DECEMBER 2006 – NP1 FOUNDATION OF PROFESSIONAL NURSING PRACTICE 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 of 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 line-up 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 3. Auditing skills 2. Forecasting 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 pre-menopausal 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 B. 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 C. Alleviate pain B. maintains fluid and electrolytes 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 B. empty a sample urine from the collecting bag into the specimen container C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container. 28. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation? A. to the patient’s inner thigh C. to the patient’ B. to the patient’s lower thigh D. to the patient lower abdomen 29. Which of the following menu is appropriate for one with low sodium diet? A. instant noodles, fresh fruits and ice tea B. ham and cheese sandwich, fresh fruits and vegetables C. white chicken sandwich, vegetable salad and tea D. canned soup, potato salad, and diet soda 30. Howe will you prevent ascending infection to Eileen who has an indwelling catheter? A. see to it that the drainage tubing touches the level of the urine B. change he catheter every eight hours C. see to it that the drainage tubing does not touch the level of the urine

D. clean catheter may be used since urethral meatus is not a sterile area Situation 7: Miss Tingson is assigned to Mang Carlos, a 60 year old newly diagnosed diabetic patient. She is beginning to write objectives of her teaching plan. 31. Which of the following objectives is written in behavioral terms? A. Mang Carlos will know about diabetes related to foot care and the techniques and equipments necessary to carry it out B. Mang Carlos daughter should learn about DM within the week C. Mang Carlos wife needs to understand the side effects of insulin D. Mang Carlos sister will be able to determine in two days his insulin requirement based on blood glucose levels obtained from glucometer 32. Which of the following is the BEST rationale for written objectives? A. ensure communication among staff members B. facilitate evaluation of the nurse’s performance C. ensure learning on the part of the nurse D. document the quality of care 33. Which of the following behavior BEST contribute to the learning of Mang Carlos regarding his disease condition? A. frequent use of technical terms for familiarization B. drawing him into discussion about diabetes C. detailed lengthy explanation about his condition D. loosely structured teaching session 34. Miss T should encourage exercise in the management of diabetes, because it: A. decrease total triglyceride levels C. lowers blood glucose B. improves insulin utilization D. accomplishes all of the above 35. The chief life-threatening hazard for surgical patient w/ uncontrolled diabetes is: A. dehydration B. hypertension C. hypoglycemia D. glucosuria Situation 8: Caring for the perioperative patient. 36. An appendectomy during a hysterectomy would be classified as: A. Major, emergency, diagnosis C. Minor, elective, ablative B. major, urgent, palliative D. minor, urgent, reconstructive 37. An informed consent is required for: A. closed reduction of a fracture C. irrigation of the external ear canal B. insertion of intravenous catheter D. urethral catheterization 38. The circulating nurse’s responsibilities, in contrast to the scrub nurse’s responsibilities, include: A. assisting the surgeon C. setting up the sterile tables B. monitoring aseptic practices D. all of the above functions 39. The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: A. Laryngospasm C. hypoxemia and hypercapnea B. hyperventilation D. pulmonary edema ad embolism

40. Unless contraindicated, any unconscious patient should be positioned: A. flat on his of her back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications B. in semi-fowlers position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand. c. in fowler’s position, which most closely stimulates a sitting position, thus facilitating reparatory as well as gastrointestinal functioning. D. on his or her side without a pillow at the patient’s back and his or her chin ext ended to minimize the danger of aspirations Situation 9: To prevent further injury to patients with problems of immobility / mobility, the nurse should observe certain principles of body mechanics for herself and her patients. 41. Which of the following are appropriate goals for client with positioning and mobility needs? A. developing of contractures C. sensory alterations B. proper body alignment D. decrease in activity tolerance 42. Which for the following would MOST likely cause injury to the nurse when moving the patient from bed to the wheelchair? A. bending at the knees C. using body weight to assist with the movement B. standing with feet together D. standing with feet apart 43. Which of the following is the CORRECT guideline when positioning patients? A. put pillows above a joint to immobilize it B. position of the joint should be slightly extended C. joints of patient to be supported with pillow D. patient’s position should be changed at least three or four times a day 44. 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. sandbag B. side-rail C. trochanter roll D. trapeze bar 45. The importance of forcing fluids with an immobilized patient is to: A. prevent pneumonia C. prevent skin breakdown B. prevent urinary stasis D. maintain peristalsis 46. Which of the following is the least nursing activity in performing assessment of the patient? A. laboratory test C. Health history B. physical examination D. systemic review 47. One of the responsibilities of Mr. Lata, RN, an industrial nurse, is to conduct physical head-to-toe assessment of a newly hired factory worker. As part of the assessment, he took the vital signs. Which of the four assessment techniques did he utilize? 1. auscultation 2. percussion 3. palpation 4. inspection A. 1,2 & 3 B. 3 &4 C. 1 & 2 D. 1,3 & 4 48. Which of the following are the purpose of performing a physical assessment? 1. gather baseline data about the client’s health 2. confirm and identify nursing diagnosis 3. evaluate physiological outcome of care 4. make clinical judgment of patients’ diagnosis

1. the nurse supervisor B. In primary nursing who among the following is needed to her leadership and quality control in the ward? A. carefully ink out the erroneous material C. systematic and orderly 4. 51. During the initial interview. 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. place as asterisk next to the statement. find out from interview how many patients are willing to participate B. Mr. the holistic approach provides fro a therapeutic relationship continuity of care and efficient nursing care D. big group of patients like 10-15 patients D. the nurse is concerned with: A. use of checklist A. over-all manager of the unit B. relevant rows and columns D. 2 & 3 55. What is the function of the primary nurse in primary nursing? A. preparation of the equipment C. narrative charting 2. 1.2 & 3 C. thoroughness and currentness 3. physical preparation of the client 50. When the nurse writes in the chart and discovers an error has been made. Which of the following research activities should you initially do? A. accountability is clearest since our nurse is responsible for the overall plan and implementation of care C. he becomes uncomfortable and politely leaves the room. 58. erase the erroneous material B. quasi experimental Situation 14: The nurse meets a new client. serve as a record of financial charges C.2. Which is the role of the associate nurse in primary nursing? A. interpreting data B. Which of the following qualities are relevant in documenting patients care? 1. 49. POMR charting is different from traditional method because of which of the following practices? 1. specific title of table B. use of flow sheet 4 . Accuracy and consciousness 2. establishing a data base D.3. Which of the following actions will facilitate analysis of research data? A. 53. serve as a vehicle for communication D. ensure that the message is received 52. organizing staff assignments and help in solving problem in the unit . the head nurse D. Shortly after.4 & 5 B.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. categories of data collected C. experimental D. The research methodology that is appropriate for the above problem would be: A. categorize data collected 65. names and sample of the selected 64. properly dated and signed 5. descriptive B. 1 & 2 C. 3 & 4 C. prepare the tool for collecting data 62. well-defined problem statement B. potential use of findings C. consult a physician C. speech therapist 54. the patient B. coordinates the care given to a group of patients by support staff 57. 1. then footnote it D.3. get the permission from the hospital director C. measurability of variables 63. coordinator of comprehensive. 2. consult a complete expert B. Which of the following should be given the HIGHEST PRIORITY before physical examination is done to a patient? A. use of locally accepted abbreviation A. acts as patient advocate and coordinate the health care team for specific group of patients B. A main function of the patient’s records is to: A. 1. the whole unit 60. physical therapist C. the chief nurse C. She is able to communicate to the other member of the team by documenting the nursing care plan and the appropriate nursing intervention. review literature on the topic D. patient advocate in the health care team D. 1. act as the charge nurse. prepare the nurse for the shift worked B. normative C.4 & 5 C. plans and coordinate the patient care assigned to her from admission to discharge D. preparation of the environment B. which is the BEST approach? A. comparing client responses with the anticipated outcome Situation 11: The nurse is responsible to accurately records and reports patient’s progress. 1 & 3 D.A. consult an adviser D. continuity of patients care promotes efficient nursing care. legibly. 1. lawyer of the family D. Which of the following persons cannot have the access to the patient record? A. 61. small group of patient like 3-5 patients C. A study /research table should NOT contain which of the following ? A. 50 years old. responsible for the over-all care of the patient during off days of primary nurse C. the nurse begins to feel irritated towards the client. holistic patient care 59. During the assessment phase of the nursing process. SOAP charting 3. psychological preparation of the client D. the nurse is responsible for which of the following group of patient? A. 3 & 4 B. 3 & 4 D. Principe. the whole ward B.2 & 4 B. autonomy and authority for planning care are best delegated to a nurse B.2. readability of findings D. In primary nursing. Which of the following statements do NOT contribute to the researchabilty of your proposed problem? A. designing nursing strategies C. draw a straight line through the error and initial it. 2. Primary nursing is MOST advantageous and satisfying to the patient and nurse because of which of the following principles? A.3 & 5 D.

One morning when the nurse enters the client’s room. the nurse will not be able to accurately document that the patient actually took the medication d. 71. You want to know the sleeping pattern of Mr. Which accessory device would be appropriate for his condition? A. A student nurse is observed putting a standard size cuff on an obese client. 8981 82. The nurse can be involved with health promotion as a significant person in helping the family: A. the nurse has to be therapeutic at all times D. it is convenient for the nurse c. “Why you are angry with me? What did I do anything to upset you? D. Non-pharmacologic pain management includes all the following EXCEPT: a. interview the clients and relatives B. the nurse talks about his personal feelings towards the client B. this is an essential part of the nursing process C. get self out of the way while he assists the client and his family express their feelings of impending loss C. 30 c. the nurse suppresses his feelings and continue to take care of the client C. The MOST important initial nursing approach when admitting client is to: A. use of herbal medicines b. how the nurse thinks and feels affects her actions and behavior towards her client and her work Situation 15: Mr. 81. “You seem upset this morning” and remains with the client B. introduce the client to the ward staff B. avoid sleepless. How many seconds after deflating the cuff should the nurse wait before rechecking the pressure? a. rehabilitative aspect of care d. Mr. help the family plan for the funeral arrangement and burial services 69. relaxation techniques c. undetectable Situation 16: Health is wealth specifically in this time of the century. Republic Act No. massage d. do auscultation B. periodic travels for rest and recreation B. body movement 80. In the Philippines. prevent self from being affected by the family’s grief and remain objective D. the nurse uses his awareness and asks to be reassigned to another client D. the bedside table is not sterile b. the BEST way for you to check if the client has pedal edema is to: A. Ong You will: A. “I understand and will leave you for a while” 70. 9173 b. Principe reminds him of his strict disciplinarian father who abused him physically. run away from polluted. interview the client D. Seeing that his negative feelings for Mr. health promotion and prevention of illness b. Ong is for admission to the medical unit and you are his nurse. the nurse finds it necessary to recheck the reading. 10 b. transference 67. The nurse understands that the nurse-client relationship is a therapeutic alliance when: A. 7164 c. the Philippine Nursing Act of 1991 or R. How does a nurse promote one’s well being? A. faithful and observance of healthy simple lifestyle C. false low C. 66. this law is : a. bed board D. rolled pillows 75. 76. Principe could affect his nursing care. take V/S fro baseline assessment 72. counter transference C. orient the client to the physical set up of the unit C. take his BP before sleeping and upon waking up C. normal D. false high B. denial B. “You are probably upset because you don’t feel well” C. Principe is terminally ill and his family is coping with his impending death. IRR or Resolution 425 of 2003 d. observe his sleeping pattern over a period of time D. 79. perform physical assessment 74. The Philippine Nursing Act delineates the scope of nursing. The action would probably result in BP reading that is: A. The Philippine Nursing Act of 2002 or R. Mr. 60 Situation 17: Safe nursing practice involves an understanding of the law. Collaborating with other healthcare providers for health restoration and alleviation of suffering . Mr. Revenge D. The nurse should NOT leave medication at the bedside because: a. control their symptoms D. 45 d.A. do a physical assessment 73. over fatigue nights 77. The nurse has to deal with his own thoughts and personal feelings about death and grieving in order to: A. administration of written prescription for treatment and therapies c. the nurse is a role model for a client B. cradle C. prevent disease C. stressful areas D. The nurse is trained to promote well being of the people. the patient may forget to take it. It specifies that independent practicing nurse is responsible for: a. the nurse uses self-awareness to manage his feelings and thoughts towards the client 68.The nurse realizes the behavior and mannerism of Mr. identify the most immediate needs of the client and implement the necessary intervention D. Principe asks the nurse to “leave me alone and stop bothering me and I don’t want your pity”. modify health promotive behaviors 78. The recognize that his feeling for the client is known as: A. avoid sharing personal thought about their impending loss and feeling of grief since this is very subjective B. When assessing a client’s blood pressure.A. the nurse applies the concept of therapeutic use of self when: A. When gathering baseline data. Ong has severe pedal edema. talk to the relatives C. The following response by the nurse would be MOST appropriate? A. footboard B. become a better family B.

summarizing clients views 92. was diagnosed to have pneumonia. open-ended questioning C. 86. an adolescent. nonmalifecence 85. administer morphine SO4 PRN B. diagnosis and treatment B. Beneficence d. chronic C. Standards of care provide the legal basis for evaluation of nursing practice or malpractice. Since morphine is an addicting drug. justice c. Bill of rights as provided in the Philippine Constitution B. the nurses should remember that a client’s personal space is: A. illness prevention C. As a standard in ethics. that which revolves around the client C. intractable D. This technique involves the use of which element of communication? A.A. “Have you taken something to relieve the pain?” D. maintain maximum functions C. Psychosomatic 97. To get accurate information about the quality of pain the patient is experiencing. the same as that of the nurse 94. Autonomy b. non-verbal communication B. reduce risk factor D. Board of Nursing resolution adopting the Code of Ethics Situation 19: One of the professional competencies that nurse must always demonstrate is in the area of communication: 91. clearly visible to others B. which of the following will help clients MOST? A. promote habits related to health care B. In interpersonal communication is LEAST threatening during what type of relationship? A. 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 Code of Ethics refers to standards of behavior or ideals of conduct. appropriateness C. which of the following is BEST for the patient? A. feedback D. double-bind communication D. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate services. Patient’s Bill of Rights ( as adopted by American Nurses Association ) D. professional 95. promote health habits B. maintain maximum function C. active listening B. health promotion D. used by nurse experts to define what appropriate nursing practice is in a given situation b. change the clients perception of pain B. Which of the following terms refer to the sender’s attitude towards the self. use to measure or evaluate the conduct of nurse specialists who are certified in their own specialty fields 84. rehabilitation of patients 89. the nurse places the hands on the client’s abdomen to explain diaphragmatic movement. 9173 C. which of the following statements would be MOST APPROPRIATE? A. hospice D. administer morphine on a routine schedule as ordered C. veracity d. this represents an understanding and agreement to respect another person’s right to decide a course his or her own destiny: a. relatively recent in popularity and oftentimes focuses on maintenance of comfort and satisfactory lifestyle of clients in the terminal phase of illness? A. Which of the following is the nurse’s primary goal in caring for clients with chronic pain? A. the message and the listener? A. 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. intimate D. highly mobile depending upon certain situation D. which of the following can decrease his chest pain? A. Roy is constantly asking to be relieved from pain. verbalizing observations D. teaching him D. “What cause you the pain?” B. Which of the following health care agencies is usually family-centered. community health center B. function and role of the nurse d. create better ways of providing nursing care and develop new nursing roles. Its functions include all EXCEPT: a. 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. meta communication 93. divert the attention by not limiting visitors 98. By experience. support group 90. supporting his rib cage when he coughs B. reduce the costs of health care D. “Is it stubbing or radiating pain?” 99. reduce the clients perception of pain . In demonstrating the method for deep breathing exercises. used to delineate the scope. acute B. manage stress 88. message Situation 20: Roy. “ Tell me what your pain feels like” C. channel B. responsibility Situation 18: An understanding of the factors influencing the health care delivery system will enable nurses to adjust to change. advocacy b. As the nurse assigned to Ray. In interacting with patients. identify disease symptoms 87. verbal communication C. used to measure or evaluate nursing conduct to determine if the nurse acted reasonably as any prudent nurse would under similar circumstances c. accountability c.83. give instructions on relaxation technique to reduce frequency of pain sensation D. 96. He constantly complains of chest pain and has a standing order of Morphine SO4. The ability to answer for and stand by one’s action refers to: a. non-government organization C. With regards to illness prevention activities as part of nursing care. social C. personal B. Which communication technique would be MOST effective in eliciting detailed information from the client? A. advising him C. Which of the following purposes LEAST helps clients in cases of these health promotion activities? A. encouraging him to breathe deeply 100.

walk for at least half an hour daily to stimulate peristalsis 9. Maybe it was my fault to be abused”. Based on this. that is why only a small amount is removed DECEMBER 2006 – NP2COMMUNITY HEALTH NURSING AND CARE OF MOTHER AND CHILD 1. some dehydration D. anxiety C. enumerate the source of pain B. What measure would you suggest she take to help prevent this? A. chronic low self-esteem D. and she is drinking poorly and irritable. basic discharge plans involve referral to community resources B. make an appointment with an elder adult counselor C. the vaccines have been stored at a temperature between 0 deg C and 8 deg C D. simple referral involves use of a discharge planner D. Ms. a loop diuretic C. increased calcium intake prevents constipation C.C. ranitidine (zantac) B. 40 breaths per minute or more D. Her patient seems upset. complex referral includes interdisciplinary collaboration 3. Amodia suspects that either abuse has occurred. mycobacterium tubercle C. RN works for a home health agency and cares for an older adult mental patient. who happens to be female resident of the barangay you are covering. you have taken out the vaccine at the health center for some other reasons B. a non-steroidal inflammatory agent 7. lacerations can provoke allergic responses due to gonadotropic hormone release B. Maria is developing constipation from being on bed rest. which would be your most appropriate nursing diagnosis? A. The primary preventive measures against HIV-AIDS is: A. Ms. skin pinch goes back very slowly. Which of the following is the most important reason for doing a literature review for constructing a research study? A. convince victims to leave their abusers C. existing knowledge about the identified problem can be found C. change the clients reaction to pain D. persistent diarrhea C. 30 breaths per minute or more B. discharge plans involve referral to community resources C. A bilateral amputee is assisted by his wife and children to the commode for bowel evacuation. Elimination C. Hansen’s bacillus D. a determination of the study’s feasibility could be extrapolated D. She has sunken eyes. What would be the best activity for her? A. Amodia. no more amniotic fluid forms afterward. A nurse may keep opened vials of OPV for use in the next session if: A. withdrawal C. The infectious agent that causes pulmonary tuberculosis is: A. what would be the drug you would anticipate to be prescribed and that you would have to administer? A. lying in bed with a cold cloth on her forehead B. virus killing drugs D. ineffective family coping 16. foams and gels use B. This example best demonstrates the family’s assistance to meet which need? A. a woman is less able to keep the laceration clean because of her fatigue C. How will you classify Fely’s illness? A. void immediately before the procedure to reduce your bladder size B. drink more milk. What instructions would you give her before this procedure? A. the vaccines have change its color 4. social isolation B. sitting with her feet elevated while playing cards D. health perception and health maintenance 10. I would have been able to make him stop. reading while resting in a trendelenburg position C. drink 8 full glasses of fluid such as water daily . Your client. tell them how to solve their problems B. She is not able to drink and there is no blood in the stool. helpful information on demographic instrument development could be uncovered B. Wuchereria bancrofti B. call her supervisor right away to report the findings 6. contact the mobile police to investigate the abuse B. severe dehydration B. nutrition and metabolism B. Martina develops endometritis. is an adult survivor who states: “Why couldn’t I make him stop the abuse? If I were stronger person. activity D. wake her son and ask him who would hurt his mother D. she observes numerous bruise and red marks on her patients face. Amodia should: A. Which of the following is true about discharge planning? A. magnesium sulfate D. A child who is 13 months has fast breathing if he has: A. the research design can be copied from another study 11. eat more frequent small meals instead of three large ones daily D. increased bleeding can occur from uterine pressure on leg veins 13. 60 breaths per minute C. On reporting to work. Why are lacerations of lower extremities potentially more serious among pregnant women than other? A. Fely has diarrhea for 2 days. Maybelle is also scheduled to have an amniocentesis to test for fetal maturity. develop safety escape plans for them 8. Ms. the expiry date has not passed C. Grace sustained a laceration on her leg from automobile accident. As a community health nurse you always bear in mind that the purpose of empowering victims of violence is to: A. mycobacterium diphtheria 15. healing is limited during pregnancy so these will not heal until after birth D. walking around her room listening to music 12. condom use 5. 50 breaths per minute 2. If there develops severe pre-eclampsia. no dehydration 14. help clients become aware that they have control over their lives D.

the intravenous fluid infused to dilate your uterus does not hurt the fetus D. ask what are the child’s problem B. use plan C if there is bleeding from the nose or gums B. The nurse is assisting Mr. increase her intake of carbohydrates-breads and sweets to prevent protein metabolism C. a child at a general danger sign C. no urgent measures 24. 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.C. frequency of urination B. Her temperature is 38. check for the general danger signs 31. positivism C. Carol is 15 months old and weighs 5. the chin should touch the breast while the mouth is wide open and the lower lip turned inward. e.g.5 kgs and it is her initial visit. more areola is visible above than below 25. the IMCI chart uses illness classification. Using the integrated management of childhood illness or IMCI strategy. Oxytocin is administered to Rita to augment labor. no specific treatments such as antibiotics B. When planning teaching strategy for a pregnant woman. a high choking voice B. additional weight from pregnancy may disturb balance when walking B. the pink row needs: A. 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. the first thing that a nurse should do is to: A. the x-ray used to reveal your fetus position has no long-term effects 17. appropriate antibiotics D. natural inquiry 26. jugular vein distention is evident when lying at 45 degrees D. the mouth is wide open while the lower lip turned outward and more areola visible above than below C. provide all information to the woman in a group session with other pregnant women so she can have someone to discuss it with D. has no convulsion and not abnormally sleepy or difficult to awaken. Bonnie. Her mother says that Carol is not eating well and unable to breastfeed. When a nurse uses the IMCI model. he has no vomiting. abdominal bleeding and pain 29. severe pneumonia B. They are prone to falls for which of the following reasons? A. the chin should touch the breast. Which of the four signs of good attachment is true in this statement? A.9 deg C. bedrest is maintained at home after the 36th week of gestation B. increased adrenalin released during pregnancy causes women to move faster than usual 23. A child with diarrhea is observed for the following EXCEPT: A. Which of the following symptoms is LESS commonly noted in EARLY pregnancy? A. Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever? A. fetal activity stimulates the nerves of the legs and causes weakness C. Which of the following supplies should be readily available for the infant immediately after birth? A. limit intake of amino acids to prevent development of diabetic ketoacidosis 20. give aspirin D. the nurse should do which of the following? A. Braxton Hicks’ Contractions 19. heating lamp to avoid chilling from water evaporation 21. how long the child has diarrhea C. they are more active than usual so they throw off comes 28. how will you classify her illness? A. give information about how the woman can manage the specific problems she identifies as relevant in her life B. chills and fever C. severe malnutrition 27. “Knowledge deficit related to potential for altered tissue perfusion in fetus or mother related to maternal cardiovascular disease”? A. check for the four main symptoms D. persistent vomiting. signs of dehydration . teach a woman the care measures necessary for health promotion throughout the pregnancy 18. they are preterm so are born relatively small in size C. has reported for her first prenatal visit. understanding the human expertise?) A. eat whenever she feels hungry because her body will let her know when she needs nutrients and extra calories D. vitamin K to avoid bleeding B. In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy. quantitative research D. The nurse should instruct her to do which of the following? A. during the first prenatal visit. omit information related to minor pains of pregnancy to prevent the woman from developing hypochondria C. eat more dairy products and green leafy vegetables to provide an additional 300 calories each day B. and Mrs. fetal heart rate will remain between 120 and 160 beats a minute C. skin Petechiae D. they do not have as many fat stored as other infants D. high levels of hormones often impair judgment resulting in reckless behavior D. Cruz to prepare for childbirth in the home setting. presence of blood in the stool B. Which of the following could be included in the outcome criteria for a patient with a nursing diagnosis. g. mild soap without perfume so as not to irritate the skin C. a swollen tender tongue D. Why are small for gestational age newborns at risk for difficulty maintaining body temperature? A. give ORS if there is skin Petechiae. 3 months pregnant. Which type of research inquiry investigates the issues of human complexity ( e. bulb syringe to suction fluid and mucous from the mouth D. maternal blood pressure maintained above 150 systolic 22. Pregnant women should be taught to be careful to avoid accidental injury. headache and vomiting C. if you were the nurse in charge of Carol. varicosities D. and positive tourniquet test C. their skin is more susceptible to conduction of cold B. check the patient’s level of consciousness C. prevent low blood sugar 30. urgent referral C. logical position B. very severe febrile disease D. What are the first symptoms of water intoxication to observe for during this procedure? A.

The fetus is in the most common anterior fetal positions D. Tony’s: A. You do not see them washing their hands. and a parade is planned to honor Mr. noting if the placenta makes a Schultz presentation. loss of eyebrows C. Wash your hands first before getting the bread” 36. The nurse would recognize which of the following? A. The child with no dehydration needs home treatment. nonmaleficence D. justice and beneficence C. pain medication given during the latent phase of labor is not likely to impair contractions D. light hospital gown to prevent the development of postpartal fever 47. When patients cannot make decisions for themselves. believes that a patient should be treated as individual. no dehydration B. fidelity and nonmaleficence D. maternal concerns regarding fetal health D. your hands are dirty. fidelity and justice 35. the use of medications during pregnancy C. the nurse advocate relies on the ethical principle of: A. the acceleration phase of labor can be a time of true discomfort and high anxiety 42. The boys club in his hometown was renamed the Tony boys club. the nurse would address which of the following? A. do not give BCG if the child has known AIDS C. whether the pregnancy was planned B. clawing of fingers D. use words that the mother understand B. give drugs every 4 hours C. self-perception and self concept B. In asking the mother about her child’s problem the following communication skills should be used EXCEPT: A. you have the responsibility of participating in protecting the health of people. consistency and position and take vital signs to obtain baseline data D. which is a sign of gross complication D. This ethical principle that the patient referred to: A. all of the above 44. to remove any fecal incontinence or vaginal secretions B. those with cavitary lung findings after two successive negative sputum examination C. give the child more fluids B. They receive money with these hands. do not give DPT to a child who has recurrent convulsion or active neurologic disease D. all newly discovered and reconfirmed sputum positive cases B. All of these C. which of the following nursing measures should be implemented during the labor stages? A. the nurse may have which of the following responsibilities? A. If a child with diarrhea has 2 or more signs in the IMCI pink row chart. If the capillary refill takes more than 3 seconds it may mean: A. severe dehydration 37. Being a community health nurse. While interviewing a woman in labor. do not give DPT2 or DPT3 to a child who has had convulsions within 3 days of DPT1 49. moderate dehydration C. Ms. coordinated. autonomy 34. early labor contractions are usually regular. cognition and perception C. thickening or painful nerves 39. administration of intramuscular Oxytocin to facilitate uterine contractility B. monitor the woman for shaking and complaints of chill sensations. protect the woman from visitors and family members who might try to change her mind D.When planning comfort measures to help the woman in active labor to tolerate her pain. contractures B. If a woman will be placing her baby for adoption. beneficence and nonmaleficence B. The nurse locates fetal heart sounds in the upper left quadrant of the mother’s abdomen. avoid discussing the baby during the historical assessment to minimize the woman’s anxiety B. “Miss. this position is referred to as being left anteriopelvic 43. remove all coverings except a clean. “Miss. excessive risk to subject is required . in order to gather data for the research. then perineum and vulva. Which of the following might prevent the conduct of a research study? A. Consider this situation: Vendors selling bread with their bare hands. they will require no pain medication to manage their pain C. some dehydration D.32. This indicates Francis will probably have a breech delivery C. give time for the mother to answer the question C. the classification will be: A. cleanse the woman’s anal area. Immediately following episiotomy repair. Francis is admitted in active labor. monitoring for blood loss greater than 100 cc. pushing down on the relaxed uterus to aid in the removal of the placenta 46. patients without having been given consent for anti-TB treatment D. health perception and health maintenance D. patients willing to undergo treatment 41. ask checking questions 40. take the baby away as soon as possible after birth to prevent bonding from occurring 45. coping and stress tolerance 48. and very painful B. RN. the child is alright 38. beneficence C. continue feeding the child D. which may indicate an adverse reaction to medications C. which would indicate gross hemorrhage C. Which of the following is NOT included in the care for home management at this case? A. inform when to return to the health center 33. Patients eligible under the short term chemotherapy (STC) are the following EXCEPT: A. if women are properly prepared. “Miss. support the woman as needed by accepting the decisions she makes regarding holding the baby C. Tony. Leprosy is a chronic disease of the skin and peripheral nerves. may I get the bread myself because you have not washed your hands” B. it is better to use a pick up forceps/ bread tong” D. Tony has been hospitalized for months following special spinal cord surgery. What should you say/do? A. Mr. the nurse must consider which of the following? A. palpate the uterus fundus for size. During the third stage of labor. do not give BCG if the child has known hepatitis B. Jordan. the nurse would do which of the following? A. circulatory failure B. Francis will probably deliver very quickly and without problems] B. Which of the following conditions is not true about contraindication to immunization? A. Such community action should positively influence Mr. respect for person B. the child is in shock C. Which of the following signs are present in the early stage? A. the child is dehydrated D. listen attentively D.

The application of public health. if the child gives adequate weight for his age B. Tiangco what happened. like all newborns. Arnie. call Mr. fecal waste 60. occupational safety measures reduce.00 per day. 100 – 220 ml C. general and context 56. sputum examination should be done to the following groups: A. Tiangco was found lying on the floor next to his bed. The nurse wants to immunize a 1 year old child for measles. the eldest son Rhio is 7 years old. Lying on the floor. which of the following interventions can lend assistance to them? A. The Santiago Family lives in a makeshift house in Julugan. Queenie and Quency are twins 5. ignore the advance directive 63. follow the directive even though the nurse is uncomfortable with the directives B. ask if the child has had no convulsion D. occupational health D. transfusion and injection B. 54. antitoxin D. No complaints verbalized. costs for conducting the study are low compared to the potential benefits from the researcher C.H. Aling Rosa works in a laundry earning Php 1. allergen 64. B. B. Peter and the twins are enrolled in the day care. antibodies C. Mr. “I was asleep and the next thing I knew I was on the floor”. The side rails on the bed are down. if the child is breastfed less than 8 times in 24 hours 59. he stated “I was asleep and the next thing I knew I was on the floor”. broad and theoretical 57. When asked what happened. school health B. give Aling Rosa’s family a Php 2. quantitative 58. How will the nurse explain the importance of immunizing the child with measles now? A.00 a month and husband Mang Sony works as fish vendor earning Php 150. the research problem is based on untested nursing theories 50. he replies. C. Mr. Mr. Appears to have fallen out of bed while asleep. refer the children to a hospice care facility B. the child will recover faster if the child will be immunized D. If the child is 4 months. developmental D. What is the usual amount of blood loss with cesarean birth? A. all persons of all ages above 1 year with symptoms indicative of tuberculosis C. if the infant is wet from amniotic fluid C. Hepatitis A is differentiated from hepatitis B by their mode of transmission. The resear ch typed used of this nature is: A. side rails down. You have just entered Mr. 300 – 500 ml 51. A literature review should be: A. Barmonte’s lawyer C. Hepatitis B is transmitted through: A. ask if the child is able to breastfeed C. children below 10 years old with fever for 3-5 days D. the child has lower resistance and more prone to disease C. it is the child’s schedule to have the immunization 61. mental health 55. The child has been classified as having pneumonia and no anemia and not very low weight. 500 – 1000 ml D. Barmonte was brought home with an advance directive. can loose body heat by conduction.500. Composed of 8 members. D. ask if the child vomits everything 52. 250 – 350 ml C. Side rails down.000. Marsha is concerned she may loose an excessive amount of blood with cesarean surgery. Tiangco’s room and observed him lyin g on the floor next to the bed. assist Aling Rosa to be referred to the DSWD for livelihood assistance C. Under which conditions is this most apt to occur? A. rehabilitation C. advise Aling Rosa to use contraceptive pills . When you asked Mr. discuss with the interdisciplinary team in charge of Mr. ask if the child is eating well during illness B. experimental B. if Arnie is placed in a cold bassinet D. Cavite. brief and limited B. if the child shows interest in semi solid foods C.B. The nurse should: A. A term concerning body resistance which refers to protein present in the serum of the blood: A. health promotion B. With the current condition besetting the Santiago family. community health C. Rhean is 6. To implement the case finding aspect of TB control. Rhio and Rhean stopped studying to help their parents for their younger brothers and sisters. A health care service in which risk factors are identified. The child’s mother do es not want her child to be immunized and instead they will just return as soon as the child is better. children 0-9 years old with cough for 2 weeks or more B.O. Which of the following examples of documentation is MOST APPROPRIATE for this situation? A. Barmonte and the organization’s ethics committee D. Rolled out of bed while asleep. illness prevention C. but the nurse is not sure that she can follow his wishes. urine D. the identified problem is covered in the literature D. When should the mother give complementary foods to a 5 months old infant? A. Lying on floor next to bed. all persons ages 10 years and over with progressive loss of weight 62. both side rails were left down. Tiangco fell out of bed while asleep. and a public education program begun is: A. the child’s condition is not a hindrance to immunization according to W. which of the following questions SHOULD NOT be included in checking the general danger signs? A. if there is a breeze from an open window 53. treatment facility D. Every year we discover new methods or gadgets to improve man’s life. applied C. supplementary foods should be given before breastfeeding D. Peter is 4 and the youngest is 6 months old named Oscar.00 worth of capital for them to put a fishball stand D. systematic and exhaustive D. medical and engineering practices to health services and effectiveness of workers may be termed as: A. if the nursery is cooled by air conditioning B. Tanza. antigen B. insect bites C.

The appropriate intervention is: A. clarification B. Which of the following statement SHOULD NOT be included? A. The nurse could suggest which of the following foods to increase protein content with little increase in food expenditure? A. the mental status of family and friends 71.65.” Mrs. In barangay Y. it will not be implemented C. 38 breaths per minute D. conduct of pre and post consultation conference for clinic patients 73. 6 to 8 months B. available resources C. regardless of the staff’s preference B. A home visit is a professional interaction between the community health nurse and his patient or the family. indigestion D. secure donations in the form of toilet bowls B. reflecting her culture. and time orientation B. Gomez shrugs her shoulders and says. one of the identified problems is unavailability of toilet facility for the residents. aiming the infant’s lips well below the nipple . 40 breaths per minute B. needs recognized by the family D. The following are the concerns of the Public Health Nurse on the third trimester of pregnancy EXCEPT: A. moral B. the perceived health status and illness patterns of the family D. oranges and potatoes C. the nurse should ask the mother if the diarrhea has stopped when: A. records and reports D. choice 68. increase weight B. When the nurse assists the clients in understanding personal values. hand washing 82. this is an example of value: A. values. 55 breaths per minute C. the community health nurse determines the family’s diet is inadequate in protein content. the child has less than 3 loose bowels per day B. Assessment areas for the nurse is working with the family on health promotion strategies would include: A. Although family income seems adequate. the child has 5 formed stools D. food-borne infection C. “Tomorrow may never come. While doing a nutritional assessment of a low-income family. indicating that her budget needs is a private matter 66. clinic schedules after home visit 79. tell the staff that if they really do not want the change. give necessary health teaching D. encourage each side to share their views with each other 72. document file C. conduct a community assembly and discuss the consequences of this problems 77. touch the infant’s lips with her nipples C. The nurse would suggest the MOST APPROPRIATE age to begin vegetables is: A. follow-up of medication and treatment B. the television shows that they watch B. the family and all the relative’s statuses C. Gomez’s reaction is described as: A. value D. the child has 4 semi formed stool C. A positive or negative feeling toward a person. provision of technical and administrative support to rural health midwives D. explain that the change will occur as designed. none of the above D. Which of the following is a priority? A. proper timing in the separation of mother to other siblings D. provide extensive and detailed rationale for the proposed change D. state the purpose or objective of the visit C. When a child with persistent diarrhea returns for follow-up visit after 5 days. An effective strategy for resolving this difference in acceptance would be to: A. Eating habits of the family has changed due to the existing fast food establishment in the area. Gomez is unable to budget it over a 4-week period. leave to the BHW the responsibilities of educating the community B. type of feeding 75. or idea is known as a/an: A. Where could the nurse get available information about the patient or the family to be visited? A. object. where to give birth C. the nurse considers the individual needs. 4 to 5 months D. The nurse manager wishes to implement a new way of determining the vacation schedule for the staff. 3 to 4 months C. The nurse asks what may be done to help Mrs. The senior staff opposes the change while the newer staff seems more accepting of the change. place the infant in your most convenient position B. An 8 month old has fast breathing if he has: A. validation C. one of not caring about her family’s needs C. ask help from local government C. acceptance of the family B. The following are the duties of the Public Health Nurse EXCEPT: A. A new mother who is breast-feeding her baby asks the nurse when she should start her feeding baby vegetables. potatoes and rice D. Which factor must be considered by the nurse as vital to determine frequency of the home visit? A. In planning a home visit. family health record 78. What health risk should you warn the family? A. her belief that income may not be adequate as perceived by the CHN D. peas and beans 69. attitude 67. doctor’s office B. rice and macaroni B. 9 to 12 months 70. needs of all family members C. A community health nurse (CHN) visits the Gomez family weekly. greet the client or the household members B. inquire about welfare and health condition of the client 80. advice for the mother to take oral contraceptive B. provision of nursing care to the sick and well individuals C. the child has 3 loose stools/day 76. discovery D. To show a mother how to help her to have good attachment of the infant during breast feeding. policy of the agency D. Mrs. wait until the infant’s mouth is widely open D. Which of the following is the FIRST action of the nurse during a home visit? A. past nursing services 81. 45 breaths per minute 74. merit C. move the infant quickly onto her breast.

administration of BCG vaccine for a 10 days old baby B. 11 cm B. Which among these activities is the concern of the Primary Level? A. disinfect all work areas in the patient’s home 92. specific medical treatment 96. Ayuyao. enmeshed D. immobility B. reducing genetic risk factors for illness D. nurse’s professional effort C. BCG B. organizing methods to achieve optimal mental health C. In assessing the level of family cohesion. attention disorders D. Which of the following vaccine in the Expanded Program of Immunization have a 4 weeks interval? A. What size should the ischial tuberosity diameter be. Nona had her pelvic measurement taken. ability to be self-directed B. obesity B. malnutrition 93. each illness is classified according to whether it requires the following EXCEPT: A. allow health workers to withhold fluids and medications 86. When providing care in a home. Which of the following is the best type of disease prevention? A. The intravenous fluid infused to dilate your uterus does not hurt the fetus B. you remember that living wills: A. secondary prevention D. Which of the following is a leading health problem of school-age children? A. A nurse has scheduled a hypertension clinic. community social events B. connected B. dispose off patient’s syringes in the patient’s garbage D. you will need to drink at least 3 glasses of fluid before the procedure C. Nurses who deliver community-based care must have which of the following qualities? A. administer diuretics such as furosemide per doctors order D. As a license nurse. has been admitted with pneumonia. and members are highly dependent on one another.83. primary prevention B. insertion of a nasogastric tubes to patients C. adaptability C. When members of the community identify needs. OPV C. allow the individual to express his or her wishes regarding care D. check for ear pain C. 8 cm D. the boss assures you of a big promotion if you go out on a couple of dates with him B. Mrs. encourages behavior modification program C. Tetanus Toxoid 99. providing information and skills to maintain lifestyle changes 100. check for tender swelling behind the ear B. to be considered adequate? A. allow the court to decide when the care can be given C. remove the patient’s wound dressings from the home C. have the width of symphysis pubis C. how might the nurse best implement infection control? A. accepts death as an outcome of life DECEMBER 2006 – NP3 NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS . The nurse who is planning a health promotion program with clients in the community will have the LEAST focus on: A. you have determined that the family is very close and has very high loyalty. Which of the following is an example of hostile environment in terms of sexual harassment? A. A holistic belief system by the nurse would be most evident if the nurse: A. check for malnutrition 94. immunization C. This service would be an example of which of the following types of health care? A. lack of information available to patients D. immunization B. are legally binding in all states B. check for ear drainage D. regulate intravenous fluid drop rates 98. cleanse the hands before and after giving direct patient care B. community organizing B. urgent pre-referral treatment and referral C. got to diet question. what should the nurse do? A. void immediately before the procedure to reduce your bladder size D. poor prenatal care C. ear aches C. your supervisor makes masturbatory gestures every time you walk pass him C. the personnel manager hints that the job will be yours if you cooperate sexually with him D. supports goal-directed learning to improve health D. behavior that promotes health 89. In classifying the child’s illness using the IMCI color-coded triage. What is the most common type of health problem seen in the health care system? A. you can have medicine for pain for any contractions cause by the test 87. increased rate of chronic disease 88. Her husband asks the nurse about the living will. If the child does not have ear problem. You would document this as which level of cohesion: A. yearly physical exam D. simple advice on home management D. incorporates client perceptions of health when planning care B. twice the width of the conjugate diameter 95. 77 year old. government assistance D. protection 91. AMV D. your boss suggests that your “raise” is dependent upon having sex with him 97. leadership through traditional leaders 84. work on its solutions with confidence in the spirit of cooperation. all of the above 90. The process is: A. assisting the clients to make informed decisions B. Maybelle is scheduled to have an ultrasound examination. What instructions would you give her before her examination? A. separated C. tertiary prevention C. disengaged 85. tolerance of various lifestyle D.

a nurse at the PACU discovered that Luisa.m. The MOST appropriate reply by the nurse would be: a. life and death prior to conception and birth d. OR reports. gender choice for children 13. urinary output c. One of the hidden dangers in the OR is missing instruments. to Luisa c. Venipuncture. to prevent the cross-contamination of infection between OR staff and patient 14. check the patient’s vital signs 16. E. intake and output d. no administrative support d. exempting circumstances b. increase instrument inventory 15. apply direct pressure to the laceration to her head b. Benny can determine their understanding of circumstantial evidence if they can identify which of the following in the case? a. verify the order from the M. fast turn-around of nurses c. The nurse’s priority action would be: a. The patient is scheduled for adrenalectomy. justifying circumstances c. notify the physician d. What one condition besetting the nursing service prevents the use of team approach? a. report to the nurse supervisor for opinion d. b. presence of a neck injury b. Drooling from an increase of saliva on the affected side may occur 11. There is a heightened awareness of taste. treatment orders. 7 to 8 days after conclusion of the menstrual period c. The perioperative nurse assumes responsibility and accountability for nursing judgments and actions exemplified by the following. mitigating circumstances 2.M. restlessness d. prn for pain”.1. 50 kilos who is 3 hours post cholecystectomy was in severe pain. exposing the arm to sunlight to increase circulation d. The eye is susceptible to injury if the eyelid does not close d. symptoms b. so that foods must be bland c. De Leon is suffering from Bell’s palsy as indicated by a feeling of stiffness and a drawing sensation of the face. OR reports and patient’s abstract d. She is unconscious and has a large laceration to the head that is bleeding profusely. What is the appropriate approach to this happening? a. professional choice of children b. Examples of non-verbal communication in patient-nurse relationship are the following EXCEPT: a. she found out that Luisa had “Demerol 100 mg I. the 26th day of the menstrual cycle b. blood urea nitrogen results 12. 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. What should Fe do? a. understaffing b. laboratory results. install a flush sterilizer in the OR d.D. politics in the nursing department 8. shift only d. Upon checking the chart.M. BP) to the arm on the operative side b. She fell while crawling over the side rails of her bed. the nurse places the highest priority on assessment for: a. avoiding unnecessary trauma (e. Fe. Demerol I. using a sling to keep arm flexed at the side . urine for glucose and acetone b. Ms. neurological status with the Glasgow Coma Scale c. nurse’s notes 4. One of the reasons why behavior in the OR is so tightly controlled is: a. wound drainage 5. EXCEPT: a. the same day each month 3. and surgery technique b. W. the priority nursing action would be to monitor: a. Ms. Virtue ethics gives us a special prospective in the parent’s role to decide for their children including decision of: a. laboratory results and abstract only c. the door of OR suite are closed c. In teaching her about the disease. is found on the floor of her room. cerebrospinal fluid leakage from ears or nose d.” She understands that this type of fluid loss can occur through: a. inject 100 mg. Copies of certain portions of the chart maybe released at the discretion of the hospital but may be limited to: a. Postoperatively. wrapping the arm with elastic bandages during the night 10. vital signs c. accepting on-call assignment b. the gastrointestinal part d. selecting a. maintaining basic nursing procedure c. the nurse teaches the patient with a modified radical mastectomy to prevent lymphedema by: a. A group of nurses are studying the case of a 16-year old nursing student who was accused of frustrated homicide. x-ray result. In the preoperative period. laboratory results. During admission of a patient with a severe head injury to the emergency department.g. what would be important to tell her? a. using an interpreter like a family member 6. signs c. aggravating circumstances d. Jenny is reading the progress notes of her patient and reads that the physician had documented “insensible f luid loss of approximately 800 ml daily. the skin b. during her menstruation d. Communication can be verbal and non-verbal. everybody is busy doing their operation d.M. “a place for everything and everything in its place” c. ensure the patient has an open airway c.O. There may be increased sensitivity to sound b. correct labeling b. spouse choice for children c. it is hard to move around in a OR gown b. accepting committee assignment c. administer the recommended dose which is 50 mg because Luisa weighs 50 kilos 9. patency of airway 7.

He is very dyspneic and must sit up to breath. Licensed nurses from foreign countries can practice nursing in the Philippines in the following condition: a. toast with peanut butter and cocoa c. Cheyne-stokes c. the lungs fill with fluid b. gangrene d.Coli c. The primary goal of nursing interventions after a craniotomy is: a. 3 minutes c. verbal communication d. Will I be naked during the operation? d.O. K. x-ray technician b. fat embolism 27. the best indicator of quality is: a. non-verbal communication b. 15 minutes b. surgeon 28. irrigate with water for 15 minutes or longer d. Circulation must be restored within 4 minutes of cardiopulmonary arrest because: a. prevention of infection 21. patients come back of their doctor’s advice 18. is diagnosed with chronic bronchitis. 30 minutes d. T. The nurse recognizes that the MOST common causative organism in pyelonephritis is: a. Mr. compartment syndrome c. brain cells begin to die d. active listening 19. use clean. E. c. Another worthy study is the compliance to the principles of aseptic technique among the sterile OR team. pruritus and erythema of the conjunctiva 31. assistant surgeon d. The patient demonstrates knowledge of the psychological response to the operation and other invasive procedure when she asks about: a. provides a shorter treatment period with a fewer long term complications d. deep. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a modified radical mastectomy. 34. the consent should describe the prognosis if the recommended care is refused. presence of floaters d. . The MOST appropriate choice for this client to meet nutritional needs would be which of the following: a. preserves the normal appearance and sensitivity of the breast. Pseudomonas 22. wet cloth to gently wipe away the pus c. Who will be with me in the OR? b. When questioned by the patient about these options. squirt a small amount on the inside of the infected eye’s lower lid b. wash hands before medication administration d. age 13. ensuring patient comfort c. cover the eyes with a sterile gauze 24. irreversible kidney failure develops 29. the consent should offer a thorough explanation of the procedures to be done and the consequences of it. has about the same 10-year survival rate as the modified radical mastectomy c. need for universal testing d. cast syndrome b. giving stereotyped comments c. patients come back with referral like their family and friends c. orthopnea d. How is the post operative pain over the site like? c. Benny elaborated on the concept of informed consent. special projects with hospitals with a fixed fee c. has undergone surgery for lyses of adhesions. halos around lights b. the consent should include the medical diagnosis and explanation of the patient’s condition d. employed in state colleges and universities b. A most critical strategy in nursing communication is: a. Klebsiella d. Is it cold inside the 33. 20 minutes 20. He determines that the nurses need more explanation if their response is one of the following: a. public support and understanding 23. Who does NOT belong to the sterile OR team? a. intermittent loss of vision c. do not use other eye ointments or drops or put anything else in eyes. In teaching the mother the proper administration of tetracycline eye ointment. He is transferred from Post Anesthesia Care Unit (PACU) to the Surgical floor. reduces the fear and anxiety that accompany the diagnosis and treatment of cancer b. which of the following is MOST crucial? a. the nurse informs the patient that the lumpectomy with radiation: a. the consent should provide a description of alternative treatments or procedures b. patients recover but spend more on supplies b. scrub nurse c. medical mission whose services are free 25. The initial priority care following the chemical burn is to: a. eupnea b.17. preventing increased intracranial pressure d. The diabetic patient asks for a snack and something to drink. unrelenting pain in the hand or foot unrelieved by analgesics or elevation of the extremity indicate which complication? a. duty siblings and spouse c. dyspnea 26. irrigate with normal saline for 1 to 15 minutes b. pulse and respiration every: a. Mr. Candida Albicans b. transport to a physician immediately c. patients demand more use of technology d. graham crackers and warm milk 32. An abnormal condition in which there is discomfort in breathing in any bed or sitting position is: a. confidentiality b. WT is cleaning the garage and splashes a chemical to his eyes. In the hospital. Which of the assessment findings would indicate a need for possible glaucoma testing? a. There are legal and ethical concerns specially: a. Mr. complaints of sharp. 30. Following a fracture of the forearm or tibia. vanilla wafers and coffee with cream d. the nurse should obtain blood pressure. the blood begins to coagulate c. There is a global concern on AIDS. crackers with cheese and tea b. avoiding need for secondary surgery b. employees by private hospitals d.

the physical property of the hospital c. Dyazide and carafate 36. tell the mother the reason for giving the drug to the child 53. Discharge teaching would include: a. blood bank services b. Which finding is MOST closely associated with TB? a. the following can assume the role. red blood cells 15-20 c. 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. has satisfactorily completed with the requirements to practice nursing as set by the state. Which of the following interventions would the nurse employ? . the patient assessment priority is the: a. surgeon 46. perioperative nurse d. lifting light objects is acceptable 38. has a baccalaureate degree in nursing c. Who monitors the activities of each OR suite? a. bending at the knees and keeping the head straight d. is being evaluated to rule out pulmonary tuberculosis. Salvo. Ms. demonstrate to the mother how to measure a dose d. has been admitted with the diagnosis of peptic ulcers.0 37. can be revoked for reasons stipulated in RA 9173 b.O.. tell the client that Cathy has to administer the pain medication first. call to order d. puncture site 49. turbid d. When reading the urinalysis report. responsible caregiver 40. age 45. The nurse recognizes which drugs as those MOST commonly used in these patients to decrease acid secretions? a. Christian of the U. night sweats d. R. then will return as soon as possible c. leg cramps b. Dr. cardiopulmonary resuscitation 44. hanging system drainage b. Dr. the nurse recognizes this result as abnormal: a. The OR team collaborates from the first to the last surgical procedure. respiratory effort c. scrub nurse c. the administration of the analgesic morphine may cause: a. anesthesiologist d. ask the nursing aide to stay with the other client while Cathy finishes the bed bath 52. Organ donation to save life was initially with the first transplant done by: a. The patient’s medical record is the best evidence of the care that is given to the patient.35.N. chief nurse 51. C. glucose negative b. A thumb mark of a comatose patient in the informed consent is considered: a. a not valid signature b. Tagamet and zantac c. finish the bed bath. What department should the nurse collaborate which is unusual in conventional surgery? a. “nothing” d. The appropriate action of Cathy is: a. Urinary tract infection is the most common site of nosocomial infection particularly with urinary catheterization. code means a call for: a. raise side rails. nursing practice in the operating suite? a. spasms of the sphincter of Oddi 50. chaplain d. closed system drainage 42. Following a renal angiography. Maalox and kayexalate d. urinary retention d. ph 6.A. ask the mother to give the first dose of the drug to her child c. Cathy is giving bed bath to an assigned client. the doctor owns the record 54. Christian Barnard of the Union of South Africa b. Mr.S. Which of the following health teachings by the nurse will be MOST appropriate in home medication administration? a. linen section 39. Christian Barnard of U. OR nurse supervisor b. Christian Barnard of Soviet Union d. transferable c. EXCEPT: a. a 35 year old male. a valid signature 45. 47. In medical and nursing practice. family members c. the patient owns the record b. Hizon has had cataract surgery. A nursing aide enters the patient’s room and informs her that another patient is in pain needs pain medication. is professionally ready to practice nursing d. paralytic ileus b. bending at the waist acceptable if done slowly c. the health team property d. urinary output b. Cover the client. addiction c. determine the appropriate drug and dosage for the child’s age or weight b. In patients with acute pancreatitis. Edna classified the patient as having diarrhea with severe dehydration. engineering department c. surgeon c. denotes that a nurse: a. Who is responsible in daily monitoring the standards of safe. Dr. a misrepresentation c. c. wearing eye patches for the first 72 hours b. erythromycin and flagyl b. significant others b. just a title 41. Mr. Endoscopic minimally invasive surgery has evolved from diagnostic modality to a widespread surgical technique. blood pressure d. DNR state c . Dr. circulating nurse b. personal 43. When the client is discharged from the hospital and is not capable of doing the needed care services. skin discoloration 48.K. The professional license of an RN is: a. x-ray department d. lifetime d. intermittent drainage c. It is the property of: a. green-colored sputum c. then administer the pain medication d. b. clinical case b. open system drainage d. It can be reduced significantly by through: a.

Which is a deterrent factor in written communications? a. it refers to the quality of being righteous. Which of the following attributes is shown by Monica? a. reliability 70. monitored b. movement of personnel should be: a. Which of the following statements is NOT one of the strengths of non-experimental designs? a. a young female executive admitted with bleeding peptic ulcer. fair and impartial 63. “I need to exercise at least some everyday. During surgery. The patient has a right to information regarding the operation or other invasive procedure and potential effects. 65. decreasing diameter d. mole symmetry 66. can be completed in a short span of time b. She is being seen by the nurse at the health maintenance organization for signs of fatigue. Mr. age 52 had a laryngectomy due to cancer of the larynx. it reflects the moral values and beliefs that are used as guides to personal behavior and actions c. 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.O. consistency. Which response by written communication from Mr. XP underwent D and C for dysfunctional bleeding. and the client can self-bolus with an additional dosage from the pump prior to each meal. charting b. e-mail c. “I need to be sitting straight up and my chin slightly tucked so I won’t choke when I eat or drink. checking the patient’s low residue diet. c. transmission of infection during processing is avoided b. Each has its own limitations. prudence d. easier to gain cooperation of study subjects 71. This right is achieved through: a.” c. informed consent c. It is MOST important to assess the adolescent with acne for: a. Communication can take many forms. He bases the response on the information that the pump: a. respirations 18 and regular 60. “If I miss an occasional dose of the medication. perineal pad c. placing the client prone to facilitate drainage of secretions d. suicide tendencies b. so does non-experimental researches. observing vomitus for color. increase intake of fatty foods 68. E. 57. signs and symptoms of hypothyroidism 56. Ms. is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals c. A nurse develops a plan of care for the client. eliminated when possible 59. extending client’s chin while on his side and pillow at the back b. and his family. resourcefulness c. less expensive c. A priority nursing assessment to be included in the plan regarding this medication is to assess for: a. F. “I should eat a diet high in fiber and roughage to decrease my constipation.O. preoperative visit d. An external insulin pump is prescribed for a client with with diabetes mellitus. integrity and functionality is assured. will be a signal to the nurse that the instructions need to be reclarified? . which response would indicate the need for further education? a. give vitamin A 55. A nursing intervention associated with this type of patient is: a. is surgically attached to the pancreas and infuses regular insulin into the pancreas. give a tetracycline tablet c. continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels d. frequently monitoring arterial blood levels b. or verbal response from the family. Discharge instructions are given to Mr. monitored b. A clear advantage of singleuse items is: a. doctor’s rounds 62. As experimental research designs have their strengths.” b. poor skin turgor d. checking the blood pressure and pulse rates each shift d. Which of the following data from the nursing history indicates that the anemia is NOT currently managed effectively? a. 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. and volume 58. turning the client from side to side at 10-minute interval c.” d. useful for predictive purposes d. The client asks Eddie about the function of the pump. Dee is a 27-year-old housewife and mother of two children. it assists in the control of feelings. vaginal packing d.O. gelfoam 64. convenience c. In evaluating the care of Ms. smooth surface c. correct.a. honesty b. performing jaw thrust maneuver while client is supine 61. guaranteed first class quality d. fax d. signs of renal toxicity b. Which of the following is a warning sign of cancer? a. In teaching the patient with Parkinson’s disease. refer urgently to the nearest hospital d. restricted d. low self esteem d. kept to a minimum c. suicide tendencies b. A physician has prescribed propylthiouracil for a client with hyperthyroidism.P. gives a small continuous dose of regular insulin. relief of pain d. it is not of much significance. use of non-universal abbreviation 69. She has the history of iron deficiency anemia. pallor c.F. it encourages the constructive use of the pleasure of the senses d. which in turn releases the insulin into the bloodstream. change in weight c. b. signs and symptoms of hyperglycemia c. It is important to teach the patient the warning signs for skin cancer. What is inserted vaginally to prevent postoperative bleeding? a. Reusable supplies/instruments are still widely used in the Philippine OR setting. thoughts and emotions in the face of difficulty b.” 67. Mrs. Which statement about a person’s character is evident in the OR team? a. O. vaginal suppository b. border irregularity b. the nurse focuses on nursing interventions.. advise the mother regarding follow-up after 5 days b.

ensure efficient completion of surgical instrument 81. on the right side of the body with the head of the bed elevated 45 degrees b. effective followers b. The doctrine that justifies the death of the fetus is: a. pre-operative visit d. scrub nurse 83. Before administering the enema. As the nurse in-charge for scheduling you will collaborate with the following departments EXCEPT: a. restructure OR scheduling system b. Negligence in the practice of nursing can be a ground for: a.a. Ms. streamline instrument inventory c. phrasing intelligently b. call the nursing supervisor and report the incident b. Maria will be preparing a patient for thoracentesis. alienated d. dietary d. 72. S. The MOST appropriate nursing action is to: a. anesthetize the cornea c. Tuazon scheduled Mrs. pat dry. The machine activates but instead of the report. revocation of license by the Ombudsman b. cut the photograph and throw it away. cream peas d. “I check my mouth and teeth after each meal” d. A research on “Surgical Instrument Availability” will help the surgical team: a. “YES” people c. first case. OR nurse b. the suctioning at home must be a clean procedure. When a patient comes to the clinic for an eye examination. If we choose to be successful nursing professionals. “My lips are dry an d cracking. the ophthalmologists administers phenylephrine 2. restricted semi-restricted and unrestricted areas b. According to AORN recommended practices. call the unit who sent it and ask for the name of person who sent the photograph 76. Lying in bed on the unaffected side with the head of the bed elevated 45 degrees 84. surgeon c. she should place the patient in which of the following positions? a. c. F. restricted and semi-restricted areas . use hydrogen peroxide and rinse with water. In the process the fetus died. “I’ve been very constipated and need an enema” 86. operating room only d. A nurse is waiting for a report to be sent by fax. anatomy d. At present. speaking distinctly using enough volume 79. PRN c. yes people. improve instrument decontamination d. This is researchable. Maria is administering a cleansing enema to a patient with fecal impaction. right Sim’s position 82. Dr. left Sim’s position c. alienated. lean fish. is the responsibility of the: a. Sim’s position with the head of the bed flat d. A mother who is pregnant and has ovarian cancer has to undergo surgery to treat the cancer. Patients undergoing surgery display different levels of anxiety. rice and pastry c. NPO 74. removed any obstruction on the cornea 85. surgical attire intended only for use within the surgical suite should be worn within the: a. a low platelet count and a hemoglobin measurement of 5. call the police d. justice c. OD d. it is acceptable to take over-the-counter medications now that condition is stable b. prone with the head turned to the side and supported by a pillow b. revocation of license by the DOH d. a chemotherapy patient with a low WBC count.6 g would indicate the need for further teaching? a. exception to the rule b. Which of the following trays would be acceptable for her? a. “My husband and I have been using vaginal lubrication before my intercourse” c. pre-anesthetic drugs c. anesthesia b. dilate the pupil d. shower prior to surgery b. What other factors can reduce anxiety that is currently done among postoperative cases? a. it has been found out that music can decreases anxiety. c. NNO b. pathology c. sheep 80. One way of verifying that the right message/doctor’s order was communicated effectively is by: a. skim milk. I need some lubricant” b. revocation of license by the BON c. the nurse received a sexually oriented photograph. Which of the following statements by Ms. not sterile. repeating the order message c.X. fried potatoes and avocado b. dilate retinal blood vessels b. surgery 73. She should assist the patient to which of the following positions for the procedure? a. liver.. presence of any members of the family 87. on the left side of the body with the head of the bed elevated 45 degree d. ham. whole milk.5% drops to: a. report swelling. survivor and effective followers. Poe for a right breast mass incision with frozen section and possible mastectomy on Monday. lying in bed on the affected side with the head of the bed elevated 45 degrees c. we have to become one these and influence other: a. bio-med technician d. mashed potatoes. Which of the following is NOT a standard abbreviation? a. cleans skin around stoma BID. pain or excessive drainage d. documenting d. restricted area only c. double effect 75. has been admitted with right upper quadrant pain and has been placed on a low fat diet. Kelly identified five categories of followers in an organization: sheep.O. tapioca pudding 77. The functionality and integrity of instruments and medical devices used in surgical procedure. Charting should be legible and include only standard abbreviations. revocation of license by the Nursing Department 78.

Based on the DOH and World Health Organization (WHO) guidelines. withholding anticholinergic medications d. but new drugs being developed can interfere with the body’s reaction to inflammati on and better control the disease process. DILG d.” c. specific procedures treatment and risks involved 100. be informed of administrative and policies and practices b. explain details of perioperative preparation with a tour and viewing of area and equipments d. use birth control to avoid pregnancy 98. Rescue c. use OTC vitamin D preparation b. handwashing c. the patien t’s pharynx is anesthesized with Xylocaine spray. cost b. relevant current and understandable information concerning diagnosis. In providing general information and assessing the patients level of interest or reaction to surgery. “No. A client with decreased kidney function 92. reusability d.d. decrease fluids to prevent sickling of RBC’s d. respond d. Records Management and Archives Office (RMAO) c. Surgical instruments are expensive and are a lifetime investment of the O. a negative Homan’s sign b. treatment diagnosis. avoid strenuous ex ercises c. on the same day of each month C. supplement calcium intake 97. offer general information about the surgery 93. but the patient must take medication for at least 10 years. one whole human being b. increase fluids to stimulate erythropoises c. A heavily researched topic in infection control is about the single most important procedure for preventing hospital acquired infections. increasing restlessness d. run 94. hypoactive bowel sounds in all four quadrants 99. which criterion is evaluated? a. He would become MOST concerned with which of the following signs which could indicate an evolving complication? a. new drugs being developed offer a cure. on the first day of her menstruation . allowing fluids up to 4 hours before examination 95. MMDA DECEMBER 2006-NP4 NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS Situation 1: It is Cancer Consciousness Week and you are participating in an Early Cancer Detection Drive of the Department of Health. What is this procedure called? a. cancerous lumps D. areas of thickness or fullness B. In preparing the patient for endoscopic examinations of the upper GI tract. KN is monitoring the status of a postoperative patient. A client with CHF b. “Yes. “Yes. If you are to instruct a postmenopausal woman about BSE. shelf life c.” 91. fibrocystic masses C. considerate and respectful ca re c. the mainstay for early detection method for breast cancer that is recommended for developing countries is: A. A client with colostomy d. alternate periods of rest and activity to balance oxygen supply and demand b. prohibiting smoking before the test c. when would you tell her to do BSE: A. use of scrub suite d. a monthly breast self examination (BSE) and an annual health worker breast examination B. multiple specialty c. The MOST appropriate response is: a. multi-organ d. OR staff are instructed to follow the international RACE. DOH b. 1. Discharge teaching for the client with hypoparathyroidism should include which of the following instructions: a. most patients with RA also develop osteoarthritis. compartmentalized body 96. What does R stand for? a. Rita is assigned to care for group of patients. The purpose of performing the breast self examination (BSE) regularly is to discover: A. BP of 110/170 mmHg and a pulse of 80 beats per minute c. Nursing interventions for post-endoscopic examination include: a. keeping patient NPO until gag reflex returns b. brain washing 89. Collaboration of the specialists will in effect treat the client as: a. He asks if there is a cure for RA.” b. “No. Modern medicine has divided the human body into different systems/organs or the so called “specialty medicine practice”. Que. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency? a. she determines that which patient is at risk for fluid volume deficit? a. 61 years of age is suffering from rheumatoid arthritis. confidentiality of communications and records d.R. an annual mammogram D. avoid diuretics to minimize calcium loss 88. which of the following nursing intervention will received priority? a. use of facemask b. Which of the following should NOT be included in the list? a. A client receiving frequent wound irrigations c. The Patient’s Bill of rights helps practitioners provide more effective patient care. Mr. An important nursing intervention goal to establish for Mang Carlos who has iron-deficiency anemia is: a. an annual hormone receptor assay C. a physician conduct a breast clinical examination every 2 years 2. tell the patient when the surgery is scheduled b. To ensure quality of these instruments. On review of the patient’s medical record. In the event of a fire. integrity and functionality after each use and processing 90.” d. changes from previous BSE 3. Rest b. let the patient know that the family will be kept in formed c.

edema provides a milieu for bacterial proliferation D. Which statement by DS indicates the need for further teaching before true informed consent can be obtained? A. hematuria and seizure D. deep partial thickness burns B. Now. You will need to provide instruction and information to your clients to prevent complications. painless. burn shock D. intramuscularly C. 16. Which statement by KP indicates a lack of understanding about his rights as a research study participant? A. tell FB that “ Treatments are only three times a week. FB. The MOST effective method of delivering pain medication during the emergent phase is: A. To prevent recurrent attacks on FT who has glomerulonephritis. 6. right after the menstrual period D. moon face and muscle atrophy 18. neurogenic shock C. for the rest of my life 17. you can live with that” D. you must observe KJ for signs of rejection which includes: A. orally B. first degree or superficial burns 12. and leathery in texture describes a: A. LM has chest tube attached to a pleural drainage system. axillary D. ventilation exchange B. clamp the chest tube when suctioning 7. on the last day of her menstruation A. Which of the following can be a fatal complication of upper airway burns? A. FB tells you “I want to go off dialysis. “I wonder if there is another way to protect these bad rhythms” D. keep calm because there is no immediate emergency C. How would you respond to him? A. hemorrhage D. change the dressing daily using aseptic technique B.B. After the kidney transplant. supplementary oxygen Situation 3: Severe burn is one of the most devastating kinds of injury one can experience. GT had a laryngectomy. leave the room and allow him to collect his thoughts B. lumps in the breast tissue B. empty the drainage system at the end of the shift C. When caring for LM you should: A. take showers instead of tub bath 9. myocardial infarction B. “this implanted defibrillator will protect me from those bad rhythms my heart goes into” 20. 11. He is now for discharge. subcutaneously D. recognize that prompt closure of the tracheal opening D. a tender. loss of protein prevents tissue repair B. change in size and contour 5. When preparing to examine the left breast in a reclining position. palpate the surrounding areas for crepitus D. cyclosporine and prednisone? You recognized that KJ understood the teaching when he states. tell FB that “ We all have days when we don’t feel like going on” C. until the supply is over B. bring the breast closer to the examiner’s right hand B. notify the physician at once 10. chest tube drainage C. KJ. blood replacement D. third degree or full thickness burn D. You have been ready to provide holistic care for patients with severe burns. FB was told by his physician that he was a poor candidate for transplant because of his hypertension and diabetes mellitus. “I must take these medications: A. the sign that would be indicative of a developing thrombophlebitis would be: A. a pitting edema of the ankle B. 28 years old with chronic renal disease plans to receive a kidney transplant. I’d rather not live than to be in this treatment the rest of my life”. a reddened area of the ankle 8. edema impedes tissue perfusion/oxygenation C. stress ulcers C. during the preoperative period D. Edema presents a significant problem in burn wounds because: A. you should instruct her to: A. avoid situations that involve physical activity D. It can affect any group. the purpose of standing in front of the mirror it to observe the breast for: A. “ I’ll have to find a new physician if I don’t complete this study” . balance the breast tissue more evenly on the chest wall D. your PRIORITY would be to maintain: A. A burn that is white. second degree burn C. reinsert another tubing immediately B. “ I understand the risk associated in this study” C. polyuria and jaundice B. “I can withdraw from the study anytime” D. until the anastomosis heals C. tense the pectoral muscle C. who is to have a kidney transplant asks you how long will he take azathioprime (Imuran). painful area on the leg C. After pelvic surgery. facilitate lateral positioning of the breast Situation 2: Ensuring safety is one of your most important responsibilities. When caring for TU after an exploratory chest surgery and pneumonectomy. laryngeal spasms and swelling Situation 4: You are assigned to take care of four patients with different conditions. He verbalized his concern regarding his laryngectomy tube being dislodged. continue to take the same restrictions on fluid intake B. Critically ill patients are at high risk for the following complication during the emergent phase: 13. thickening of the tissue C. the purpose of placing a small folded towel under the client’s left shoulder is to: A. take a sit next to him and sit quietly 19. DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators. contractures 4. edema can produce a tourniquet effect 15. “a wire from the generator will be attached to my heart” B. intravenously 14. During breast self-examination. What would you teach him FIRST? A. KP is participating in a cardiac study in which his physician is directly involved. pruritus on the calf and ankle D. seek early treatment for respiratory infections C. fever and weight gain C. shock B. “the physician will make a small incision in my chest wall and place the generator there” C. Recently. “My confidentiality will not be compromised in this study” B.

hyperthyroidism D. vascular functions D. you would suspect that TR is: A. FT. MRI – may reveal the site of infarction. pruritus C. As a nurse caring for patients in pain. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also develop in a client with: A. optic functions B. type of opioid being used Situation 8: To be able to provide care for patients in the critical areas. ECG – may reveal abnormal electrical activity. effectiveness for patient C. You are assigned in the neurology stroke unit. Cerebral Angiography – is used to identify collateral blood circulation and may reveal site of rupture or occlusion B. treat transient ischemic attacks (TIA) early C. cold. the extent of collateral circulation 25. Peripheral neuropathy can BEST be controlled by: A. comes to the emergency room complaining of sudden onset of lower leg pain. respiratory depression D. general pain management choices based on level of pain C. The guidelines for choosing appropriate nonpharmacologic intervention for pain include all of the following EXPECT: A. physical dependence 33. C. motor functions 29. alcoholism. sensory functions C. cadaverous left calf. thrombosis 24. gender D. it is caused by a cerebral hemorrhage D. hematoma and shift of brain structures D. liver disease B. avoid using a nail clipper to cut toe nails D. TR has been on morphine on a regular basis for several weeks. Research study show that nurses who work with critically patients as opposed to nurses who work with less acute patient: A.Situation 5. To guide you in your assessment. you should evaluate for opioid side effects which include the following EXCEPT: A. you should: A. When teaching a client with peripheral vascular disease about foot care. paresthesia and a mottled. diabetes insipidus Situation 7: You are assigned to take care of a group of elderly patients. drug abuse) to children of patients with stroke D. severity of damage C. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. You should be able to address their concerns in a holistic manner. Assuming that nothing has changed in his condition. maintain serum cholesterol level between 220 and 180 mm/dL B. hypertension C. skill of the clinician health professional B. The WHO analgesic ladder provides the health professional with: A. Which of the components of HARDINESS has been linked to burnout? . cyanotic. To prepare for this assignment. 21. specific pain management choices based on severity of pain B. cerebral arterial spasm B. needing to have the morphine discontinued B. who has no known history of peripheral vascular disease. you should include which instructions: A. vitamin supplement B. Which of the following is the MOST common cause of stroke or brain attack? A. there is no slowing the process 30. Peripheral neuropathies primarily affect: A. obesity. pain associated with cancer and the terminal phase of the disease occurs in majority of patients C. experience greater stress 37. 26. PET Scanning – may reveal information on cerebral metabolism and blood flow characteristics. 36. nonpharmacologic interventions based on level of pain 32. Which of the following statements can BEST describe/define stroke or brain attack? A. developing tolerance to the morphine D. it occurs when circulation to a part of the brain is disrupted B. The purpose of each of the following diagnostic examination is correct EXCEPT: A. such as focal slowing and assess amount of brain wave activity. are most acceptable to burn out B. good glucose control C. avoid wearing cotton socks 27. it is usually caused by abuse of prescribed medications C. pain problem identification D. elevate the affected calf as high as possible 28. Inspection and palpation reveal absent pulses. Which of the following statements about cancer pain is NOT true? A. place a healing pad around the calf C. 23. exaggerating his level of pain 35. opioids are drugs of choice for severe pain B. screen for systolic hypertension Situation 6: Foot care among patients with peripheral vascular problems is very important. steroid therapy D. nonsteroidal anti-inflammatory drugs enhance pain perception 34. it may be the results of a transient ischemic attack (TIA) 22. Pain and urinary incontinence are their common concerns. keep the affected leg level or slightly dependent D. 31. anti convulsants. avoid wearing canvas shoes C. teach preventive health behaviors (consequences of smoking. becoming psychologically dependent C. artery affected B. While the physician determines the appropriate management. adjuvant medications such as steroids. avoid use of cornstarch on the foot B. pharmacologic and nonpharmacologic pain management choices D. nothing. shave the affected leg in anticipation of surgery B. Several diagnostic tests may be ordered for proper evaluation. 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. are more satisfied with their role C. it is also important for you to remember that the clinical features of stroke vary with the following factors EXCEPT: A. embolism C. you should be able to answer the following questions. 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. you should look into factors that will enhance your ability to provide quality nursing care. move a greater support system D. constipation B. hemorrhage D.

it prevents air from getting into the stomach C. Nursing Practice Act D.. the length of the tube D. a nasotracheal tube does not require securing D.A. the internal diameter of the tube C. the length of the person’s airway D. Excessive fluid volume B. Impaired urinary elimination C. encouraging self-care d. regular. You have important responsibilities as a nurse. the length of the tube 50. informed consent and treatment refusal? A. the length of the person’s airway 48. FF knows which food sources are rich in potassium C. efficient and safe environment B. JJ reports midsternal chest pain radiating down the left arm. FF. What will be your PRIORITY nursing action? a. management requires a multidisciplinary approach. Upon discharge. recognition and appreciation of a person’s unique and social environmental relationships B. Deficient fluid volume D. Which of the following interventions would support your patient’s circadian rhythm cycle? A. 51. slightly diaphoretic. hourly hyperextension neck exercises b. heart rate of 10 beats/min. Which nursing diagnosis takes HIGHEST PRIORITY? A. community referral 40. keep the body parts in good alignment to prevent contractures C. helping the patient to a position of comfort c. decreased cardiac output C. who sustained 40% severe flame burn yesterday. disaster management C. These assessments indicate which nursing diagnosis? A. TD with dry skin and dry mucous membranes has had a urine output of 600 m and a fluid intake of 800 ml. Which document addresses the patient’s right to information. FF knows all the complications of the disease process . it prevents stomach contents from getting into the lungs 49. delegated responsibility C. the circumference size of the tube C. 3 year old boy just sustained full thickness burns of the face. which among these interventions should be your PRIORITY? A. putting a wall clock up on your patient’s room B. Your primary therapeutic goal for DS during the ACUTE PHASE is: a. FF correctly identifies three potassium rich foods D. What’s the correct written client outcome for this diagnosis? A. the inflated cuff provides sufficient securing Situation 11: Because of the serious effects of severe burns. You are caring for GG with a history of falls. For the past 24 hours. appreciation of the collaborative role of all health team members 39. seal off the oropharynx from the esophagus D. assess for airway. has a nursing diagnosis of “Risk for injury related to adverse effects of potassium-wasting diuretics”. TD’s urine is dark amber. Common aspects of the critical care nursing role include: A. Shortly after being admitted to the CCU for acute MI. 46. Endotracheal tube size indicated on the tube reflects what measurements: A. less commitment to work B. Upon discharge. slightly labored respirations at 26 breaths/min and a blood pressure of 150/90 mmHg. dimming light during normal sleeping time Situation 9: To ensure continuity of care and for legal purposes. Code for Nurses C. keep the bedpan available so she does not have to get out of bed C. breathing and circulation problems D. it seals off the nasopharynx from the oropharynx D. decreasing environmental noise C. acute pain B. An endotracheal tube had to be inserted to correct the hypoxia. emotional support b. AW. encouraging normal bowel movement D. a sense of control over the patient D. seal off the lower airway from the esophagus C. instruct GG not to get out of bed unassisted B. Standard of Nursing Practice 43. reconstructive surgery d. In adults. thorough knowledge of the interrelatedness of body system D. seal off the lower airway from the upper airway 47. placing the call light for easy access D. keep the bed at the lowest position ever 44. you have important responsibilities to accurately document all nursing activities. Which of the following statements is TRUE about securing the artificial airway? A. staff liaison D. provide a calm. Endotracheal tube size indicated on the tube reflects what measurements: A. direct care provider B. the circumference size of the tube B. and has a temperature of 37. sense of control to life Situation 10 : You are taking care of LC who develops acute respiratory distress. CV who sustained upper torso and neck burns. The FIRST PRIORITY when caring for GG who is at risk for falls is: A. discouraging pillows behind the head 54. Which action is MOST likely to cause a functional contracture? a. artificial airways must be secured directly to the patient B. Patient’s Bill of Rights B. anxiety D. seal off the oropharynx from the nasopharynx B. chest and neck. You notice that JJ is restless. the internal diameter of the tube B. Nurses who work with critically ill patients should base their practice on all of the following EXCEPT: A. 41.8 deg C. wound healing c. When caring for DS. Imbalanced nutrition: less than body requirement 42. risk for imbalanced body temperature 45. The primary purpose of the endotracheal tube cuff is to: A. an inflated E-T tube cuff is necessary for mechanical ventilation primarily because: A. assess the injury for signs of sepsis 52. it seals off the lower airway from the upper airway B. fluid resuscitation 53. perception of change C. FF states the importance of eating potassium rich foods daily B. Risk for infection related to epidermal disruption 38. the airway is generally sutured in place C.

BC diagnosed with cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. the tissue becomes less resilient d. To promote perineal wound healing after an abdominoperineal resection. a presurgical decrease in fluid intake c. On the second day following abdominoperineal resection. “Do you hold your urine for a long time before voiding?” d. you should encourage BC to assume: a. As a nurse you have important roles and responsibilities in infection control. with flushed skin and painful when touched b. keep skin test areas moist with mild lotion. EF was admitted to the hospital with a tentative diagnosis of acute pyelonephritis. A colostomy patient who wishes to avoid flatulence should not eat the following EXCEPT: a. proper functioning of the nasogastric tube d. primarily to: a. BC returns from surgery with a permanent colostomy. changing the dressing just prior to meals b. indications and care. and weakness c. a febrile state due to release of pyrogens b. promote rest of the bowel by minimizing peristalsis 68. corn and peanuts c. you anticipate that the colostomy stoma will appear: a. aseptic wound care c. Ineffective airway clearance related to edema d. retrograde bacterial contamination may occur c. stay out of the sun until the skin tests are read b. what question should you ask? a. ischemia d. cutting the colon and bringing the proximal end through the abdominal wall b. excising a section of the colon and doing an end-to-end anastomosis d. control of upper respiratory tract infection d. Impaired urinary elimination related to fluid loss c. purple and depressed below the skin surface . double-barreled 63. These include all of the following EXCEPT: a. arteriosclerotic changes b. prevent irritation of the intestinal mucosa b. transverse loop colostomy b.Before surgery. During the 24 hours. the colostomy does not drain. left or right Sim’s position c. dry. a low residue diet is ordered. empty the bowel of solid waste d. dry. 56. loss of appetite and pain d. “Have you taken any analgesic recently?” b. a. with a full thickness burns involving entire circumference of an extremity will require frequent peripheral vascular checks to detect: a. “Do you have pain at your back?” c. You explain to BC that this is necessary to: a. cabbage and asparagus d. A colostomy can BEST be defined as: a. During the first post operative week. 61. administration of prophylactic antibiotic 59. A wound that has hemorrhaged has increased risk for infection because: a. the patient should be informed he/she will have a. the patient may be given sulfasuxidine and neomycin. You are assigned to take care of a patient with such a condition. as the nurse should realize that this is a result of: a. reduce the bacterial content of the colon c. left or right side lying position d. leukopenia due to increased WBC production 58. FG. proper handwashing technique b. Impaired body image related to physical appearance 55. moist. temporary colostomy c. One of the MOST effective nursing procedures for reducing nosocomial infection is: a. “Have you had any sore throat lately?” 57. of reduced amounts of oxygen and nutrients are available 60. reduce the amount of stool in the large bowel c. limit production of flatus in the intestines d. While caring for a patient with an infected surgical incision. anorexia. Several days prior to bowel surgery. lower the bacterial count in the GI tract 67. dorsal recumbent position b. pink. deodorizing the room periodically with a spray can d. malaise. 62. moist.b. removing the rectum and suturing the colon to the anus. dead space and dead cells provide a culture medium b. encouraging the patient to observe the stoma and its care c. hypothermia c. pale pink and with flushed skin d. 66. knee-chest position 69. The following are taken up: types of ostomies. you observe for signs of systemic response. red and raised above the skin surface c. come back on the specified date to have the skin tests read c. You. chewing gum and carbonated beverages 64. soften the stool by retaining water in the colon b. wash skin test areas with soap and water daily d. the absence of intestinal motility b. permanent colostomy d. You should teach her to: a. You are instructing EP regarding skin tests for hypersensitivity reactions. intestinal edema following surgery 70. To assess her risk factors. When an abdominoperineal resection is done. Situation 13 : TR attends a Health Education Class on colostomy care. adequate wound healing Situation 12: Infection can cause debilitating consequences when host’s resistance is compromised and environmental factors are favorable. the nurse can BEST help the patient with a colostomy to accept the change in body image by: a. mangoes and pineapples b. creating a stomal orifice from the ileum c. 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 anagement.

As the nurse of BL which of the following nursing diagnosis will be your PRIORITY? a. encourage oral fluid intake d. has terminal cancer. The physician gave a tentative diagnosis of right ureterolithiasis. clamp the tubing 75. acute pain d. dysfunctional grieving 77. expansion of the remaining lung b. During the immediate post operative period following a pneumonectomy. ineffective airway clearance 85. Situation 16: Renal stones can cause one of the most excruciating pain experienced by a patient. activity intolerance B. person and place b. You are caring for YA. change the tubing d. impaired physical mobility 84. risk for infection 78. 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. administering the prescribed analgesic immediately prior to exercises c. What should you do as a nurse when the chest tubing is accidentally disconnected? a. impaired physical mobility related to surgery B. placing the patient on his/her operative side during exercises 73. ineffective cerebral tissue perfusion B. Upon physical examination. orient him to time. Which nursing diagnosis takes HIGHEST PRIORITY for WW? A. splinting the patient’s chest with both hands during the exercises b. You are caring for WE. administering intravenous solution at a keep vein open rate d. KJ has an indwelling urinary catheter and she is suspected of having urinary infection. who is admitted with acute chest pain. offer the bed pan every 4 hours c. administering opioid analgesics preferably intravenously c. prevention of mediastinal shift d. with renal stones. She is admitted for treatment of gastroenteritis. impaired urinary elimination d. Which of the following observations indicates that the closed chest drainage system is functioning properly? a. less than 25 ml drainage in the drainage bottle b. your nursing diagnosis is: a. providing rest for 6 hours before exercises d. Has anyone in your family been sick lately? 82. impaired gas exchange D. Do you need anything now? c. Post-operatively. You have important perioperative responsibilities in caring for patients with lung cancer. 71. age 89. Which question will be MOST HELPFUL for you to ask? a. knowledge deficit regarding health 79. he demonstrates signs of dementia.Situation 15: Specific surgical interventions may be done when lung cancer is detected early. impaired urinary elimination c. anxiety C. intermittent bubbling through the long tube of the suction control bottle. GM is scheduled to have lobectomy. Her urine is dark amber. Which of the following is the appropriate intervention for BL who has ureterolithiasis? a. disconnect the tubing from the urinary catheter and let urine flow into a sterile container d. inserting a nasogastric tube (low suction) . risk for infection related to anesthesia D. you noted perineal excoriation. which nursing diagnosis takes HIGHEST PRIORITY for BO? A. imbalance nutrition: less than body requirements b. Based on the above data. imbalance nutrition. the fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration d. RR. bathing or hygiene self care deficit D. ineffective breathing pattern C. fluid volume deficit c. the patient will not be able to tolerate coughing c. absence of bubbling in the suction-control bottle c. You are documenting your care for CC who has iron deficiency anemia. 30 year old business woman. As a nurse of BL which of the following nursing diagnosis will be your PRIORITY? 76. promotion of wound healing 72. You are obtaining a history of MR. risk for injury C. and dry Situation 17: You are caring for several patients with various disease problems. BL was brought to the Emergency Room for severe left flunk pain. wipe the self-sealing aspiration port with antiseptic solution and aspirate urine with a sterile needle 80. keep the perineal area clean. Following thoracic surgery. notify the physician b. Which nursing diagnosis is MOST appropriate? A. What seem you doing when the pain started? d. a 56 year old man who is dehydrated and with urinary incontinent. Why do you think you had a heart attack? b. What will be your PRIORITY intervention? a. The purpose of closed chest drainage following a lobectomy is: a. How should you collect a urine specimen for culture and sensitivity? a. clump tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine b. WW is blind. drain urine from the drainage bag into the sterile container c. the tracheobronchial tree are dry d. reconnect the tube c. the bronchial suture line maybe traumatized 74. the remaining normal lung needs minimal stimulation b. deep tracheal suction should be done with extreme caution because: a. You should give HIGHEST PRIORITY to which nursing diagnosis: A. facilitation of coughing c. 81. nausea and vomiting. acute pain related to surgery 83. inserting an indwelling urinary catheter b. decrease fluid volume related to blood and fluid loss from surgery C. less than body requirements b. deficient fluid volume B. risk for injury D. BO who received general anesthesia returns from surgery. you can BEST help GM to reduce pian during the deep breathing and coughing exercises by: a.

she is guided with basic beliefs about the practice. add the total amount of blood to be transfused to the intake and output B. verify client identity and blood product. An arteriovenous fistula was created for hemodialysis in his left arm. who is in acute renal failure. urine output of 30-60 ml/hour D. 86. call the physician. infuse NSS. You are assigned to take care of a group of elderly patients. urine output directly related to the amount of IV fluid infused B. immediately stop the BT. blood type. What diet instructions will you need to reinforce prior to his discharge? A. Which of the following statement reflects the scope of mental health psychiatric nursing? A.B. are expected to experience chronic pain B. hypercalcemia Situation 18: The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta. Pain in the elder persons require careful assessment because they: A. You should be able to address the concerns in a holistic manner. hypernatremia 94. how long should you infuse it? A. be sure to eat meat every meal 95. BN. dilated urethra 99. As a nurse it is important that you understand the rationale behind the treatment regimen used. discontinue the primary IV of Dextrose 5% Water C. fluid retention is enhanced when salt substitutes are included in the diet D. increased glomerular filtration C. expiration date with another nurse C. blood type. breathing D. Administration of analgesics to the older persons requires careful patient assessment because older people: A. 96. what is the effect of the rennin-aldosterone-angiotensin system on renal function? A. Pain and urinary incontinence are common concerns experienced by them. immediately stop the BT. restrict your salt intake D. notify the blood bank D. have increased sensory perception D. is also advised not to use salt substitute in the diet because: A. mobilize drugs more rapidly 98. it includes nursing actions aimed at returning the patient to his highest potential of productivity. From the time you obtain it from the blood bank. it is an integral aspect of all nursing and a specialty service to all people affected by mental illness. check the vital signs every 15 minutes D. increased absorption of sodium and water 93. 91. PL. expiration date B. notify the blood bank and administer antihistamines Situation 19. The kidneys have very important excretory. drink plenty of water C. 4 hours B. erythropoietic functions. stay with WQ for 15 minutes to note for any possible BT reactions 89. disability (neurologic) B. Any disruptions in the kidney’s functions can cause disease. renal and gastrointestinal function C. circulation. it consist of early recognition and treatment of mental disorders to reduce severity and duration of mental illness . 1. metabolic. it includes nursing actions to reduce the rate of new cases of mental disorder in population D. monitor your fruit intake and eat plenty of bananas B. immediately stop the blood transfusion. disability (neurologic). verify physician’s order 88. increased urine output. have increased hepatic. stop the blood transfusion and monitor the patient closely C. BN. hypertension and flushing B. a substance in the salt substitute interferes with fluid transfer across the capillary membrane Situation 20. are more sensitive to drugs B. decreased urine output. decreased absorption of sodium and water C. what will you do AFTER the transfusion has started? A. B. decreased absorption of sodium and water D. increased urine output. cross matching results. increased absorption of sodium and water B. no urine output. airway. is admitted to the Nephrology Unit. 6 hours C. airway. have increased sensory perception D. headache. 2 hours 87. Which of the following is the MOST COMMON sign of infection among the elderly? A. have a decreased pain threshold 97. breathing. During the shock phase. chills. airway. As you are caring for PL who has acute renal failure. experienced reduce sensory perception C. decreased breath sounds with crackles C. check IV site and use appropriate BT set and needle D. oliguria and jaundice C. breathing. limiting salt substitutes in the diet prevents a buildup of waste products in the blood C. kidneys in a state of suspension 92. verify client identity and blood product serial number. one of the collaborative interventions you are expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat: A. The elderly patient is at higher risk for urinary incontinence because of: A. You are preparing the first unit of whole blood for transfusion. hypokalemia D. breathing C. salt substitute contain potassium which must be limited to prevent arrhythmias B. As a beginning professional nurse. C. 1 hour D. Priorities when caring for the elderly trauma patient: A. As WQ’s nurse. cross matching results. circulation DECEMBER 2006 – NP5 NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS Situation 1: The nurse is envisioning a career path in mental health psychiatric nursing. urticaria and wheezing D. decreased bladder capacity B. In case WQ will experience an acute hemolytic reaction. change in mental status 100. fever 90. The EARLIEST signs of transfusion reactions are: A. diuretic use D. airway. pain B. hyperkalemia C. urine output is less than 400 ml/24 hours C. serial number. WQ is undergoing blood transfusions of the first unit. Which assessment parameter for kidney function will you use during the oliguric phase? A. what will be your PRIORITY intervention? A. fever D. The period of oliguria usually lasts for about 10 days. What should you do FIRST before you administer blood transfusion? A. decreased urine output. infuse Dextrose 5% in Water and call the physician B. 40 year old with chronic renal failure.

C. the nurse should do this action before giving the client fluids. The rationale is: A. to encourage expression on topics of interest C. Eva is a member of a group who controls endless talking. confrontation 5. Paul finds sketching relaxing and rewarding 9. general anesthesia B. Karen. Vic goes in the garden where he work with plants. ensuring physical safety and maintaining therapeutic attitude towards the patients 4. The purpose of these meetings would be: A. 11. electrocardiogram 13. assess the gag reflex C. Alcoholics Anonymous D. chief nurse 15. X-ray D. permission may be taken from the: A. reframing B. young professionals entering the workplace D. latency period 18. Jon and Pia play scrabble every night after supper C. seedlings. actively psychotic patients C. this defect in the personality reflects a disturbance of the: A. Psychodynamically. next of kin or guardian D. It is BEST for parents to teach healthy interpersonal relationships to their children by: A. check O2 Sat with a pulse oximeter Situation 4: The community health nurse encounters special children in the community. encouraging their children to attend secondary school C. Which of these people. Studies on biological depression support electroconvulsive therapy as a mode of treatment. super ego D. teaching their children good manners and right conduct 19. ECT relieves depression psychologically by increasing the norepinephrine level D. restraining patients who violates policies and do not follow schedule of activities. his needs are being met B. school children with behavioral problem 3. Tommy. The preparation of a patient for ECT ideally is MOST similar to preparation for a patient for: A. Which of the following is a possible side effect which you will discuss with the patient? A. opportunity to learn democratic living 8. Remotivation Group C. women preparing for overseas employment Situation 2: Some activity therapies are organized and conducted in groups where nurses may participate in. next of kin or guardian B. tree planting and watering them D. The treatment serves as a symbolic punishment for the client who feels guilty and worthless C. The nurse teaches parents about children’s beginning concepts of right and wrong by emphasizing child rearing attitude and practices during the: A. B. school age C. Which of the following determines the success of client government groups? A. parents with child rearing concerns B. to focus on issue arising from group living B. and bells and encourages client participation B. Informed consent is necessary for the treatment for involuntary clients. a way of permitting clients provide themselves with a more creative and wholesome life C. Community meetings are held as a part of milieu therapy on an in-patient psychiatric unit. id 17. doctor C. confusion. Her role is that of a/an: A. treat the child according to his chronological age 7. An important principle for the nurse to follow in interacting with retarded children is: A. When this cannot be obtained. shame and guilt in going against the norms of society. 6. keeping a restrictive environment to prevent patients from becoming assaultive and hostile D. Which of this client situation appropriately illustrate horticulture therapy? A. food or medication: A. disorientation and short term memory loss 14. encephalitis D. The foundation of the therapeutic process is the therapeutic relationship. willingness of psychiatric professionals to be open and receptive to client’s ideas and suggestions B. 16. empathy D. modeling to their children B. A professional responsibility of the mental health psychiatric nurse is to provide a safe and therapeutic environment. hemorrhage within the brain B. seen that if the child appears contented. A mental health nurse may not be a member of this self help group because help given to members comes from members themselves: A. Art Therapy Group D. blocker C. humor C. ECT produces massive brain damage which destroys the specific area containing memories related to the events surrounding the development of psychotic condition B. robot-like body stiffness C.2. adults going through active skills B. single elderly with no social support C. toddler age D. ego C. EXCEPT: A. monopolizer 10. the highest in population groups that would need priority mental health therapy? A. Activity Therapy Group B. tambourine. infancy period B. means to acquire a variety of social skills D. maintaining a closed door policy to prevent patients from absconding. encouraging their children at home to behave properly D. out of school adolescents D. to provide direction from the treatment plan . The beginning professional nurse can do mental health counseling with the following clients. After ECT. electroencephalogram C. self-confessor D. the therapist brings bongos. provide an environment appropriate to their development task as scheduled C. An individual with antisocial personality disorder lacks remorse. This is BEST reflected in: A. ego ideal B. social worker B. ECT is seen as a life-threatening experience and depressed patients mobilize all their bodily defenses to deal with this attack. 12. to encourage expression of intrapsychic conflicts Situation 3: The patient who is depressed will undergo electroconvulsive therapy. recognition seeker B. every afternoon. What is the essential component that the nurse must bring to the relationship? A. assess the sensorium D.

motivation Situation 6 : Bernie and John in their late 40’s have been married for 20 years and at the peak of their careers. A young overweight adult smokes 5-10 sticks of cigarettes/day. recognizing the impact of unhealthy habits D. All of these are the behavior intervention to stress management. role-playing B. problem-solving C. neurotic B. The nurse has achieved self-awareness in which of the following verbalizations? A. 36. usual problem solving methods and coping mechanisms produce a solution D. relaxing muscles from tension D. Panic C. The anxiety of Felisa is disabling and interferes with her job performance. psychotic 32. Mental retardation is: A. empathy D. “ I should not drive or operate machines” 35. the nurse wants to stop all the mainstream weight-loss diets D. situational support D. 1 – 2 months B. skills to attempt change B. counter transference C. The nurse needs to assess this lifestyle because: A. Bernie discovered that her husband was falling in love with another woman. chlorpromazine ( Thorazine ) 34. behavior modification D. Suddenly. This behavior is categorized as: A. meditation B. provide alternative behaviors to deal with increased anxiety D. when the patient yelled at me I became speechless . normal D. Assessment data of the nurse include all the following EXCEPT: A. a hazardous or threatening event occurs B. anxiety or depression continue to increase 28. avoid limits on her behavior to release her anxiety B. imipramine Hcl ( Tofranil ) B. To minimize such problems. commitment C. call attention to her ritualistic pattern C. Basic to progressive muscle relaxation is: A. the nurse knows that being overweight is a major health hazard C. transference B. she is likely to be given: A. pharmacotherapy D. Dietary practices are very important to the health of the Filipino family. it has a growth promoting potential C. delusional C. a delay in normal growth and development caused by an inadequate environment B. guided imagery C. treat the child according to his developmental level 20. a severe lag in neuromuscular development and motor abilities Situation 5: The nurse recognizes the need to learn to cope with stress and change. sympathy 37. All of these are characteristics of crisis EXCEPT: A. both developmental and situational crisis 27. progressive muscle relaxation 23. “I might have constipation” C. ignore her behavior totally 33. Shaken by this situation. stopping disturbing thoughts 24. She becomes interested to practice natural ways to enhance well being. it is imperative that the nurse is accountable to oneself hence the importance of personal and professional development. The duration of crisis usually lasts several days and usually: A. focusing on an image to relax C. EXCEPT: A. information D. anticipated crisis B. ambitious. Mild B. Felisa understands the effects of her medicine when expresses: A. use of industrial equipment B. Nurse: “I feel personally involved with my client’s problems” demonstrates: A. Lifestyle modification begins with: A. “I might feel changes in my body temperature” D. 2 – 4 weeks C. The nurse employs this approach in crisis intervention: A. 31. diazepam ( Valium ) C. Moderate Situation 8: As a professional. coping mechanisms C. she started to have problems sleeping and could not function well at work and at the risk of losing her job. repressed problems 30. initially needs: A. having an exercise regimen to follow regularly C. a lack of development of sensory abilities C. avoiding pollutants in the environment 22. interpersonal relationships and other activities of daily living. “I should watch out for signs of sore lips or sore throat” B. 21. minimizing eating in fast food restaurants B. Severe D. I feel upset and withdrawn B. haloperidol ( Haldol ) D. situational crisis C. developmental crisis D.D. the nurse wants to change the eating patterns of the Filipino family B. A therapeutic intervention in this situation is: A. every time people around me yell. looks at life as challenging and perfect and never considers change in his lifestyle. The level of anxiety that Felisa is experiencing is: A. John asked forgiveness and regret very much the hurt his wife was going through and suffered guilt feelings: 26. the nurse has to find out what people are eating 25. perception of the event B. 4 – 6 weeks Situation 7: Felisa has a ritualistic pattern of constantly washing her hands with soap and water followed by rubbing alcohol. nurse-patient relationship 29. a condition of subaverage intellectual functioning that originates during the developmental period and is associated with impairment in adaptive behavior D. Bernie and John are going through a: A. 1 – 2 weeks D.

A step by step procedure for the management of common problems is a : A. value and find meaning in experience 48. behavior therapy 52. Z should: 1. Mr. B. demonstrate an understanding of the relationship between his nervousness and cardiac condition 44. psychotherapy C. benevolent . he moved frequently in the bed and his palms were sweaty. Mina: (angrily) “ I am angry. plan for alternatives D. Which is the subjective data? A. survey D. To safeguard anonymity of data after the report is written. knowledge and understanding of human behavior and communication skills define what is essential in caring for every nurse to be able to demonstrate: A. Self-awareness. I leave you. Z does not seem to tolerate stress too well which will aggravate his cardiac condition. NANDA Diagnosis C. Considering that man is by nature social. Mr. flowchart C. observation B. demonstrate an ability to cope with nervousness 2. He understands Little about his health which may be increasing his state of anxiety. Just when we were getting somewhere. receiver C. test new patterns of behavior 54. Preparation for termination of the nurse-patient relationship begins during the: A. community meeting C. C. This gives the clients a venue to: A. working phase D. have the papers recycle but not as writing scratch paper 45. In order to get active participation of the clients to carry out the objective of the program. algorithm B. tolerant of the faults of others D. decision tree protocol B. “I am nervous at times”. The nurse’s style of leadership in milieu therapy is: A. pharmacotherapy B. I thought it was rude for the patient to yell hence I kept quiet 38. the nurse asked after a period of silence. I got reminded of how my father would be so angry and this made me anxious D. The nurse researcher mutually agreed with the research subjects that all personal data of the subjects shall be kept confidential. communicate C. positive self-projection C. 46. To facilitate identification of persons and relationships. Problem Oriented Medical Recording 43. message D. therapeutic use of self B. pedigree chart D.” A. Z was nervous during the interview. the mental health psychiatric nurse is tasked to provide general patient management. have a corrective emotional experience B. burnt or shred the papers D. clarify problems C. Gavin chart C. The nurse is aware that identifying the aspects of general patient management and identifying interventions for meeting these basic needs are distinctions of: A. This is a SOAP recording of the patient’s problem of “Nervousness”. it is BEST for the nurse to conduct a/an: A. Through the nurse’s role modeling of effective communication. The nurse utilized which communication technique: A. selective interview of patients 53. 51. 41. non judgmental B. focusing on client B. Mina’s past reactions to ending relationships is withdrawal. the clients learned new ways of dealing with authority figures. aware of ones biases C. autocratic C. hypnotherapy D. identify their problems B. participating in intensive group experiences B. it is BEST for the nurse to gain self-awareness by: A. understanding 49. orienting B. self-mastery 40. suggesting D. I should never have gotten involved with you” (silence) Nurse: “You have reason to be disappointed and to feel angry. the family nurse utilizes this diagrammatic representation of members of a family and their relationships: A. with the patients tone of voice and stare. reflecting words C. assertiveness D. keep the papers for 5 years and dispose of these after C. laissez-faire D. problem listing Situation 10: The nurse works with Mina to help her work through termination of the nurse-patient relationship. conceptualize her problem B. kardex 42. During the early part of the interaction. develop interpersonal relationship Situation 11: As a program manager. genogram D. socialize D. writing an autobiography for self introspection Situation 9: Recording and the nurse. Nursing Care Plan D. Mr. This element of communication facilitates evaluation of the program: A. “Perhaps we would talk about my leaving”.C. A problem oriented recording system that utilizes the problem solving process as the basis of patient care management: A. individual psychotherapy C. orientation phase 47. encouraging C. The objection of the nurse-patient relationship is to provide an opportunity of the patient to: A. sender B. therapeutic milieu D. the nurse researcher should: A. The nurse assists he r to practice better ways of coping termination by providing opportunities to: A. understanding D. An accepting attitude requires being: A. test new patterns of behavior C. Exerts himself physically and is hesitant to discuss problems. in control of tendency to blame 39. develop insights D. reflecting feelings 50. termination phase C pre-orientation phase B. democratic B. Gordon’s Functional Health Patterns B. feedback 55. throw the papers in a wastebasket B. D.

An appropriate topic would be: A. assisting people to use their own resources C. seminar D. warmth C. experiencing recurrence of symptoms in front of particular people or among people in general 63. joke about her thought to help her feel at ease B. 66. skills for maintaining daily living C. sympathy D. coolness D. skills and attitudes D. To maximize communication with the elderly. courage D. an advocacy that she can participate 58. a serious call for a need of transformation B. delusion D. prudence 69. simply accept D. 56.Situation 12: Loretta is a 28 years old. ceases to talk about “Virgin Mary” D. Her mission to propagate peace is: A. asking for an open ended response . Which of the following concepts BEST describe the nurse’s interaction when she/he can recognize and identify feelings and emotions of another person without even having personally experienced those feelings and emotions? A. goes to the coffee shop alone more often B. having chronic episodes of stress and anxiety while interacting with others D. All of these describe what counseling. fashion shown in personal pictures B. helping people manage their own problems B. those who are not responding to usual motivators C. role play B. playing complex computer games 72. how to tell a joke 64. providing a picture album B. it is MOST practical to: A. an attempt to overcome low self-esteem 65. trustworthiness 70. She was observed laughing and talking to herself. invite a resource person D. those who are not solving their problems which they have the resources to solve D. memories of their teenage parties 73. The nurse evaluates that Loretta’s ready for a rehabilitation program when she: A. how to spend the summer vacation C. empathy Situation 15: Communicating effectively with dementia patients is a challenge to psychiatric nurses. 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. psychodrama 71. C. judgment B. attitudes of society towards the mentally ill B. asking simple questions C. imagination C. giving advices 68. Her thought processes were profoundly disorganized. This quality of the nurse allows “connecting with others feelings”: A. carries a book “The Purpose Driven Life” 60. those who are plotting to commit suicide B. sensitivity B. transference B. firmness C. The nurse is leading a group meeting of patients to prepare them to be discharged. ways to celebrate Valentine’s Day in February B. help build self esteem and self confidence B. restating B. guiding the patient one step at a time D. do not convince her that her perception is unreal 59. singing to or with the patients C. obsession 57. Social skills training is NOT primarily indicated for psychiatric patients who are: A. She described herself as the “Virgin Mary” and her mission is to propa gate peace. recall of their courtship and love life C. awareness of interpersonal patterns of interactions D. admitted to the psychiatric unit with a diagnosis of chronic undifferentiated schizophrenia. realistic and laudable D. unemployed patient. practice skills in relating with people D. hallucination B. “To refuse gossip” is a reflection of the mental health nurses quality of: A. psychological trauma D. listening to old familiar music D. lecture C. having difficulties starting and maintaining interpersonal relationships C. explore deep seated intrapsychic conflicts C. 61. Loretta’s claim of being the “Virgin Mary” is a/an: A. Considering that it is BEST to learn by example. An appropriate goal for the group members is to develop: A. She was also fearful and suspicious of others. Which of this intervention would NOT be therapeutic in decreasing Loretta’s anxiety? A. Therapeutic ways to engage the elderly to be stimulated include all of the following EXCEPT: A. model good social skills throughout the session B. Who among these clients need immediate referral for psychotherapy? A. listen to her thoughts and feelings C. relate successful past experiences C. over involvement C. An appropriate technique for the participants to practice how to communicate effectively is through/a: A. those who are engaging in self-defeating behaviors 67. in acute stage of illness B. a set of technique. an unforgettable experience as a child D. develop and practice general coping skills 62. The LEAST area of satisfying communication with the elderly is on: A. which of the following ways of verbal communication should the nurse use minimally? A. approaches the nurse at frequent intervals C. insight into personal problems Situation 13 : A group of adult chronic schizophrenic patients were recommended to undergo social skills training. EXCEPT: A. The focus of the group interaction is “here and now”. The following are the objectives of a social skills training program EXCEPT: A.

The independent variable is: A. make a rigid structured plan that he will have to follow C. Harry’s condition is a disturbance of: A. the staff should decide solely what activities to be done and what rules apply C. a survey D. isolate the client in a quiet room 92. reduction of anxiety D. age 28 years old had not been participating in activity therapies. ignore his behavior D. Which of the following remarks from the nursing attendants indicates a need for further teaching and observation? A. rapid pulse and hyperventilation. expressive role 88. Harry’s disruptive behavior on the unit has been increasingly annoying other cli ents. Marie read a book while other patients played a ballgame 82. pilot study B. An optimal supportive environment for a person with dementia includes all. they are being laughed at because they are singing and acting like children”. patients B. nasogastric insertion C. The research is experimental which means that utilized: A. painting a mural with other patients 78. control and experimental groups 87.74. affect 77. results of tests made on the groups are compared D. hyperventilation C. engaging in activity therapy and group exercises C. 91. compensation B. conducting a drama workshop D. test-retest 90. sublimation B. influence B. denial D. nasogastric ingestion B. developing a realistic uniformed and consistent daily schedule C. encourage her to participate in an ongoing activity in the ward B. keeping D. novelty and creativity B. vocational choices C. proposal D. Your nursing intervention should be to: A. expressive role D. compensation Situation 18: A research was conducted on. ballgames should be limited to male patients only D. protest study C. it is BEST to plan activities they can engage in through a: A. Marie made no response to an invitation to play B. regression D. EXCEPT: A. In the ward. checklist B. Harry approaches you and says “I have awarded Top Salesman of the Year. age and needs of patient should be considered in the choice of games 83. Marie preferred to sit at the bench and watch the ballgame C. safety and security C. reduction of anxiety 89. feedback evaluation forum 84. achievement C. addressing economic problems B. Adults. simple nurse care for the patient day after day Situation 16: Harry. research ideas are capable of being tested C. The MOST useful activity for him would be: A. a questionnaire B. Unconditional positive regard for the elderly is BEST achieved when the nurse-patient relationship is based upon: A. patients should be allowed solely to decide what they want to do on their own C. “ The effects of the nurse expressive role in the reduction of anxiety in patients who will undergo nasogastric tube insertion”. delivering supply of linen to other rooms B. cognition B. Harry manifests excess energy and is difficult for him to sit still. community meeting D. Which of the following would the nurse do? A. displacement C. patients C. reference D. 76. it is essential to consider FOREMOST: A. one to one interaction C. Marie is aloof and indifferent to co-patients D. Marie said “I don’t like to be a part of it. The nurse notes that in order for the activity therapy to be therapeutic: A. She is having palpitations. excitement and challenge 85. age 36 is admitted to the psychiatry unit in an acute manic episode of bipolar disorder. the CNS D. panic . tell him that he is annoying other clients and isolate him in his room 79. value plays a significant part in research B. She thinks she is going crazy. providing warmth and caring 75. reaction formation Situation 17: The nurse observed that Marie. The defense mechanism utilized by manic patients to cover up depression is: A. 81. an interview scheduled C. Which of the following is NOT a characteristic of experimental research? A. 86. Look. sensorium B. grandeur 80. engaging the elderly in logical and abstract thinking B. variety and fun D. stay with her in a calm environment C. displacement C. Which of the following is a behavioral manifestation of anxiety? A. In planning activities for the patients. “ singing and acting like children” is a form of: A. tell her to stop thinking that she is going crazy D. You know for a fact that this is NOT true. My boss will come and celebarate with me”. Harry is demonstrating a delusion of: A. handling memory loss by distracting or diverting patient’s attention to something more positive D. set limits on his behavior and be consistent in approach B. The dependent variable is: A. To encourage active participation among patients. 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. This study was done to check the procedures of the research: A.

religious delusion B. Haldol (Haloperidol) D. delusion of grandeur 97. have him see a priest for confession B. His fasting for several days was not sufficient for him to feel forgiven. repressed unresolved conflicts create anxiety C. anxiety is contagious B. disturbance of thought D. trust D. was admitted to the Psychiatric Ward because of religious preoccupation. delusion of being controlled C. severe D. rapid pulse 93. This medication is indicated for anxious patients: A. identity C. It is BEST to: A. hence a threat to a persons well being D. reactions to a perceived threat maybe real or imaginary 94. somatic delusion D. Which of the following statements about anxiety is NOT true? A. hence “selective attention” in this level of anxiety: A. agree with him and sympathize how sinful he has really been B. acknowledge how he feels and focus on reality oriented topics 100. 96. encourage him to pray to atone for his sins C. intimacy ***END*** . Thorazine (Chlorpromazine) Situation 20: Andy. Andy is demonstrating: A. There is increased tension and reduced ability to perceive and communic ate. deterioration in self-care and disturbed thoughts. anxiety at any level is destructive. moderate C. socialize him with a group to keep him in touch with reality 99. help him develop a positive self image D. mild 95. The psychosocial task that Andy needs to work on is a sense of: A. mood disturbance C. explore the nature of his sins C. psychomotor disturbance B. tachycardia D. explain that he is depreciating himself too much D. Tofranil (Imipramine HCL) C. Valium (Diazepam) B. 30 years old. He is threatened by people reaching out to him. He believes that he has committed a lot of sins. panic B. disturbance of perception 98. A delusion is: A. autonomy B. The nursing goal for Andy is to: A. As Andy talks about his sins that he believes make people look down upon him.B.

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