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FORMATIVE EXAM 2

1. Career planning is a continuous process of self-assessment and goal setting. It helps nurses adapt to change in their
own development, in the profession and in the environment in which they live and practice. Daniel has been the nurse
supervisor of the Medical Unit for five years already. He has already submitted his letter of retirement because of his plans to
pursue other career. Daniel is said to be in which stage of career planning?
A. Consolidation
B. Learning
C. Withdrawal
D. Commitment

RATIONALE:
FIVE STAGES OF CAREER PLANNING:
1. Learning - which takes place within the basic educational program and in additional learning, e.g. with specialization.
2. Entry – when newly graduated nurses select their first employment in nursing
3. Commitment – when nurses identify their likes and dislikes in terms of clinical area, geography, work life, etc.
4. Consolidation – when nurses become comfortable with their chosen career path and with their relationship between the
personal and the professional
5. Withdrawal – when nurses prepare for retirement
(International Council of Nurses, pp. 7:
http://www.icn.ch/images/stories/documents/publications/guidelines/guideline_career_take_charge.pdf)

2. Career development is a repetitive and continuous rather than a linear process. The process is really the
development of a life skill, one that nurses can apply in their workplaces, and in their personal life. Damon, a nursing
unit supervisor is discussing career planning to his applicants. One of the applicants raised a question regarding a strategic
career plan. Damon would be most correct if he replied with the following, except:
A. ―It is a constant plan of what you want to achieve, your goals and approaches in achieving your goals.‖
B. ―It is a blueprint for action.‖
C. ―No one should do a strategic career plan other than yourself.‖
D. ―It must be derived from your career vision and should outline specific actions that you can take to achieve clearly defined
goals.‖

RATIONALE:
OPTION A: The strategic career plan is always a ―work in progress‖, continuously being evaluated and revised.
OPTION B: A strategic career plan is a blueprint for action. It specifically identifies the goals, activities, timelines, and
resources you need to help you achieve your career vision. This is the part of the process where you start to put on paper the
specific strategies you will use to take charge of your future. (Correct statement)
OPTION C: Developing a strategic career plan is critical to taking control of your own career. Designing it is not something
that someone else can do for you. You must do it for yourself to ensure that you are continually and satisfactorily progressing
towards your personal career goals. (Correct statement)
OPTION D: Correct statement

FIVE PHASES OF CAREER PLANNING AND DEVELOPMENT MODEL:
1. Scanning your environment - It involves understanding current realities in the health care system and the work
environment as well as the future trends at the global, national, and local levels in society, health care, and nursing.
Through the scanning process you become better informed, learn to see the world through differing perspectives, and are
able to identify career opportunities, both current and future.
2. Completing your self-assessment and reality - enables you to identify values, experiences, knowledge, strengths, and
limitations. These should be - linked those with your environmental scan to help create your career vision and identify the
directions for your future. As you begin self-assessment, you will focus on yourself and so that you can recognize, your
attributes, what you have to offer. Completing your self-assessment and reality check will allow you to give honest,
accurate answers to the two questions, ―Who am I?‖ and ―How do others see me?‖
3. Creating your career vision - Once you determine a realistic and comprehensive picture of your own values, beliefs,
knowledge, and skills, and have looked at those in the context of the real world scan you have completed, you are ready
to think about your career possibilities. Because the vision of your potential future is grounded in your scan and self-
assessment, it is focused on what is possible and realistic for you, both in the short and the longer term. Your career
vision is the link between who you are and what you can become.
4. Developing a strategic career plan
5. Marketing yourself - This involves the ability to package your professional and personal qualities, attributes and
expertise so that you can effectively communicate, either to your employer or client, what you have to offer and why you
are the best person for the service that needs to be delivered. (International Council of Nurses, pp. 16-17:
http://www.icn.ch/images/stories/documents/publications/guidelines/guideline_career_take_charge.pdf)

3. Power is the ability to influence other people despite resistance on the part of the other person. Power may be actual
or potential, intended or unintended. It may also be used for good or for evil, for serious purposes or for selfish ones.
In the hospital organization, registered nurses have which of the following sources of power over nursing aides?
A. Expert and Authority
B. Authority and Coercive
C. Expert and Reward
D. Reward and Authority

RATIONALE:
There are many sources of power. Some of them are readily available to nurses, but some of them are not.
 Authority: The power granted to an individual or a group by virtue of position (within the organizational hierarchy, for
example).
 Reward: The promise of money, goods, services, recognition, or other benefits.
 Expertise: The special knowledge an individual is believed to possess.
 Coercion: The threat of pain or of harm, which may be physical, economic, or psychological.

OPTION A: Nurses have expertise power and authority over licensed practical nurses, aides, and other personnel by virtue of
their position in the hierarchy. They are critical to the operation of most healthcare organizations and could cause considerable
trouble if they refused to work, another source of power. (Tappen, Weiss, Whitehead, pp. 91-92)

4. An organization is a group of persons with specific responsibilities who are acting together for the achievement of a
specific purpose determined by the organization. Nurse Manager Atehjhay wanted to increase the efficiency and
productivity of his subordinates in the clinical setting. She is planning to involve every staffs in decision making and imposes
rewards for every improvement in their performance evaluation. Basing on the action of nurse manager, you would correctly
identify that she is applying which organizational theory?
A. Classical theory C. Contingency theory
B. Systems theory D. Humanistic theory

RATIONALE:
 OPTION D: HUMANISTIC THEORY (NEOCLASSICAL THEORY) - It placed emphasis on cooperation and
participation in the workplace. The key factor in this theory is motivation. A motivated employee will produce better
output in the job. If employees are given satisfactory working conditions and have opportunities to socialize with other
employees, job satisfaction will improve, and the employee will be more motivated. The Neoclassical Theory links
with a democratic style of leadership because the employees are encouraged and allowed to participate in the
functions of the organization and the decision-making process.
 OPTION A: CLASSICAL THEORY - The focus of this theory was on the structure of the formal organization: it
examined the efficiency of the organization as a by-product of the design of the system. The concept was that the
people of an organization will be productive if they are given a well-defined task to complete. By dividing work into
tasks and requesting employees to complete the same task every day, the theory proposed that productivity would
increase because of the repetition of the task.
 OPTION B: SYSTEMS THEORY - This theory asserts that systems are a whole and that organizations should be
viewed as a whole, considering the relationships within the structure of the organization. A system is a complex mix
of intertwined elements, including inputs, throughputs, and outputs. Inputs: resources such as materials, patients,
employees; throughput: process, work; output: product
 OPTION C: CONTINGENCY THEORY - the organization‘s structure must match the working of the environment. The
most common aspect of the Contingency Theory recognizes the style of the leader and how this influences the
situation. How the leader leads will determine how the organizational structure is established. There is variation in
leadership style to gain expected outcomes. There is no one leadership style that fits every situation; a good leader
will learn how to adapt to each situation to support the desired outcomes. The organizational structure based on this
theory is flexible and varies based on the needs of the organization and the leader.
 CHAOS THEORY - stresses the importance of change within organizations. Leaders must constantly assess the
organizational environment and determine whether there is consistency within the structure. Organizational leaders
working under the Chaos Theory will excel with change and creativity. The overall goal of the organization is to be
successful in an environment of constant change. (Jones, pp. 42-44)

5. The organizational structure affects communication patterns, relationships, and authority within the health-care
setting. The structure provides stability for the mission, the vision, the values, and the goals of the organization.
Becky is a newly hired staff nurse in United Medical Center, during her orientation she observed that the organization‘s
structure is centralized. You know that all of the following are true with regard to this type of structure, aside from:
A. Decision making and power are held by a few people within the top level.
B. Leaders are more predisposed to acquiring an autocratic style of leadership.
C. Managers have a narrow span of control.
D. Delays in decision making are less likely to happen.

RATIONALE:
OPTION D: A disadvantage is that there may be a delay in decision making due to the many layers of people that the
decision must pass through to get to the top administrative level.

TYPES OF ORGANIZATIONAL STRUCTURE:
1. TALL/ CENTRALIZED/ BUREAUCRACY - Decision making and power are held by a few people within the top level.
Each person who has some power and authority is responsible for only a few people. There are many layers of
departments, and communication tends to be slow as it travels through this type of a system. This type of structure is
noted for its subdivision and specialization of labor. Advantages to this type of structure are that managers have a narrow
span of control and can maintain close supervision of their employees. A disadvantage is that there may be a delay in
decision making due to the many layers of people that the decision must pass through to get to the top administrative
level. It predisposes leaders to an autocratic style of leadership because many decisions must go to the top of the
organization or the higher-level supervisor for an answer.
2. FLAT/ DECENTRALIZED - The decentralized structure is flat in nature, and organizational power is spread out
throughout the structure. There are few layers in the reporting structure, and managers have a broad span of control.
Communication patterns are simplified, and problems tend to be addressed with ease and efficiency at the level at which
they occur. Employees have autonomy and increased job satisfaction within this type of structure. A disadvantage is the
broad span of control, which may make it hard for management to process information quickly and efficiently for the
employees. This is especially true for decisions that need to span the whole structure. Management at all levels takes on
a greater sense of responsibility within this structure, so education across teams is important. Managers may be
supervising areas with which they are not familiar or have limited working experience.
3. AD HOC/ ADHOCRACY - an open, free-form system; this type of structure is used with specialized teams to complete a
specific task. From an organizational perspective, the entire organization consists of specialized teams, each assigned to
complete a specific task. The major disadvantage of this type of structure is the lack of a formal chain of command. The
teams work together, but when problems are encountered there is no assigned person within the structure on whom they
can rely for resolution.
4. MATRIX STRUCTURE - The matrix structure is a combination of two structures, consisting of the product (output) and
the function, linked into one structure. The structure works to balance the function and service of the organization into one
operational outcome. The functions are the tasks required to complete the product. The manager of the product division
works with the manager of the function division, creating two lines of authority, accountability, and communication. The
team approach is incorporated, and there is a decrease in the number of formal rules for this type of structure. Issues with
the matrix structure include the vague chain of command and goal variation between the two structures. This type of
structure implements the use of resources efficiently. (Jones, pp. 49-51)

6. The organization chart outlines the formal working relationships and the way people interact within the given
structure. The chart displays the decision-making authority within the organization, illustrating who has the
power to make and enforce decisions for the organization. The director of Mekeni Medical Center is refurbishing the
organizational structure. He is correct to use which line in order to depict the relationship between the vice presidents of
each department?
A. Broken horizontal lines
B. Solid horizontal lines
C. Broken vertical lines
D. Solid vertical lines

RATIONALE:
The organization chart establishes following:
1. Formal lines of authority—the official power to act
2. Responsibility—the duty or assignment
3. Accountability—the moral responsibility

 Only two lines are used in making an organizational structure: Broken Horizontal lines and Solid vertical lines
 OPTION A: used to depict staff positions; shows the relationship between two people who work together to
support objectives within the organization. These positions are primarily advisory in nature, with no direct
authority over the people they are working with. The staff positions support each other within the organization by
consultation, education, role modeling, and development. An example would be the vice presidents of the
organization with respect to one another. These members advise and consult with each other but report to a
person in a higher position, through the vertical line connection.
 OPTION D: used to depict line position; these lines demonstrate who is responsible to whom within the
organization. The positions with the most decision making power are near the top of the organization chart.
(Jones, pp. 47-48)

7. In determining whether the act is ethically good or bad, the question to ask is, “What is reasonable, or rational or
the human thing to do?” The act of making a judgment is an act of the intellect. When the intellect makes a
judgment, it is always for the sake of the truth because the intellect is ordained to seek the truth. Fuji City was
struck by an earthquake which caused several casualties. Many patients were brought to the hospital. Due to the small
number of staff nurses in the area, the head nurse forced a nursing aide to perform straight catheterization to a comatose
patient. The aide was intimidated that‘s why even against his will, he performed the procedure. Which of the following is
true about the above scenario?
A. Both the head nurse and the aide's actions are unethical.
B. The nursing aide's action is neither ethical nor unethical.
C. The head nurse's action is neither ethical nor unethical.
D. The head nurse's act is unethical, while the nursing aide's act is ethical.

RATIONALE: When choice is not free, as when the ability to choose is denied, forced, or coerced, the act cannot be
subjected to ethical judgment so it‘s neither ethical nor unethical. The head nurse's act is considered unethical because it
came from free will and the nature of the act itself is bad. The nursing aide's act is neither ethical nor unethical because
his ability to choose is coerced. (Duque 2005, page 2)
8. In ethics, what may be legal may not be necessarily ethical, and vice-versa. Jesse is giving a report regarding the
behaviors of man. Among these nurses, whose act will be most considered to be ethically good?
A. Liam, who caused the death of a terminally-ill client as requested by the patient himself.
B. Zayn, who steals money from her mother to give it to his patient who cannot afford his prescribed medicines
C. Harry, who becomes productive whenever the nurse supervisor is around.
D. Emily, who took the responsibility of performing physical assessment of another nurse who feels sick and tired.

RATIONALE:
In order for an act to be ethical, the nature of the act, the intention, and the circumstances surrounding the act should be
good. Only nurse Emily met the above criteria.(Duque 2005, pages 6-7)

9. Six ethical principles guide the protection of prospective research participants: beneficence, non-maleficence,
fidelity, justice, veracity and confidentiality. The nursing department of Felicity General Hospital is to conduct a
research. The nurse manager wants to ensure that she does not violate the moral and ethical rights of their participants.
All of the following are considered true, except:
A. Being honest with informing them of all known potential risks and benefits
B. If a researcher is conducting interviews, the researcher should maintain anonymity
C. Providing benefits to research participants such as access to experimental therapies
D. Building rapport with the research participants

RATIONALE:
Beneficence means doing good for the research participant and society. It includes the benefit of participating in a study,
such as access to regular health care in an ongoing clinical trial or access to experimental therapies. Fidelity means
creating trust between the investigator and participant. Researchers should assess how they will build trust with their
subjects over time. Veracity means telling the truth to study participants. Investigators are ethically responsible for being
honest with subjects and informing them of all known potential risks and benefits. Confidentiality means safeguarding
personal information collected during a study and making sure others do not see it, usually by never reporting an
individual‘s data. Maintaining confidentiality is different from ensuring anonymity. If a researcher is conducting interviews,
data collection cannot be anonymous, as the investigator has met the participants. (Holzemer, pages 169-170)

10. Informed consent means that participants have adequate information regarding the research, are capable of
comprehending the information, and have the power of free choice, enabling them to consent to or decline
participation voluntarily. The research department finished scouting their target participants. Prior to conducting the
study, they are opt to inform the participants regarding the study. The researchers need further teaching about informed
consent when they state the which of the following:
A. The informed consent form should only be signed by the participant
B. Information on who is sponsoring or funding the study should be known by the participant
C. The use of medical jargons and technical terms are avoided whenever possible
D. Researchers must assume the role of teacher in communicating consent information

RATIONALE:
 OPTION A: Prospective participants (or their legally authorized representative) should have ample time to
review the written document before signing it. The document should also be signed by the researcher, and a
copy should be retained by both parties.
 OPTION D: Because informed consent is based on person‘s evaluation of the potential risks and benefits of
participation, it is important that the critical information not only be communicated but understood.

CONTENTS OF AN INFORMED CONSENT:
1. Participant status
2. Study goals
3. Type of data that will be collected
4. Procedures
5. Nature of the commitment
6. Sponsorship (OPTION B)
7. Participant selection: how many will be participating, how are they chosen
8. Potential risks
9. Potential benefits
10. Alternatives
11. Compensation
12. Confidentiality
13. Voluntary consent
14. Right to withdraw or withhold information
15. Contact information



GUIDELINES:
1. Organize the form coherently
2. Use large enough font so that the form can be easily read and use spacing that avoids making the document
appear too dense.
3. In general, simplify. Use clear and consistent terminology, and avoid technical terms if possible. If terms are
needed, include definitions. (OPTION C)
4. Make revisions to ensure an appropriate reading level for the group under study.
5. Test the form with people similar to those who will be recruited, and ask for feedback (Polit, 150-154)

11. Models can be helpful in assisting health professionals to meet the health and wellness needs of individuals.
Rhea, a student nurse is experiencing cough and colds so she was not able to attend her class today. She borrowed the
notes of her classmate and asked for any home works. At home she was able to complete her school works. Based on
the scenario, Rhea is considered unhealthy in which health model?
A. Clinical model
B. Role Performance model
C. Adaptive model
D. Eudemonistic model

RATIONALE:
 CLINICAL MODEL: People are viewed as physiological systems with related functions, and health is identified
by the absence of signs and symptoms of disease or injury. It is considered the state of not being "sick." In this
model the opposite of health is disease or injury. Many medical practitioners use the clinical model in their focus
on the relief of signs and symptoms of disease and elimination of malfunction and pain. When these signs and
symptoms are no longer present, the medical practitioner considers the individual's health restored
 ROLE PERFORMANE MODEL: Health is defined in terms of the individual's ability to fulfill societal roles, that is,
to perform in his or her work. People usually fulfill several roles (e.g., mother, daughter, friend), and certain
individuals may consider nonwork roles paramount in their lives. According to this model, people who can fulfill
their roles are healthy even if they have clinical illness.
 ADAPTIVE MODEL: health is a creative process; disease is a failure in adaptation, or maladaptation. The aim of
treatment is to restore the ability of the person to adapt, that is. to cope. According to this model, extreme good
health is flexible adaptation to the environment and interaction with the environment to maximum advantage
 EUDEMONISTIC MODEL: Health is seen as a condition of actualization or realization of a person's potential.
Actualization is the apex of the fully developed personality. In this model the highest aspiration of people is
fulfillment and complete development, which is actualization. Illness, in this model, is a condition that prevents
self-actualization (Kozier, pp. 301)

12. Dunn described a health axis and an environmental axis intersects. The grid demonstrates the intersection of the
environment with the illness-wellness continuum. Selena is a medical unit staff nurse. She is aware on the
importance of exercise in maintaining good health, however, due to her schedule and responsibilities at work and at home
as a single parent, she is having a hard time engaging in any form of exercise program. According to Dunn‘s High Level
Wellness Grid, you properly identify Selena‘s situation as:
A. Poor health in an unfavorable environment
B. Protected poor health in a favorable environment
C. Emergent High – level wellness in an unfavorable environment
D. High – level wellness in a favorable environment

RATIONALE:
































1. High-level wellness in a favorable environment. An example is a person who implements healthy lifestyle
behaviors and has the biopsychosocial, spiritual, and economic resources to support this lifestyle.
2. Emergent high-level wellness in an unfavorable environment. An example is a woman who has the knowledge to
implement healthy lifestyle practices but does not implement adequate self-care practices because of family
responsibilities, job demands, or other factors.
3. Protected poor health in a favorable environment. An example is an ill person (e.g., one with multiple fractures or
severe hypertension) whose needs are met by the health care system and who has access to appropriate
medications, diet, and health care instruction.
4. Poor health in an unfavorable environment. An example is a young child who is starving in a drought-stricken
country. (Kozier, pp. 302-303)

13. The physical examination is performed in all health care settings for all age groups to gather comprehensive,
pertinent assessment data. Mr. Sercheef, 63 years old, is admitted in the private ward for observation after complaints
of severe chest pain. When doing an initial assessment, the best way for you to identify the client‘s priority problem is to:
A. Converse with the relatives to gather data about history of illness
B. Do auscultation to check for chest congestion
C. Interview the client for chief complaints and other symptoms
D. Do a physical examination while asking the relevant questions

RATIONALE:
Health history ascertains the client‘s chief complaints and directs the focus of physical examination. The complete
assessment data are used to:
 Ascertain the client‘s level of health and physiological function
 Identify factors placing the clients at risk and to determine area of preventive nursing
 Confirm alterations, disease, or inability to perform the activities of daily living
 Identify the need for additional testing or examination
 Evaluate the outcomes of treatments and therapy

OPTION A: Secondary data
OPTION B: Chest pain suggests heart problem; auscultation for chest congestion focuses on respiratory connditions
OPTION C: Interviewing the client is avoided due to the client‘s chest pain

14. Many clients become anxious about being physically exposed and/ or experiencing pain during the examination.
The client and the environment require special consideration. Nurse Eric is preparing his client for a physical examination.
He does all but one of the following to prepare the environment before the examination:
A. Put the equipment on a surface that is clean and not free from movement
B. Make sure the room is free from draft
C. Makes a family member present because the client requested
D. Inform other personnel about the time of examination

RATIONALE:
 OPTION A: Adjust the environment to allow for placement of the equipment on a surface that is clean and free
from movement. Remove from the floor any items that would place the client at risk for falling
 OPTION B: The room needs to be quiet, warm, without drafts and adequately lit
 OPTION C: Depending on the setting, make necessary adjustments to ensure privacy. Family members may be
present during the time of examination for the comfort of the client.
 OPTION D: Inform other personnel about the time of examination to avoid interruptions, which are frustrating to
both the client and the nurse. (Kozier, pp. 577)

CONSIDERATIONS IN PE: (ULG, pp. 38)
PELUCA- Position, Expose, Lighting, Unhurried, Compare, Attention to details

15. All equipment required for the health assessment should be clean, in good working order, and readily
accessible. Equipment is frequently set up on trays, ready for use. Nurse Colby plans to assess the 1
st
and 9
th

cranial nerve of her client. To properly assess her client, she should prepare which of the following equipment?
A. Cotton and tongue depressor
B. Penlight and Aromatic substance
C. Aromatic substance and tongue depressor
D. Cotton and Penlight

RATIONALE:
Several items that are frequently used in the physical examination include:
 Aromatic substances (e.g. Vanilla) to test the 1
st
cranial (olfactory) nerve
 Cotton balls to assess sensory response to light touch
 Toothpick to assess sensory response to slight pain
 Drapes to cover the client
 Gloves to reduce the transmission of microorganisms
 Calibrated tape measure for assessing circumference, length and width
 Tongue depressor to inspect mouth and to stimulate gag reflex for assessing 9
th
and 10
th
(glossopharyngeal and
vagus) cranial nerves (Ladner, pp. 541)

16. Most people need an explanation of the physical examination. When assessing adults it is important to recognize
that people of the same age differ markedly. Nurse Megg is tasked by her supervisor to conduct physical examination
on a thirty year old female client. Which of the following would call the Supervisor‘s attention?
A. Nurse Megg addresses the client as Miss Thompson
B. Nurse Megg explains why the physical examination is necessary
C. Nurse Megg determines which positions are contraindicated for her client
D. Nurse Megg instructs the client to empty her bladder before the examination

RATIONALE:
 OPTION A: It is important that the clients should be asked how they wish to be addressed. Megg should‘ve
asked first if the client wants to be addressed as Mrs. or Ms.
 OPTION B: The nurse should explain when and where the examination will take place, why is it important, and
what will happen. Instruct the client that all information gathered and documented during the assessment is kept
confidential. Only those health care providers who have a legitimate need to know the client‘s information will
have access to it.
 OPTION C: The client may need modification of the usual positioning necessary for examination and
assessment. It is important to consider the client‘s ability to assume a position. Some positions are embarrassing
and uncomfortable and therefore should not be maintained for long. The assessment is organized so that
several body areas can be assessed in one position, thus minimizing the number of position changes needed.
 OPTION D: Clients should empty their bladders before the examination. Doing so helps them feel more relaxed
and facilitates palpations of the abdomen and pubic area. If a urinalysis is required, the urines should be
colledted in a container for that purpose. (Kozier, 576-577)

17. Nurses use national guidelines and evidenced-based practice to focus health assessment on specific conditions.
You are to conduct physical examination on your 72-year old male client. Which of the following actions shows that you
don‘t need further teaching regarding the special considerations that need to be taken in assessing older adults?
A. Remain quiet all throughout the assessment
B. Plan one assessment session in order to not overtire the client
C. Instruct client to make position changes quickly in order to be more timely and efficient
D. Check if eyeglasses or hearing aids are nearby

RATIONALE:
 OPTION D: Adapt assessment techniques to any sensory impairment
 OPTION A: Older clients are often anxious about what the nurse will find. They can be reassured during the
examination by explanations at each step. The nurse should permit ample time for the client to answer questions
 OPTION B: If clients are elderly and/ or frail, it is wise to plan several assessment times in order to not overtire
them.
 OPTION C: Quickly position changes may cause orthostatic hypotension (Kozier, pp. 577)

18. The nurse should position the client to ensure accessibility to the body part being assessed. Head Nurse Mia is
evaluating her staff in performing physical examination on their patients. Who among the following nurses should call the
attention of Head Nurse Mia?
A. Nurse Miko asked his patient with CHF to sit because he will be examining his anterior chest.
B. Nurse Niko who positioned his patient with rheumatoid arthritis in left Sim‘s position to examine his rectum.
C. Nure Milo who avoided the dorsal recumbent position when examining his patient‘s abdomen.
D. Nurse Nilo positioned his patient on prone to assess hip any hip deformity.

RATIONALE:

POSITION DESCRIPTION AREAS ASSESSED KEY POINT/ CAUTION
Dorsal recumbent Back lying position with
knees flexed and hips
externally rotated; small
pillow under the head; soles
of feet on the surface.
Head, neck, anterior thorax
and lungs, breast, axillae,
heart
Client comfortable;
increases abdominal
muscles. Contraindicated in
abdominal assessment.
(OPTION C)
Prone Lies on abdomen with head
turned to the side, with or
without a small pillow
Posterior thorax and lungs,
hip
Assessment of hip
extension. Contraindicated
in clients with
cardiopulmonary alterations
(OPTION D)
Sim‘s Side lying position with
lowermost arm behind the
uppermost leg flexed and
knee, upper arm flexed at
shoulder and elbow
Rectum and vagina Relaxes rectal muscles.
Painful for clients with joint
deformities (OPTION B)
Knee chest Lies prone with buttocks
elevated and knees drawn
to the chest
Rectum Maximal rectal exposure.
Contraindicated in clients
with respiratory alterations.
Sitting Head, neck, back, posterior
thorax and lungs, anterior
thorax and lungs, breast,
axillae, heart, extremities.
Clients can expand lungs;
nurse can inspect symmetry.
Institute risk precautions for
elderly and debilitated
clients. (OPTION A)
Lithotomy Lies supine with hips flexed,
and calves and heels
parallel to the floor using
stirrups.
Female genitalia, rectum,
genital tract

Maximal genitalia exposure,
embarrassing and
uncomfortable for client.
Contraindicated in clients
with joint disorders.
(Ladner, pp. 560)

19. Palpation is the examination of the body using the sense of touch. There are two types of palpation: Light and
Deep. Nurse Sam is planning to assess the client‘s abdominal area. In palpating the abdomen, he should keep in mind
the following, except:
A. For light palpation, Nurse Sam extends the dominant hand‘s fingers perpendicular to the skin surface and presesses
gently.
B. Area with tenderness should be palpated last.
C. Light palpation should be done first before deep palpation
D. Deep palpation can be done with two hands or one hand

RATIONALE:
OPTION A: For light palpation, the nurse extends the dominant hand‘s fingers PARALLEL to the skin surface and
presses gently while moving the hand in a circle.
OPTION B: Area with tenderness should be palpated last to avoid muscle tensing of the entire abdominal muscles.
Contracted muscles won‘t allow accurate palpation of the abdomen and compromises client comfort during the
examination.
OPTION C: Light (superficial) palpation should always precede deep palpation because heavy pressure on the fingertips
can dull the sense of touch.
OPTION D: Deep palpation is done with two hands (bimanually) or one hand. In deep bimanual palpation, the nurse
extends the dominant hand as for light palpation, then places the finger pads of the nondominant hand on the dorsal
surface of the distal interphalangeal joint of the middle three fingers of the dominant hand. The top hand applies pressure
while the lower hand remains relaxed to perceive the tactile sensations. For deep palpation using one hand, the finger
pads of the dominant hand press over the area to be palpated. (Kozier, pp. 578-579)

20. Restraints are protective devices used to limit the physical activity of a client or to immobilize a client of
extremity. They are used to protect the client, allow for treatment in a safe environment, and reduce the risk of
injury to other. Nurse Lally‘s client is diagnosed with Dementia and refuses treatments and likes to wander around the
ward most of the time. Prior to requesting for an order for restraints, Nurse Lally could utilize first the following
alternatives, aside from:
A. She positioned the client‘s bed at its lowest level
B. Assign the client in a room away from the nurses‘ station to prevent overstimulation
C. She placed big plants on the boundary where her client is only allowed to go.
D. She provided her client with a rocking chair.

RATIONALE:
Alternatives to Restraints
• Assign nurses in pairs to act as "buddies" so that one nurse can observe the client when the other leaves the unit.
• Place unstable clients in an area that is constantly or closely supervised. (OPTION B)
• Prepare clients before a move to limit relocation shock and resultant confusion.
• Stay with a client using a bedside commode or bathroom if the client is confused or sedated or has a gait disturbance
or a high-risk score for falling.
• Monitor all the client's medications and, if possible, attempt to lower or eliminate dosages of sedatives or
psychotropics.
• Position beds at their lowest level to facilitate getting in and out of bed. (OPTION A)
• Replace full-length side rails with half-or three-quarter length rails to prevent confused clients from climbing over rails
or falling from the end of the bed.
• Use rocking chairs to help confused clients expend some of their energy so that they will be less inclined to wander.
(OPTION D)
• Wedge pillows or pads against the sides of wheelchairs to keep clients well positioned.
• Place a removable lap tray on a wheelchair to provide support and help keep the client in place.
• To quiet agitated clients, try a warm beverage, soft lights, a back rub, or a walk.
• Use "environmental restraints," such as pieces of furniture or large plants as barriers, to keep clients from wandering
beyond appropriate areas. (OPTION C)
• Place a picture or other personal item on the door to clients' rooms to help them identify their room.
• Try to determine the causes of the client's sundowner syndrome (nocturnal wandering and disorientation as darkness
falls, associated with dementia). Possible causes include poor hearing, poor eyesight, or pain.
• Establish ongoing assessment to monitor changes in physical and cognitive functional abilities and risk factors.
(Kozier, 739)

21. Because restraints restrict the individual’s freedom, their use has legal implications. Improper use of restraints
and lack of monitoring can lead to injury and death and to psychological harm. Nurse Cara obtained an order for a
physical restraints for her aggressive client with Dementia and Raynaud‘s Disease. She won‘t be liable for malpractice if
she does the following, except:
A. She applied wrist restraints and frequently checks the circulation of the hands of the client.
B. She applies the restraint using a clove hitch knot
C. She explained the reason why restraints were applied to the relatives of the client.
D. She renews the order for restraints daily.

RATIONALE:
Before selecting a restraint, nurses need to understand its purpose clearly and measure it against the following five criteria:
1. It restricts the client's movement as little as possible. If a client needs to have one arm restrained, do not restrain the entire
body.
2. It is safe for the particular client. Choose a restraint with which the client cannot self-inflict injury. For example, a physically
restrained person could incur injury trying to climb out of bed if one wrist is tied to the bed frame. A jacket restraint would
restrain the person more safely.
3. It does not interfere with the client's treatment or health problem. If a client has poor blood circulation to the hands, apply a
restraint that will not aggravate that circulatory problem. (OPTION A)
4. It is readily changeable. Restraints need to be changed frequently, especially if they become soiled. Keeping other guidelines
in mind, choose a restraint that can be changed with minimal disturbance to the client.
5. It is as discreet as possible. Both clients and visitors are often embarrassed by a restraint, even though they understand why it
is being used. The less obvious the restraint, the more comfortable people feel. (OPTION C)
6. Obtain consent from the client or guardian.

Guidelines:
• Ensure that a primary care provider's order has been provided or, in an emergency, obtain one within 24 hours after applying
the restraint.
• Assure the client and the client's support people that the restraint is temporary and protective. A restraint must never be
applied as punishment for any behavior or merely for the nurse's convenience.
• Apply the restraint in such a way that the client can move as freely as possible while remaining safe.
• Ensure that limb restraints are applied securely but not so tightly that they impede blood circulation to any body area or
extremity.
• Pad bony prominences (e.g., wrists and ankles) before applying a restraint over them. The movement of a restraint without
padding over such prominences can quickly abrade the skin.
• Always tie a limb restraint with a knot (e.g., a clove hitch) that will not tighten when pulled. (OPTION B)
• Tie the ends of a body restraint to the part of the bed that moves to elevate the head. Never tie the ends to a side rail or to the
fixed frame of the bed if the bed position is to be changed. (Kozier, 780)

22. Assessment of arterial blood gases (ABG) reveals the ability of the lungs to exchange gases by measuring the
partial pressures of oxygen, carbon dioxide and evaluates the pH of arterial blood. An arterial blood gas is ordered
for you client following an attack of myocardial infarction. After obtaining the specimen, the most appropriate nursing
action is:
A. Observe the site for hematoma
B. Obtain ice for specimen
C. Apply direct pressure to the site
D. Put a sterile dressing to the site

RATIONALE:
 Regardless of who performs the arterial puncture, the nurse is responsible for assessing the client for symptoms of bleeding or
occlusion postpuncture. Direct pressure must be applied to the puncture site until all bleeding has stopped, a minimum of 5
minutes. Ensure that all bleeding has stopped before releasing the pressure. (Ladner, pp. 639)
Steps of the Procedure
1. Before beginning the actual procedure it is a good idea to make sure the patient is seated comfortably. He should rest his arm
on a pillow in front of him, palm facing up. This position is necessary to perform the procedure and is the most comfortable for
the patient.
2. Assess the patency of Ulnar artery and adequacy of distal arteries to wrist by Allen test. Rest patients hand in his lap, palms
up. Clenching of fist blanches skin of the palms. Now compress Radial artery and have patient relax hands in partly flexed
position. Normally the skin should turn pink indicating normal Ulnar artery and collateral flow. If there is a problem select a
different artery for arterial puncture.
3. Next, the area over the radial artery should be cleaned with alcohol wipes. Wear gloves.
4. Draw 2% xylocaine into a syringe. Infiltrate the skin and the area around the radial artery with thislocal anesthetic.
5. Next, draw heparin into a glass syringe. Rinse the syringe with the heparin and then empty the syringe. Kits nowadays have
pre-heparinised syringes, in which case skip this step.
6. The small amount of heparin left in the needle and syringe is sufficient.
7. Hyper extend the patient's hand to stretch the radial artery. Line up the artery with two fingers with the beveled edge facing
upper portion of the vessel. Enter the artery and attempt to go through andthrough the vessel.
8. Slowly withdraw the syringe, stopping as soon as it begins to fill spontaneously.
9. Withdraw the needle while applying pressure to the vessel with gauze.
10. Expel any air from the syringe and then cap the needle. Caution. Leave the cap on table and thread the needle into it to avoid
accidental needle puncture
11. Gently roll the syringe between the palms of your hands to mix the heparin with the blood.
12. Place the syringe in ice and send the specimen immediately to the lab for analysis.
13. Either you or the patient should keep applying pressure to the vessel for a few minutes. Then apply a band-aid and the
procedure is complete. (http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/procedur/artstep1.htm)
23. Body fluids are normally maintained within a narrow range that is slightly alkaline. The lungs help regulate acid-
base balance by eliminating or retaining carbon dioxide (CO2). The ABG result of your patient is as follows: pH of 7.
32, HCO3=27, PaCO2= 47. You should expect which of the following as a sign of compensation?
A. RR of 9 breaths per min, shallow
B. RR of 11 breaths per min, deep
C. RR of 22 breaths per min, deep
D. RR of 28 breaths per min, shallow

RATIONALE:
When combined with water, carbon dioxide forms carbonic acid (C02 -I- H20 = H2CO,). This chemical reaction is reversible;
carbonic acid breaks down into carbon dioxide and water. The lungs help regulate acid-base balance by altering the rate and depth of
respirations. The response of the respiratory system to changes in pH is rapid, occurring within minutes.
Carbon dioxide is a powerful stimulator of the respiratory center in the brain. When blood levels of carbonic acid and carbon
dioxide rise, the respiratory center is stimulated and the rate and depth of respiration increase. This causes an increased amount of
carbon dioxide to be exhaled, and carbonic acid levels fall. By contrast, when blood levels of carbonic acid and carbon dioxide fall, the
rate and depth of respiration decrease. This causes an increased level of carbon dioxide to be retained, and carbonic acid levels rise.
(Kozier, 1458)

24. Three simple clinical measurements that the nurse can initiate without a primary care provider's order are daily
weights, vital signs, and fluid intake and output. Nurse Liam wants to assess the fluid status of his client. He plans to
monitor his weight each day. He‘s data would be accurate if he does all but one:
A. He weighed the client before breakfast everyday.
B. He weighed the client wearing the hospital gown everyday.
C. He records q weight gain of 2. 2 lbs as 1000 mL fluid gained
D. None of the above

RATIONALE:
Significant changes in weight over a short time (e.g., more than 5 pounds in a week or more than 2 pounds in 24 hours) are indicative
of acute fluid changes. Each kilogram (2.2 lb) of weight gained or lost corresponds to 1 L of fluid gained or lost. To obtain accurate
weight measurements, the scale should be balanced before each use, and the client should be weighed (a) at the same time each day
(e.g.. before breakfast and after the first void), (b) wearing the same or similar clothing, and (c) on the same scale. The type of scale
(i.e.. standing, bed. Or chair) should be documented. (Kozier, 1472)

25. Achieving optimal hydration is an essential part of holistic patient care. Maintaining fluid balance is important to
avoid complications such as dehydration and overhydration, both of which can have serious clinical
consequences. Nurse Ryza reads three liters of Lactated Ringer‘s solution is charted over 12 hours. The drop factor is
15. The IV has been running for 9 hours and at 800 mL level upon checking. How many drops per minute are needed so
that the IV finishes in the required time?
A. 69 gtts/ min
B. 67 gtts/ min
C. 63 gtts/ min
D. 61 gtts/ min

RATIONALE:
Answer: 67 drops / minute
Drops per minute = Total infusion volume X drop factor
Total time of infusion in minutes
800 mls X 15 drops/ml
----------------------------
180 min

12000 drops
------------------
180 min = 67 drops / min
[time remaining = 3 hours = 3 x 60 = 180 minutes] [volume remaining = 800 mL]

26. Public health nurses should be aware that they have to understand the health care delivery system wherein they
are working because it influences their status and functions and that they need to properly relate with the
dynamics of political, organizational structure surrounding their positions in the health care delivery system.
Which of the following indicates a lack of understanding of the Philippine Health Care Delivery System (PHCDS)?
A. The Department of Health has the control and supervision over all barangay health stations, rural health units and
hundreds of hospitals throughout the country.
B. The provincial hospitals are under the provincial government and the provincial health board chaired by the
Governor.
C. The PHCDS is composed of the public sector only, primarily financed by the people through taxes and where health
care is generally given free at the point of service.
D. The PHCDS is composed of the private sector only which is largely market-oriented and where health care is paid
through user fees at the point of service.

RATIONALE:
The Philippine health care delivery system is composed of two sectors: (1) the public sector, which is largely financed through tax-
based budgeting system at both national and local levels and where health care is generally given free at the point of service (although
socialized user fees have been introduced in recent years for certain types of services), and (2) the private sector (for profit and non-
profit providers), which is largely market-oriented and where health care is paid through user fees at the point of service. With the
devolution of health services, the local health system is now run by Local Government Units (LGUs). The provincial and district
hospitals are under the provincial government while the city/municipal government manages the health centers/rural health uni ts
(RHUs) and barangay health stations (BHSs). In every province, city or municipality, there is a local health board chaired by the local
chief executive. (Public Health Nursing in the Philippines, NLPGN, Inc., 2007: 19) The DOH used to have control and supervision over
all barangay health stations, rural health units and hundreds of hospitals throughout the country. Today, only regional hospitals,
medical centers, special and specialty hospitals and few re-nationalized provincial hospitals are directly under it. (Maglaya, 2009: p. 23)
27. The PHCDS is affected by laws and policies enacted in response to the increasing number of problems regarding
the discharge of health care services in the Philippines. This system is influenced by policies, including Republic
Act 9439. Which of the following accurately describes RA 9439‘s effect on the health care system?
A. RA 9439 promotes and advocates the use of traditional, alternative, preventive and curative healthcare modalities
that are proven safe, effective and consistent with government standards.
B. RA 9439 makes it possible for health and dental services to reach rural areas providing services to the poor
members of the community who cannot afford these services.
C. RA 9439 is an act that makes the medicines and drugs more affordable for the indigenous members of the society. It
provides for the discount acknowledgements of individuals and families, making health care accessible to the rest of
the community.
D. RA 9439 prohibits the detention of patients who cannot pay the necessary amount after having been hospitalized in
institutions such as hospitals and medical clinics.

RATIONALE:
OPTION D: RA 9439 is defined as an Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of
Nonpayment of Hospital Bills or Medical Expenses, which addresses the problem involving some hospitals and medical clinics that
refuse to discharge patients due to the latter‘s inability to pay their hospital bills or medical expenses by encouraging them to employ
appropriate payment schemes
OPTION A: RA 8523 which is an act creating the Philippine Institute of traditional and alternative health care (PITAHC) to accelerate
the development of traditional and alternative health care in the Philippines.
OPTION B: RA 1891 which strengthened the health and dental services in the rural areas and created rural health units of eight
categories of staffing pattern
OPTION C: RA 9502 which is an act providing for cheaper and quality medicines (Maglaya 2009 pp. 22)

28. Health problems that are beyond the capability of the PHC units and beyond the competence of PHC workers are
referred to an intermediate health facility, usually a Rural Health Unit (RHU) located in a town or poblacion. The
Philippine Health Care Delivery System is divided into three levels the primary, secondary and tertiary level. All of
the following do not portray what the secondary level of PHCDs is, except:
A. Goot Private Clinic
B. Barangay Sapang Rural Health Unit
C. Veterans Regional Hospital which serve as the teaching and training ground for student nurses and nurse trainees.
D. Wilkins Emergency Hospital

RATIONALE:

PRIMARY LEVEL Barangay Health stations, Rural health unit (community hospitals, health
centers), community hospitals and health centers, private practitioner and
puericulture center
SECONDARY LEVELS Emergency or district hospital, provincial or city health services and provincial
city hospitals
TERTIARY LEVEL National health services, regional medical centers, teaching and training
hospitals, regional health services, regional medical centers and training
hospitals
(Reyala pp. 34)

29. Health care delivery system is the network of facilities and personnel which carries out the task of rendering
health care to the people. Nurse David is a staff nurse at Viridian District Hospital. He will be incorrect if he states which
of the following about the institution he is currently employed in:
A. It serves as a referral center for primary health facilities.
B. It involves care rendered by specialists, and it can handle complicated cases and intensive care.
C. It is capable of performing minor surgeries and simple laboratory examinations
D. It can be privately owned or government operated.

RATIONALE:
 Primary Level of Care – Primary care is devolved to the cities and the municipalities. It is health care is provided by
center physicians, public health nurses, rural health midwives, barangay health workers, traditional healers and others at
the barangay health stations and rural health units. It is usually the first contact between the community members and the
other levels of health facility.
 Secondary Level of Care – Secondary care is given by physicians with basic health training. This is usually given in
health facilities either privately owned or government operated such as infirmaries, municipal and district hospitals and
out-patient departments of provincial hospitals. This serves as a referral center for the primary health facilities. Secondary
facilities are capable of performing minor surgeries and perform some simple laboratory examinations.
 Tertiary Level of Care – Tertiary care is rendered by specialists in health facilities including medical centers as well as
regional and provincial hospitals, and specialized hospitals such as the Philippine Hearth Center. The tertiary health
facility is the referral center for the secondary care facilities. Complicated cases and intensive care requires tertiary care
and all these can be provided by the tertiary care facility. (DOH Book, pp. 39 - 40)

30. Various categories of health workers make up the primary health care team. In the Philippines, the physician,
public health nurse and midwife compose the basic primary health care team. All are included in the Intermediate
Level Health worker, aside from:
A. Rural Sanitary inspector
B. Dentist
C. Medical practitioner
D. Health auxiliary volunteer

RATIONALE:
Levels of Primary Health Care Workers
1. Village or Barangay Health Workers (V/BHWs) – this refers to trained community health workers or health auxiliary
volunteer or a traditional birth attendant or healer.
2. Intermediate Level Health Workers – general medical practitioners or their assistants. Public health nurse, rural sanitary
inspector and midwives, may compose these groups. (DOH Book, pp. 32)

31. The Department of Health, in its new role as the national authority on health providing technical and other
resource assistance to concerned groups as mandated by Executive Order 102 has three general functions:
leadership in health, enabler and capacity builder and administrator of specific services. As the leader in health,
the DOH performs which of the following tasks:
A. Administer health emergency response services
B. Ensure the highest achievable standards of quality health care
C. Serve as advocate in the adoption of health policies, plans and programs
D. Innovate new strategies in health

RATIONALE:

ROLES AND FUNCTIONS
LEADERSHIP IN HEALTH ENABLER AND CAPACITY
BUILDER
ADMINISTRATOR OF SPECIFIC
SERVICES
-serve as the national policy and
regulatory institution
-innovate new strategies in health
(OPTION D)
-manage selected national health
facilities and hospitals with modern
-provide leadership in the
formulation, monitoring and
evaluation of national health policies,
plans and programs
-serve as advocate in the adoption of
health policies, plans and programs
(OPTION C)
-exercise oversight functions and
monitoring and evaluation of national
health plans, programs and policies.
-ensure the highest achievable
standards of quality health care,
promotion and protection. (OPTION
B)
and advanced facilities
-administer direct services for
emergent health concerns that
require new complicated
technologies
-administer health emergency
response services (OPTION A)
(ULG, pp.367)

32. In order for the public health nurse to fully appreciate the public health system in this country, it is important to
have an understanding of the development of the government agency mandated to protect the health of the
people. The Department of Health was first established as the Department of Public Works, Education and
Hygiene in 1898. The Department of Health‘s vision by 2030 is:
A. A global leader for attaining better health outcomes, competitive and responsive health care system, and equitable
health financing.
B. Health in the Hands of the People by the year 2020
C. To guarantee equitable, sustainable and quality health for all Filipinos, especially the poor, and to lead the quest for
excellence in health.
D. Health for All Filipinos

RATIONALE:
OPTION A: DOH Vision by 2030
OPTION B: Vision of PHC
OPTION C: Current mission of the DOH
OPTION D: DOH Vision by 2010 (http://www.doh.gov.ph/Mission_Vision.html)

33. Health Sector Reform Agenda is the overriding goal of the DOH. Support mechanisms will be through sound
organizational development, strong policies, systems and procedures, capable human resources and adequate
financial resources. In order to gain success in the implementation of the HSRA, the DOH adopted which of the following
framework?
A. Sentrong Sigla
B. FOURmula One for Health
C. National Health Insurance Program
D. Field Health Service Information System

RATIONALE:
 OPTION B: FOURmula One for Health is adopted as the implementation framework for health sector reforms under
the current administration. It intends to implement critical interventions as a single package backed by effective
management infrastructure and financing arrangements following a sectorwide approach.

Goals for FOURmula One for Health:
1. Better health outcomes
2. More responsive health systems
3. Equitable health care financing

OPTION A: Sentrong Sigla Movement is a DOH program which aims to promote the availability of quality health
services. Four pillars: Quality assurance, Grants and technical assistance, Health promotion, Award
OPTION C: National Health insurance Program (NHIP) is the key feature in the implementation of FOURmula One
for Health. The NHIP supports each of the elements in terms of:
 Financing, as it reduces the financial burden placed on Filipinos by health care costs
 Governance, as it is a prudent purchaser of health care thereby influencing the health care
market and related institutions
 Regulation, as the NHIP‘s role in accreditation and payments based on quality acts as a
driver for improved performance in the health sector; and
 Service delivery, as the NHIP demands fair compensation for the costs of care directed at
providing essential goods and services in health
OPTION D: Field Health Service and Information System (FHSIS) is a major component of the network
information sources developed by the Department of Health (DOH) to enable it to better manage in nationwide health
delivery activities. This has been designed to provide the basic service data needed to monitor activities in each
programs. (DOH Book, pp. 25-26)

34. FOURmula One for Health as a framework for the implementation of HSRA has four elements: health financing,
health regulation, health service delivery and good governance. The Municipal Health Officer of Brgy. Barnabas
submitted a proposal for the construction of their Botika ng Barangay for the cheaper medicines and other health needs of
the people. The above scenario exemplifies which element of FOURmula One?
A. Health financing
B. Health regulation
C. Health service delivery
D. Good governance

RATIONALE:
Four Elements:
1. Health financing – the goal of this health reform area is to foster greater, better and sustained investments in health. The
Philippine Health Insurance Corporation, through the National Insurance Program and the DOH through sectorwide policy
support will lead this component jointly.
2. Health regulation – the goal is to ensure the quality and affordability of health goods and services
3. Health service delivery – the goal is to improve and ensure the accessibility and availability of basic and essential health
care in both public and private facilities and services
4. Good governance – the goal is to enhance health system performance at the national and local levels. (DOH Book, pp. 26)

35. Primary health care is an important part of a community’s health system and overall development. Teamwork in
PHC entails joint planning, implementation, and evaluation of community activities by the team members with
the community health needs/problems as bases of action. The implementation of primary health care is guided by the
following principles except:
A. Individuals, families, and the community need to be viewed and treated as partners.
B. To ensure health for all, health services are made equally available, accessible, and free
C. The health sector along with other different sectors are utilized to in promoting health
D. Community participation should be ensured in all phases of the nursing process.

RATIONALE:
Active participation, intra and intersectoral linkages, use of appropriate technology, support mechanism made available are the four
cornerstones of PHC. The principles observed in the implementation of PHC are (1) accessibility, availability, and acceptability of
health service; (2) provision of quality basic and essential services; (3) community participation; (4) self-reliance; (5)recognition of
interrelation between health and government; (6) social mobilization; (7) decentralization. Choice A and D is true in the context of
community participation; Choice C is also true as regards intra- and intersectoral linkages and recognition of interrelationship between
health and government as well as social mobilization. (Public Health Nursing in the Philippines, NLPGN, Inc., 2007: 31; Balita
2008:p.369) In choice B, although availability and accessibility are principles of PHC, the statement is still erroneous and misleading:
(1) because the definition of PHC and its principles state that health care should be ―at a cost that the community and country can
afford‖ or ―affordability‖ not ―free‖ as what was submitted in choice B; (2) another principle that guides the provision of health services,
particularly in the government-owned facility is distributive justice. In a ―mirco‖ setting, this could mean ―fair, equitable, and appropriate
distribution‖ (Beuchamp and Walters, p.26, cited in Maglaya, 2009: p. 44). Primarily because resources are limited, PHNs should be
guided by the equity rule that is, (assuming the need is the same) the scarce resources should be given to the one who is in greater
need. Ergo, primary health care does not require ―equality‖.

36. Primary health care is an essential care made universally accessible to individuals and families in the community
by means acceptable to them through their full participationand at a cost that the community can afford.
Accessibility means:
A. The health services can be afforded by the people
B. Health care providers make full use of the service of traditional healers whom the people commonly approach for
health problems.
C. Health service providers are within 5 kilometers from most of the catchment population.
D. 24-hour availability of health services in health facilities

RATIONALE:
Accessibility is travel impedance (distance or time) between patient location and service points. While the distinction between
availability and accessibility can be useful, in the context of urban areas, where multiple service locations are common, the two
dimensions should be considered simultaneously. We refer to this fusion as "spatial accessibility" (SA), a term that is common in the
geography and social sciences literature and is gaining some favor in the healthcare geography literature [Guagliardo, M. Spatial accessibility
of primary care: concepts, methods and challenges (2004). International Journal of Health Geographics citing AA, Bhardwaj SM: Access to health care. A conceptual
framework and its relevance to health care planning.; Eval Health Prof 1994, 17:60-76.;also in Luo W, Wang F: Measures of spatial accessibility to healthcare in a
GIS environment: Synthesis and a case study in Chicago region. Environment and Planning B 2003, 30(6):865-884.]

Option A refers more to affordability,option B to acceptability, option D to availability.

37. Support for immediate and efficient provision of health care and management of province-wide health system is
one of the strategic instruments used to achieve the goals of Universal Health Care for All Filipinos. To facilitate
the implementation of this strategy, Nurse Josef should adhere to the national policies regarding Field Health Service and
Information System (FHSIS). All of the following are components of the FHIS, except:
A. Individual Treatment Record
B. Target Client List
C. Summary Table List
D. Weekly Consolidation Table

RATIONALE:
The fundamental building block or foundation of the Field Health Service Information System is the INDIVIDUAL TREATMENT
RECORD. This is a document, form or piece of paper upon which is recorded the date, name, address of patient, presenting symptoms
or complaint of the patient on consultation and the diagnosis (if available), treatment and date of treatment.

The TARGET CLIENT LISTS constitute the second ―building block‖ of the FHSIS and are intended to serve several purposes. First is
to plan and carry out patient care and service delivery. Such lists will be of considerable value to midwives/nurses in monitoring service
delivery to clients in general and in particular to groups of patients identified as ―targets‖ or ―eligibles‖ for one or another program of the
Department. The primary advantage of maintaining the Target Client Lists is that the midwife/nurse does not have to go back to
individual patient/family records as frequently in order to monitor patient treatment or services to beneficiaries. The second purpose of
Target Client Lists is to facilitate the monitoring and supervision of service delivery activities. The third purpose is to report services
delivered. The fourth purpose of the Target Client Lists is to provide a clinic-level data base which can be accessed for further studies.

The SUMMARY TABLES is a form with 12-month columns retained at the facility (BHS) where the midwife records monthly all relevant
data. The Summary Table is composed of: (1) Health Program Accomplishment – summary table of all the data that are found at the
TCL; (2) Morbidity Diseases --10 leading causes of morbidity; monthly trending.

The MONTHLY CONSOLIDATION TABLE (MCT) is an essential form in the FHSIS where the nurse at the RHU records the reported
data per indicator by each BHS or midwife. This is the source document of the nurse for the Quarterly Form. The Consolidation Table
shall serve as Output Table of the RHU as it already contains listing of BHS per indicator (categorized as maternal care, child care,
family planning and disease control). [Manual of Operations, Electronic Field Health Information System, DOH: 2011]

38. The vision of poverty reduction and sustainable development is exemplified by the Millenium Development Goals
(MDGs) which are based on the fundamental values of freedom, equality, solidarity, tolerance, health, respect of
nature and shared responsibility. The following MDGs are health or health related, except for:
A. 2 and 3
B. 1 and 7
C. 4 and 6
D. 3 and 5

RATIONALE:
Eight Millenium Development Goals:
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/ AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
 Except for goals 2 and 3, all the MDGs are health or health-related. Health is essential to the achievement of
these goals and is a major contributor to the overarching goal of poverty reduction. (DOH Book, pp. 3)

39. For over forty years after post war independence, the Philippine health care system was administered by a
central agency based in Manila. This control agency provided the singular sources of resources, policy
direction, technical and administrative supervision to all health facilities nationwide. Local government units are
transformed into active partners and self-reliant communities through a system of decentralization that is mandated in:
A. RA 7610
B. RA 6710
C. RA 7160
D. RA 6170

RATIONALE:
RA 7160 – LOCAL GOVERNMENT CODE;
RA7610 -- "Special Protection of Children Against Abuse, Exploitation and Discrimination Act";
RA 6710 – ―AN ACT DECLARING SEPTEMBER 1 OF EACH YEAR AS BAGUIO CHARTER DAY AND A SPECIAL NON-WORKING
HOLIDAY IN THE CITY OF BAGUIO IN ORDER TO COMMEMORATE THE ANNIVERSARY OF THE SAID CITY‖
RA 6170 -- AN ACT ESTABLISHING A FLOATING CLINIC IN THE MUNICIPALITY OF BACACAY IN THE PROVINCE OF ALBAY
AND AUTHORIZING THE APPROPRIATION OF FUNDS THEREOF

40. Devolution made local government executives responsible to operate local health care services. With LGUs
running the local health systems because of devolution, it is important to institutionalize local health systems.
The following programs are under the local government, except:
A. Maternal and Child Health Program
B. Non-communicable Disease Prevention and Control
C. Primary Health Care
D. Environmental Health and Communicable Disease Control

RATIONALE:
The foremost strategy in Primary Health Care (PHC) is reorientation and reorganization of the national health care system with
establishment of functional support mechanism in support of the mandate of devolution under the Local Government Code of 1991.
Corollary to this, it is incumbent upon local government units to engage themselves in activities that are responsive to the elements and
components of PHC to wit: (1) environmental sanitation, (2) control of communicable diseases, (3) immunization, (4) health
education, (5) maternal and child health and family planning, (6) adequate food and proper nutrition, (7) provision of medical and
emergency treatment, (8) treatment of locally endemic diseases, and (9) provision of essential drugs.(Maglaya, 2009: p. 31)



41. Asepsis is the freedom from disease-causing microorganisms. To decrease the possibility of transferring
microorganisms from one place to another, aseptic technique is used. The following has correct understanding
regarding medical and surgical asepsis, except for:
A. Nurse Nina who is very careful in applying the sterile technique during operations because she knows that surgical
asepsis does not destroy spores.
B. Nurse Karen who stated that medical asepsis includes all practices intended to confine a specific microorganism to a
specific area, limiting the number, growth, and transmission of microorganisms.
C. Nurse Anna who coined surgical asepsis as sterile clean technique which kills all microorganisms.
D. Nurse Mika who is aware that in medical asepsis some microorganisms are not killed so the possibility of the
development of infection is still likely.

RATIONALE:
MEDICAL ASEPSIS includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth,
and transmission of microorganisms. In medical asepsis, objects are referred to as clean, which means the absence of almost all
microorganisms, or dirty (soiled, contaminated), which means likely to have microorganisms, some of which may be capable of causing
infection.

SURGICAL ASEPSIS, or sterile technique, refers to those practices that keep an area or object free of all microorganisms: it includes
practices that destroy all microorganisms and spores (microscopic dormant structures formed by some pathogens that are very hardy
and often survive common cleaning techniques) (Kozier, pp. 671).

42. All health care providers must apply PPE (clean or sterile gloves, gowns, masks and protective eyewear)
according to the risk of exposure to potentially infective materials. A group of students were assigned in the
Communicable Disease Pavilion of One Republic Medical Center. Prior to their exposure, they must learn the correct use
of PPEs. To remove PPEs, they must proceed in which sequence?
1. Protective Eyewear
2. Gown
3. Gloves
4. Handwashing
5. Mask

A. 2, 3, 1, 5, 4
B. 2, 3, 4, 5, 1
C. 3, 4, 1, 2, 5
D. 3, 4, 2, 5, 1

RATIONALE:
1. To remove soiled PPE, remove the GLOVES first since they are the most soiled
 If wearing a gown that is tied at the waist in front, undo the ties before removing gloves.
 Remove the glove by grasping it on its palmar surface, taking care to touch only glove to glove.
 Pull the first glove completely off by inverting or rolling the glove inside out.
 Continue to hold the inverted removed glove by the fingers of the remaining gloved hand. Place the first two
fingers of the bare hand inside the cuff of the second glove.
 Pull the second glove off to the fingers by turning it inside out. This pulls the first glove inside the second glove.
 Using the bare hand, continue to remove the gloves, which are now inside out, and dispose of them in the refuse
container.
2. Perform HAND HYGIENE
3. Remove PROTECTIVE EYEWEAR and dispose of properly or place in the appropriate receptacle for cleaning
4. Remove the GOWN when preparing to leave the room.
 Avoid touching soiled parts on the outside of the gown, if possible.
 Grasp the gown along the inside of the neck and pull down over the shoulders. Do not shake the gown.
 Roll up the gown with the soiled part inside, and discard it in the appropriate container.
5. Remove the MASK.
 Remove the mask at the doorway to the client‘s room. If using a respirator mask, remove at after leaving the
room and closing the door.
 If using a mask with strings, first untie the lower strings of the mask.
 Untie the top strings and, while holding the ties securely, remove the mask from the face. If side loops are
present, lift the side loops up and away from the ears and face. Do not touch the front of the mask. (Kozier, pp.
696-697)

TO APPLY PPE:
Gown – Mask – Eyewear – Gloves

43. The isolation guidelines contain a two tiered approach. The nurse follows the Tier one of precautions by performing
the following, aside from:
A. Assigning client in a private room
B. Safe injection practices
C. Utilization of Personal Protective Equipment
D. Hand hygiene

RATIONALE:
The isolation guidelines contain a two tiered approach:
1. STANDARD PRECAUTIONS - include a group of infection prevention practices that are based on the assumption that every
person is potentially infected or colonized with an organism that could be transmitted in the health care setting. These practices
include: hand hygiene; personal protective equipment (PPE), which is the use of gloves, gown, mask, eye protection or face
shield, depending on the anticipated exposure; and safe injection practices.
Three new practices were added to the revised 2007 guidelines that focus on protection of clients: respiratory
hygiene/cough etiquette; safe injection practices; and use of masks for insertion of catheters or injections of material into spinal or
epidural spaces through lumbar puncture procedures. The safe injection practices apply to the use of needles, cannulas that
replace needles, and, where applicable, IV delivery systems.

2. TRANSMISSION-BASED PRECAUTIONS - are used in addition to standard precautions for clients with known or suspected
infections that are spread in one of three ways: by airborne or droplet transmission, or by contact. (Kozier, pp. 693)

44. The three types of transmission-based precautions may be used alone or in combination but always in addition
to standard precautions. Ramon Batista, 10 years old is diagnosed of having Varicella. As part of the second tier of
precaution, the nurse must perform which of the following?
A. Wear a mask upon transport of the client
B. Assign the client in a private room with a negative air pressure
C. Maintain a three feet distance
D. All of the above

RATIONALE:
 Varicella (Chickenpox) – airborne precaution

1. AIRBORNE PRECAUTION – used for clients known to have or suspected of having serious illness transmitted by
airborne droplet nuclei smaller than 5 microns. Examples: rubeola, varicella, TB.
2. DROPLET PRECAUTION – used for clients known or susceptible to have serious illnesses transmitted by particle
droplets larger than 5 microns. Examples: diphtheria, pneumonia, pertussis, mumps, rubella
3. CONTACT PRECAUTION – used for clients known or suspected to have serious illnesses easily transmited by direct
client contact or by contact with items in the client‘s environment. (Kozier, pp. 693)

Category Private room Gloves Gown Mask
CONTACT If possible; cohort if
not available
Required If anticipate contact
with soiled items;
client is incontinent;
or there is diarrhea,
ileostomy,
colostomy, or wound
drainage
Not required
DROPLET If possible; cohort or
maintain separation
of 3 feet
Not required Not required Required when
within 3 feet
AIRBORNE Required. Negative
air pressure, 6–12
air changes
per hour, keep door
closed, discharge air
outdoors or HEPA
filter
Not required Not required N95 respirator
required for
known or suspected
tuberculosis and
measles or varicella
if not immune
(Ladner, pp. 687)

45. Transmission of microorganisms to clients may also occur through contact with inanimate objects. Cleansing,
disinfecting, and sterilizing can break this link in the chain of infection by reducing or destroying
microorganisms on objects. Nurse Lebron is cleaning the scalpel holders and forceps used in the operation of his
client. He does cleansing properly if he does all but one:
A. Rinsed the object under warm water after scrubbing.
B. He wore gloves, mask, and goggles before cleansing.
C. Rinsed the object under warm water before applying detergent and scrubbing.
D. Applied detergent and scrubbed under running water with soft-bristled brush.

RATIONALE:
Contaminated objects are cleaned using a soft-bristled brush to scrub the surface. The steps for proper cleansing are:
1. Rinse object under cold water, since warm water causes proteins in organic material to coagulate and stick.
2. Apply detergent and scrub object under running water with soft-bristled brush.
3. Rinse the object under warm water.
4. Dry the object prior to sterilization or disinfection.

Cleansing presents a potential hazard to the nurse through the splashing of contaminated material onto the body. Nurses should wear
gloves, masks, and goggles during cleansing. (Ladner, pp. 681)

46. The contraceptive approach of natural family planning involves no introduction of chemical or foreign material
into the body or sustaining from sexual intercourse during a fertile period. Mr. and Mrs. Poon visited the clinic and
expressed an interest to use family planning. They both decided to use the calendar method. The nurse should correct
them if they state which of the following:
A. ―I must keep a diary of at least six menstrual cycles to be able to use this method.‖
B. ―I must subtract 18 from my shortest cycle, this is my first fertile day.‖
C. ―I must subtract 11 from my longest cycle, this is my last fertile day.‖
D. ―If I had six menstrual cycles ranging from 25 to 29 days, my fertile period would be from the 9th day to the 19th day.

RATIONALE:
The calendar method requires a couple to abstain from coitus (sexual relations) on the days of a menstrual cycle when the woman is
most likely to conceive (3 or 4 days before until 3 or 4 days after ovulation). To plan for this, the woman keeps a diary of six menstrual
cycles. To calculate ―safe‖ days, she subtracts 18 from the shortest cycle documented. This number represents her first fertile day. She
subtracts 11 from her longest cycle. This represents her last fertile day. If she had six menstrual cycles ranging from 25 to 29 days, her
fertile period would be from the 7th day (25 minus 18) to the 18th day (29 minus 11).To avoid pregnancy, she would avoid coitus during
those days. (Pillitteri, pp. 120)

47. There are a variety of ways, or methods, to determine a fertile period such as calculating the period based on a
set of formula, measuring the woman’s body temperature, observing the consistency of cervical mucus, using an
over-the-counter test kit, or using a combination of these methods. Nurse Mariah is giving information regarding
family planning to a mother‘s class. To assess their learning, she asked question about the Basal Body Temperature
method. The class would need additional information if they state which of the following?
A. As soon as I know that I‘m ovulating, I will refrain from having coitus for the next three days.
B. Just before the day of my ovulation, I will notice that my basal body temperature rises about 0.5
o
F
C. On the time of my ovulation, my BBT will rise a full degree
D. I must take my temperature each morning immediately after waking before I do any activity.

RATIONALE:
OPTION B: Just before the day of ovulation, a woman‘s basal body temperature (BBT), or the temperature of her body at rest, falls
about 0.5° F.
OPTION A: As soon as she notices a slight dip in temperature followed by an increase, she knows that she has ovulated. She refrains
from having coitus for the next 3 days (the life of the discharged ovum). Because sperm can survive for at least 4 days in the female
reproductive tract, it is usually recommended that the couple combine this method with a calendar method, so that they abstain for a
few days before ovulation as well.
OPTION C: At the time of ovulation, her BBT rises a full degree because of the influence of progesterone.
OPTION D: To use this method, the woman takes her temperature each morning immediately after waking either orally or with an ear
thermometer before she undertakes any activity; this is her BBT. (Pillitteri, pp. 120)

48. Probable indications of pregnancy are objective findings that can be documented by an examiner. Although
these signs are strong indicators of pregnancy, a positive diagnosis of pregnancy cannot be based on these
findings because they may be caused by other conditions. Nurse Jojo documents all of the following as probable
signs of pregnancy, except:
A. Upon Nurse Jojo‘s palpation, he felt an outline of the fetus in the client‘s abdomen.
B. Upon Nurse Jojo‘s palpation of the client‘s abdomen, he felt a movement caused by a fetus.
C. Nurse Jojo tapped the lower uterine segment of the abdomen of the mother and she felt the rise of a possible fetus
against the wall of the abdomen.
D. Ultrasound result showing an evident characteristic ring

RATIONALE:

PRESUMPTIVE PROBABLE POSITIVE
(changes felt by the mother) (changes observed by the examiner) (definitive signs of pregnancy)
 Morning Sickness
 Amenorrhea
 Changes in breast
 Fatigue
 Lassitude
 Urinary Frequency
 Quickening (18
th
-20
th
week)
 CHADWICK’s - bluish
discoloration of VAGINAL wall
 HEGAR – softening of lower
UTERINE segment
 Uterine Enlargement
 Positive Pregnancy Test
 Ballotment – sinking and
rebound of fetus (OPTION C)
 Outlining of Fetal Body
(OPTION A)
 GOODELLS – softening of the
CERVIX
 Souffle Contraction and Braxton
Hicks (painless contraction at 28
weeks)
 Fetal Heartbeat (10 weeks by
Doppler; 16 weeks by
Fetoscope; 18-20 weeks by
Auscultation)
 Fetal Movement (after 20
weeks) (OPTION B)
 Fetal skeleton (by
sonography)
(ULG, pp. 199-201)

49. A more comprehensive system of classifying pregnancy status (GTPALM) provides greater detail on a woman’s
history. A pregnant woman with 4 living children report the following obstetric history: a stillbirth at 34 weeks gestation,
triplets (2 sons and a daughter) born via cesarean section at 30 weeks age of gestation, a miscarriage at 8 weeks of
gestation and a daughter born vaginally at 38 weeks of gestation. Which of the following accurately expresses this
woman‘s OB history?
A. G5 P3, 1-3-1-4
B. G5 P3, 1-4-1-4
C. G4 P3, 1-4-1-4
D. G5 P3, 1-1-1-4

RATIONALE:

PARA Number of pregnancies that have reached viability, regardless of
whether the infants were born alive (24 wks)
GRAVIDA Number of pregnancies
TERM Number of full term infants (37 weeks or more)
PRETERM Number of pre term infants born (less than 37 weeks)
ABORTION Number of pregnancies less than 24 weeks
LIVING Number of living children
MULTIPLE Number of multiple pregnancies
(Pilliteri, pp. 253)

50. The Leopold’s maneuver is a systematic method of observation and palpation to determine fetal presentation
and position. It involves four different maneuvers which serve different purposes. A newly employed nurse was
asked by the obstetrician to perform the Leopold‘s maneuver to her client. She correctly performed the procedure if she
does all of the following, except:
A. She listened for FHT at the right lower quadrant of the mother‘s abdomen because the fetus is in a breech position
and the fetal back is at the right side of the mother
B. During the third maneuver, she can press her hands together so she concluded that the presenting part is not yet
engaged.
C. She allowed the mother to empty her bladder immediately prior the procedure.
D. Prior to performing the procedure, she washed her hands with warm water.

RATIONALE:
OPTION C: Instruct the client to empty her bladder because this promotes comfort and allows for more productive palpation because
fetal contour will not be obscured by the distended bladder.
OPTION D: Wash your hands using warm water. Handwashing prevents the spread of possible infection. Using warm water aids in
client comfort and prevents tightening of abdominal muscles.

First Maneuver (Fundal Grip) Determines whether fetal head or breech is in the presentation
Head is more firm, hard and round that moves independently of the body.
Breech is less well defined that moves only in conjunction with the body.
Second Maneuver (Umbilical
Grip)
Locates the back of the fetus
Fetal back is smooth, hard, resistant surface. Knees and elbows of the fetus
feel with a number of angular nodulation (OPTION A –RUQ)
Third maneuver (Pawlik’s Grip) Determines the part of the fetus at the inlet and its mobility.
By grasping the lower portion of the abdomen. Not engaged (not firmly
settled in the pelvis) if the presenting part moves upward so an examiner‘s
hands can be pressed together. (OPTION B)
Fourth maneuver (Pelvic grip) Determines the fetal attitude and degree of fetal extension into the pelvis; it
should be done only if the fetus is in a cephalic presentation. Information
about the infant‘s AP position may also be gained.
(ULG, pp. 213) (Pilliteri, pp. 369-370)

51. A good preparation for the upcoming labor and delivery prevents life threatening risks to the mother and the
baby. The estimates in pregnancy tries to estimate the age of pregnancy and possible date of delivery for the
mother to be prepared. A pregnant woman visited that clinic for her first pre-natal check-up. She asked you regarding
her expected date of delivery. You know that the following methods can be used to determine the EDD when the LMP is
unknown, aside from:
A. Bartholomew‘s rule of fourths
B. McDonald‘s rule
C. Quickening
D. Naegele‘s rule

RATIONALE:
OPTION D: NAEGELE’S RULE – uses the woman‘s LMP : count back three months from 1
st
day of last mense and add seven days
and one year (except for January, February and March LMP: add nine months, seven days and one year)
OPTION A: BATHOLOMEW’S RULE OF FOURTHS - estimates the age of gestation relative to the height of the fundus of the uterus
above the symphysis pubis.
 12 weeks – above the symphysis pubis
 16 weeks – midway the symphysis pubis and umbilicus
 20 weeks – umbilicus
 38 weeks – xiphoid process
 39-40 weeks – slightly below the xiphoid process
OPTION B: MCDONALD’S RULE – a symphysis-fundal height measurement
 Height of fundus in cm x 2/7 = duration in lunar months
 Height of fundus in cm x 8/7 = duration in weeks
OPTION C: Quickening usually occurs on the 20
th
week of pregnancy (Pilliteri, pp. 205) (nursingcrib)

52. Although most signs indicating complications of pregnancy occur toward the end of pregnancy, women need to
know what these are from the beginning. Nurse Katy is instructing her pregnant client about the danger signs of
pregnancy. Which of the following should she tell her to report if it should occur?
A. 1 lb per week gain during the third trimester
B. Extended vomiting up to the 12
th
week of pregnancy
C. Painless contractions on her 8
th
month
D. Palpable uterus over the symphysis pubis at 12
th
week AOG

RATIONALE:
Danger Signs of Pregnancy:
1. Vaginal bleeding
 a woman should report vaginal bleeding, no matter how slight, because some of the serious bleeding complications of
pregnancy begin with only slight spotting.
2. Persistent vomiting
 once or twice daily vomiting is not uncommon during the first trimester. vomiting that continues past the 12
th
week of
pregnancy is also extended vomiting. Persistent of extended vomiting depletes the nutritional supply available to the
fetus so is a danger to the pregnancy
3. Chills and Fever
 Maybe symptoms of benign gastroenteritis, but also indicate intrauterine infection.
4. Sudden escape of clear fluid from the vagina
 May suggest rupture of membranes which could increase the risk of infection. If a fetus is small so the head does not fit
snugly into the cervix, the umbilical cord may prolapsed following membrane rupture. If the cord is then compressed by
the fetal head, oxygenation is compromised and fetus will be in immediate danger.
5. Abdominal or chest pain
 Abdominal pain may suggest tubal (ectopic) pregnancy, separation of the placenta, preterm labor or something
unrelated to the pregnancy but perhaps equally as serious, such as appendicitis, ulcer or pancreatitis. Chest pain may
indicate a pulmonary embolus, a complication that can follow thrombophlebitis.
6. PIH
 Rapid weight gain (over 2 lbs per week in the second trimester, 1 lb per week in the third trimester)
 Swelling of the face and fingers
 Flashes of light or dots before the eyes
 Dimness or blurring of vision
 Severe, continuous headache
 Decreased urine output
7. Increase or Decrease in Fetal movement
 Because a fetus normally moves more or less the same amount every day, an unusual increase or decrease in
movement suggests that a fetus is responding to a need for oxygen. (Piliteri, pp. 271)

53. It is universally agreed that breast milk is the preferred method of feeding a newborn, because it provides
numerous health benefits to both the mother and the infant. You overheard the intent of a pregnant mother not to
breast feed her baby. You encourage the mother to breastfeed her baby by not discussing the following benefits, aside
from:
A. Breastfeeding is an effective contraceptive method because it delays menstruation.
B. Breastfeeding may serve a protective function in preventing breast cancer.
C. Breastfeeding will help them lose weight gained during pregnancy.
D. Breastfeeding causes release of oxytocin from the anterior pituitary gland that aids in uterine involution.

RATIONALE:
Advantages of Breastfeeding to the Mother:
 Breastfeeding may serve a protective function in preventing breast cancer.
 The release of oxytocin from the posterior pituitary gland aids in uterine involution.
 Successful breastfeeding can have an empowering effect, because it is a skill only a woman can master.
 Breastfeeding reduces the cost of feeding and preparation Time
 Breastfeeding provides an excellent opportunity to enhance a true symbiotic bond between mother and child. Although this
does occur readily with breastfeeding, a woman who holds her baby to formula feed can form this bond as well.

Advantages of Breastfeeding to the Infant:
 Secretes immunoglobulins which protects the infant from infection
 Contains the ideal electrolyte and minerals needed for infant growth
 Protein is easily digested which favors rapid brain growth.

Fallacies about Breastfeeding:
 Some women believe that breastfeeding, because it causes a delay in menstruation (lactational amenorrhea), is a foolproof
contraceptive technique. It is not: 50% of women resume ovulating by the fourth week after delivery, even while breastfeeding
(Van der Wijden, Kleijnen, & van den Berk, 2009).
 Some women believe that breastfeeding will help them lose weight gained during pregnancy. This also is not true, and women
who are breastfeeding need to concentrate on eating a well-balanced diet to ensure their milk will be rich in nutrients.
 Some women are reluctant to breastfeed because they fear that having to be available to feed the baby every 3 or 4 hours will
tie them down. Like mothers who formula feed, however, they can leave a bottle (with expressed breast milk) with the baby‘s
father or a caregiver if they need to be away from their baby at the time of a feeding. (Pillitteri, pp. 492)


54. Hemorroids (varicosiites of the rectal veins) occur commonly in pregnancy because of pressure on these veins
from the bulk of the growing uterus. Mrs. Candida Albinas, 11 weeks pregnant mother visited the clinic due to some
discomforts. She reported that she has hemorrhoids and asked for your help on how to be relieved from the discomfort.
You advise her to do the following, except:
A. Replacing hemorrhoids with gentle finger pressure.
B. Assume a knee-chest position for 13 minutes at the end of the day
C. Daily bowel evacuation to relieve constipation and rest in a modified Sim‘s position daily
D. Apply warm compress to external hemorrhoids to help relieve pain

RATIONALE:
 Daily bowel evacuation to relieve constipation and resting in a modified Sim‘s position daily are both helpful.
 At day‘s end, assuming a knee-chest position for 10-15 minutes is an excellent way to reduce the pressure on rectal veins.
The weight of the uterus is shifted forward; this position promotes free flow of urine from the kidneys (preventing urinary tract
stasis and infection) and better circulation in the rectal area (preventing hemorrhoids). A knee-chest position may make a
woman feel lightheaded initially. If this happens, she should remain in this position for only a few minutes at first, and then
gradually increase the time until she can maintain the position comfortably for about 15 minutes.
 A stool softener such as docusate sodium (Colace) may be recommended for a woman who already has hemorrhoids.
 Applying witch hazel or COLD COMPRESS to external hemorrhoids can help relieve pain.
 Replacing hemorrhoids with gentle pressure can also be helpful. (Pilliteri, pp. 285)

55. Breastfeeding should begin as soon after birth as possible, ideally while the woman is still in the birthing room
and while the infant is in the first reactivity period. Mrs. Green, 36 weeks pregnant decided to breastfeed her baby
once born. She expressed interest in learning ways to prepare for breastfeeding. The teaching of the nurse has been
effective if the client states all but one:
A. I should do nipple rolling to make my nipples more protuberant for breastfeeding.
B. I will practice breast massage to move the milk forward in the ducts.
C. When I do manual expression, I should expect that I will obtain colostrums now and immediately after birth.
D. I will not wash my breast using strong soap.

RATIONALE:
OPTION A: Physical preparation such as nipple rolling, advised in the past as a way of making a woman‘s nipples more protuberant, is
not necessary because few women have inverted or nonprotuberant nipples. In addition, oxytocin, which is released by this maneuver,
could lead to preterm labor (nipple rolling is used to create uterine contractions for stress tests).
OPTION B: Practicing breast massage to move the milk forward in the milk ducts (manual expression of milk) may be helpful. This can
help a woman who feels hesitant about handling her breasts grow accustomed to doing so, and allows her to assist with milk
production in the first few days after birth. Manual expression consists of supporting the breast firmly, then placing the thumb and
forefinger on the opposite sides of the breast, just behind the areolar margin, first pushing backward toward the chest wall and then
downward until secretions begins to flow.
OPTION C: During the last months of pregnancy and immediately after birth, the fluid obtained will be colostrum. By the third day of
infant life, milk will be obtained.
OPTION D: Teach women to wash their breasts with clear water because soap tends to dry and crack nipples. (Pillitteri, 494)

56. Republic Act 9288 is an act promulgating a comprehensive policy and a national system for ensuring Newborn
Screening. A newly-wed couple visited the clinic for counseling. They asked you with regard the Newborn Screening
Your health teaching was not effective if you included which of the following information:
A. The test screens for six metabolic disorders.
B. A negative screen means that the NBS result is normal.
C. Newborn Screening result is available after 5 working days from the time samples are received.
D. The sample for NBS may be collected by the nurse, medical technologist or trained midwife

RATIONALE:
Newborn Screening (NBS) is a simple procedure to find out if your baby has a congenital metabolic disorder that may lead to mental
retardation or even death if left untreated.
 OPTION C: Results can be claimed from the health facility where NBS was availed. Normal NBS Results are available by 7 -
14 working days from the time samples are received at the Newborn Screening Center.
 OPTION A: Congenital hypothyroidism; Congenital Adrenal hyperplasia; Galactosemia; Phenylketonuria; Glucose-6-Phosphate
Dehydrogenase Deficiency; Maple Syrup Urine Disease (Maple syrup urine disease is caused by a gene defect. Persons with
this condition cannot break down the amino acids leucine, isoleucine, and valine. This leads to a buildup of these chemicals in
the blood. In the most severe form, MSUD can damage the brain during times of physical stress such as infection, fever, or not
eating for a long time
 OPTION B: A NEGATIVE SCREEN MEANS THAT THE NBS RESULT IS NORMAL; A positive screen means that the newborn
must be brought back to his/her health practitioner for further testing.
 OPTION D: The blood sample for NBS may be collected by any of the following: physician, nurse, medical technologist or
trained midwife. (http://www.newbornscreening.ph/index.php?option=com_content&view=section&layout=blog&id=3&Itemid=60)

57. Most babies with metabolic disorders look "normal" at birth. By doing NBS, metabolic disorders may be detected
even before clinical signs and symptoms are present. Which among the following metabolic disorders may cause the
baby to have hemolytic anemia?
A. G6PD Deficiency
B. Congenital Adrenal Hyperplasia
C. Galactosemia
D. Phenylketonuria

RATIONALE:

Glucose-6-Phosphate-
Dehydrogenase Deficiency
 G6PD deficiency is a condition where the body lacks the enzyme G6PD
 Babies with this deficiency may have hemolytic anemia resulting from exposure to
certain drugs, foods and chemicals
Phenylketonuria  PKU is a metabolic disorder in which the body cannot properly use one of the building
blocks of protein called Phenylalanine in the body causes brain damage
Congenital Hypothyroidism  CH results from lack or absence of thyroid hormone, which is essential to growth of
the brain and the body
 If the disorder is not detected and hormone replacement is not initiated within 4
weeks, the baby‘s physical growth will be stunted and she/he may suffer from mental
retardation.
Galactosemia  GAL is a condition in which the body is unable to process galactose, the sugar
present in milk. Accumulation of excessive galactose in the body can cause may
problems, including liver damage, brain damage and cataracts.
Congenital Adrenal Hyperplasia  CAH is an endocrine disorder that causes severe salt loss, dehydration and
abnormally high levels of male sex hormones in both boys and girls.
 If not detected and treated early, babies may die within 7 -14 days.
(ULG, pp. 387)

58. The ultimate decision to breastfeed should depend on what would please a woman and her infant most. Nurse
Ana is talking to mothers in the community who are breastfeeding their infants. Breastfeeding is not contraindicated in the
following circumstances:
A. Mrs. Anna, whose child was diagnosed with galactosemia
B. Mrs. Karen, who exclaims that she has mastitis of the left breast.
C. Mrs. Nina, who follows a strict vegetarian diet.
D. Mrs. Perlita, who has varicella rash for a day now.

RATIONALE:
Breastfeeding is contraindicated in only a few circumstances, such as:
 An infant with galactosemia (such infants cannot digest the lactose in milk)
 Herpes lesions on a mother‘s nipples
 Maternal diet is nutrient restricted, preventing quality milk production
 Maternal exposure to radioactive compounds (e.g., during thyroid testing)
 Breast cancer
 Maternal active, untreated tuberculosis, hepatitis B or C, cytomegalovirus, or human immunodeficiency syndrome
 Maternal active, untreated varicella. Once the infant has been given varicella zoster immunoglobulin, the infant can receive
expressed breast milk if there are no lesions on the breast. Within 5 days of the appearance of the rash, maternal antibodies
are produced, and thus breastfeeding could be beneficial in providing passive immunity against varicella (Sadeharju et al.,
2007)
 Mothers receiving antimetabolites or chemotherapeutic agents
 Mothers receiving prescribed medications that would be harmful to an infant such as lithium or methotrexate
 A mother lives in an area where environmental contaminants can be carried via breast milk to the infant (AAP
Committee on Drugs, 2002)
 Sore nipples, like engorgement, are not a contraindication to breastfeeding. If steps to prevent sore nipples are
followed, the problem is unlikely to become acute again. (Pilliteri, pp. 492)

59. Some infants seem to swallow little air when they breastfeed, whereas others swallow a great deal. As a rule, it is
helpful to bubble (burp) newborns after they have emptied the first breast and again after the total feeding. Lea, a
first time mother expresses concern regarding feeding her baby. You give her instructions about burping her baby. Which
among the following would you suggest as the best position?
A. Place the baby over one shoulder and gently pat the back
B. Hold the baby in a sitting position on the lap leaning forward against one hand and gently pat the back
C. Place the baby in a prone position over the lap and gently pat the back
D. Place the baby over one shoulder and gently shake the baby

RATIONALE:
Placing the baby over one shoulder and gently patting or stroking the back is an acceptable position. However, this position is not
always satisfactory for a small infant, who has poor head control. In addition, a parent may have difficulty supporting the baby‘s head
and patting the back at the same time. Holding the baby in a sitting position on the lap, then leaning the child forward against one hand,
with the index finger and thumb supporting the head, is often the best position to use. This position provides head support but leaves
the other hand free to pat the baby‘s back. Parents usually need to be shown this method, because it does not seem as natural as
placing a baby against the shoulder. Laying the baby prone across the lap is another alternative position. (Pilliteri, pp. 498)

60. Women who develop a breast abscess may be advised not to breast feed. Women should use commercial
formulas for formula feeding because they so closely mimic human milk. A mother expressed her worries of not
being able to continue breastfeeding her baby because she will be returning to work soon. She asked you how much fluid
should her baby receive if she is now weighing 7 lbs. Your best response would be?
A. 525 – 630 mL of fluid in 24 hours
B. 155 – 385 mL of fluid in 12 hours
C. 450 – 750 mL of fluid in 24 hours
D. 386 – 943 mL of fluid in 12 hours

RATIONALE:
To calculate the adequacy of a formula, remember these two rule of thumb:
1. The total fluid ingested for 24 hours must be sufficient to meet the infant‘s needs: 75 – 90 mL (2.5 – 3 oz) of fluid per pound of
body weight (150 – 200 mL/Kg) per day.
2. The number of calories required per day is 50 – 55 per pound of body weight (100 – 120 kcal/Kg)
 A quick rule of the thumb is to estimate how much an infant will drink at a feeding is to add 2 or 3 to the infant‘s age
in months.

7 lbs x 75 mL = 525 mL
7 lbs x 90 mL = 630 mL
(Pilliteri, pp. 505)
61. Infant formula of any type must be prepared with careful attention to cleanliness to prevent pathogenic
microorganisms from growing in it. You are teaching a mother‘s class regarding the proper preparation of formula milk
for their infants. To warm the formula milk, you should include which of the following in your teaching?
A. Use the microwave oven to warm the bottle with milk.
B. Stand the bottle in a bowl of warm water
C. Place the bottle inside a pan with water and warm it using a stove
D. Just leave the bottle in a sturdy table in a warm room.

RATIONALE:
OPTION B: The best method to warm formula is to stand the bottle in a bowl of warm water or hold it under a faucet of running hot
water for a few minutes.
OPTION A: it also is not recommended to warm bottles in a microwave oven, because the milk in the center of the bottle can become
hotter than that near the sides. If parents do not follow this recommendation, caution them to heat no longer than 30 seconds for a 4 oz
bottle and 45 seconds for an 8 oz bottle.
OPTION C: Caution parents not to use a pan on the stove to warm formula because if the pan boils dry, the bottle of milk will burst.
Disposable bottles with plastic liners should definitely not be heated on the stove; the liner tends to melt and then leak during feeding.
 After warming, they should add the nipple and shake the bottle well to mix the cold and warm portions. Finally, with all
warming methods, parents should test the temperature of the formula by allowing a drop or two to fall onto the inside of a
wrist, to make sure it is not hot enough to burn the baby‘s mouth. (Pilliteri, pp. 505-506)

62. Although the gastrointestinal tract is usually sterile at birth, bacteria may be cultured from the intestinal tract in
most babies within 5 hours after birth and from all babies at 24 hours of life. Mrs. Socorro looks concerned because
her 36 hour-old baby had not passed stool. To address the concern of the mother, your best response would be?
A. A newborn should have passed the first stool within 30 hours. I would tell this to the doctor for immediate
assessment.
B. Normally, a newborn‘s stool is passed within the first 24-48 hours. After this time period, if there is still no stool, we
will do further assessment.
C. A newborn should have passed the first stool within 24 hours. I would tell this to the doctor for immediate
assessment.
D. Normally a newborn‘s stool is passed within the first 48-72 hours. After this time period, if there is still no stool will do
further assessment.

RATIONALE:
The first stool of a newborn is usually passed within 24 hours after birth. It consists of meconium, a sticky, tarlike, blackish-green,
odorless material formed from mucus, vernix, lanugo, hormones, and carbohydrates that accumulated during intrauterine life. If a
newborn does not pass a meconium stool by 24 to 48 hours after birth, the possibility of some factor such as meconium ileus,
imperforate anus, or volvulus should be suspected. (Pilliteri, pp. 453)

63. The first stool of a newborn consists of meconium, a sticky, tar-like, blackish-green, odorless material formed
from mucus, vernix, lanugo, hormones that accumulated during intraunterine life. You are assigned to care for a
mother who delivered vaginally two days ago. The baby cannot be breastfed by the mother because she developed
breast abscess. You expect the stool to be:
A. Light yellow stools
B. Bright green stools
C. Green and loose stools
D. Clay colored stools

RATIONALE:
OPTION C: About the second or third day of life, newborn stool changes in color and consistency, becoming green and loose.
This is termed transitional stool, and it may resemble diarrhea to the untrained eye.
OPTION A: By the fourth day of life, breastfed babies pass three or four light yellow stools per day. They are sweet-smelling, because
breast milk is high in lactic acid, which reduces the amount of putrefactive organisms in the stool.
OPTION B: A newborn placed under phototherapy lights as a treatment for jaundice has bright green stools because of increased
bilirubin excretion.
OPTION D: Newborns with bile duct obstruction have clay-colored (gray) stools, because bile pigments are not entering the intestinal
tract.
 Blood-flecked stools usually indicate an anal fissure. Occasionally, a newborn has swallowed some maternal blood during birth
and either vomits fresh blood immediately after birth or passes a black tarry stool after 2 or more days. Maternal blood may be
differentiated from fetal blood by a dipstick Apt test. If the stools remain black or tarry, intestinal bleeding should be suspected.
If mucus is mixed with stool or the stool is watery and loose, a milk allergy, lactose intolerance, or some other condition
interfering with digestion or absorption should be suspected. (Pilliteri, pp. 453)

64. Mature newborns demonstrate neuromuscular function by moving their extremities, attempting to control head
movement, exhibiting a strong cry, and demonstrating newborn reflexes. The Moro reflex is the single best
assessment of neurologic disability in a newborn. What is the best way to test this reflex?
A. Pressure is applied on the soles of the feet of a newborn lying supine
B. Newborns lie supine and her paravertebral area is touched by a probing finger
C. Make a sharp noise, such as clapping your hands, to wake the infant.
D. Lift the infant‘s head while she is supine and allow it to fall back 1 inch.

RATIONALE:

MORO REFLEX (OPTION D) A Moro (startle) reflex can be initiated by startling a newborn with a loud
noise or by jarring the bassinet. The most accurate method of eliciting
the reflex is to hold newborns in a supine position and allow their heads
to drop backward about 1 inch. In response to this sudden head
movement, they abduct and extend their arms and legs. Their fingers
assume a typical ―C‖ position. Finally, they swing their arms into an
embrace position and pull up their legs against their abdomen
(adduction). The reflex simulates the action of someone trying to ward
off an attacker, then covering up to protect himself. It is strong for the
first 8 weeks of life and then fades by the end of the fourth or fifth month,
at the same time an infant can roll away from danger.
MAGNET REFLEX (OPTION A) If pressure is applied to the soles of the feet of a newborn lying in a
supine position, he or she pushes back against the pressure. This and
the two following reflexes are tests of spinal cord integrity.
TRUNK INCURVATION REFLEX
(OPTION B)
When newborns lie in a prone position and are touched along the
paravertebral area by a probing finger, they flex their trunk and swing
their pelvis toward
the touch
Pilliteri, pp. 455-456)

65. Limpness or total absence of a muscular response to manipulation is never normal and suggests narcosis,
shock, or cerebral injury. Nurse Haley is assessing the spinal integrity of the baby‘s L2 – L4, in line with this, she elicits
which of the following?
A. Patellar reflex
B. Biceps reflex
C. Landau reflex
D. Crossed extension reflex

RATIONALE:


DEEP TENDON REFLEXES:

PATELLAR REFLEX  Can be elicited in a newborn by tapping the patellar tendon with the
tip of the finger. The lower leg moves perceptibly if the infant has
an intact reflex.
 A patellar reflex is a test for spinal nerves L2–L4.
BICEPS REFLEX  To elicit a biceps reflex, place the thumb of your left hand on the
tendon of the biceps muscle on the inner surface of the elbow. Tap
the thumb as it rests on the tendon. You are more likely to feel the
tendon contract than to observe movement.
 A biceps reflex is a test for spinal nerves C5 and C6

LANDAU REFLEX  A newborn who is held in a prone position with a hand underneath,
supporting the trunk, should demonstrate some muscle tone.
Babies may not be able to lift their head or arch their back in this
position (as they will at 3 months of age), but neither should they
sag into an inverted ―U‖ position. The latter response indicates
extremely poor muscle tone, the cause of which should be
investigated.
CROSSED EXTENSION REFLEX  If one leg of a newborn lying supine is extended and the sole of
that foot is irritated by being rubbed with a sharp object, such as a
thumbnail, the infant raises the other leg and extends it, as if trying
to push away the hand irritating the first leg.
(Pilliterri, pp. 456)
66. Hiatal hernia occurs when part of your stomach pushes upward through your diaphragm. Your diaphragm
normally has on opening called hiatus through which your food tube or esophagus passes. The stomach can
push up and cause a hiatal hernia. A newly diagnosed patient with hiatal hernia was seen really worried about her
condition. She told the nurse she often felt like vomiting after every meal, that she‘d feel as if having chest pain and
sometimes having difficulty swallowing. You as her nurse know well what kind of condition she has. In order to intervene
appropriately, you instruct the client to do all of the following, except:
A. Elevate the head of your bed about 6 inches.
B. Lie down immediately after eating.
C. Eat at least 2hrs before bedtime.
D. Avoid foods like chocolates, onions, spicy and citrus foods.

RATIONALE:
Elevating the head of the bed and eating a tleast 2hrs before bedtime prevents signs and symptoms of acid reflux caused by hiatal
hernia. Avoiding foods like the ones mentioned above would prevent triggering a heart burn. Lying down immediately after a meal
would cause acid reflux or a sensation of acid backing up into your throat or mouth which can produce a sour or bitter taste or a feeling
of vomiting.

Management for an axial hernia includes frequent, small feedings that can pass easily through the esophagus. The patient is advised
not to recline for 1 hour after eating, to prevent reflux or movement of the hernia, and to elevate the head of the bed on 4- to8-inch (10-
to 20-cm) blocks to prevent the hernia from sliding upward. Surgery is indicated in about 15% of patients. Medical and surgical
management of a paraesophageal hernia is similar to that for gastroesophageal reflux; however, paraesophageal hernias may require
emergency surgery to correct torsion (twisting) of the stomach or other body organ that leads to restriction of blood flow to that
area.(Brunner, pp.977 )

67. A hiatal hernia occurs when weakened muscle tissue allows your stomach to bulge up through your diaphragm.
It’s not always clear why this happens, but pressure on your stomach may contribute to the formation of hiatal
hernia. After admitting a client who just had nissen fundoplication, curious, the student nurse asked her clinical instructor
what kind of surgical procedure it was. The clinical instructor correctly answered the student by stating the following
except:

A. Procedure wherein the surgeon wraps a portion of the stomach fundus around the distal esophagus to anchor it and
reinforce the LES.
B. It is the most common surgical technique for hiatal hernia repair.
C. A common complication is a ―gas bloat syndrome‖.
D. Major surgery operation involving the pancreas, duodenum and all other organs.

RATIONALE:
Nissen Fundoplication is a surgical procedure wherein the surgeon wraps a portion of the stomach fundus around the distal esophagus
which is used to anchor it and reinforce the LES or the Lower Esophageal Sphincter. Indeed it is the most widely used and most
common technique for hiatal hernia repair. A ―gas bloat syndrome‖ is the most common complication of this surgical procedure. In a
gas bloat syndrome, fundoplication can alter the mechanical ability of the stomach to eliminate swallowed air by belching leading to gas
accumulation.

68. Excessive reflux of gastric or duodenal contents to the esophagus may occur because of an incompetent lower
esophageal sphincter, pyloric stenosis, or a motility disorder. The incidence of reflux seems to increase with
aging. Your client with GERD complains about having difficulty sleeping at night. Appropriate intervention would include
which of the following?
A. Administering antacids such as Sodium bicarbonate
B. Sleeping on two or three pillows
C. Eliminating carbohydrates from the diet
D. Suggesting a glass of milk before retiring

RATIONALE:
 OPTION B: Sleeping on pillows raises the upper torso and prevents reflux of the gastric contents.
 OPTION A: The effects of antacids is not long lasting enough to promote a full night‘s sleep; sodium bicarbonate is not
recommended as an antacid
 OPTION C: This would have no effect on the reflux of gastric contents
 OPTION D: Increasing the content of the stomach before lying down would aggravate the symptoms associated with a
gastroesophageal reflux.
Management begins with teaching the patient to avoid situations that decrease lower esophageal sphincter pressure or cause
esophageal irritation. The patient is instructed to eat a low-fat diet; to avoid caffeine, tobacco, beer, milk, foods containing peppermint
or spearmint, and carbonated beverages; to avoid eating or drinking 2 hours before bedtime; to maintain normal body weight; to avoid
tight-fitting clothes; to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks; and to elevate the upper body on pillows.
(Brunner, pp. 979)

69. Fibroscopy of the upper GI tract allows direct visualization of the esophageal, gastric, and duodenal mucosa
through a lighted endoscope (gastroscope). EGD is valuable when esophageal, gastric, or duodenal disorders or
inflammatory, neoplastic, or infectious processes are suspected. Nurse Gangnam is assessing Mr. Oppa, a patient
who just underwent gastroscopy an hour ago. Which of the following assessment could indicate complication?
A. Mild pain
B. Increased GI motility
C. Nausea and vomiting
D. Unusual dysphagia

RATIONALE:
After gastroscopy, assessment by the nurse includes observing for signs of perforation, such as pain, bleeding, unusual difficulty
swallowing, and an elevated temperature. The nurse monitors the pulse and blood pressure for changes that can occur with sedation.
The nurse can test the gag reflex by placing a tongue blade onto the back of the throat to see whether gagging occurs. After the
patient‘s gag reflex has returned, the nurse can offer lozenges, saline gargle, and oral analgesics to relieve minor throat discomfort.
Patients who were sedated for the procedure must stay on bed rest until fully alert. After moderate sedation, the patient must be
accompanied and transported home if the procedure was performed on an outpatient basis. The nurse instructs the patient not to drive
for 10 to 12 hours if sedation was used.
 The patient should not eat or drink for 6 to 12 hours before the examination. Patient preparation includes helping the patient
spray or gargle with a local anesthetic, and administering midazolam (Versed) intravenously just before the scope is
introduced. Midazolam is a sedative that provides moderate sedation and relieves anxiety during the procedure. The nurse
also may administer atropine to reduce secretions, and may give glucagon, if needed and prescribed, to relax smooth muscle.
The nurse positions the patient on the left side to facilitate saliva drainage and to provide easy access for the endoscope.
(Brunner, pp. 952)

70. A diverticulum is an outpouching of mucosa and submucosa that protrudes through a weak portion of the
musculature. The most common type of diverticulum, which is found three times more frequently in men than in
women, is Zenker’s diverticulum. A 90 year old client with history of diverticulitis is admitted with severe abdominal
pain, anorexia, nausea, vomiting for 24 hours, a markedly elevated temperature, and increased WBC. The primary reason
for performing surgery is most likely that:
A. The client‘s age indicated that immediate correction of the potentially fatal condition was needed.
B. The symptoms exhibited by the client on admission were life threatening
C. In some instances diverticulitis is difficult to differentiate from carcinoma except surgically
D. Surgery is usually indicated for clients with a diagnosis of diverticulitis
RATIONALE:
OPTION D: The client‘s status requires immediate intervention; to delay treatment may prove dangerous because symptoms indicate
possible perforation.
OPTION A: Age is not the factor; the symptoms indicate possible peritonitis
OPTION B: Diverticulitis can in most cases be treated by diet, rest and antibiotic therapy
OPTION C: This is not true with the diagnostic techniques presently available.

 A diverticulum forms when the mucosa and submucosal layers of the colon herniate through the muscular wall because of
high intraluminal pressure, low volume in the colon (ie, fiber-deficient contents), and decreased muscle strength in the colon
wall (ie, muscular hypertrophy from hardened fecal masses). Bowel contents can accumulate in the diverticulum and
decompose, causing inflammation and infection. A diverticulum can become obstructed and then inflamed if the obstruction
continues. The inflammation tends to spread to the surrounding bowel wall, giving rise to irritability and spasticity of the colon
(ie, diverticulitis). Abscesses develop and may eventually perforate, leading to peritonitis and erosion of the blood vessels
(arterial) with bleeding.

 Complications of diverticulitis include peritonitis, abscess formation, and bleeding. If an abscess develops, the associated
findings are tenderness, a palpable mass, fever, and leukocytosis. An inflamed diverticulum that perforates results in
abdominal pain localized over the involved segment, usually the sigmoid; local abscess or peritonitis follows. Abdominal pain,
a rigid boardlike abdomen, loss of bowel sounds, and signs and symptoms of shock occur with peritonitis. Noninflamed or
slightly inflamed diverticula may erode areas adjacent to arterial branches, causing massive rectal bleeding. (Brunner, pp.
1037)

71. Although acute diverticulitis usually subsides with medical management, immediate surgical intervention is
necessary if complications (eg, perforation, peritonitis, abscess formation, hemorrhage, and obstruction) occur.
A client with diverticulitis refused to be treated in the hospital and insisted to go home instead. You plan to give her health
teaching to with regard to her condition. You should not include which of the following in your health teachings?
A. Strictly follow your physician‘s order of antibiotic for 7 days.
B. To manage your pain, you may use Morphine as prescribed by your physician
C. You should increase your intake of food high in fiber and limit fatty foods
D. Increase your oral fluid intake to facilitate evacuation of stool

RATIONALE:
DIETARY AND MEDICATION MANAGEMENT
Diverticulitis can usually be treated on an outpatient basis with diet and medicine therapy. When symptoms occur, rest, analgesics, and
antispasmodics are recommended. Initially, the diet is clear liquid until the inflammation subsides; then, a high-fiber, low-fat diet is
recommended. This type of diet helps to increase stool volume, decrease colonic transit time, and reduce intraluminal pressure.
Antibiotics are prescribed for 7 to 10 days. A bulkforming laxative also is prescribed. In acute cases of diverticulitis with significant
symptoms, hospitalization is required. Hospitalization is often indicated for those who are elderly, immunocompromised, or taking
corticosteroids. Withholding oral intake, administering intravenous fluids, and instituting nasogastric suctioning if vomiting or distention
occurs rests the bowel. Broad-spectrum antibiotics are prescribed for 7 to 10 days. An opioid is prescribed for pain relief; morphine is
not used because it increases segmentation and intraluminal pressures. Oral intake is increased as symptoms subside. A low-fiber diet
may be necessary until signs of infection decrease. Antispasmodics such as propantheline bromide (Pro-Banthine) and
oxyphencyclimine (Daricon) may be prescribed. Normal stools can be achieved by using bulk preparations (Metamucil) or stool
softeners (Colace), by instilling warm oil into the rectum, or by inserting an evacuant suppository (Dulcolax). Such a prophylactic plan
can reduce the bacterial flora of the bowel, diminish the bulk of the stool, and soften the fecal mass so that it moves more easily
through the area of inflammatory obstruction. (Brunner, pp.1038)

72. A peptic ulcer is frequently referred to as a gastric, duodenal, or esophageal ulcer, depending on its location, or
as peptic ulcer disease. Erosion of a circumscribed area of mucous membrane is the cause. The nurse provides
medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates the best
understanding of the medication therapy?
A. ―Sucralfate (Carafate) will change the fluid in my stomach‖
B. ―Antacids will coat my stomach‖
C. ―Omeprazole (Prilosec) will coat the ulcer and help it heal‖
D. ―Cimetidine (Tagamet) will cause me to produce less stomach acid‖

RATIONALE:
Cimetidine (Tagamet), histamine H2 receptor antagonist will decrease the secretion of gastric acid. Sucralfate (Carafate) promotes
healing by coating the ulcer. Antacids neutralize acids in the stomach. Omeprazole (Prilosec) inhibits gastric acid secretions.

Antibiotics and Bismuth Salts
 Bismuth subsalicylate (Pepto-Bismul)
 Metronidazole (use with PPI and clarithromycin)
 Amoxicillin (Clarithromycin, PPI)
Suppresses H. pylori bacteria in the gastric mucosa and assists with
healing of mucosal lesions
Histamine2 Receptor Antagonists
 Cimetidine (Tagamet)
 Ranitidine (Zantac)
 Famotidine (Pepcid)
 Nizantidine (Axid)
Inhibits acid secretion by blocking the action of histamine on the
histamine receptors of the parietal cells in the stomach
Proton (Gastric acid) Pump inhibitor
 Omeprazole (Prilosec)
 Lansoprazole (Prevacid)
 Rabeprazole (Aciphex)
Decreases gastric acid secretion by slowing the hydrogen-potassium
adenosine triphosphatase (H+, K+-ATPase) pump on the surface of
the parietal cells
Cytoprotective Medications
 Misoprostol (Cytotec)


 Sucralfate (Carafate)

 A synthetic prostaglandin; protects the gastric mucosa from
ulcerogenic agents; also increases mucus production and
bicarbonate levels
 In the presence of gastric acid, sucralfate creates a viscous
substance that forms a protective layer at the site of the
ulcer and prevents digestion by pepsin
(Brunner, pp. 1013-1014)

73. Surgery is usually recommended for patients with intractable ulcers (those that fail to heal after 12 to 16 weeks of
medical treatment), life-threatening hemorrhage, perforation, or obstruction, and for those with ZES not
responding to medications. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the
purpose of this procedure. The nurse does not need further teaching if she states which of the following:
A. Decreases food absorption in the stomach
B. Reduces stimulus to acid secretions
C. Diminishes pain sensation
D. Halts stress reaction

RATIONALE:
A vagotomy or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion.
Surgical procedures include vagotomy, with or without pyloroplasty, and the Billroth I and Billroth II procedures.

VAGOTOMY Severing of the vagus nerve. Decreases gastric acid by diminishing
cholinergic stimulation to the parietal cells, making them less responsive to
gastrin. May be done via open surgical approach, laparoscopy, or
thoracoscopy
PYLOROPLASTY A surgical procedure in which a longitudinal incision is made into the pylorus
and transversely sutured closed to enlarge the outlet and relax the muscle
BILROTH I (Gastroduodenostomy) Removal of the lower portion of the antrum of the stomach (which contains the
cells that secrete gastrin) as well as a small portion of the duodenum and
pylorus. The remaining segment is anastomosed to the duodenum (Billroth I)
or to the jejunum (Billroth II)
BILROTH II (Gastrojejunostomy)
(Brunner, pp. 1018-1019)

74. Irritable Bowel Syndrome occurs more commonly in women than in men, and the cause is still unknown. Sarah
Ghie was brought to the hospital due to complaints of severe abdominal pain. You will suspect IBS if during the
assessment she stated which of the following:
A. ―I can‘t understand my bowel pattern, at some time I‘m having diarrhea then I‘ll be constipated, it just changes a lot.‖
B. ―The pain becomes more intense when I defecate.‖
C. ―I feel nauseated most of the time.‖
D. ―When I defecate, I can see blood on my stool.‖

RATIONALE:
IBS results from a functional disorder of intestinal motility. The change in motility may be related to the neurologic regulatory
system, infection or irritation, or a vascular or metabolic disturbance. The peristaltic waves are affected at specific segments of the
intestine and in the intensity with which they propel the fecal matter forward. There is no evidence of inflammation or tissue changes in
the intestinal mucosa.
There is a wide variability in symptom presentation. Symptoms range in intensity and duration from mild and infrequent to
severe and continuous. The primary symptom is an alteration in bowel patterns—constipation, diarrhea, or a combination of both. Pain,
bloating, and abdominal distention often accompany this change in bowel pattern. The abdominal pain is sometimes precipitated by
eating and is frequently relieved by defecation.

75. Irritable Bowel Syndrome is one of the most common GI problems. It is a functional disorder that affects
frequency of defecation and consistency of stool; associated with crampy abdominal pain and bloating. You are
instructing Mr. Carey, a patient diagnosed of having IBS on measures he can take to control his manifestations. You do
not need further teaching if you stated all of the following, aside from:
A. Be sure to eat foods with high-fiber content
B. Fluids should be taken with meals to facilitate faster digestion and evacuation of undigested food substances
C. Sign up for any exercise programs in your community to reduce your anxiety
D. Commit yourself in regularly taking the anticholinergic or calcium channel blockers prescribed by your physician

RATIONALE:
The goals of treatment are aimed at relieving abdominal pain, controlling the diarrhea or constipation, and reducing stress.
Restriction and then gradual reintroduction of foods that are possibly irritating may help determine what types of food are acting as
irritants (eg, beans, caffeinated products, fried foods, alcohol, spicy foods). A healthy, high-fiber diet is prescribed to help control the
diarrhea and constipation. Exercise can assist in reducing anxiety and increasing intestinal motility. Patients often find it helpful to
participate in a stress reduction or behavior-modification program. Hydrophilic colloids (ie, bulk) and antidiarrheal agents (eg,
loperamide) may be given to control the diarrhea and fecal urgency. Antidepressants can assist in treating underlying anxiety and
depression. Anticholinergics and calcium channel blockers decrease smooth muscle spasm, decreasing cramping and constipation.

The nurse‘s role is to provide patient and family education. The nurse emphasizes teaching and reinforces good dietary
habits. The patient is encouraged to eat at regular times and to chew food slowly and thoroughly. The patient should understand that,
although adequate fluid intake is necessary, fluid should not be taken with meals because this results in abdominal distention. Alcohol
use and cigarette smoking are discouraged. (Brunner, pp. 1033-1034)

76. Malabsorption is the inability of the digestive system to absorb one or more of the major vitamins (especially
vitamin B12), minerals (ie, iron and calcium), and nutrients (ie, carbohydrates, fats, and proteins). Mr. Jordan was
seen by the physician due to complaints of greasy, bulky and smelly stools without a drop in the iron level of his body.
Nurse Kareen noted this as steatorrhea. Among the following, which condition could have most likely caused Mr. Jordan‘s
malabsorption?
A. Zollinger-Ellison Syndrome
B. Lactose Intolerance
C. Celiac Disease
D. Whipple‘s Disease

RATIONALE:
The conditions that cause malabsorption can be grouped into the following categories:
 Mucosal (transport) disorders causing generalized malabsorption (eg, celiac sprue, regional enteritis, radiation enteritis)
 Infectious diseases causing generalized malabsorption (eg, small bowel bacterial overgrowth, tropical sprue, Whipple‘s
disease)
 Luminal problems causing malabsorption (eg, bile acid deficiency, Zollinger-Ellison syndrome, pancreatic insufficiency)
 Postoperative malabsorption (eg, after gastric or intestinal resection)
 Disorders that cause malabsorption of specific nutrients (eg, disaccharidase deficiency leading to lactose intolerance)

ZOLLINGER – ELLISON SYNDROME  Hyperacidity in duodenum inactivates pancreatic enzymes
 Ulcer diathesis, steatorrhea
LACTOSE INTOLERANCE  Deficiency of intestinal lactase results in high concentration of
intraluminal lactose with osmotic diarrhea
 Varied degrees of diarrhea and cramps after ingestion of lactose-
containing foods; positive lactose intolerance test, decreased intestinal
lactase
CELIAC DISEASE  Toxic response to a gluten fraction by surface epithelium results in
destruction of absorbing surface
 Weight loss, diarrhea, bloating, anemia (low iron, folate), osteomalacia,
steatorrhea, azotorrhea, low D-xylose absorption; folate and iron
malabsorption
WHIPPLE’S DISEASE  Bacterial invasion of intestinal mucosa
 Arthritis, hyperpigmentation, lymphadenopathy, serous effusions, fever,
weight loss; steatorrhea, azotorrhea

CLINICAL MANIFESTATIONS:
The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have
increased fat content and are often grayish. Patients often have associated abdominal distention, pain, increased flatus, weakness,
weight loss, and a decreased sense of well-being. The chief result of malabsorption is malnutrition, manifested by weight loss and other
signs of vitamin and mineral deficiency (eg, easy bruising, osteoporosis, anemia). Patients with a malabsorption syndrome, if untreated,
become weak and emaciated because of starvation and dehydration. Failure to absorb the fat-soluble vitamins A, D, and K causes a
corresponding avitaminosis. (Brunner, pp. 1034-1035)

77. Hemorrhoids are classified as one of two types. Those above the internal sphincter are called internal
hemorrhoids, and those appearing outside the external sphincter are called external hemorrhoids. Aling Elsa, a
forty three year old female patient, reports that she has hemorrhoids and that it is causing her so much discomfort. Which
of the following statements made by Nurse Eadji needs to be corrected?
A. ―You should avoid straining during defecation.‖
B. ―The discomfort can be relieved by good personal hygiene.‖
C. You should shift to a low residue diet with increased fluid intake.‖
D. ―Warm compresses, sitz baths, and bed rest reduce engorgement.‖

RATIONALE:
Hemorrhoid symptoms and discomfort can be relieved by good personal hygiene and by avoiding excessive straining during
defecation. A high-residue diet that contains fruit and bran along with an increased fluid intake may be all the treatment that is
necessary to promote the passage of soft, bulky stools to prevent straining. If this treatment is not successful, the addition of
hydrophilic bulk-forming agents such as psyllium and mucilloid may help. Warm compresses, sitz baths, analgesic ointments and
suppositories, astringents (eg, witch hazel), and bed rest allow the engorgement to subside. (Brunner, pp. 1067)

78. Viral hepatitis is a systemic, viral infection in which necrosis and inflammation of liver cells produce a
characteristic cluster of clinical, biochemical, and cellular changes. To date, five definitive types of viral hepatitis
have been identified: hepatitis A, B, C, D, and E. A client is suspected of having hepatitis. Which diagnostic test results
will assist in confirming this diagnosis?
A. Decreased erythrocyte sedimentation rate
B. Elevated serum bilirubin
C. Elevated hemoglobin
D. Elevated blood urea nitrogen

RATIONALE:
Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated ESR, and leucopenia.
An elevated NUM may indicate renal dysfunction. A hemoglobin is unrelated to this diagnosis. (Saunders, pp. 704)

Bilirubin is a pigment derived from the breakdown of hemoglobin by cells of the reticuloendothelial system, including the Kupffer cells of
the liver. Hepatocytes remove bilirubin from the blood and chemically modify it through conjugation to glucuronic acid, which makes the
bilirubin more soluble in aqueous solutions. The conjugated bilirubin is secreted by the hepatocytes into the adjacent bile canaliculi and
is eventually carried in the bile into the duodenum. The bilirubin concentration in the blood may be increased in the presence of liver
disease, when the flow of bile is impeded (ie, with gallstones in the bile ducts), or with excessive destruction of red blood cells. With bile
duct obstruction, bilirubin does not enter the intestine; as a consequence, urobilinogen is absent from the urine and decreased in the
stool (Brunner, pp. 1077)

79. The patient is usually managed at home unless symptoms are severe. Therefore, the nurse assists the patient
and family in coping with the temporary disability and fatigue that are common in hepatitis and instructs them to
seek additional health care if the symptoms worsen. The client is admitted to the hospital with viral hepatitis,
complaining of ―no appetite‖ and ―losing my taste for food.‖ To provide adequate nutrition, the nurse would instruct the
client to:
A. Eat a good supper hen anorexia is not as severe.
B. Eat less often, preferably only three large meals daily.
C. Increase intake of fluids including juices
D. Select foods high fats

RATIONALE:
OPTION C: An adequate fluid intake of 2500 to 3000 mL per day that includes nutritional juices is important
OPTION A: Frequently, appetite is better in the morning, so it is easier to eat a good breakfast
OPTION B: Small frequent meals are preferable and may even prevent nausea.
OPTION D: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a diet with
low-fat content because fat may be tolerated poorly because of decreased bile production (Saunders, pp. 709)

80. During Liver biopsy, a needle is inserted through the abdominal wall to the liver to obtain a tissue sample for
biopsy and microscopic examination. The client with hepatitis is scheduled for a liver biopsy. The nurse implements
which of the following to assess for the most common symptom of bile peritonitis following the liver biopsy?
A. Monitoring for bloody diarrhea
B. Assessing for rebound tenderness
C. Assessing for increased flatulence
D. Monitoring for abdominal pain

RATIONALE:
OPTION D: Abdominal pain is the most common symptom of peritonitis.
OPTION A: Bloody diarrhea is a major symptom of ulcerative colitis
OPTION B: Although tenderness over the involved area is a universal sign, rebound tenderness is most often associated with
appendicitis
OPTION C: Increased flatulence commonly occurs with irritable bowel syndrome

 Liver biopsy is the removal of a small amount of liver tissue, usually through needle aspiration. It permits examination of liver
cells. The most common indication is to evaluate diffuse disorders of the parenchyma and to diagnose space-occupying
lesions. Liver biopsy is especially useful when clinical findings and laboratory tests are not diagnostic. Bleeding and bile
peritonitis after liver biopsy are the major complications; therefore, coagulation studies are obtained, their values are noted,
and abnormal results are treated before liver biopsy is performed.

POSTPROCEDURE
a. Immediately after the biopsy, assist the patient to turn onto the right side; place a pillow under the costal margin, and caution the
patient to remain in this position, recumbent and immobile, for several hours. Instruct the patient to avoid coughing or straining.
(In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile
through the perforation is prevented).
b. Measure and record the patient‘s pulse, respiratory rate, and blood pressure at 10- to 15-minute intervals for the first hour, then
every 30 minutes for the next 1 to 2 hours or until the patient‘s condition stabilizes.(Changes in vital signs may indicate bleeding,
severe hemorrhage, or bile peritonitis, the most frequent complications of liver biopsy).
c. If the patient is discharged after the procedure, instruct the patient to avoid heavy lifting and strenuous activity for 1 week.
(Activity restriction reduces the risk of bleeding at the biopsy puncture site). (Brunner, pp. 1078-1080)

81. Hepatic dysfunction results from damage to the liver’s parenchymal cells, either directly from primary liver
diseases or indirectly from obstruction of bile flow or derangements of hepatic circulation. The nurse is reviewing
the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. To
assess for the presence of this sign, the nurse would do which of the following?
A. Instruct the client to lean forward
B. Measure the abdominal girth
C. Ask the client to extend the arms
D. Assess for the presence of Homan‘s sign

RATIONALE:
Asterixis is the irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms
down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing.

Ammonia accumulates because damaged liver cells fail to detoxify and convert to urea the ammonia that is constantly entering the
bloodstream. Ammonia enters the bloodstream as a result of its absorption from the GI tract and its liberation from kidney and muscle
cells. The increased ammonia concentration in the blood causes brain dysfunction and damage, resulting in hepatic encephalopathy.

Clinical manifestations:
The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The patient appears slightly
confused, has alterations in mood, becomes unkempt, and has altered sleep patterns. The patient tends to sleep during the day and
have restlessness and insomnia at night. As hepatic encephalopathy progresses, the patient may be difficult to awaken. Asterixis
(flapping tremor of the hands) may occur. Simple tasks, such as handwriting, become difficult. A handwriting or drawing sample (eg,
star figure), taken daily, may provide graphic evidence of progression or reversal of hepatic encephalopathy. Inability to reproduce a
simple figure is referred to as constructional apraxia. In the early stages of hepatic encephalopathy, the deep tendon reflexes are
hyperactive; with worsening of hepatic encephalopathy, these reflexes disappear and the extremities may become flaccid (Brunner,
pp.1091).

82. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen
is small, the appendix is prone to obstruction and is particularly vulnerable to infection. The nurse is monitoring a
client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client
begins to complain increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is
distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
A. Administer the prescribed pain medications
B. Notify the physician
C. Call and ask the operating room team to perform the surgery as soon as possible
D. Reposition the client and apply a heating pad on warm setting to the client‘s abdomen

RATIONALE:
Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the physician.
Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of the client with
suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would
perform the surgery earlier than the prescribed time.

Medical Management:
Surgery is indicated if appendicitis is diagnosed. To correct or prevent fluid and electrolyte imbalance and dehydration, antibiotics and
intravenous fluids are administered until surgery is performed. Analgesics can be administered after the diagnosis is made.
Appendectomy (ie, surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. It may be
performed under a general or spinal anesthetic with a low abdominal incision or by laparoscopy.

Nursing Management:
Goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection from the potential or actual
disruption of the GI tract, maintaining skin integrity, and attaining optimal nutrition. The nurse prepares the patient for surgery, which
includes an intravenous infusion to replace fluid loss and promote adequate renal function and antibiotic therapy to prevent infection. If
there is evidence or likelihood of paralytic ileus, a nasogastric tube is inserted. An enema is not administered because it can lead to
perforation. After surgery, the nurse places the patient in a semi-Fowler position. This position reduces the tension on the incision and
abdominal organs, helping to reduce pain. An opioid, usually morphine sulfate, is prescribed to relieve pain. When tolerated, oral fluids
are administered. Any patient who was dehydrated before surgery receives intravenous fluids. Food is provided as desired and
tolerated on the day of surgery (Brunner, pp. 1036-1037)

83. Acute pancreatitis can be a medical emergency associated with a high risk for life-threatening complications and
mortality, whereas chronic pancreatitis often goes undetected until 80% to 90% of the exocrine and endocrine
tissue is destroyed. The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this
client for pain that is:
A. Burning and aching, located in the epigastric area and radiating to the umbilicus
B. Burning and aching, located in the left lower quadrant and radiating to the hip
C. Severe and unrelenting, located in the epigastric area and radiating to the back
D. Severe and unrelenting, located in the left lower quadrant and radiating to the groin.

RATIONALE:
Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Abdominal pain and
tenderness and back pain result from irritation and edema of the inflamed pancreas that stimulate the nerve endings. Increased tension
on the pancreatic capsule and obstruction of the pancreatic ducts also contribute to the pain. Typically, the pain occurs in the
midepigastrium. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion, and it may be
diffuse and difficult to localize. It is generally more severe after meals and is unrelieved by antacids. Pain may be accompanied by
abdominal distention; a poorly defined, palpable abdominal mass; and decreased peristalsis. Pain caused by pancreatitis is
accompanied frequently by vomiting that does not relieve the pain or nausea (Brunner, pp. 1136)

84. Cholecystitis is defined as inflammation of the gallbladder that occurs most commonly because of an
obstruction of the cystic duct from cholelithiasis. Mrs. Krissy, 75 years old complains of severe abdominal pain on
her right upper quadrant. Her temperature is elevated and has a palpable mass on her abdomen. A year ago started to
feel abdominal distention and vague pain in the right upper quadrant of the abdomen whenever she takes a meal rich in
fried or fatty foods. The physician suspects Cholecystitis, to rule this out, you would expect him to order the diagnostic
procedure of choice for this disorder which is:
A. Cholecystography
B. Ultrasonography
C. Endoscopic retrograde cholangiopancreatography
D. Radionuclide imaging or Chholescintigraphy
RATIONALE:
Ultrasonography has replaced cholecystography as the diagnostic procedure of choice because it is rapid and accurate and can be
used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation.

On the other hand, cholescintigraphy is used successfully in the diagnosis of acute cholecystitis or blockage of a bile duct. In this
procedure, a radioactive agent is administered intravenously. It is taken up by the hepatocytes and excreted rapidly through the biliary
tract. The biliary tract is then scanned, and images of the gallbladder and biliary tract are obtained. This test is more expensive than
ultrasonography, takes longer to perform, exposes the patient to radiation, and cannot detect gallstones. It is often used when
ultrasonography is not conclusive.

Finally, Endoscopic retrograde cholangiopancreatography (ERCP) permits direct visualization of structures that previously could be
seen only during laparotomy. The examination of the hepatobiliary system is carried out via a side-viewing flexible fiberoptic endoscope
inserted through the esophagus to the descending duodenum. (Brunner, pp. 1173-1174)

85. Surgical treatment of gallbladder disease and gallstones is carried out to relieve persistent symptoms, to remove
the cause of biliary colic, and to treat acute cholecystitis. Your client will be undergoing surgery for cholecystitis four
days from now. Prior to the procedure you provided dietary instructions to your client to prevent reoccurrence of the
symptoms after the procedure. Which of the following food choice would not endanger your client?
A. Rice, steamed chicken, breast with broccoli
B. Poached egg, nilagang saba and blanched cabbage
C. Lettuce salad in cream and vinegar dressing with mashed potatoes
D. Bread, tea and coffee

RATIONALE:
The diet after an attack should consist only of cooked fruits, rice or tapioca, lean meats, mashed potatoes, non–gas-forming
vegetables, bread, coffee, or tea. The patient should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming
vegetables, and alcohol. It is important to remind the patient that fatty foods may induce an episode of cholecystitis. Gas forming
vegetables can cause a lot of discomfort for the patient especially when it makes the abdomen bloated
OPTION A: Broccoli – gas forming vegetable
OPTION B: Poached egg and cabbage – gas forming
OPTION C: Cream dressing – creams should be avoided (Brunner, pp. 1175)

86. Depression affects feelings, thoughts and behaviors. Treatment includes counseling, antidepressant medication
and electroconvulsive therapy. Eros, a thirty year old patient with depression, was prescribed with Nardil 50mg/ day.
Which of the following statements indicates that Eros needs further teaching regarding his therapy?
A. ―I should be careful when taking over the counter drugs. I‘ll make sure to ask my doctor first.‖
B. ―I will not expect immediate results. The drug will take effect in 2-4 weeks.‖
C. ―I‘m going to have pizza tonight.‖

D. ―I might have insomnia, weight gain, and dry mouth when I take this drug.‖

RATIONALE:
All the other statements are correct. Monoanime Oxidase Inhibitors like Nardil need 2 to 4 weeks for effectiveness. The most common
side effects of MAOIs include daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction.
Prohibitive concurrent use of over-the-counter medications without
physician notification is also a must since many drugs may cause serious interactions with MAOIs.

However, of particular concern with MAOIs is the potential for a life-threatening hypertensive crisis if the client ingests food that
contains tyramine or takes sympathomimetic drugs. Because the enzyme monoamine oxidase is necessary to break down the tyramine
in certain foods, its inhibition results in increased serum tyramine levels, which causes severe hypertension, hyperpyrexia, tachycardia,
diaphoresis, tremulousness, and cardiac dysrhythmias.















(Videbeck, 2004)

87. Antidepressant medications are used in the treatment of dysthymic disorder, major depression with melancholia
or psychotic symptoms, depression associated with organic disease, alcoholism, schizophrenia, or mental
retardation; depressive phase of bipolar disorder and depression accompanied by anxiety. Janjan, a newly
admitted client was prescribed with sertraline (Zoloft) 50 mg PO. Being a knowledgeable nurse, you would know that the
therapeutic action of this medication involves:
A. Blocking the destruction of norepinephrine, epinephrine, dopamine and serotonin by the enzyme monoamine
oxidase.
B. The inhibition of destruction and neuronal uptake of serotonin.
C. Prolonging the action of norepinephrine, dopamine and serotonin to varying degrees.
D. Reducing the release of norepinephrine and increases the uptake of tryptophan.

RATIONALE:
Sertraline (Zoloft)is a Selective Serotonin Reuptake Inhibitor (SSRI). SSRIs act by inhibiting the reuptake of and destruction of
serotonin from the synaptic cleft, thereby prolonging the action of the neurotransmitter. Choice A is the action of MAOIs, Choice C is
the action of TCAs and Choice D is the action of lithium. (Lippincott, pp. 1054)

88. Electroconvulsive therapy (ECT) is the induction of a grand mal (generalized) seizure through the application of
electrical current to the brain. Nurse Goot is preparing his client for ECT. Which of the following actions would suggest
that Nurse Goot does not need further teaching regarding the procedure?
A. In the treatment room, the psychiatrist administers a long-acting epidural anesthetic
B. Atropine sulfate is given eight hours prior before the treatment.
C. The client is oxygenated with pure oxygen during and after the treatment
D. Succinylcholine chloride is given to decrease secretions.

RATIONALE:
Several medications are associated with ECT. A pretreatment medication, such as atropine sulfate or glycopyrrolate (Robinul), is
administered intramuscularly approximately 30 minutes before the treatment. Either of these medications may be ordered to decrease
secretions and counteract the effects of vagal stimulation induced by the ECT.

In the treatment room, the anesthesiologist administers intravenously a short-acting anesthetic, such a thiopental sodium (Pentothal) or
methohexital sodium (Brevital). A muscle relaxant, usually succinylcholine chloride (Anectine), is given intravenously to prevent severe
muscle contractions during the seizure, thereby reducing the possibility of fractured or dislocated bones. Because succinylcholine
paralyzes respiratory muscles as well, the client is oxygenated with pure oxygen during and after the treatment, except for the brief
interval of electrical stimulation, until spontaneous respirations return. (Townsend, pp. 381)

 ECT is an effective treatment for depression that consists of inducing grand mal (tonic-clonic) seizure by passing an electrical
current through electrodes that are attached to the temples.
 The usual course is 6-12 treatments given to 2-3 times per week.
 Indications for use: clients with major depressive and bipolar depressive disorders especially when psychotic symptoms are
present such as delusions of guilt, somatic delusions and delusions of infidelity; clients who have depression with significant
psychomotor retardation and stupor; manic clients whose conditions are resistant to lithium and antipsychotic medications and
in clients who are rapid cyclers (a clent with a bipolar disorder who has many episodes of mood swings close together); clients
with Schizophrenia (especially catatonia), those with schizoaffective syndromes, and psychotic clients. (Saunders, pp. 1114)

89. A Group Therapy is a form of psychosocial treatment in which a number of clients meet together with a therapist
for purposes of sharing, gaining personal insight, and improving interpersonal coping strategies. Nurse Yara
wants to help organize a group therapy session for patients with post-traumatic stress syndrome at Tsui‘s Center for
Mental Health. The group therapy will last for twenty weeks. When planning, Nurse Yara considers the physical conditions
that influence group dynamics. Which of the following decision made by the nurse is incorrect?
A. Since the patients have a similar concern, Nurse Yara will organize an open-ended group.
B. She arranges the chairs in a circle instead of setting the chairs around a table to promote openness.
C. She plans to have the members of the group sit in a different chair each meeting.
D. She is aware that fifteen is the maximum number of patients to be included in a group therapy session.


RATIONALE:
 Nurse Yara should organize a closed-ended group because the patients have a similar concern.

PHYSICAL CONDITIONS THAT INFLUENCE GROUP DYNAMICS

MEMBERSHIP
Whether the group is open or closed-ended is another condition that influences the dynamics of group process. Open-ended groups
are those in which members leave and others join at any time while the group is active. The continuous movement of members in and
out of the group creates the type of discomfort described previously that encourages unsettled behaviors
in individual members and fosters the exploration of feelings. These are the most common types of groups held on short-term inpatient
units, although they are used in outpatient and long-term care facilities as well. Closed-ended groups usually have a predetermined,
fixed time frame. All members join at the time the group is organized and terminate at the end of the designated time period. Closed-
ended groups are often composed of individuals with common issues or problems they wish to address.

SEATING
The physical conditions for the group should be set up so that there is no barrier between the members. For example, a circle of chairs
is better than chairs set around a table. Members should be encouraged to sit in different chairs each meeting. This openness and
change creates an uncomfortableness that encourages anxious and unsettled behaviors that can then be explored within the group.

SIZE
Various authors have suggested different ranges of size as ideal for group interaction: 5 to 10 (Yalom & Leszcz, 2005), 2 to 15
(Sampson & Marthas, 1990), and 4 to 12 (Clark, 2003). Group size does make a difference. The larger the group, the less time is
available to devote to individual members. In fact, in larger groups, those more aggressive individuals are most likely to be heard,
whereas quieter members may be left out of the discussions altogether. On the other hand, larger groups provide more opportunities
for individuals to learn from other members. The wider range of life experiences and knowledge provides a greater potential for
effective group problem-solving. Studies have indicated that a composition of seven or eight members provides a favorable climate for
optimal group interaction and relationship development (Townsend, pp. 169-170)

90. Leaders of group therapy generally have advanced degrees in psychology, social work, nursing, or medicine.
Approaches based on theories are used by the group therapy leaders to encourage improvement in the ability of
group members to function on an interpersonal level. Jai, a depressed client who has been unkempt and untidy for
weeks, today comes to group therapy wearing make-up and a clean dress and having washed and combed her hair.
Which of the following responses by the nurse is most appropriate?
A. ―‖Jai, you look wonderful today! ―
B. ―Jai, I see you have put on a clean dress and combed your hair.‖
C. ―Now that you see how important it is, I hope you will do this everyday.‖
D. ―Jai, I‘m sure everyone will appreciate that you have cleaned up for the group today.‖

RATIONALE:
OPTION B: TheraComm: GIVING RECOGNITION - Acknowledging; indicating awareness; better than complimenting, which reflects
the nurse‘s judgment
OPTION A: NonThera: MAKING STEREOTYPED COMMENTS – Clichés and trite expressions are meaningless in a nurse-client
relationship. When the nurse makes empty conversation, it encourages a like response from the client.
OPTION C: NonThera: Assuming
OPTIOND : NonThera: GIVING REASSURANCE – Indicating to the client that there is no cause for anxiety, thereby devaluating the
client‘s feelings; may discourage the client from further expression of feelings if he or she believes they will only be downplayed or
ridiculed (Townsend, pp. 120-122)

91. Yalom and Leszcz describe 11 curative factors that individuals can achieve through interpersonal interactions
within the group, some of which are present in most groups in varying degrees. After taking part in a therapeutic
group, Marcus tells his nurse, ―Wow. I guess I‘m not the only one who fears rejection. There are many others who have
the same problems and feelings as me.‖ Which of these curative factors describe Marcus‘ realization?
A. Instillation of hope
B. Universality
C. Existential factors
D. Catharsis

RATIONALE:
Why are therapeutic groups helpful? Yalom & Leszcz (2005) describe 11 curative factors that individuals can achieve through
interpersonal interactions within the group, some of which are present in most groups in varying degrees:

1. Instillation of hope By observing the progress of others in the group with similar problems, a group
member garners hope that his or her problems can also be resolved.
2. Universality Individuals come to realize that they are not alone in the problems, thoughts, and
feelings they are experiencing. Anxiety is relieved by the support and
understanding of others in the group who share similar (universal) experiences.
3. Imparting of information Knowledge is gained through formal instruction as well as the sharing of advice
and suggestions among group members.
4. Altruism Altruism is assimilated by group members through mutual sharing and concern
for each other. Providing assistance and support to others creates a positive self-
image and promotes self growth.
5. Corrective recapitulation of
the primary family group
Group members are able to reexperience early family conflicts that remain
unresolved. Attempts at resolution are promoted through feedback and
exploration.
6. Development of socializing
techniques
Through interaction with and feedback from other members within the group,
individuals are able to correct maladaptive social behaviors and learn and
develop new social skills.
7. Imitative behavior In this setting, one who has mastered a particular psychosocial skill or
developmental task can be a valuable role model for others. Individuals may
imitate selected behaviors that they wish to develop in themselves.
8. Interpersonal learning The group offers many and varied opportunities for interacting with other people.
Insight is gained regarding how one perceives and is being perceived by others.
9. Group cohesiveness Members develop a sense of belonging that separates the individual (―I am‖) from
the group (―we are‖). Out of this alliance emerges a common feeling that both
individual members and the total group are of value to each other.
10. Catharsis Within the group, members are able to express both positive and negative
feelings— perhaps feelings that have never been expressed before—in a
nonthreatening atmosphere. This catharsis, or open expression of feelings, is
beneficial for the individual within the group.
11. Existential factors The group is able to help individual members take direction of their own lives and
to accept responsibility for the quality of their existence. It may be helpful for a
group leader to explain these curative factors to members of the group. Positive
responses are experienced by individuals who understand and are able to
recognize curative factors as they occur within the group.
(Townsend, pp. 169-170)

92. Freud organized the structure of the personality into three major components: the id, ego, and superego. They
are distinguished by their unique functions and different characteristic. Nurse Alden is taking care of Kristoff, a 26
year old male patient admitted for multiple fractures caused by a motor vehicle accident. Spencer says to the nurse, ―So
what if I drag race? I don‘t care what everyone else thinks. My motto in life is ‗you only live once‘. That‘s why I do
whatever makes me happy.‖ Which of the following describes the psychoanalytical structure of Kristoff‘s personality?
A. Strong id, weak ego, punitive superego
B. Strong id, weak ego, weak superego
C. Weak id, weak ego, punitive superego
D. Weak id, strong ego, weak superego

RATIONALE:

ID
The id is the locus of instinctual drives—the ―pleasure principle.‖ Present at birth, it endows the
infant with instinctual drives that seek to satisfy needs and achieve immediate gratification. Id-
driven behaviors are impulsive and may be irrational.
EGO
The ego, also called the rational self or the ―reality principle,‖ begins to develop between the
ages of 4 and 6 months. The ego experiences the reality of the external world, adapts to it, and
responds to it. As the ego develops and gains strength, it seeks to bring the influences of the
external world to bear upon the id, to substitute the reality principle for the pleasure principle
(Marmer, 2003). A primary function of the ego is one of mediator, that is, to maintain harmony
among the external world, the id, and the superego.
SUPEREGO
If the id is identified as the pleasure principle, and the ego the reality principle, the superego
might be referred to as the ―perfection principle.‖ The superego, which develops between ages 3
and 6 years, internalizes the values and morals set forth by primary caregivers. Derived from a
system of rewards and punishments, the superego is composed of two major components: the
ego-ideal and the conscience. When a child is consistently rewarded for ―good‖ behavior, the
self-esteem is enhanced, and the behavior becomes part of the ego-ideal; that is, it is
internalized as part of his or her value system. The conscience is formed when the child is
consistently punished for ―bad‖ behavior. The child learns what is considered morally right or
wrong from feedback received from parental figures and from society or culture. When moral
and ethical principles or even internalized ideals and values are disregarded, the conscience
generates a feeling of guilt within the individual. The superego is important in the socialization of
the individual because it assists the ego in the control of id impulses. When the superego
becomes rigid and punitive, however, problems with low self-confidence and low self-esteem
arise.
(Townsend, pp. 18)

93. Sullivan described six stages of personality development. He believed that individual behavior and personality
development are the direct result of interpersonal relationships. Bhabha Jhay verbalizes that although he is already
26 years old, he still lives with his parents. He is still weighing the pros and cons of moving out and being on his own.
―Actually, after college, I felt lost. I don‘t even know what career path to take,‖ he reports. Bhabha Jhay is also single, is
not seeing anyone, and has not been in any serious relationships since birth. In what stage of development is Bhabha
Jhay fixed according to Sullivan‘s interpersonal theory?
A. Late adolescence because he is working to develop a lasting relationship.
B. Early adolescence because he is struggling to form an identity.
C. Juvenile because he is learning to form satisfactory peer relationships.
D. Childhood because he has not learned to delay gratification.

RATIONALE:

Sullivan’s Stages of Personality
AGE STAGE MAJOR DEVELOPMENTAL TASK
Birth – 18 months Infancy Relief from anxiety through oral gratification of needs
18 months – 6 years Childhood Learning to experience a delay in personal gratification without
undue anxiety
6–9 years Juvenile Learning to form satisfactory peer relationships
9–12 years Preadolescence Learning to form satisfactory relationships with persons
of same gender initiating feelings of affection for another
person
12–14 years Early
adolescence
Learning to form satisfactory relationships with persons of the
opposite gender; developing a sense of identity
14–21 years Late
adolescence
Establishing self-identity; experiencing satisfying relationships;
working to develop a lasting, intimate opposite gender
relationship
(Townsend, pp. 20)

94. Ego defense mechanisms become maladaptive when an individual uses them to such a degree that there is
interference with the ability to deal with reality, with interpersonal relations, or with occupational performance.
Kanye told Nurse Keri his story on how he became a physical therapist. According to him, when he was still a teenager,
he required lengthy rehabilitation after an accident, as a result of his experience he pursued physical therapy. Kanye‘s
action is an example of which defense mechanism?
A. Introjection
B. Identification
C. Undoing
D. Intellectualization

RATIONALE:

COMPENSATION
Covering up a real or perceived
weakness by emphasizing a trait
one considers more desirable
ISOLATION
Separating a thought or memory
from the feeling tone or emotion
associated with it
DENIAL
Refusing to acknowledge the
existence of a real situation or the
feelings associated with it
PROJECTION
Attributing feelings or impulses
unacceptable to one‘s self to
another person
DISPLACEMENT
The transfer of feelings from one
target to another that is
considered less threatening or
that is neutral
RATIONALIZATION
Attributing feelings or impulses
unacceptable to one‘s self to
another person
IDENTIFICATION
An attempt to increase selfworth
by acquiring certain attributes and
characteristics of an individual
one admires
REACTION FORMATION
Preventing unacceptable or
undesirable thoughts or behaviors
from being expressed by
exaggerating
opposite thoughts or types of
behaviors
INTELLECTUALIZATION
An attempt to avoid expressing
actual emotions associated with a
stressful situation by using the
intellectual processes of logic,
reasoning, and analysis
REGRESSION
Responding to stress by retreating
to an earlier level of development
and the comfort measures
associated with that level of
functioning
INTROJECTION
Integrating the beliefs and values
of another individual into one‘s
own ego structure
REPRESSION
Involuntarily blocking unpleasant
feelings and experiences from
one‘s awareness
SUBLIMATION
Rechanneling of drives or
impulses that are personally or
socially unacceptable into
activities that are constructive
SUPPRESSION
The voluntary blocking of
unpleasant feelings and
experiences from one‘s
awareness
UNDOING
Symbolically negating or
canceling out an experience that
one finds intolerable

(Townsend, pp. 8-9)

95. Cognitive therapy is a type of therapy in which the individual is taught to control thought distortions that are
considered to be a factor in the development and maintenance of emotional disorders. Jelai is a 16-year old high
school senior who is very active in school, has good grades and is the vice president of the student council. However,
when her boyfriend broke up with her, she stopped going out with her friends and participating in student council
activities, had lost weight and her grades have fallen. She would often just lock herself in her room and cry until she falls
asleep. She once said to her mother ―Why would he break up with me? I hate myself! I just want to die!‖ While still in the
psychiatric unit, Jelai was scheduled for cognitive therapy. The goal of cognitive therapy with depressed client is to:
A. Provide feedback from peers who are having similar experiences.
B. Resolve the symptoms and initiate or restore adaptive family functioning.
C. Identify and change dysfunctional patterns of thinking.
D. Alter the neurotransmitters that are creating the depressed mood.

RATIONALE:
 In cognitive therapy, the individual is taught to control thought distortions that are considered to be a factor in the development
and maintenance of mood disorders. In the cognitive model, depression is characterized by a triad of negative distortions
related to expectations of the environment, self, and future. The environment and activities within it are viewed as unsatisfying,
the self is unrealistically devalued, and the future is perceived as hopeless.
 The general goals in cognitive therapy are to obtain symptom relief as quickly as possible, to assist the client in identifying
dysfunctional patterns of thinking and behaving, and to guide the client to evidence and logic that effectively tests the validity
of the dysfunctional thinking.
 Choice A is for Group Therapy, Choice B is for Family Therapy and Choice D is for Psychopharmacology.(Townsend, pp. 379)

96. A milieu therapy is the scientific structuring of the environment in order to effect behavioral changes and to
improve the psychological health and functioning of the individual. John tells the nurse, ―I think lights out at 10
o‘clock on a weekend is stupid. We should be able to watch TV until midnight!‖ Which of the following is the most
appropriate response from the nurse on the milieu unit?
A. ―John, you were told the rules when you were admitted.‖
B. ―You may bring it up before the others at the community meeting, John.‖
C. ―Some people want to go to bed early, John.‖
D. ―You are not the only person on this unit, John. You must think of the others.‖

RATIONALE:

BASIC ASSUMPTIONS
Skinner (1979) outlined seven basic assumptions on which a therapeutic community is based:

1. The health in each individual is to be realized and encouraged to grow: All individuals are considered to have strengths as well
as limitations. These healthy aspects of the individual are identified and serve as a foundation for growth in the personality and in the
ability to function more adaptively and productively in all aspects of life.

2. Every interaction is an opportunity for therapeutic intervention: Within this structured setting, is virtually impossible to avoid
interpersonal interaction. The ideal situation exists for clients to improve communication and relationship development skills. Learning
occurs from immediate feedback of personal perceptions.

3. The client owns his or her own environment: Clients make decisions and solve problems related to government of the unit. In this
way, personal needs for autonomy as well as needs that pertain to the group as a whole are fulfilled.

4. Each client owns his or her behavior: Each individual within the therapeutic community is expected to take responsibility for his or
her own behavior.

5. Peer pressure is a useful and a powerful tool: Behavioral group norms are established through peer pressure. Feedback is direct
and frequent, so that behaving in a manner acceptable to the other members of the community becomes essential.

6. Inappropriate behaviors are dealt with as they occur: Individuals examine the significance of their behavior, look at how it affects
other people, and discuss more appropriate ways of behaving in certain situations.

7. Restrictions and punishment are to be avoided: Destructive behaviors can usually be controlled with group discussion. However,
if an individual requires external controls, temporary isolation is preferred over lengthy restriction or other harsh punishment.
(Townsend, pp. 158-159)

97. In 1991, Hildegard Peplau introduced the term Psychodynamic Nursing and established a framework for it. Which of the
following accurately describes the focus of psychodynamic nursing?
A. The interpersonal involvement between the nurse and the client.
B. Identification of the needs that motivate and drive people.
C. The importance of the client as the key to the healing process.
D. The identification of ―irrational beliefs‖ that people use to make themselves unhappy.

RATIONALE:
Peplau (1991) applied interpersonal theory to nursing practice and, most specifically, to nurse-client relationship development. She
established a framework for psychodynamic nursing, the interpersonal involvement of the nurse with a client in a given nursing
situation. Peplau stated, ―Nursing is helpful when both the patient and the nurse grow as a result of the learning that occurs in the
nursing situation.‖ Peplau correlated the stages of personality development in childhood to stages through which clients advance during
the progression of an illness. She also viewed these interpersonal experiences as learning situations for nurses to facilitate forward
movement in the development of personality. She believed that when there is fulfillment of psychological tasks associated with the
nurse-client relationship, the personalities of both can be strengthened.
Choice B is for Maslow‘s Hierarchy of Needs, Choice C is for Rogers‘s Client-centered Therapy and Choice D is for Rational Emotive
therapy. (Townsend, pp. 26)

98. Hildegard Peplau provided a framework for “psychodynamic nursing,” the interpersonal involvement of the
nurse with a client in a given nursing situation. Nurse Bella clarifies with her client, Tonio, the roles that they will play
in their therapeutic relationship. In which stage of the Nurse-Client relationship according to Peplau are they in?
A. Orientation
B. Identification
C. Exploitation
D. Resolution

RATIONALE:

Stage Tasks
Orientation Patient‘s problems and needs are clarified.
Patient asks questions.
Hospital routines and expectations are explained.
Patient harnesses energy toward meeting problems.
Patient‘s full participation is elicited.
Identification Patient responds to persons he or she perceives as helpful.
Patient feels stronger.
Patient expresses feelings.
Interdependent work with the nurse occurs.
Roles of both patient and nurse are clarified.
Exploitation Patient makes full use of available services.
Goals such as going home and returning to work emerge.
Patient‘s behaviors fluctuate between dependence and independence.
Resolution Patient gives up dependent behavior.
Services are no longer needed by patient.
Patient assumes power to meet own needs, set new goals, and so forth.
(Videbeck 2011, p. 50-51)

99. Erikson described eight stages of the life cycle from birth to death. He believed that individuals struggled with
developmental “crises” and that each must be resolved for emotional growth to occur. The mother of Tina, 2 ½
years old, always does everything for her child. She tells Nurse Maya that, ―My little girl is still a baby, and she needs her
mommy to do everything for her. I don‘t want her to get dirty, so I spoon-feed her and all. That‘s what mommy‘s for,
right?‖ Nurse Maya tells her that:
A. ―That‘s right ma‘am, keep it up.‖
B. ―You‘re spoiling her. You‘re raising a brat in the future.‖
C. ―I can see that you care a lot or your child. But allowing her to do some things on her own could help develop her
virtue of will.‖
D. ―I can see that you care a lot or your child. But allowing her to do some things on her own could help develop her
virtue of purpose.‖

RATIONALE:
Stages of Development in Erikson‘s Psychosocial Theory
Infancy(Birth–18 months)Trust vs. mistrust -TRUST
Early childhood(18 months–3 years)Autonomy vs. shame and doubt –WILL
Late childhood(3–6 years)Initiative vs. guilt -PURPOSE
School age(6–12 years)Industry vs. inferiority –COMPETENCE
Adolescence(12–20 years)Identity vs. role confusion –FIDELITY
Young adulthood(20–30 years)Intimacy vs. isolation –LOVE
Adulthood(30–65 years)Generativity vs. stagnation –CARE
Old age(65 years–death)Ego integrity vs. despair –WISDOM
(Videbeck 2011,p.48)

100. Knowledge regarding the different developmental stages is important because it influences how the nurse
would interact with the patients. Jansen, 28 years old, often takes the liability for situations that he is not responsible
for. He does this because he feels inadequate and defeated even if he did his best on the work assigned to him. He did
not resolve the task in what psychosocial stage?
A. Trust vs. Mistrust
B. Autonomy vs. shame and doubt
C. Initiative vs. Guilt
D. Identity vs. role confusion

RATIONALE:
A. Nonachievement results in emotional dissatisfaction with the self and others, suspiciousness, and difficulty with
interpersonal relationships.
B. Nonachievement results in a lack of self-confidence, a lack of pride in the ability to perform, a sense of being
controlled by others, and a rage against the self.
C. Nonachievement results in feelings of inadequacy and a sense of defeat. Guilt is experienced to an excessive
degree, even to the point of accepting liability in situations for which one is not responsible.
D. Nonachievement results in a sense of self-consciousness, doubt, and confusion about one‘s role in life. Personal
values or goals for one‘s life are absent.(Townsend 2011,p.22-24)