for overseas employment Situation 2: Some activity therapies are organized and conducted in groups where nurses may participate in. young professionals entering the workplace B. fluid retention is enhanced when salt substitutes are included in the diet D. change in mental status 100. are more sensitive to drugs B. restraining patients who violates policies and do not follow schedule of activities. willingness of psychiatric professionals to be open and receptive to client’s ideas and suggestions B. diuretic use D. have increased sensory perception D. monopolizer path in mental health psychiatric nursing. is also advised not to use salt substitute in the diet because: A. have increased sensory perception C. Pain in the elder persons require careful assessment because they: A. This is BEST reflected in: A. the highest in population groups that would need priority mental health therapy? A. C. Pain and urinary incontinence are common concerns experienced by them. it includes nursing actions to reduce the rate of new cases of mental disorder in population D. disability (neurologic) B. STRICTLY NO ERASURE! Situation 1: The nurse is envisioning a career 2 C. A mental health nurse may not be a member of this self help group because help given to members comes from members themselves: A. a way of permitting clients provide themselves with a more creative and wholesome life C. school children with behavioral problem 3. breathing. Remotivation Group C.diet instructions will you need to reinforce prior to his discharge? A. mobilize drugs more rapidly 98. decreased bladder capacity B. Eva is a member of a group who controls endless talking. out of school adolescents D. parents with child rearing concerns B. Alcoholics Anonymous D. breathing C. decreased breath sounds with crackles C. fever D. adults going through active skills C. Tommy. and bells and encourages client participation B. opportunity to learn democratic living 8. increased glomerular filtration C. airway. . The beginning professional nurse can do mental health counseling with the following clients. B. tambourine. EXCEPT: A. pain B. airway. The elderly patient is at higher risk for urinary incontinence because of: A. Which of the following is the MOST COMMON sign of infection among the elderly? A. You are assigned to take care of a group of elderly patients. have increased hepatic. limiting salt substitutes in the diet prevents a buildup of waste products in the blood C. actively psychotic patients C. What is the essential component that the nurse must bring to the relationship? A. circulation. A professional responsibility of the mental health psychiatric nurse is to provide a safe and therapeutic environment. confrontation 5. salt substitute contain potassium which must be limited to prevent arrhythmias B. Which of this client situation appropriately illustrate horticulture therapy? A. BN. humor C. every afternoon. Jon and Pia play scrabble every night after supper 1 SET A Seat No. single elderly with no social support D. disability (neurologic). be sure to eat meat every meal 95. Paul finds sketching relaxing and rewarding 9. Administration of analgesics to the older persons requires careful patient assessment because older people: A. Which of the following determines the success of client government groups? A. dilated urethra 99. Activity Therapy Group B. blocker C. empathy D. 96. restrict your salt intake D. tree planting And watering them D. it consist of early recognition and treatment of mental disorders to reduce severity and duration of mental illness 2. are expected to experience chronic pain D. renal and gastrointestinal function C. self-confessor D. the therapist brings bongos. Her role is that of a/an: A. Priorities when caring for the elderly trauma patient: A. Art Therapy Group 7. breathing. airway. Vic goes in the garden where he work with plants. reframing B. 1. circulation B. Which of the following statement reflects the scope of mental health psychiatric nursing? A. a substance in the salt substitute interferes with fluid transfer across the capillary membrane Situation 20. drink plenty of water C. recognition seeker B. keeping a restrictive environment to prevent patients from becoming assaultive and hostile D. it includes nursing actions aimed at returning the patient to his highest potential of productivity. means to acquire a variety of social skills D. she is guided with basic beliefs about the practice. maintaining a closed door policy to prevent patients from absconding. experienced reduce sensory perception B. You should be able to address the concerns in a holistic manner. it is an integral aspect of all nursing and a specialty service to all people affected by mental illness. Karen. As a beginning professional nurse. monitor your fruit intake and eat plenty of bananas B. Which of these people. ensuring physical safety and maintaining therapeutic attitude towards the patients 4. 6. The foundation of the therapeutic process is the therapeutic relationship. breathing D. C. airway. have a decreased pain threshold 97.
both developmental and situational crisis 27. his needs are being met 4 D. The purpose of these meetings would be: A. Informed consent is necessary for the treatment for involuntary clients. ego C. Bernie discovered that her husband was falling in love with another woman. provide an environment appropriate to their development task as scheduled C. check O2 Sat with a pulse oximeter Situation 4: The community health nurse B. The nurse teaches parents about children’s beginning concepts of right and wrong by emphasizing child rearing attitude and practices during the: A. After ECT. infancy period B. latency period 18. meditation B. confusion. to encourage expression of intrapsychic conflicts Situation 3: The patient who is depressed will undergo electroconvulsive therapy. Studies on biological depression support electroconvulsive therapy as a mode of treatment. ambitious. Community meetings are held as a part of milieu therapy on an in-patient psychiatric unit. to provide direction from the treatment plan D. The nurse needs to assess this lifestyle because: A. use of industrial equipment B. ego ideal B. usual problem solving methods and coping mechanisms produce a solution 3 D. hemorrhage within the brain C. id 17. EXCEPT: A. it has a growth promoting potential C. encouraging their children at home to behave properly 21. 11. All of these are characteristics of crisis EXCEPT: A. robot-like body stiffness D. a hazardous or threatening event occurs B. next of kin or guardian B. She becomes interested to practice natural ways to enhance well being. teaching their children good manners and right conduct 19. food or medication: A. The preparation of a patient for ECT ideally is MOST similar to preparation for a patient for: A. John asked forgiveness and regret very much the hurt his wife was going through and suffered guilt feelings: 26. social worker C. When this cannot be obtained.10. The rationale is: A. seen that if the child appears contented. encounters special children in the community. ECT relieves depression psychologically by increasing the norepinephrine level D. super ego D. modeling to their children B. The treatment serves as a symbolic punishment for the client who feels guilty and worthless C. to encourage expression on topics of interest C. school age C. pharmacotherapy D. 16. anticipated crisis B. An important principle for the nurse to follow in interacting with retarded children is: A. relaxing muscles from tension D. this defect in the personality reflects a disturbance of the: A. toddler age D. permission may be taken from the: A. Shaken by this situation. encephalitis B. An individual with antisocial personality disorder lacks remorse. Basic to progressive muscle relaxation is: A. Suddenly. skills to attempt change B. the nurse knows that being overweight is a major health hazard C. Mental retardation is: A. minimizing eating in fast food restaurants B. the nurse wants to stop all the mainstream weight-loss diets D. Which of the following is a possible side effect which you will discuss with the patient? A. electrocardiogram 13. chief nurse 15. having an exercise regimen to follow regularly C. encouraging their children to attend secondary school C. It is BEST for parents to teach healthy interpersonal relationships to their children by: A. a lack of development of sensory abilities C. a severe lag in neuromuscular development and motor abilities Situation 5: The nurse recognizes the need to learn to cope with stress and change. assess the gag reflex C. Psychodynamically. to focus on issue arising from group living B. she started to have problems sleeping and could not function well at work and at the risk of losing her job. the nurse should do this action before giving the client fluids. motivation Situation 6: Bernie and John in their late 40’s have been married for 20 years and at the peak of their careers. guided imagery C. X-ray D. stopping disturbing thoughts 24. situational crisis C. focusing on an image to relax C. looks at life as challenging and perfect and never considers change in his lifestyle. All of these are the behavior intervention to stress management. shame and guilt in going against the norms of society. ECT produces massive brain damage which destroys the specific area containing memories related to the events surrounding the development of psychotic condition B. avoiding pollutants in the environment 22. general anesthesia B. commitment C. a delay in normal growth and development caused by an inadequate environment B. anxiety or depression continue to increase . doctor D. assess the sensorium D. next of kin or guardian B. Bernie and John are going through a: A. recognizing the impact of unhealthy habits D. initially needs: A. ECT is seen as a life-threatening experience and depressed patients mobilize all their bodily defenses to deal with this attack. 12. A young overweight adult smokes 5-10 sticks of cigarettes/day. a condition of subaverage intellectual functioning that originates during the developmental period and is associated with impairment in adaptive behavior D. Lifestyle modification begins with: A. treat the child according to his chronological age D. the nurse has to find out what people are eating 25. treat the child according to his developmental level 20. electroencephalogram C. progressive muscle relaxation 23. disorientation and short term memory loss 14. information D. the nurse wants to change the eating patterns of the Filipino family B. Dietary practices are very important to the health of the Filipino family. developmental crisis D.
non judgmental A. I thought it was rude for the patient to yell hence I kept quiet 38. Problem Oriented Medical Recording 43. problem-solving C. participating in intensive group experiences B. algorithm B. perception of the event B. To facilitate identification of persons and relationships. termination phase C. assertiveness D. 2 – 4 weeks C. the nurse researcher should: A. counter transference C. situational support D. demonstrate an ability to cope with nervousness 2. Nurse: “ I feel personally involved with my client’s problems” demonstrates: A. Mr. “Perhaps we would talk about my leaving”. “I should watch out for signs of sore lips or sore throat” B. individual psychotherapy C. value and find meaning in experience 48. every time people around me yell. orientation phase 47. NANDA Diagnosis C. Exerts himself physically and is hesitant to discuss problems. The nurse has achieved self-awareness in which of the following verbalizations? A. therapeutic use of self B. Which is the subjective data? A. A step by step procedure for the management of common problems is a : A. This is a SOAP recording of the patient’s problem of “Nervousness”. flowchart C. conceptualize her problem B. behavior modification D. 31. genogram D. D. Self-awareness. 36. Felisa understands the effects of her medicine when expresses: A. writing an autobiography for self introspection Situation 9: Recording and the nurse. neurotic B. with the patients tone of voice and stare. problem listing Situation 10:The nurse works with Mina to help her work through termination of the nurse-patient relationship. Mr. 1 – 2 weeks D. psychotic 32. Z should: 1. plan for alternatives D. “I am nervous at times”. “I might feel changes in my body temperature” D. Mild B.28. The nurse assists her to practice better ways of coping termination by providing opportunities to: A. sympathy 37. she is likely to be given: A. The nurse utilized which communication technique: 5 B. 46. The duration of crisis usually lasts several days and usually: A. avoid limits on her behavior to release her anxiety B. haloperidol ( Haldol ) D. transference B. A problem oriented recording system that utilizes the problem solving process as the basis of patient care management: A. imipramine Hcl ( Tofranil ) B. normal D. Mr. Z does not seem to tolerate stress too well which will aggravate his cardiac condition. Preparation for termination of the nurse-patient relationship begins during the: A. B. role-playing B. This behavior is categorized as: A. provide alternative behaviors to deal with increased anxiety D. test new patterns of behavior C. when the patient yelled at me I became speechless C. the family nurse utilizes this diagrammatic representation of members of a family and their relationships: A. pedigree chart D. empathy D. “ I should not drive or operate machines” 35. I feel upset and withdrawn B. 41. interpersonal relationships and other activities of daily living. keep the papers for 5 years and dispose of these after C. Severe D. To minimize such problems. Considering that man is by nature social. Z was nervous during the interview. Gavin chart C. the nurse asked after a period of silence. The nurse researcher mutually agreed with the research subjects that all personal data of the subjects shall be kept confidential. diazepam ( Valium ) C. He understands Little about his health which may be increasing his state of anxiety. he moved frequently in the bed and his palms were sweaty. in control of tendency to blame 39. burnt or shred the papers D. it is BEST for the nurse to gain self-awareness by: A. Assessment data of the nurse include all the following EXCEPT: A. Gordon’s Functional Health Patterns B. positive self-projection C. self-mastery 40. A therapeutic intervention in this situation is: A. During the early part of the interaction. “I might have constipation” C. delusional C. aware of ones biases C. pre-orientation phase B. coping mechanisms C. C. it is imperative that the nurse is accountable to oneself hence the importance of personal and professional development. knowledge and understanding of human behavior and communication skills define what is essential in caring for every nurse to be able to demonstrate: . call attention to her ritualistic pattern C. 1 – 2 months B. nurse-patient relationship 29. The anxiety of Felisa is disabling and interferes with her job performance. Mina’s past reactions to ending relationships is withdrawal. repressed problems 30. I got reminded of how my father would be so angry and this made me anxious D. kardex 42. The nurse employs this approach in crisis intervention: A. chlorpromazine ( Thorazine ) 34. Nursing Care Plan D. To safeguard anonymity of data after the report is written. 4 – 6 weeks Situation 7: Felisa has a ritualistic pattern of constantly washing her hands with soap and water followed by rubbing alcohol. An accepting attitude requires being: A. throw the papers in a wastebasket B. ignore her behavior totally 33. working phase D. tolerant of the faults of others D. decision tree protocol B. Panic C. have the papers recycle but not as writing scratch paper 45. Moderate Situation 8:As a professional. The level of anxiety that Felisa is experiencing is: A. demonstrate an understanding of the relationship between his nervousness and cardiac condition 44. hypnotherapy D.
An appropriate goal for the group members is to develop: A. reflecting words C. develop interpersonal relationship Situation 11: As a program manager. approaches the nurse at frequent intervals C.” A. having chronic episodes of stress and anxiety while interacting with others D. giving advices 68.6 A. relate successful past experiences C. Social skills training is NOT primarily indicated for psychiatric patients who are: A. Her mission to propagate peace is: A. helping people manage their own problems B. This gives the clients a venue to: A. Through the nurse’s role modeling of effective communication. She was also fearful and suspicious of others. sender B. in acute stage of illness B. goes to the coffee shop alone more often . 66. Which of this intervention would NOT be therapeutic in decreasing Loretta’s anxiety? A. psychodrama 65. community meeting C. attitudes of society towards the mentally ill B. psychotherapy C. selective interview of patients 53. a serious call for a need of transformation C. Loretta’s claim of being the “Virgin Mary” is a/an: A. I should never have gotten involved with you” (silence) Nurse: “You have reason to be disappointed and to feel angry. test new patterns of behavior 54. invite a resource person D. listen to her thoughts and feelings C. seminar D. encouraging C. suggesting D. observation B. I leave you. develop insights D. skills for maintaining daily living C. The following are the objectives of a social skills training program EXCEPT: A. The nurse’s style of leadership in milieu therapy is: A. awareness of interpersonal patterns of interactions D. Who among these clients need immediate referral for psychotherapy? A. hallucination B. courage D. experiencing recurrence of symptoms in front of particular people or among people in general 63. do not convince her that her perception is unreal 61. simply accept D. an advocacy that she can participate in 58. Mina: (angrily) “ I am angry. pharmacotherapy B. prudence 8 69. health psychiatric nurse is tasked to provide general patient management. how to tell a joke 64. therapeutic milieu D. sensitivity B. feedback 55. understanding D. help build self esteem and self confidence B. those who are plotting to commit suicide B. The nurse is leading a group meeting of patients to prepare them to be discharged. the mental B. the clients learned new ways of dealing with authority figures. those who are not responding to usual motivators C. obsession 57. develop and practice general coping skills 62. watch a movie Situation 14: Community health nurses integrate their knowledge of mental health with their clients in their practice when they do mental health counseling. carries a book “The Purpose Driven Life” 60. admitted to the psychiatric unit with a diagnosis of chronic undifferentiated schizophrenia. laissez-faire D. realistic and laudable B. model good social skills throughout the session B. ways to celebrate Valentine’s Day in February B. those who are engaging in self-defeating behaviors 67. democratic B. EXCEPT: A. practice skills in relating with people D. judgment B. skills and attitudes D. receiver C. clarify problems C. benevolent Situation 12: Loretta is a 28 years old. The nurse evaluates that Loretta’s ready for a rehabilitation program when she: A. those who are not solving their problems which they have the resources to solve D. Which of the following concepts BEST describe the nurse’s interaction when she/he can recognize and identify 7 59. Just when we were getting somewhere. understanding 49. survey D. This quality of the nurse allows “connecting with others feelings”: A. joke about her thought to help her feel at ease B. ceases to talk about “Virgin Mary” D. assisting people to use their own resources C. socialize D. The nurse is aware that identifying the aspects of general patient management and identifying interventions for meeting these basic needs are distinctions of: A. role play B. An appropriate topic would be: A. Her thought processes were profoundly disorganized. trustworthiness 70. an attempt to overcome low self-esteem D. it is BEST for the nurse to conduct a/an: A. 51. autocratic C. 56. delusion D. orienting B. This element of communication facilitates evaluation of the program: A. an unforgettable experience as a child D. reflecting feelings 50. have a corrective emotional experience B. firmness C. imagination C. behavior therapy 52. An appropriate technique for the participants to practice how to communicate effectively is through/a: A. identify their problems B. how to spend the summer vacation C. focusing on client B. a set of technique. The objection of the nurse-patient relationship is to provide an opportunity of the patient to: A. warmth C. All of these describe what counseling. insight into personal problems Situation 13: A group of adult chronic schizophrenic patients were recommended to undergo social skills training. Considering that it is BEST to learn by example. unemployed patient. The focus of the group interaction is “here and now”. coolness D. it is MOST practical to: A. message D. having difficulties starting and maintaining interpersonal relationships C. communicate C. lecture C. explore deep seated intrapsychic conflicts C. “ To refuse gossip” is a reflection of the mental health nurses quality of: A. In order to get active participation of the clients to carry out the objective of the program. She described herself as the “Virgin Mary” and her mission is to propagate peace. She was observed laughing and talking to herself.
pilot study B. one to one interaction C. The LEAST area of satisfying communication with the elderly is on: A. expressive role B. patients D. grandeur 80. playing complex computer games 72. developing a realistic uniformed and consistent daily schedule C. “ dementia patients is a challenge to psychiatric nurses. In planning activities for the patients. 71. restating B. excitement and challenge 85. displacement C. encourage her to participate in an ongoing activity in the ward B. set limits on his behavior and be consistent in approach B. reduction of anxiety B. providing a picture album B. empathy Situation 15: Communicating effectively with A. it is BEST to plan activities they can engage in through a: A. influence B. research ideas are capable of being tested C. This study was done to check the procedures of the research: A. She is having palpitations. The nurse notes that in order for the activity therapy to be therapeutic: A. The independent variable is: A. sensorium C. results of tests made on the groups are compared D. compensation Situation 18: A research was conducted on. it is essential to consider FOREMOST: A. delivering supply of linen to other rooms C. transference B. nasogastric insertion 88. they are being laughed at because they are singing and acting like children”. make a rigid structured plan that he will have to follow C. age 36 is admitted to the psychiatry unit in an acute manic episode of bipolar disorder. safety and security C. guiding the patient one step at a time D. over involvement C. The MOST useful activity for him would be: A. the staff should decide solely what activities to be done and what rules apply B. Look. 86. reference D. Marie preferred to sit at the bench and watch the ballgame C. reduction of anxiety 89. You know for a fact that this is NOT true.feelings and emotions of another person without even having personally experienced those feelings and emotions? A. cognition D. age and needs of patient should be considered in the choice of games 83. Unconditional positive regard for the elderly is BEST achieved when the nurse-patient relationship is based upon: A. Your nursing intervention should be to: A. displacement C. singing to or with the patients C. community meeting D. patients should be allowed solely to decide what they want to do on their own C. Adults. The defense mechanism utilized by manic patients to cover up depression is: The effects of the nurse expressive role in the reduction of anxiety in patients who will undergo nasogastric tube insertion”. an interview scheduled C. engaging in activity therapy and group exercises D. Harry approaches you and says “I have awarded Top Salesman of the Year. research subjects are randomly selected and placed into groups for the purpose of manipulation Situation 19: The client is walking to and fro along the hospital corridor and swinging her hands. regression D. My boss will come and celebarate with me”. Marie said “I don’t like to be a part of it. tell her to stop thinking that she is going crazy . engaging the elderly in logical and abstract thinking B. sympathy D. Which of the following remarks from the nursing attendants indicates a need for further teaching and observation? A. recall of their courtship and love life C. painting a mural with other patients 78. proposal D. memories of their teenage parties 73. Harry’s disruptive behavior on the unit has been increasingly annoying other clients. In the ward. a survey D. a questionnaire B. value plays a significant part in research B. stay with her in a calm environment C. addressing economic problems B. 76. Which of the following is NOT a characteristic of experimental research? A. To encourage active participation among patients. Harry manifests excess energy and is difficult for him to sit still. EXCEPT: A. 10 9 91. expressive role D. vocational choices C. 81. ballgames should be limited to male patients only D. The research is experimental which means that utilized: A. Harry’s condition is a disturbance of: A. conducting a drama workshop B. nasogastric ingestion C. “ singing and acting like children” is a form of: A. providing warmth and caring 75. simple nurse care for the patient day after day Situation 16: Harry. Harry is demonstrating a delusion of: A. variety and fun D. asking simple questions C. An optimal supportive environment for a person with dementia includes all. achievement C. handling memory loss by distracting or diverting patient’s attention to something more positive D. control and experimental groups 87. affect 77. denial D. sublimation B. feedback evaluation forum 84. She thinks she is going crazy. asking for an open ended response 74. Marie is aloof and indifferent to co-patients D. compensation B. fashion shown in personal pictures B. listening to old familiar music D. novelty and creativity B. test-retest 90. keeping D. rapid pulse and hyperventilation. age 28 years old had not been participating in activity therapies. checklist B. patients C. To maximize communication with the elderly. protest study C. reaction formation Situation 17: The nurse observed that Marie. the CNS B. psychological trauma D. Marie made no response to an invitation to play B. Marie read a book while other patients played a ballgame 82. tell him that he is annoying other clients and isolate him in his room 79. The dependent variable is: A. ignore his behavior D. Which of the following would the nurse do? A. Therapeutic ways to engage the elderly to be stimulated include all of the following EXCEPT: A. which of the following ways of verbal communication should the nurse use minimally? A.
It is BEST to: A. somatic delusion B. encourage him to pray to atone for his sins C. was admitted to the Psychiatric Ward because of religious preoccupation. deterioration in self-care and disturbed thoughts. There is increased tension and reduced ability to perceive and communicate. He is threatened by people reaching out to him. isolate the client in a quiet room 92. Which of the following statements about anxiety is NOT true? A. The nursing goal for Andy is to: A. 30 years old. As Andy talks about his sins that he believes make people look down upon him. mood disturbance D. intimacy . psychomotor disturbance C. hence a threat to a persons well being D.D. autonomy B. His fasting for several days was not sufficient for him to feel forgiven. anxiety is contagious B. Tofranil (Imipramine HCL) C. Thorazine (Chlorpromazine) Situation 20: Andy. The psychosocial task that Andy needs to work on is a sense of: A. trust D. Valium (Diazepam) B. acknowledge how he feels and focus on reality oriented topics 100. mild 95. tachycardia D. He believes that he has committed a lot of sins. disturbance of thought B. A delusion is: A. Which of the following is a behavioral manifestation of anxiety? A. help him develop a positive self image D. disturbance of perception 98. This medication is indicated for anxious patients: A. panic B. identity C. delusion of being controlled 97. hence “selective attention” in this level of anxiety: A. have him see a priest for confession B. reactions to a perceived threat maybe real or imaginary 94. severe D. Andy is demonstrating: A. religious delusion C. repressed unresolved conflicts create anxiety C. rapid pulse 93. explore the nature of his sins C. moderate C. delusion of grandeur D. agree with him and sympathize how sinful he has really been B. panic B. explain that he is depreciating himself too much D. socialize him with a group to keep him in touch with reality 99. Haldol (Haloperidol) D. 96. anxiety at any level is destructive. hyperventilation C.
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