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FORMATIVE 1

MAY NLE 2014


1.

The first step in a job search is to prepare a resume. A resume is a step toward getting an interview. It organizes your thinking and shows
how your past experiences support your objectives. Rocky, a newly registered nurse, is busy preparing her resume and is getting ready to apply for
a job at BCMC. Rocky is aware of her too-many competition in the field, and therefore strives to make an impression through her resume. In preparing
for the resume, Rocky is precise not to execute which of the following?
A. Print the resume in an off white paper.
B. Begin sentences with action verbs and makes sure that the resume is completely error free.
C. Write down accomplishments in a very detailed manner.
D. Exclude religious affiliation and health status as data in the resume.

RATIONALE:
The resume represents the professionalism of the applicant and recruiters use it to summarize an applicants qualifications. It must be professionally
prepared, make an impression, and quickly capture the readers attention. The following are general guidelines in resume preparation:
Typed in a single font format that is easy to read.
Maximize strong points and minimize weaknesses. Put those strong points where they are most likely to be read.
Reflect good grammar, correct punctuation, and proper sentence structure.
High-quality, white, or off-white paper should be used to print the resume (OPTION A)
Strive to be concise and clear. The purpose of the resume is to get an interview, not a job, so it is not necessary to go into every detail
of accomplishments. (OPTION C)
Use bulleted sentences rather than lengthy paragraphs. A resume is typically reviewed in just 15- 30 seconds. Bullets make it easier for someone
to quickly scan a resume and still absorb it.
Use font size no smaller than 10 point.
Limit the length of resume to 1- 2 pages.
(Leadership Roles and Management Functions in Nursing by Marquis, 2008, pg 255)
ESSENTIAL ELEMENTS OF A GOOD RESUME:
1. Your contact and personal information. Name appears at the top of your resume and that it is written in a larger font than the rest of your
resume. It should also include a way for employers to contact you through phone and/or email.
2. Career objective or goal. Optional; specific; keep it short, no more than three or four lines; explain your career goals, expertise, and main
strengths; tailored to the specific role or position you are seeking to obtain.
3. Education and training. Always begin with your most recent education. Include the name of the university or college you attended along with the
degree title. If you have any special certifications, you can include them here.
4. Work Experience. Include the dates of employment along with your job title and the name of the company you worked for. The most common
way to present this information is chronologically, although some situations call for the use of the functional style where achievements are listed
first. Sometimes, a combination of the two styles are used.
5. Additional Information. Any foreign languages; any specialized skills.
6. Other Considerations
Limit the use of personal pronouns such as "I. Begin sentences with action verbs (CHOICE B). Be honest but avoid writing anything negative in
your resume.
Well-Written. No spelling or grammatical mistakes; clear and concise. Have someone proofread your resume (CHOICE B). Use a simple, easy
to read font style, 10-14 point. Use high quality paper.
Proper Length. 1 2 pages. 1 page for entry level candidates and those with 5 years of experience or less. 2 page resumes - over ten years of
experience.
Attractive. Typed and professional in appearance.
Relevant. Include only information having to do with the job you are seeking or your career goals.
Personalized
Appropriate. Information and format must conform to the employer expectations.
Balanced. Include only data that will help you get an interview. Eliminate any information that may not act in your favor such as age, religious
affiliation, etc. Always ask your-self the question, Will this bit of data help get an interview? If not, do not use it. (CHOICE D)
Reference:
https://www.tcc.edu/students/career/resumes/pic_of_you.htm
http://www.washington.edu/doit/Careers/resume_key.html
2.

Cover letters should always be used when submitting a resume. Their purpose is to introduce the applicant, briefly highlight key points of
the resume, and make a positive first impression. Rocky has finished making a resume and proceeds to making a cover letter. She understands
that it can reveal her level of professionalism and consequently incorporates which of the following guidelines to her cover letter?
A. Prefers to use her natural writing style in creating the letter.
B. Includes only what position to apply for in the body of the cover letter.
C. Signs her name using a black ink pen
D. Avoids a business format in accomplishing the cover letter

RATIONALE:
Qualities of an Effective Cover Letter:

Brief, neat, without errors


In business format (Option D)
Name and title of person to whom the letter is addressed
Why interested and what position would like to apply for (Option B)
Express appreciation for consideration and eagerness to be part of team
How can be reached (telephone number)
Use 9- by 12-inch envelope to send rsum and cover letter (first-class mail)
Expect response to letter in 2 weeks. If not, call after 3 weeks; check with Human Resources
Use positive language and write in your natural writing style. This way they can get clues about your personality. (Option A)
In signing the letter, blue ink is preferred. (Option C)
(Leadership and Management by Jones, 2007, pg 383)
3.

Leadership is not necessarily tied to a position of authority and that each of us has the potential. Leadership involves influencing other
people to work toward the achievement of the groups goals. Leaders can be broadly classified into two kinds: formal and informal leaders.
Nurse Loki was the newly appointed by the management to act as the leader of the Medical Surgical Unit of Townsville Medical Center. As the
appointed leader of the unit, he is fully aware that the following are his advantages, aside from:
A. Nurse Loki has greater commitment to the group rather than the organization.
B. Nurse Loki has the authority to castigate errant behaviors.
C. Nurse Loki organizes available resources and work out logistics.
D. Nurse Loki can express more power over the other members of the group.

RATIONALE:
**Since Nurse Loki was appointed by the organization, he is considered as a FORMAL Leader.
Option A - The informal leader has greater commitment to the group, while the formal leaders commitment lies with the organization.
Option B and D - Formal leaders, one appointed by the organization, have the power and authority to discipline and punish members with undesirable
behavior; and reward them for good behavior.
Option C Formal leaders organize available resources, work out logistics and motivate members. Informal leaders rely on open communication, a shared
vision, guidance and charisma.
FORMAL LEADERSHIP

INFORMAL LEADERSHIP

Officially designated/ assigned as leader.


Organize the available resources, work out
logistics and motivate members.

Members look to him for motivation and inspiration;


recognized as leader by peers.

Has authority, power, certain rights


privileges. (e.g. rewards and discipline)

LACK authority and power over the members; relies


on open communication and charisma

Greater commitment to the organization


4.

NOT officially appointed as leader

and

Greater commitment to the group

The purpose of staffing activities is to provide each nursing unit with an appropriate and acceptable number of workers in each category to
perform the nursing tasks required. Objectives of nurse staffing are excellent care and high productivity. Nurse Joaquin is studying the
several kinds of staffing systems to prepare himself for the position of a nurse manager. While reviewing the staffing systems, he is certain that
which statement holds true about centralized staffing?
A. It is a system in which individual problems are always taken into consideration.
B. Centralized staffing offers a comprehensive overview of a facility while offering individualization for unit and staff members.
C. There is loose management control over the entire scheduling and staffing system.
D. It uses cyclical scheduling.

RATIONALE:
Staffing systems can be centralized, decentralized, or mixed.
A. Centralized staffing - uses cyclical scheduling in which work days and time off for personnel are repeated in regular cycles, such as every 2, 4,
or 6 weeks. Centralized staffing involves a system whereby a master plan is developed by the top level of the organization (Chief Nurse) in a
centralized location, frequently the central nursing office. This system offers the opportunity to oversee the entire organizations nursing services
activities.
B. Decentralized staffing - is a unit-based plan with corresponding schedules managed by the unit nurse manager.
C. Mixed staffing - combines centralized and decentralized to offer a comprehensive overview of a facility while offering individualization for unit and
staff members.
Option A- A disadvantage of centralized system is that individual considerations are minimized
Option B- mixed staffing
Option C- rather than LOOSE, it has closer control of the entire scheduling and staffing system.
(Nursing Leadership and Management by Jones, 2007, pg 287- 288)

5.

The staffing and scheduling process incorporates professional nursing standards and accounts for the health-care setting, the care delivery
method, patient acuity, and the nursing staff. The Chief Nurse of San Lazarus Medical hospital is preparing to make a 4-week schedule for the OR
unit. He is thoroughly reviewing the past schedule of the OR unit for flaws he should not repeat. Taking into consideration the many factors in making
schedules, the Chief Nurse will not incorporate which of the following to the new schedule, except?
A. Assigning Nurse Liam with afternoon shifts after an ample of night shifts.
B. Assigning Nurse Louis to work 1 week straight on the PM shift.
C. Assigning Nurse Zayn from the family training unit to relieve for an absent staff.
D. Assigning more staff in the afternoon shift than in morning and night shifts.

RATIONALE:
Nurses should be granted rotating work shifts. It is desirable that there be equal share of morning, afternoon, and night shifts as prolonged night shifts may
affect the health of the personnel. Although rotation from night to afternoon or morning shifts may be quite stressful, adequate rest is provided before the
rotation since it is inadvisable for nurses to stay in long periods of night shifts.
Option B- Long stretches of consecutive working days should be avoided as much as possible because it might affect the health of the nursing
personnel. It is advisable that work days are not more than 4-5 consecutive days.
Option C- Unscheduled absences may require a staff to be pulled out from her regular area of assignment to cover for another unit. However, this
may cause disruption in the unity of work groups and job dissatisfaction the nurse does not have the necessary skill and knowledge that the unit
may require. Relievers are required to undergo cross-training and orientation to the special unit before being assigned to one. In emergency
cases, nurses with the experience on the area are usually assigned as relievers.
Option D- Morning shifts needs most number of nursing personnel. Distribution of shifts in the Philippines is 45% for the morning shift, 37% for
the afternoon shift, and 18% for the night shifts.
(Nursing Management by Venzon, 3rd ed, pg 62- 66)
6.

Patient Classification System (PCS) is a measurement tool used to articulate the nursing workload for a specific patient or group of patients
over a specific period of time. The measure of nursing workload that is generated for each patient is called the patient acuity. Wacky Boi, 8
years old, is admitted due to Dengue Hemorrhagic Fever. His condition is currently stable but needs periodic observations for danger signs. He has an
intravenous fluid and an on-going blood transfusion attached to him. The nurse on duty will classify Wacky Boi under which category of patient care
classification system?
A. Minimal care
B. Intermediate care
C. Total care
D. Critical care

RATIONALE:
Option A- Level I or Self Care/ Minimal Care- Patient can take a bath on his own, feed himself, and perform his ADLs. Falling under this category
are patients about to be discharged, those in non-emergency, newly admitted, do not exhibit unusual symptoms, require little treatment or
observation. 1.5 NCH/patient/ day.
Option B- Level II or Moderate Care/ Intermediate Care- Patients under this level need some assistance in bathing, feeding, or ambulating for
short periods of time. Patients may have their v/s ordered up to 3 times per shift, intravenous fluids and blood transfusions; are semi conscious;
and with periodic treatments and observations. 3 NCH/patient/ day
Option C- Level III or Total, Complete, or Intensive Care- Patients under this category are completely dependent upon the nursing personnel.
They are provided complete bath, with vital signs more than 3 times per shift, and require close observation at least every 30 minutes for
impending hemorrhage. 4.5 NCH/patient/day
Option D- Level IV or Highly specialized critical care are patients who need continuous treatment and observation; with many medications, IV
piggy backs; vital signs every 15- 30 minutes; and hourly output. There are significant changes in docotrs orders. 6 NCH/patient/day
(Nursing Management by Venzon, 3rd ed, pg 54- 55)
7.

R.A. 7164, known as The Philippine Nursing Act of 1991, has been repealed by the Philippine Nursing Act of 2002 (R.A. 9173). Section 25 of
the article states that the nursing education program shall provide sound general and professional foundation for the practice of nursing.
Juliana Manansala expressed her interest in the field of nursing education after having acquired clinical experience. After thoroughly reading Article V
of the Nursing Law, Juliana Manansala will not take note of which of the following requirements and qualifications of the nursing education program,
apart from?
1. Member of PNA
2. MAN plus 3 years of experience in nursing to become a dean of a college
3. Inactive nurses will undergo 2 months of didactic training and 4 months of practicum
4. Inactive nurses will undergo 1 month of didactic training and 3 months of practicum
5. Clinical practice of at least 1 year in a field of specialization and a masters degree in education to become a faculty
6. Clinical practice of at least 3 years in a field of specialization and a masters degree in nursing to become a faculty
A.
B.
C.
D.

1, 4, and 5
1, 3 and 6
2, 4, and 5
3, 5 and 6

RATIONALE:
Article V: Nursing Education
Sec 25: Nursing Education Program- specific requirements must be complied as embodies in the prescribed curriculum as promulgated by
CHED.
Sec 26: Requirements for Inactive Nurses Returning to Practice.
Inactive Nurses (have not practiced for 5 consecutive years) are required to undergo 1 month of didactic training and 3 months of practicum.
Section 27: Qualifications of the Faculty:
Be an RN
1 year clinical practice in field of specialization
Member of good standing in APO of nurses (PNA)
Holder of masters degree in nursing, education, or other allied medical and health sciences
Dean of college:
Qualifications of faculty + MAN + at least 5 years of experience in nursing
(Professional Nursing in the Philippines by Venzon, 10th ed, pg 256- 257)
8.

A professional nurse is a person who has completed a basic nursing education program and is licensed in his country or state to practice
professional nursing within the scope of nursing practice. Head Nurse Peetah is very particular with the duties and responsibilities of a nurse
within the scope of nursing practice. Because of his utmost respect to the law and the nursing profession, he is knowledgeable that Practice through
Special/Temporary Permit may be issued by the Board to the following, aside from:

A.
B.
C.
D.

Johana, a foreign nurse who is internationally recognized for her expertise as a Nurse Anesthetist.
Finnick, a local nurse desiring to practice the profession in the US.
Effi, a foreign nurse who offers a free medical mission in Brgy. Katapatan.
Heimich, a clinician from Japan who acts as an exchange instructor of Telemetry Nursing in UST.

RATIONALE:
RA 9173, ARTICLE IV (Examination and Registration)
Sec. 20. REGISTRATION BY RECIPROCITY A certificate of registration/ professional license may be issued without examination to nurses
registered under the laws of foreign state or country: Provided, that the requirements for registration or licensing of nurses in said country are
substantially the same as those prescribed under this Act Provided, further, that the laws of such state or country grant the same privileges to
registered nurses of the Philippines on the same basis as the subjects or citizens of such foreign state or country.
Sec. 21. PRACTICE THROUGH SPECIAL/ TEMPORARY PERMIT A special/ temporary permit may be issued by the Board to the following
persons subject to the approval of the Commission and upon payment of the prescribed fees:
A. License nurses from foreign countries/ states whose service are either for a fee or free if they are internationally well known
specialists or outstanding experts in any branch of specialty of nursing; (OPTION A)
B. Licensed nurses from foreign countries/ states on medical mission whose services shall be free in a particular hospital, center or
clinic, and; (OPTION C)
C. Licensed nurses from foreign countries/ states employed by school/ colleges of nursing as exchanges professors in a branch or
specialty of nursing; (OPTION D)
Provided, however, that the special/ temporary permit shall be effective only for the duration of the project, medical mission or employment contract.
(ULG, Balita, pp. 490)
9.

In doing research, the first thing a researcher does is identify and clearly define the problem to be studied. Initially, a research problem is
stated in a form of a question, which serves as the focus of investigation. Fourth year students of Xavier College are determined to conduct a
research study. Their group leader organized them to come up with a researchable problem. The members will not be corrected if they suggest which
of the following as sources of research problems, excluding?
A. Current social and political issues
B. Deductions from theories
C. Contradictory research results
D. None of the above

RATIONALE:
Sources of Research Problems:
E- xperience (clinical experience or observations; may be own experiences of experiences of others)
L- iterature (publications such as nursing journals or other scientific literature that may suggest problems) Ex: Contradictory research results may be
clarified and faulty methodology may be corrected, replication of a study on a new population
I- ssues (global and community concerns that should be settled)
T- heories (to clarify or substantiate an existing theory) Ex: deductions made based on the theory, hypothesis developed and tested empirically
E- xternal sources (ideas from external sources) Ex: direct suggestions from instructor, brainstorming, ANAs priorities
(ULG by Balita, pg 436)
10. A possible research problem exists when the existing condition (what is) is different from what is expected (what should be), and there are
two or more plausible causes of the discrepancy between what is and what should be. Nurse Researcher Vito Cruz has thought of several

research problems for his study. He wants to identify a good research problem and one that is indeed researchable. To accomplish this, Nurse
Researcher Vito Cruz will not look for which of the following characteristics in her research problem?
A. Variable are clearly stated.
B. It will yield answers that will contribute to knowledge and development.
C. Terms used are ambiguous.
D. Resources to conduct the research are feasible.
RATIONALE:
A good research problem should contain four essential characteristics:
It must be relevant. (Option B)
It must be feasible. (Option D)
o Resources such as time, money, and personnel must all be available to conduct the research.
It must be clear.
o The research problem must be clearly stated and variables should be measurable and specific. (Option A)
o The use of ambiguous terms must be avoided. (Option C) (ambiguous-open to more than one interpretation; having a double

meaning.)

It must be ethical.
o Not pose any danger, embarrassment, hurt, or any risk to the research respondents, subjects, or anyone.
(Understanding and Doing Research by David, 2005, pg 25- 29)
11. The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and temporal artery. Rectal
temperature readings are considered to be very accurate. Rita Ora, 18 months old, is brought to the ER due to high fever and three consecutive
days of diarrhea. With her age, the nurse is aware that the preferred route is tympanic. In taking the temperature via this route, the nurse needs further
knowledge if she performs which of the following actions?
A. The nurse pulls the pinna straight back and slightly downward.
B. The nurse pulls the pinna straight back and slightly upward
C. The nurse inserts the probe in a circular motion.
D. The nurse directs the probe tip anteriorly, toward the eardrum.
RATIONALE:
For children, the tympanic or temporal artery sites are preferred. The child is held in an adults lap with the childs head held gently against the adult for
support. Tympanic route is avoided in a child with active ear infections or tympanic membrane drainage tubes.
Option A- done for children under age 3.
Option B- done in a child over 3 years old. (child is 18 months old= 1 year and 6 months)
Option C- the probe is inserted using a circular motion until snug, or enough to seal the ear canal.
Option D- The tip is inserted toward the eardrum, but does not touch the eardrum/ tympanic membrane.
(Kozier, 8th ed, pg 536- 537)
12. A body temperature above the usual range is called pyrexia, hyperthermia, or fever. A very high fever, such as 41C, is called hyperpyrexia.
Nurse Lorde is assigned to care for a 5-year-old child who is diagnosed with an upper respiratory tract infection. While doing initial assessment, Nurse
Lorde noted a 39C fever, cough, and colds. She noticed that the temperature of her patient has a wide fluctuation over the past two shits but all are
above 38.5 oC. Nurse Lorde is correct to document this as what type of fever?
A. Intermittent fever
B. Remittent fever
C. Relapsing fever
D. Constant fever
RATIONALE:
Four common types of fever:
Intermittent fever- the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal
temperatures
Remittent fever- a wide range of temperature fluctuations (more than 2C) occurs over the 24-hour period, all of which are above normal.
Relapsing fever- short febrile periods of a few days are interspersed with periods of 1- 2 days of normal temperature
Constant fever- the body temperature fluctuates minimally but always remains above normal.
(Kozier, 8th ed, pg 530)
13. Heat stroke is an acute medical emergency caused by failure of heat-regulating mechanisms of the body. It causes thermal injury at the
cellular level, resulting in widespread damage to the heart, liver, kidney, and blood coagulation. A 67-year-old woman is rushed to the ER due to
fainting after watching Its Showtime in an open field. When assessing the patient, Nurse Kesha notes the following: temp of 42. 5C, hot, dry skin,
with absence of sweat, BP of 80/65, with decreasing level of consciousness. Nurse Kesha suspects a heat stroke and anticipates for which of the
following interventions, excluding?
A. Postpone IVF administration to avoid the occurrence of hypothermia.
B. Religiously monitor urine output of the patient.

C. Administer Benzodiazepines for seizure.


D. Submerge the patient in a cold water bath.
RATIONALE:
IVF therapy of PNSS or PLRS is initiated early, not delayed, to replace fluid losses and maintain adequate circulation. Fluids are administered carefully
because of the dangers of myocardial injury from high body temperature and poor renal function. Hypothermia, which may occur spontaneously within 3- 4
hours, is caused by rapid cooling interventions. To prevent this, the temperature is constantly monitored.
Option B- Urine output is measured frequently because acute tubular necrosis is a complication of heat stroke.
Option D- After the clothing is removed, the core temperature is reduced to 39C as rapidly as possible. During cooling, the patient is massaged
to maintain cutaneous vasodilation.
Option C- Antiseizure agents such as Benzodiazepines and Chlorpromazine are given to control seizures which may follow by recurrence of
hyperthermia. Such agents are given via the IV line of the patient during the attack
(Brunner, 10th ed, pg 2161- 2162)
14. Vital signs are frequently assessed especially during admission, when a client has a change in health status, before and after surgery and
administration of medications, and before and after any nursing intervention that could affect the vital signs. Nurse Patchot is taking the vital
signs of several clients in the ER. She does not need further teaching if she gives priority in referring which abnormality in the vital sign of her clients?
A. An ovulating woman who experienced a half - degree rise from her usual normal temperature.
B. Increase in heart rate in an elder woman who suddenly changed position from lying to sitting.
C. A middle-aged man with increased BP after fainting from intense physical activity.
D. A child with tachypnea and a history or asthma.
RATIONALE:
Nurses should be aware of the factors that can affect clients vital signs so that they can recognize variations and understand the significance of
measurements that deviate from normal.
Option D- Tachypnea is caused by a disease process and is therefore abnormal.
Option A- One factor that affects body temperature are hormones, especially in women. In women, progesterone secretion at the time of
ovulation raises body temperature by about 0.3- 0.6C above basal temperature which is normal.
Option B- Sudden postural changes affect the heart rate. When a person is sitting or standing, blood pools in dependent vessels. Pooling results
in a transient decrease in the venous blood return and a subsequent reduction in blood pressure and increase in heart rate (orthostatic
hypotension). This is common in the elderly.
Option C- Physical activity increases the cardiac output and hence the blood pressure. 20-30 minutes of rest following exercise is indicated
before reliably assessing BP.
(Kozier, 8th ed, pg 529, 538, 552)
15. Vital signs, which should be looked at in total, are checked to monitor the functions of the body. The signs reflect changes in function

that otherwise might not be observed. Monitoring a client's vital signs should not be an automatic or routine procedure; it should be a
thoughtful, scientific assessment. Vital signs should be evaluated with reference to clients' present and prior health status, their
usual vital signs results (if known), and accepted normal standards. A pulse rate varies according to a number of factors. Which of the
following statements is incorrect?
A. Fever increases pulse rate.
B. Exercise increases pulse rate.
C. Digitalis decreases pulse rate.
D. Hypovolemia decreases pulse rate.
RATIONALE:
Hypovelemia increases pulse rate. Loss of blood from the vascular system normally increases pulse rate. All other options are correct.
OPTION A: Fever increases metabolism thereby increasing the activity of the body.
16. A single elevated blood pressure reading indicates the need for reassessment. Hypertension cannot be diagnosed unless an elevated blood
pressure is found when measured twice at different times. Nurse Candace is caring for post MI patients in the cardiac unit. She is to monitor their
Vital Signs every hour paying particular attention to their blood pressure. In assessing the blood pressure, Nurse Candace will not be reprimanded if
she performs which of the following, aside from?
A. She waits for at least 1- 2 minutes before getting another measurement.
B. She supports the patients forearm at heart level with supination of the palm.
C. She positions the bell side of the amplifier of the stethoscope over the brachial pulse site.
D. She releases the valve of the cuff, allowing pressure to decrease at the rate of 1- 2 mmHg per second.
RATIONALE:
The valve of the cuff is carefully released so that the pressure decreases at the rate of 2- 3 mmHg per second. If the rate is faster or slower, an error in
measurement may occur. Deflating the cuff too quickly causes erroneously low systolic and high diastolic readings. Deflating cuff too slowly causes
erroneously high diastolic readings.
Option A- 1- 2 minutes is enough to permit blood trapped in the veins to be released. Repeating assessment too quickly causes erroneously high
systolic or low diastolic readings.
Option B- The elbow should be slightly flexed with the palm of the hand facing up and the forearm supported at heart level since the blood
pressure increases when the arm is below heart level and decreases when the arm is above heart level.

Option C- The bell side is used because the blood pressure is a low- frequency sound where it is best heard.
(Kozier, 8th ed, pg 555- 557)
17. A stethoscope is used in assessing the apical pulse which is indicated for clients with cardiovascular, pulmonary, and renal diseases and
those receiving medications that affect heart action. Nurse Primrose is caring for a client with CHF who is on Digoxin therapy. Prior to giving the
drug, she remembers to assess the clients apical pulse first. Nurse Primrose incorrectly uses the stethoscope when she performs which of the
following actions, excluding:
A. Place the stethoscope over the chest after disinfecting it.
B. Tilt the ear piece of the stethoscope slightly forward to insert them into the ears.
C. Put the stethoscope over the clients clothing and listen for heart sounds.
D. Use the bell side of the stethoscope when listening to normal heart sounds.
RATIONALE:
The earpieces of the stethoscope are inserted into the ears in the direction of the ear canal, or slightly forward to facilitate hearing.
Option A- After disinfecting, the diaphragm of the stethoscope is warmed by holding it in the palm of the hand for a moment before placing it
against the chest. The metal of the diaphragm is usually cold and can startle the client when placed immediately over the chest.
Option C- Stethoscope is placed directly on the skin, not over the clothing in order to avoid noise made from rubbing the amplifier against cloth.
Option D- The diaphragm of the stethoscope is used in listening for normal heart sounds. The bell is used in listening to S3 and S4 (abnormal
heart sounds)
(Kozier, 8th ed, pg 544, 556)
18. Pain is sensed when a nerve ending is stimulated sending an impulse along the neural pathway to the brain that interprets the impulse as
pain. Pain is assessed in a patient by asking the patient to describe the intensity of the pain on a pain scalethe higher the value, the more
severe the pain. Besides intensity, pain is assessed according to onset, duration, frequency, what started the pain (precipitating cause), and
what relieves the pain. An 80 year old client with an end-stage dementia has just been transferred to the orthopedic unit after undergoing internal
fixation on the left hip. Which of the following is the most appropriate method to manage the clients postoperative pain?
A. Administer oral opioids as needed.
B. Provide patient-controlled analgesia.
C. Administer pain medication through a transdermal patch.
D. Administer analgesic round the clock.
RATIONALE:
OPTION D- because assessing pain medication needs a client with end-stage dementia is difficult, analgesics should be administered around the clock. To
maintain freedom from pain, drugs should be given by the clock, that is every 3 6 hours, rather than on demand. This three-step approach of
administering the right drug in the right dose at the right time is inexpensive and 80-90% effective.
OPTION A-clients at this stage of dementia typically cant request oral pain medications when needed.
OPTION B-they are also unable to use patient-contro lled analgesia devices.
OPTION C-transdermal patches are used to manage chronic pain not postoperative pain because transdermal patches have low dose drugs.
WHOs PAIN LADDER (ANALGESIC LADDER)
MILD PAIN
Non- narcotic around the clock
Ibuprofen, ASA, Acetaminophen, and others NSAIDs
MODERATE PAIN
Add Opioid for Moderate Pain around the clock
Codeine
SEVERE PAIN
Start strong oral Opioid around the clock
Morphine, Dilaudid
19. When administering medications, the nurse observes specified rights to ensure accurate administration. When preparing medications, the
nurse checks the medication container label at least three times. Mrs. Potts has returned from the OR following an exploratory laparotomy. She is
receiving Meperidine HCl 100mg slow IV, RTC for pain relief. In giving this medication, Nurse Madison is mindful not to carry out which of the following
nursing actions?
A. Prepare Naloxone on the bedside table.
B. Monitor respirations and BP every 2 hours.
C. Monitor elimination pattern as diarrhea for it is a side effect.
D. Reassure that addiction is unlikely.
RATIONALE:
Meperidine HCl causes constipation, not diarrhea. Other side effects are nausea, vomiting, lightheadedness, dizziness, sedation, and sweating.

Option A- Meperidine is an opioid agonist analgesic. Keep opioid antagonist (naloxone) and facilities for assisted or controlled respiration in
cases of overdose or respiratory depression, which is an adverse effect.
Option B- Adverse effects of the drug include respiratory depression and hypotension so monitoring of vital signs is required.
Option D-Reassure client that addiction is unlikely; most clients receiving opiates for medical reasons do not develop dependence syndromes.
(Nursing Drug Guide by Karch, 2009, pg 748- 749)
20. A complete blood count (CBC), which includes hemoglobin and hematocrit measurements, RBC, WBC, and platelet count, is a basic
screening test and one of the most frequently ordered blood tests. Kristina Tampipi, 20 years old, underwent an operation to remove a mass of
round worm obstruction in her GIT. She is very pale, easily fatigued, and activity intolerance. Her CBC results have arrived and the nurse prepares to
report which of the following abnormal findings?
1. Platelet: 310,000/mm3
2. Hemoglobin: 7 g/dL
3. Hematocrit: 39%
4. Eosinophils: 8.5%
5. MCV: 72 um3
6. Lymphocytes: 37%
A. All except 1, 3, and 6
B. 2, 3, 4 and 6
C. All except 2, 4, and 5
D. All of the above
RATIONALE:
The patient has a parasitic infection and based on the assessment, it is safe to imply that she is also suffering from one of its complications which is iron
deficiency anemia. Eosinophils are increased during allergic reactions and parasitic infections. Hemoglobin is decreased in anemia and MCV (Mean
Corpuscular Volume), which is the mean or average size of the individual RBC, is decreased iron deficiency anemia (microcytic, hypochromic type).
Normal Range:
hemoglobin M= 14- 18 g/dL F= 12- 16 g/dL
hematocrit M= 37-49%
F= 36- 46%
MCV M & F= 78- 100 um3
Lymphocytes 20-40%
Eosinophils 1- 4%
Platelet count 150,000- 350,000/mm3
(Kozier, 8th ed, pg 799- 800)
21. Timed urine specimen requires collection of all urine produced and voided over a specific period of time, ranging from 1 to 2 hours to 24
hours. Mr. Percy Jackson, 57 years old, is scheduled for a 24-hour urine collection for a creatinine clearance test. Collection will start at exactly 12NN.
In planning for his care, which of the following nursing measures would most likely indicate a successful specimen collection?
A. Provide a sterile receptacle to collect the urine.
B. Collect all voided urine for a 24-hour period in a container by the station.
C. Do not include urine voided at exactly 12NN the next day.
D. Post a sign of Save all urine in Mr. Jacksons bathroom.
RATIONALE:
Posting signs in the clients chart, Kardex, room, and bathroom will alert the personnel to save all urine during the specified time. Communication of the test
to the staff is likely to result in completing the collection.
Option A- A clean, not sterile, receptacle is provided to collect urine (bedpan, commode, etc)
Option B- The first voided urine is discarded. Urine produced during the time collection period are stored in the container and inside the
refrigerator or placed in ice. This is to prevent bacterial growth or decomposition of urine components. Simply placing it by the station will spoil the
specimen, altering results.
Option C- At the end of the collection period, instruct the client to completely empty the bladder and save this voiding as part of the specimen.
Then, the collected urine is taken to the laboratory.
(Kozier, 8th ed, pg 811- 813)
URINE COLLECTION
RANDOM COLLECTION

Collected anytime using a


clean cup
Submit
immediately
to
laboratory to prevent bacterial
growth

TIMED COLLECTION

Done over a 24 hour period


Client is told to void and
discard the specimen at the
beginning of the collection
Save all urine from that time
on until 24 hours after
Collection container should be

COLLECTION FROM A CLOSED


DRAINAGE SYSTEM
Urine specimen should not be
obtained from the drainage
bag
Use aspiration port of the
catheters closed drainage
tubing for a sterile specimen
collection.

CLEAN VOIDED SPECIMEN

Done to secure a specimen


uncontaminated by skin flora
Should be obtained on first
voiding in the morning

refrigerated or kept on ice


coller throughout the 24 hours
22. Sputum specimens are collected for culture and sensitivity, for cytology, for acid-fast bacillus, and to assess the effectiveness of therapy.
Mr. Mason sought admission due to dry cough for more than 2 weeks and afternoon fever. He is suspected of having Tuberculosis. The nurse prepares
to collect a sputum specimen from Mr. Mason to aid in the diagnosis and does which of the following actions, except:
A. Offer mouthwash pre- and post sputum specimen collection.
B. Obtain early morning sputum for 3 consecutive days.
C. Ask the client to expectorate 1-2 tbsp of sputum into the specimen container.
D. Protect self by using gloves when obtaining the specimen.
RATIONALE:
Mouthwash is only offered after obtaining the sputum specimen to remove any unpleasant taste. Giving mouthwash before the test can alter the results.
Mouth care can be offered before and after the collection of specimen so that the specimen will not be contaminated with microorganisms from the mouth.
Option B- Sputum specimens are collected in the morning, upon awakening the client can cough up secretions that have accumulated during the
night. For AFB, specimen is collected for 3 consecutive days.
Option C- Ask the client to breathe deeply and cough up 1-2 tbsp of 15-30 mL of sputum. Make sure the sputum does not contact outside of the
container.
Option D- Wear gloves and PPE to avoid direct contact with the sputum.
(Kozier, 8th ed, pg 816)
23. Magnetic Resonance Imaging (MRI) is a noninvasive diagnostic scanning technique in which the client is placed in a magnetic field where
there is no exposure to radiation. Mr. Layer, 32 years old, has had several episodes of dull frontal headaches, memory lapses, and visual changes in
the last 2 months. He went for a neuro check-up and was scheduled for an MRI with contrast media. The nurse on duty starts preparing Mr. Layer for
MRI. You will not correct the nurse if she asks which of the following questions to Mr. Layer, except:
A. Are you wearing any transdermal patch right now?
B. Are you allergic to seafood or any iodine-based products?
C. Do you have any tattoos in your body?
D. Do you have any kind of implant in your body?
RATIONALE:
MAGNETIC RESONANCE IMAGING Provides detailed pictures of body structures
Assess for claustrophobia
Remove metallic objects
The contrast media used in MRI is not an iodine contrast. The most common contrast used is Gadolinium which is a paramagnetic contrast. There is no
reason to ask for allergies to iodine-based products like seafood because iodine contrast is not used.
Option A- Many transdermal patches contain a foil backing which creates an electric current that can lead to intense heat and a burn.
Option D\C- Clients with implanted metal devices (e.g. pacemaker, metal hip prosthesis) cannot undergo an MRI because of the strong magnetic
field.
Option D- Tattoo pigments may contain metal substances which create an electric current that can cause redness and swelling similar to a first
degree burn at the site of the tattoo. Permanent cosmetics (e.g. tattooed eyeliner, eyebrows, lip liner) may cause similar problems.
(Kozier, 8th ed, pg 818- 819)
24. Thoracentesis is done to remove the excess fluid or air from the pleural cavity to ease breathing and to introduce chemotherapeutic drugs
intrapleurally. Mr. Gary Bee, 50 years old, is diagnosed with bacterial pneumonia complicated by empyema. He is subjected to a thoracentesis where
the physician managed to remove 500mL of purulent fluid in his left lung. After which, the nurse caring for Mr. Gary Bee will not correct him if he says
which of the following?
A. I will lie flat on my back immediately after the procedure.
B. Its normal for me to be short of breath for a while.
C. I will lie on my right side with my head elevated for some time.
D. I will remain in a sitting position with arms above my head.
RATIONALE:
After the procedure, position the client appropriately by placing him on the unaffected side with the head of the bed elevated 30 degrees for at least 30
minutes because this position facilitates expansion of the affected lung and eases respirations.
Option A- This is not the recommended position after thoracentesis because it does not allow the affected lung to expand.
Option B- The objective of the procedure is to ease breathing by removing the accumulated fluid, so this is not normal and not expected.
Option D- Sitting position with arms above the head is the recommended position during the procedure. This position allows easy access to the
intercostal spaces. Another position is one in which the client leans forward over a pillow.
(Kozier, 8th ed, pg 821, 825)
THORACENTESIS Aspiration of fluid (or air) from the pleural space (between the parietal and visceral pleura) for diagnostic and therapeutic purposes.
Sitting with anterior thorax supported by pillows or over-bed table.
Explain use of local anesthesia

Aspiration of fluid limited to less than 1 L at a time or within 30 minutes


Monitor vital signs (auscultate breath sounds and note respiratory efforts too)
Lie on unaffected side with head elevated 30 degrees for at least 30 minutes (facilitates expansion of the affected lung).
Check for leak of fluid

25. Liver biopsy is a short procedure, generally performed at the clients bedside, in which a sample of liver tissue is aspirated. Mr. Kamachi, a
56-year-old alcoholic, has been diagnosed with liver cirrhosis. The admitting physician scheduled him for a liver biopsy and informed him about the
procedure. Mr. Kamachi anxiously says to the nurse, Im worried about the pain the big needle will give me. The nurses most appropriate response is:
A. I understand Mr. Tatum. Lets talk to your physician about that.
B. I understand that you are worried but you will be given medications so you wont feel any pain.
C. I understand that you are worried Mr. Tatum but we will let you assume the most comfortable position to ease the pain.
D. Dont worry Mr. Tatum, I will be here and support you all the way.
RATIONALE:
Before a liver biopsy, the nurse is allowed to explain that a sedative and local anesthetic will be given so the client will feel no pain in order to allay the
clients fears and anxieties. Option B is the most appropriate because it answers the main concern of the client which is pain. Vitamin K is also given before
the test to reduce the risk of hemorrhage.
Option A- There is no need to call the physician again since the client has already been informed. It is now the nurses responsibility to validate,
reiterate, and make sure that the client comprehends the procedure.
Option C- Positioning does not ease the pain but makes sure that the puncture site is properly exposed.
o Position before the procedure: Supine with right hand under the head
o Position after the procedure: Right side lying with small pillow under biopsy site
Option D- is an example of false reassurance and is non-therapeutic.
(Kozier, 8th ed, pg 825)
26. Vital statistics are indices of health and illness status of a community and serve as bases for planning, implementing, monitoring, and
evaluating community health. Nurse Coleen is a public health nurse assigned to the Provincial Health Office of the province of Quezon. She uses the
epidemiological approach to explain probable causes of health condition as they occur in the community. In reviewing the vital events in the
community, Nurse Coleen would be least concerned with:
A. Increasing number of women in the community who seek counseling as well as legal separation, due to battered women syndrome
B. Increasing number of teenage deaths because of suicide, as well as decreased deaths due to motor vehicle accidents.
C. Increasing birth rates, crowding index and population density in the community
D. Increasing number of patients in the hospital diagnosed with drug dependence, as well as a decrease in reported cases of dengue fever.
RATIONALE:
Vital statistics refers to the systematic study of vital events such as births, illness, marriages, divorce, separation and deaths. (Public Health Nursing in the
Philippines, NLGP, 2007: p. 75). The public health nurse would be more concerned with knowing the birth rates, death rates, morbidity rates, than knowing
the number of marriages, legal separation, and annulment cases.
SITUATION (27- 32): The rural health nurses of Barangay Binago-na want to know the health and illness status of the community for the year
2013. They have gathered the following data to help them in their research.
Total Population:
Total Deaths:
Total Live Births:
Total Maternal Deaths:
Total Infant Deaths:
Total Fetal Deaths:
Total Neonatal Deaths:
Total Deaths due to Dengue
Total Deaths from CVD
Pneumonia cases
People exposed to Pneumonia

9, 135
736
2, 894
58
42
10
22
8
128
68
112

27. The RHU nurses are computing for the rate of natural growth or increase of a population. Based on the given data above, they will come up with:
A. Crude Birth Rate of 316. 80 per 1,000 population
B. Crude Birth Rate of 31. 680 per 100 population
C. General Fertility Rate of 316. 80 per 1,000 population
D. General Fertility Rate of 31. 680 per 100 population
RATIONALE:
Crude Birth Rate is a measure of one characteristic of the natural growth or increase of a population.
CBR=
CBR=

General Fertility Rate=


(Maglaya, 4th ed, pg 176)
28. One of the nurses is curious about the increase in the population for the year 2013. She opts to compute for the rate of natural increase for the year
2013 and comes up with:
A. 236
B. 23
C. 145
D. 1,460
RATIONALE:
Rate of natural increase is the difference between the Crude Birth Rate and Crude Death Rate occurring in a population in a specified period of time.
(
)
Rate of Natural Increase=
(
)
CBR=
CBR=
CDR=

CDR=

Rate of Natural Increase:


(Maglaya, 4th ed, pg 173)
29. Patricia, one of the RHU nurses, would like to have an idea about the general health condition of the community. As a member of the team, you
correctly advise Patricia that a good index of finding that out would be through which of the following vital statistics?
A. 0 percent of pregnancy wastage
B. Infant mortality rate of 14. 51 per 1000 live births
C. Low specific mortality rate
D. Low Proportionate Mortality Rate
RATIONALE:
Infant mortality rate measures the risk of dying during the 1st year of life. It is a good index of the general health condition of a community since it reflects the
changes in the environment and medical condition of a community.
Option A- refers to fetal death rate.
Option C- describes more accurately the risk of exposure of certain classes or groups to particular disease.
Option D- shows the numerical relationship between deaths from all causes and the total number of deaths from all causes in all ages taken
together.
(Reyala, 2007, pg 76)
30. The RHU nurses are aware that one statistical indicator serves as an index of prenatal care and obstetrical management of the newborn. They do not
need further teaching if they compute the risk of dying in the 1st month of life and come up with:
A. Fetal death rate of 3. 46 per 100 live births
B. Fetal death rate of 34. 55 per 1000 live births
C. Neonatal death rate of 76. 01 per 100 live births
D. Neonatal death rate of 7. 60 per 1000 live births
RATIONALE:
Neonatal death rate measures the risk of dying in the 1st month of life. It serves as an index of prenatal care and obstetrical management of the newborn.
(
)
NDR=
NDR:
(Reyala, 2007, pg 77)
31. Rate shows the relationship between a vital event and those persons exposed to the occurrence of said event, within a given area and
during a specified unit of time. What is the cause specific death rate from cardiovascular disease of Brgy. Binago-na?
A. 28. 02 per 100 population
B. 280. 20 per 1,000 population
C. 14. 01 per 1,000 population
D. 1. 40 per 100 population
RATIONALE:
CSDR = no. of deaths from specific cause registered in a given year/ total population x 1,000
CSDR = 128/9, 135 = 0.0090831678 x 1,000 = 14. 01
Reference: Public Health Nursing in the Philippines, 2007, 10th edition, p.77

32. What is the attack rate of pneumonia?

31 per 1000 population


3. 15 per 100 population
9. 24 per 100 population
92. 39 per 100 population
RATIONALE:
Attack Rate = No. of persons acquiring a disease/ no. of registered deaths x 100
AR = 68/ 736 x 100
= 9.24
Reference: Public Health Nursing in the Philippines, 2007, 10th edition, p.78
A.
B.
C.
D.

33. Epidemiology rests on two important concepts: the multiple causation theory and the levels of prevention of health problems. Nurse Dominic,
the RHU nurse, administered Chloroquine IM to Kit who is preparing to travel next week to a known malaria endemic area. Nurse Dominics action is
under what level of prevention?
A. Primary Prevention
B. Secondary Prevention
C. Tertiary Prevention
D. Quaternary Prevention
RATIONALE:
Primary prevention focuses on prevention of emergence of risk factors (primordial prevention) and removal of the risk factors (specific prevention). It aims to
strengthen the host resistance, inactivate the source of infection, or interrupt the chain of infection. This can be done through personal surveillance,
quarantine, segregation, or isolation. Health promotion activities include provision of proper nutrition, safe water supply and waste disposal system, vector
control, promotion of a healthy lifestyle and good personal habits. Specific measures include provision of immunization and prophylaxis to vulnerable or atrisk groups.
Option B- Secondary prevention aims to identify and treat existing health problems through screening, casefinding, disease surveillance, and
prompt treatment.
Option C- Tertiary prevention limits disability progression through rehabilitation.
Option D- not included
(Maglaya, 4th ed, pg 180)
34. Epidemiology is the backbone of the prevention of the disease. In order to control a disease effectively, the conditions surrounding its
occurrence and the factors favoring the development of the disease must first be known. The public health nurse is aware that among which of
the following is not a purpose of epidemiology?
A. Discover the causes of health and disease.
B. Estimate the risk of disease and the chances of avoiding them.
C. Serves as bases for planning and evaluating community health programs and services.
D. Study the rise and fall of diseases and changes in their character.
RATIONALE:
Epidemiology is the study of occurrences and distribution of disease as well as the distribution and determinants of health states or events in specified
population. Option C is more on the purpose of vital statistics. Statistics of morbidity and mortality indicate the state of health of a community and the
success or failure of health work.
Option A- search for causes of health and disease by comparing the experience of groups that are clearly defined by their composition,
inheritance, experience, behavior, and environments.
Option B- Estimate the risk of disease, accident, defects and the chances of avoiding them.
Option D- Study the history of the health population and the rise and fall of diseases and changes in their character.
(Reyala, 2007, pg 63)
35. The epidemiologic triangle consists of three components- host, environment, and agent. The three elements of the ecologic triad interact
with one another in an attempt to maintain equilibrium. The public health nurse in Barangay Manabo is interested in teaching the students about
the elements of the ecologic triad. She appropriately informs them by saying which of the following, except:
A. The host of schistosomiasis is the snail oncomelania quadrasi.
B. Filariasis is caused by the agent Wuchereria bancrofti.
C. The vector of malaria is the night-biting Anopheles mosquito.
D. Extrinsic factors include urbanization.
RATIONALE:
The epidemiologic triangle or the ecologic triad are:
AGENT- any element, substance, or force, either animate or inanimate, the presence or absence of which may serve as stimulus to initiate a
disease process.
o Ex: Biological (viruses, bacteria, fungus, parasite), Chemical (insecticide, lead), Physical, Mechanical, Nutritive (vitamins, proteins)
HOST (instrinsic)- influences exposure, susceptibility, or response to agents; HUMAN is the host organism
o Ex: Immunologic experience, Age, Nonspecific resistance (intact skin, coughing, other reflexes), Human behavior (hygiene, food
handling)

ENVIRONMENT (extrinsic)- influences existence of the agent, exposure, or susceptibility to agent


o Ex: Physical environment (geology, climate), Biologic environment (sources of food, vectors such as vertebrates and other sources of
agents), Socio-economic environment (occupation, urbanization, disruption)
Option A- The snail is not the host but the vector of the disease. Vectors are part of environmental factors.
(Reyala, 2007, pg 64- 65)
36. The variables of disease as to person, time, and place are reflected in distinct patterns of occurrence and distribution in a given community.
In a given year, there are a few cases of Rabies in the Philippines. In some weeks, a few cases are scattered throughout the country. These cases
however, are not related to the cases in other areas. Nurse Jessica does not need further teaching if she regards this as:
A. Pandemic Occurrence
B. Epidemic Occurrence
C. Endemic Occurrence
D. Sporadic Occurrence
RATIONALE:
Sporadic occurrence is the intermittent occurrence of a few isolated and unrelated cases in a given locality. The cases are few and scattered, so
that there is no apparent relationship between them and they occur on and off, intermittently, through a period of time.
Endemic occurrence is the continuous occurrence throughout a period of time, of the usual number of cases in a given locality. The disease is
always occurring in the locality and is constant through a period of time.
Epidemic occurrence is of unusually large number of cases in a relatively short period of time.
Pandemic is the simultaneous occurrence of epidemic of the same disease in several countries.
(Reyala, 2007, 67- 68)
37. In order to describe the occurrence of disease condition, the nurse needs to recognize or identify the disease with reasonable certainty
through screening and case finding activities. Selena, an OFW from Mexico, returned to the Philippines for a vacation. Several days after, she
developed flu-like symptoms with abdominal pain and vomiting; at the same time, swine flu outbreak has been confirmed in Mexico. Selena has already
exposed herself to their neighborhood and her family members, who developed the same symptoms. Weeks after, their community has been officially
regarded with swine flu outbreak. What statistical association is illustrated in the situation?
A. Indirect Association
B. Spurious Association
C. Cyclic Association
D. Direct Association
RATIONALE:
Direct or Causal Causation
o involves the presence of a factor which wholly and directly explain the cause of disease (the agent (virus), the host (Elena), and the
environment play a role in the cause of disease)
o no intervening variables
o Further classified as:
one-on-one causal suggests that when one factor is present, disease results; conversely, when the disease is present, the
factor must also be present (ex: the presence of mutation on the gene that encodes for the sodium ion channel in
the cell membranes of the muscle cells of the heart )
multifactorial causation several factors acting independently or synergistically can produce a disease (ex: genetic
predisposition, smoking, alcoholism, heavy meal, etc. )
Indirect Association
o occurs when there is the presence of a known or unknown factor common to both a characteristic and a disease may wholly or partly
explain statistical association. Squarely, the abnormal ECG pattern is a known pattern factor which is common among those
respondents -- who have relatives who died with SUDs. This abnormal ECG patterns may be attributable to an underlying cardiac
disease, which may wholly or partly explain a statistical association.
Spurious or Artifactual Association
o happens when no association actually exists (Brugada is associated with acute pancreatitis - clinically, it is a hard-sell of a diagnosis if it
is to be solely implicated for cause of bangungut deaths)
38. The nurse characterizes the pattern of disease occurrence in terms of date or time onset. What kind of illness outbreak is described in Selenas
situation?
A. Common source epidemic
B. Propagated epidemic
C. Cyclic variation
D. Secular variation
RATIONALE:
Types of Outbreak patterns:
Common source epidemic
o characterized by simultaneous exposure of a large number of susceptible to a common infectious agents
Point-source- common source outbreak where the exposure occurs in less than one incubation period
Continuous source- common source outbreak where the exposure occurs in over multiple incubation periods

Cyclic variation
o recurrent fluctuations of disease that may exhibit cycles lasting for certain periods
Secular variation
o changes in disease frequency over many years
Propagated epidemic
o caused by a person to person transmission of the disease agent
(Maglaya, 4th ed, pg 183)
39. Epidemiological variables, such as time, person and place, are studied since they determine the individuals and populations at greatest risk
of acquiring a particular disease. Maya, the PHN of Barangay Sulok Sulok, is preparing herself for epidemiological investigations in cases of
outbreaks in their community. For a successful investigation, she bears in mind which of the following factors that may affect occurrence and
distribution of disease?
A. Unvarying incidence of the disease in the last 12 months.
B. Higher morbidity rates in males.
C. Level of immunity and resistance among age groups.
D. Disease spreads more rapidly in rural areas.
RATIONALE:
The epidemiology variables are time, person and place. These variables are studied since they determine the individuals and populations at greatest risk of
acquiring particular disease, and knowledge of these associations may have predictive value. Time refers both to the period during which the cases of the
disease being studied were exposed to the source of infection and the period during which the illness occurred. Person refers to the characteristics of the
individual who were exposed and who contacted the infection or the disease in question. Place refers to the features, factor or conditions which existed in or
described the environment in which the disease occurred.
Option A- For many diseases, the incidence (frequency of occurrence) is NOT uniform (varying) during each of month. The frequency is greater
in one season that any of the others. Ex: DHF is higher in rainy seasons.
Option B- In general, males experience higher mortality rates than females for a wide range of diseases. It is the female however who have
higher morbidity rates.
Option C- Level of immunity or resistance varies among different age groups. The elderly may be more susceptible to a particular disease than a
young adult.
Option D- In general, disease spreads more rapidly in urban areas than in rural areas primarily because of the greater population density of urban
area provides more opportunities for susceptible individual to come into contact with a source of infection.
(Reyala, 2007, pg 66- 67)
40. The nurse makes observations of the disease frequency and these are recorded as disease rates. There was a recent outbreak of typhoid in the
community. Nurse Harty wants to measure the risk of exposure of the population to Salmonella. He will make use of which of the following statistical
tool?
A. Exposure rate
B. Attack rate
C. Crowding index
D. Incidence rate
RATIONALE:
Attack rate is a more accurate measure of the risk of exposure to an infectious agent. It represents the incidence of the illness among the exposed
population. They are frequently used in surveillance and control of communicable diseases.
Formula:
Attack Rate= No of persons acquiring a disease registered in a given year x 100
No. of exposed to same disease in the same year
Option A- Exposure or Contact rate represents opportunities for transfer of an infectious agent to a susceptible host. It depends on the frequency
of contact, and facility of transmission.
Option C- Crowding index describes the ease by which a communicable disease will be transmitted from one host to another. This is described
by dividing the number of persons in a household with the number of rooms used by the family for sleeping.
Option D- Incidence rate measures the frequency of occurrence of the phenomenon during a given period of time.
(Reyala, 2007, pg 78)
41. TB-DOTS is the internationally-recommended TB control strategy and combines five elements. The following Nurses exhibit adherence to the
element of DOTS, except:
1. Margie, a rural health nurse, supervises the plan to go from one sitio to another to conduct direct sputum test among the residents
therein
2. Marian, a TB-DOTS volunteer teaches one of her TB clients that the latter should take two (2) anti-TB drugs for at least three (3)
months during the intensive phase and four (4) anti-TB drugs for two (2) months.
3. Merly, a registered nurse who is an incumbent city counselor, passed an ordinance providing for discounts in health services and
medications to clients identified under the TB DOTS program of the city and increasing the funding for TB case-finding activities
4. Molly, a nurse-pharmacist, makes sure that the TB Drugs are always adequate and available for dispensing in the center; she also
makes sure that she reminds clients when to come back to the center to get their stocks replenished.
5. Mark, in his health teaching, advises the client that the preferred treatment is hospital treatment.

6.
7.
A.
B.
C.
D.

Milagros counsels the family of the TB client that they should not participate in the treatment as they will be more exposed to the
bacillus
Michael, the nurse in charge of the DOTS program in the barangay, regularly updates the Client list for TB cases under Short
Course Chemotherapy to be submitted to the eFHSIS of the DOH

Only I, III, VII


Only II, V, VI
All except II, V, VI
None of the above

RATIONALE:
Elements of DOTS (Direct Observed Treatment Short-course):
Commitment sustained politically (OPTION 3)
Recording and reporting system (OPTION 7)
Enables outcome assessment of all patients and assessment of overall program performance
Access to quality-assured sputum microscopy (OPTION 1)
Direct Sputum Smear Microscopy (DSSM) shall be the primary diagnostic tool in TB case finding
In far flung areas, BHWs may be allowed to do smearing and fixing of specimens, as long as they are supervised or trained by their
respective medical technologists.
Standardized short-course chemotherapy for all cases of TB and uninterrupted (OPTION 4)
Direct observation of treatment: assign and supervise a treatment partner for patients who will undergo DOTS.
Provide continuous health education to all TB patients placed under treatment and encourage family and community participation in TB
control. This ensures better compliance to the treatment.
Supply of quality assured drugs. (OPTION 4)
(Reyala, 2007, pg 246)
OPTION 5: Mark, in his health teaching advises the client that preferred treatment is hospital treatment is not correct because domiciliary treatment is
preferred.
OPTION 6: Milagros, counsels the family of the TB client that they should not interrupt in the treatment as they will be more exposed to the bacillus is also
erroneous because as a principle under the Case holding mechanism, family members could also be treatment partners. (Reyala 2007 pp. 246-248)
Excluding the family from the treatment of the client is not warranted.
42. Tuberculosis occurs in children of underdeveloped and developing countries especially after a bout if a debilitating childhood disease such
as measles. Mr. Scott, 40 y/o, was recently diagnosed with pulmonary TB. He is very concerned of the possibility of having infected his 7 y/o child and
asked the nurse for advice. Nurse Leila would suspect primary complex if Mr. Scott says which of the following?
A. My son has been wheezing for 2 weeks now.
B. My son has a great appetite but doesnt gain weight.
C. My son has been having fever for 5 days already.
D. My son has chills and is sweating profusely.
RATIONALE:
Primary complex is TB in children.
A child shall be suspected as having TB and will be considered as a TB symptomatic if with any 3 of the ff S/Sx:
Cough/ wheezing of two weeks or more (Option A)
Unexplained fever of 2 weeks or more
Loss of appetite/ loss of weight/ weight faltering
Failure to respond to 2 weeks antibiotic therapy for lower RTI
Failure to regain previous state of health 2 weeks after a viral infection or exanthema
Option B- not great appetite but loss of appetite
Option C- unexplained fever for 2 weeks or more
Option D- chills are present during high grade fever. Fever in TB is usually low grade with no chills. This symptom is more appropriate with malaria.
(Reyala, 2007, pg 247)

43. The detection of TB cases requires that affected individuals are aware of their symptoms, have access to health facilities and are
evaluated by health workers (doctors, nurses, medical assistants, clinical officers) who recognize the symptoms of TB. The nurse is
administering the purified protein derivative (PPD) test to a homeless client. Which of the following statement concerning PPD testing is true?
A. A positive reaction indicates that the client has active TB.
B. A positive reaction indicates that the client has been exposed to the disease.
C. A negative reaction always excludes the diagnosis of TB.
D. The PPD can be read within 24 hours after the injection.
ANSWER: B
RATIONALE:

A positive reaction means that the client has been exposed to TB; it isnt conclusive of the presence of active disease. A positive reaction consists of
palpable swelling and induration of 10mm and above for normal 5mm and above for immunocompromised. It can be read 48 to 72 hours after the
injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed client, a negative
reaction doesnt exclude the presence of active disease.
44. The National Tuberculosis Program calls for improvement of access to and quality of services provided to TB patients, and TB
symptomatics. Mr. Chan, 48 y/o, manifested with cough and fever for more than 2 weeks and was asked to undergo sputum smear for diagnosis. He
noticed some blood on his sputum the following day after two positive sputum smear results. Nurse Ericka will not be reprimanded if she does which of
the following actions?
A. Perform PPD skin test instead to confirm the diagnosis.
B. Proceed with Chest X-ray.
C. Continue with another sputum smear to confirm the diagnosis.
D. Stop the sputum smear and refer for further management.
RATIONALE:
DSSM is the primary diagnostic tool in TB case finding. All TB symptomatic identified shall be asked to undergo DSSM for diagnosis before start of
treatment. The only contraindication for sputum collection is hemoptysis (as identified in the situation); in which case, DSSM will be requested after control of
hemoptysis.
Option A- Results of the PPD skin test should not be used as bases for TB diagnosis in adults. This is only used to test for previous exposure to
TB bacteria.
Option B- No TB diagnosis shall be made based on results of CXR examinations alone. CXR and culture can be used only after the patients have
undergone DSSM for diagnosis with 3 negative sputum results.
Option C- is a contraindication.
(Reyala, 2007, pg 243)
45. The national and local government units shall ensure provision of drugs to all smear-positive TB cases. Mr. Chan failed to conform to the
prescribed treatment regimen and stopped taking anti-TB drugs for several months now. If Mr. Chan plans to return to the program and continue his
treatment, Nurse Ericka will prepare to administer which additional anti-TB drug?
A. Isoniazid
B. Pyrazinamide
C. Ethambutol
D. Streptomycin
RATIONALE:

Category I
Category II
Category III
Category IV
Category I

Category II
Category III
Category IV
(ULG by Balita, pg 402)

Intensive Phase
2 mos RIPE
2 mos RIPES + 1 mos RIPE
2 mos RIPE
Refer to specialized facility

Treatment Regimen
Continuation Phase
4 mos RI
5 mos RIE
4 mos RI

-new smear + PTB


-new smear PTB with extensive parenchymal lesions on CXR
-extrapulmonary TB
-severe concomitant HIV disease
-treatment failure/ relapse/ return after default
-new smear PTB with minimal parenchymal lesions on CXR
-chronic (still smear + despite supervised treatment)

46. Labor normally begins when the fetus is sufficiently mature to cope with extrauterine life yet not large to cause mechanical difficulty. A
primigravida woman with strong, coordinated, productive labor contractions is being prepared for a normal vaginal delivery. Nurse Adele bears in mind
that none of the following factors contribute to the womans onset of labor, except:
A. Increasing progesterone levels in relation to estrogen
B. Release of oxytocin from anterior pituitary
C. Fetal membrane production of prostaglandin
D. Decreasing fetal cortisol levels
RATIONALE:
It is believed that labor is influenced by a combination of factors originating from the mother and fetus. These factors include:
Uterine muscle stretching, which results in the release of prostaglandins
Pressure on the cervix, which stimulates the release of oxytocin from the posterior pituitary (Option B)
Oxytocin stimulation initiates contractions

Increasing estrogen in relation to progesterone stimulates uterine contractions (Option A)


Placental age triggers contractions
Rising fetal cortisol levels reduce progesterone and increase prostaglandin (Option D)
Fetal membrane production of prostaglandin stimulates contractions. (Option C)
(Pillitteri, 5th ed, pg 489)
47. Beginning in the late 1950s, many specific methods for non-pharmacologic pain reduction during labor were developed. Pain perception can
be altered by distraction techniques that effectively move a womans concentration to other things than pain or by the gating control theory
of pain perception. Student nurse Thea heard Mrs. Charo and her attending physician talking about the Bradley method of delivery. She approached
her clinical instructor and asked about Bradley method. The most appropriate reply of the clinical instructor would be which of the following?
A. The Bradley method teaches replacement of usual response to pain with new learned responses (breathing, effleurage, and relaxation) in order to
block recognition of pain and promote positive sense of control in labor.
B. The Bradley method is based on the approach proposed by Grantly Dick-Read, an English physician. The premise is that fear leads to tension,
which leads to pain.
C. The Bradley method includes a program of conscious relaxation and levels of progressive breathing that encourages a woman to flow with rather
than struggle against contractions.
D. The Bradley method or partner-coached method, during pregnancy the woman performs muscle-toning exercises and limits or omits foods
containing preservatives, animal fat, or a high salt content.
RATIONALE:
METHODS OF PAIN MANAGEMENT:
Bradley method or partner-coached method - based on the premises that pregnancy and childbirth are joyful natural processes and that a
womans partner should play an important role during pregnancy, labor, and the early newborn period. During pregnancy the woman performs
muscle-toning exercises and limits or omits foods containing preservatives, animal fat, or a high salt content. Pain is reduced in labor by
abdominal breathing. In addition, a woman is encouraged to walk during labor and to use an internal focus point dissociation technique. (OPTION
D)
Lamaze Method - The method is based on the theory that through stimulus- response conditioning, women can learn to use controlled breathing
to reduce pain during labor. It was originally termed the psychoprophylactic method, as it focuses on preventing pain in labor (prophylaxis) by
use of the mind (psyche).is a psychoprophylactic method based on utilization of Pavlovs conditioned response theory. Classes teach replacement
of usual response to pain with new learned responses (breathing, effleurage, and relaxation) in order to block recognition of pain and promote
positive sense of control in labor. (OPTION A)
Dick-Read Method is based on the approach proposed by Grantly Dick-Read, and English physician. The premise is that fear leads to tension,
which leads to pain. If a woman can prevent fear from occurring, or break the chain between fear and tension or tension and pain, then she can
reduce the pain of labor contractions. A woman achieves lack of fear through education about childbirth and relaxation and reduced pain by
focusing on abdominal breathing during contractions (OPTION B)
Psychosexual Method stresses that pregnancy, labor, and birth, and the early newborn period are important points in a womans life cycle. It
includes a program of conscious relaxation and levels of progressive breathing that encourages a woman to flow with rather than struggle
against contractions. (OPTION C)
48. The passenger is the fetus. Whether a fetal skull can pass or not depends on both its structure and its alignment with the pelvis. A 25-yearold primigravid woman came to the clinic to have her prenatal check-up. She told Nurse Will that she has read some pregnancy books and asked him
to describe the significance of fetal position. Nurse Will answered her appropriately if he tells her which of the following:
A. It is the relationship of your babys presenting part to your pelvis.
B. It simply shows the posture of your baby.
C. It can be your babys head or feet at your cervical os.
D. It shows the relationship of the fetal long axis to the mother
RATIONALE:
Fetal position is the relationship of the presenting part to a specific quadrant of a womans pelvis. Position is important because it influences the process and
efficiency of labor. Typically, a fetus is born fastest from an ROA (Right occipitoanterior) and LOA (left occipitoanterior) position. Posterior positions may be
painful for the mother because the rotation of the fetal head puts pressure on the sacral nerves, causing sharp back pain.
Option B- Fetal attitude: Attitude describes the degree of flexion a fetus assumes during labor. The fetus may be in complete flexion (good
attitude), military position (moderate flexion), or partial extension.
Option C- Fetal presentation: this denotes the body part that will first contact the cervix of be born first. It may be cephalic (vertex, brow, face, or
mentum), breech (complete, frank, or footling), and shoulder presentation.
Option D- Fetal Lie: It is the relationship between the long axis of the fetal body and the long axis of the womans body. It determines whether the
fetus is lying in a horizontal (transverse) or vertical (longitudinal) position.
(Pillitteri, 5th ed, pg 493- 497)
49. Fetal station refers to the relationship of the presenting part of a fetus to the level of the ischial spines. Mrs. Laspagin, 33 years old, sought
admission due to true labor contractions. After completing a second vaginal examination, the nurse-midwife determines that the fetus is in LOA position
and at -4 station. Based on these findings, the nurse-midwife accurately tells Mrs. Laspagin which of the following statements?
a. Your babys head is fully engaged.
b. You are already crowning Mrs. Laspagin, you will give birth at any moment from now.
c. The babys head is still floating.
d. The babys head is dipping Mrs. Laspagin.

RATIONALE:
Station or degree of engagement of the fetal head is designated by centimeters above or below the ischial spines. When the presenting part is at the level of
the ischial spines, it is at a 0 station. A presenting part above the ischial spines is designated as -1, -2, -3, or -4. A presenting part below the ischial spines
are designated as +1, +2, +3, or +4.
Option A- At 0 station, head is engaged.
Option B- At +3 or +4, head is at outlet and woman is crowning
Option C- At -4 station, head is floating
Option D- Head that is descending but has not yet reached the ischial spines is said to be dipping.
(Pillitteri, 5th ed, pg 494)
50. Labor and birth are enormous emotional and physiologic accomplishments, not only for a woman but for her support person as well. For
this reason, support persons should be treated with respect and included in all phases of the process whenever possible. While nurse Betina
is conducting assessment on Mrs. Bailey, she asked the nurse what the difference between true labor pains and false labor pains are. All of the
following are false statements regarding true labor pains except:
1. Begin irregularly but become regular and predictable.
2. Felt first in lower back and sweeps around the abdomen in a wave
3. Begin and remain irregular
4. Continue no matter what the womans level of activity.
5. Felt first abdominally and remain confined to the abdomen and groin.
6. Increase in duration, frequency, and intensity.
7. Do not increase in duration, frequency or intensity.
8. Do not achieve cervical dilatation.
9. Achieve cervical dilatation.
10. Often disappear with ambulation and sleep.
A.
B.
C.
D.

1, 2, 4, 6, 9
4, 9, 5, 1, 4
10, 3, 5, 7, 8
10, 2, 9, 5, 1

RATIONALE:
Signs of true labor involve uterine and cervical changes.
Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur
throughout the pregnancy, theyre most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3-4 months in
multiparous clients.
Difference between True and False Labor Contractions
FALSE CONTRACTIONS
Begin and remain irregular.
Felt first abdominally and remain confined to the
abdomen and groin.
Often disappear with ambulation and sleep.
Do not increase in duration, frequency, or
intensity.
Do not achieve cervical dilatation.
(Pillitteri, 5th ed, pg 490)

TRUE CONTRACTIONS
Begin irregularly but become regular and
predictable.
Felt first in lower back and sweep around the
abdomen in a wave.
Continue no matter what the womans level of
activity.
Increase in duration, frequency, and intensity.
Achieve cervical dilatation.

51. One of every four labors begins with spontaneous rupture of the fetal membranes. When this occurs, the woman may feel a sudden gush of
amniotic fluid from her vagina. A 23-year-old primigravida was rushed to the RHU and tells Nurse-midwife Carmela that she believes her membranes
have ruptured. Nurse-midwife Carmela starts by obtaining her history and asks her which of the following priority questions?
A. How long since your membranes have ruptured?
B. Are you having back pains?
C. Has there been any passage of pink-tinged mucus?
D. How frequent are your contractions now?
RATIONALE:
Two risks associated with ruptured membranes are intrauterine infection and prolapse of the umbilical cord. First, the nurse should ask the client when or
how long her membranes have ruptured because the risk of perinatal infection increases with the time elapsed between membrane rupture and the onset of
contractions. In most instances, if labor has not spontaneously occurred by 24 hours after membrane rupture, labor is induced to help reduce the risks.
After determining the time of membrane rupture, the nurse should ask about the frequency of contractions and find out whether the client has back pain or
bloody show. These are signs of true labor.

(Pillitteri, 5th ed, pg 490, 514)


52. A number of immediate assessment measures are necessary to safeguard maternal and fetal health when a woman first arrives at a birthing
facility. A pregnant woman appears at the ER and complains to the nurse saying, I feel some water trickling down my legs approximately 40 minutes
ago. What action is most appropriate for the nurse to do in this situation?
A. Assess for deep tendon reflexes
B. Monitor the womans blood pressure until stable
C. Perform fern test
D. Obtain urine sample to test for protein
RATIONALE:
The pregnant woman may have ruptured her membranes. When this occurs, she may feel a sudden gush of amniotic fluid from her vagina or feeling as if
she has lost bladder control. To assess for rupture of membranes, either a vaginal examination using a sterile speculum or a fern test is performed. Fern test
is the examination of dried vaginal secretions under a microscope, showing a fern pattern due to its high estrogen content; whereas urine will not.
Taking the womans BP and testing for protein in the urine are more appropriate actions for patients with preeclampsia and eclampsia where there is usually
an elevated BP and positive protein in the urine. Assessing for DTRs is suited for pregnant women with eclampsia taking magnesium sulfate since it may
cause decreased or absent DTRs.
(Pillitteri, 5th ed, pg 428-430, 514)
53. Care during the first stage of labor centers on helping the woman feel confident in her ability to control the pain and progress of labor and
maintain physiologic stability. Nurse Rhodora is caring for a multigravida woman who is moving into the active phase of labor. Nurse Rhodora
correctly includes which of the following as the priority of care?
A. Administer analgesics as prescribed.
B. Offer support by reviewing the short-pant form of breathing.
C. Allow the mother to walk around the unit.
D. Monitor for rupture of membranes.
RATIONALE:
Active phase can be a difficult time for a woman because contractions go so strong, last longer, and begin to cause discomfort. By helping the client use the
pant form of breathing, the nurse can help the client manage her contractions and reduce the need for opioids and other forms of pain relief, which can have
an effect on fetal outcome. Breathing techniques are advantageous because they help to relax a womans abdomen and serve as effective distraction
techniques.
In the active phase, the mother is most likely too uncomfortable to walk around the unit. The nurse will observe for rupture of membranes and may
administer analgesia but these dont take priority.
(Pillitteri, 5th ed, pg 505, 547)
STAGES OF LABOR AND DELIVERY:
FIRST STAGE
1. LATENT PHASE

Encourage participation

Assist
with
comfort
measures

Keep
informed
of
progress

Offer fluids and ice chips

Encourage voiding every


1-2 hours
2. ACTIVE PHASE

Effective
breathing
pattern

Promote comfort with


back
rubs,
sacral
pressure, pillow support
and position changes

Offer fluids & ice chips

Void every 1-2 hrs


3. TRANSITION PHASE

Encourage rest between


contractions

Maintain
effective
breathing pattern

Monitor FHT throughout

SECOND STAGE

Perform
assessments
every 5 minutes (fetal and
maternal)

Assist mother into a


position that promotes
comfort and assists
pushing efforts, such as
lithotomy,
semisitting,
kneeling, side-lying, or
squatting

Provide encouragement
and praise

Prepare for birth

THIRD STAGE

Assess maternal vital


signs and uterine status.

Following birth of the


placenta, uterine fundus
remains firm and is
located 2 fingerbreadths
below the umbilicus.

Examine placenta for


cotyledons
and
membranes to verify that
it is intact.

Assess
mother
for
shivering and provide
warmth.

Promote
parentalneonatal attachment.

FOURTH STAGE

Perform
maternal
assessments every 15
minutes for 1 hour, every
30 minutes for 1 hour,
and hourly for 2 hours.

Provide warm blankets.

Apply ice packs to the


perineum.

Massage the uterus if


needed and teach the
mother to massage the
uterus.

Provide
breast-feeding
support as needed.

labor
Assess for rupture of
amniotic fluid and its
color.

54. Wide variation exists among individuals in their patterns of labor contractions and in maternal responses to labor and birth. Certain signs,
however, indicate that the course of events is deviating too far from normal. Mrs. Tarantina, 35 years old, is on active phase of labor with her
second child. She has been having a long and hard labor for almost 18 hours now. As the nurse caring for Mrs. Tarantina, you will watch out for none of
the following danger signs, except:
A. Pulse rate of 90 bpm and BP of 140/70 mmHg
B. Uterine contractions of 80 seconds in length.
C. 4cm cervical dilatation
D. Respiratory rate of 28 breaths per minute
RATIONALE:
As a rule, uterine contractions lasting longer than 70 seconds should be reported, because contractions of this length may begin to compromise fetal wellbeing by interfering with adequate uterine artery filling.
Option A- With increased cardiac output caused by contractions, systolic blood pressure rises an average 15mmHg with each contraction. Higher
increases more than 140 mmHg systolic could be a sign of pathology.
Option C- During active phase of labor, cervical dilatation increases from 4-7cm. contractions last 40-60 seconds every 3-5 minutes.
Option D- Labor involves strenuous work and effort which mandates a response from the cardiovascular system. Whenever there is an increase
in cardiovascular parameters, the body responds by increasing the respiratory rate to supply additional oxygen.
(Pillitteri, 5th ed, pg 510)
55. Although most danger signs of pregnancy occur toward the end, women need to know about them from the beginning. Mrs. Williams is
currently in her third trimester of pregnancy. She rushed to the ER for some discomforts. Initial client assessment includes the following: BP of
162/114mmHg, pulse of 88bpm, reflexes +3 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these
findings, the nurse would expect Mrs. Williams to have which of the following complaints?
A. Headache, blurred vision, and facial swelling
B. Abdomina pain, urinary frequency, and pedal edema
C. Diaphoresis, nystagmus, and dizziness
D. Lethargy, chest pains, and shortness of breath
RATIONALE:
The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most preeclamptic patients have edema. Headache and blurred
vision are indications of the effects of the hypertension.
Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of
preeclampsia.
Danger Signs of Pregnancy:
Vaginal bleeding
Persistent vomiting
Chills and fever
Sudden escape of clear fluid from vagina
Abdominal or chest oain
Pregnancy induced hypertension
Increase or decrease in fetal movement
(Pillitteri, 5th ed, pg 286- 287)
56. All children pass through predictable stages of growth and development as they mature. Understanding the stage of development a child
has reached is important because parents will often ask what to expect from their child based on his or her developmental progress. At the
age of 4 months, Baby Lala can already begin to have the ability to bring the thumb and fingers together. This is what you call Thumb Opposition. By
the time Baby Lala reaches the age of 10 months, which major developmental milestone is expected?
A. Able to transfer objects hand to hand
B. Able to hold their hands in fists so tightly
C. Able to hold a cup and spoon well
D. Able to pick up small objects such as seeds or cereals
RATIONALE:

Fine motor development is measured by observing or testing prehensile ability (ability to coordinate hand movements). A 1 month old child is able to hold
their hands in fists tightly, this is called grasp reflex. By the time the child reaches the age of 4 months, they will be able to do thumb opposition which is their
ability to bring the thumb and fingers together. They tend to pick up things in a scooping motion rather than picking them up one by one. By the time they
reach the age of 7 months, they will be able to transfer objects hand to hand. The major milestone happens during the 10 th month of age when the child
begins to pick up small objects one by one, no matter how small it is. This is called the PINCER grasp.
57. The first baby tooth (typically a central incisor) usually erupts at age 6 months, followed by a new one monthly. However, teething patterns
can vary greatly among children. While the lecture was ongoing about teething discomforts, Mother Victoria, one of the participants, was anxious
because her 5 month old daughter, Baby Tiffany, have been crying these past few weeks. Shes thinking that her daughter might already be at her
teething stage. Just to make sure, she asked the nurse lecturer about the possible signs and symptoms that can be identified when a child has reached
this stage. The nurse correctly enumerated the probable indicators of teeth eruption in an infant which includes all of the following, except:
A. Red swollen gums or a visible bump in the gums
B. Chewing or biting
C. Loss of appetite
D. Fever
RATIONALE:
Teething refers to time the tooth is breaking through the skin. During this time your baby's gums may become red, shiny and swollen. If you touch your
baby's gums with your finger you can feel the hard point of the tooth underneath. On average, the first tooth generally appears around the age of 6
months; however, this can vary. Some babies show NO signs of discomfort while teething and others may appear to be bothered by each one of their 20
baby teeth as they come through. Apart from being able to SEE or FEEL the tooth, it's possible that ALL other symptoms, commonly thought to be signs of
teething, may be due to OTHER REASONS. The following are the possible Signs and symptoms:
Red swollen gums or a visible bump in the gums (are the ONLY reliable signs).
Pain or discomfort in the mouth.
Irritable or clingy behavior.
Pulling ears.
Wakefulness.
Slightly raised temperature (a fever is NOT a sign of teething).
Flushed cheeks.
Drooling/dribbling.
Chewing or biting.
Coughing due to excessive saliva.
Chin or facial rashes.
Loss of appetite.
Feeding difficulties.
58. Toilet training is one of the biggest tasks the toddler must achieve. There are many theories concerning, and understanding the procedure
thus becomes one of the biggest tasks of this period for parents. Most first-time parents ask when to start, when the training should be
completed, and how to go about it. The mother of a 1-year-old wants to know when she should begin toilet training her child. The nurses response is
based on the knowledge that sufficient sphincter control for toilet training is present by:
A. 1215 months of age
B. 1824 months of age
C. 2630 months of age
D. 3236 months of age
RATIONALE:
OPTION B: Children ages 1824 months normally have sufficient sphincter control necessary for toilet training.
OPTION A is incorrect because the child is not developmentally capable of toilet training.
OPTIONS C and D are incorrect choices because toilet training should already be established.
Toilet training is an individualized task for each child. It should begin and completed according to a childs ability to accomplish it, not according to a set
schedule. Before children can begin to be toilet trained, they must have reached three important developmental levels, one physiologic and the other two
cognitive:
1. They must have control of rectal and urethral sphincters.
Because physiologic development is cephalocaudal, the rectal and urethral sphincters are not mature enough for control in most children
until at least the end of the first year, when tracts of the spinal cord are myelinated to the anal level. A good way for a parent to know that a
childs development has reached this point is to wait until the child can walk well independently.
2. They must have a cognitive understanding of what it means to hold urine and stools until thay release them at a certain place and time.
The markers of readiness are subtle, but as a rule children are ready for toilet training not only when they can understand what their parents
want them to do but also when they begin to be uncomfortable in wet diapers. They demonstrate this by pulling or tugging at soiled diapers;
they may bring a parent a clean diaper after they have soiled so that they can be changed.
3. They must have a desire to delay immediate gratification for a more socially accepted action.
Reference: Pillitteri, Adele, Maternal and Child Health Nursing, 2003, vol.2, pp. 842-843

59. Accidents are the major cause of death in children of all ages. Mr. and Mrs. Smith came to the well-baby clinic to have a check-up for Essel, their
18-month-old child. Nurse Chelsea is teaching the parents about accident prevention for their child. Nurse Chelsea does not need further instruction if
she says which of the following?
A. Secure that the toddler always wear a seat belt when riding a car.
B. Make sure all medications are kept in containers with childproof safety caps.
C. Never leave a toddler unattended on a bed.
D. Teach rules of the road for bicycle safety.
RATIONALE:
Accidental ingestions (poisoning) are the type of accident that occurs most frequently in toddlers. All medications should have childproof safety caps.
Poisoning accidents are common in toddlers owing to the toddlers curiosity and his increasing mobility and ability to climb. Urge parents to childproof their
house by putting all poisonous products, drugs, and small objects out of reach by the time their infant is crawling, and certainly by the time they are walking.
Option A- When riding a car, a toddler should be strapped into a car seat. Until children weigh 40-60 lbs, they need a toddler-size car seat for
safety in automobiles. Wearing a seat belt is an appropriate guideline for a school-age child.
Option C- Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and
off of beds and other furniture by themselves.
Option D- Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers shouldnt be allowed
in the road unsupervised because they do not have judgment concerning moving cars.
(Pillitteri, 5th ed, pg 868)
60. Children during the preschool age become acutely aware of the difference between boys and girls, possibly because it is a normal
progression or development, possibly because this may be the first time in their loves they are exposed to the genitalia of the opposite sex.
Mrs. Cullen is concerned about her 4-year-old son, Colton, who started to masturbate while watching television. This made her upset so she went to
consult Nurse Gigi. Nurse Gigi is correct if she advises Mrs. Cullen to do which among the following?
A. Give Colton timeout.
B. Dont allow Colton to watch TV.
C. Schedule a Psychiatric consultation and counseling for Colton.
D. Remind Colton that some activities are private.
RATIONALE:
Masturbation is normal for preschool children as they learn more about their bodies. It is common for preschoolers to engage in masturbation while watching
TV or being read to or before they fall asleep at night. The frequency of this may increase under stress. If observing the child doing this bothers the parents,
suggest they explain that certain things are done in some places but not in others. Children can relate to this kind of direction without feeling inhibited, just as
they can accept the fact that they use a bathroom in private or eat only at the table.
Calling unnecessary attention to the act can increase anxiety and cause increased not decreased, activity.
(Pillitteri, 5th ed, 902)
61. Preschool is often the time when a new sibling is born. Good preparation for this is necessary to prevent intense sibling rivalry. Karmin, 3
years old, needs to change to a new bed because her baby sister will need her old crib. What measure will you suggest that her parents take to help
decrease sibling rivalry between Karmin and her new sister?
A. Move her to the new bed before the baby arrives.
B. Ask her to get her crib ready for the new baby.
C. Tell her she will have to share it with the baby.
D. Explain that new sisters grow up to become best friends.
RATIONALE:
A bed to a preschool child is security, consistency, and home. If a preschooler has been sleeping in a crib that is to be used for the baby, it is usually best if
he or she is moved to a bed about 3 months in advance of the birth. The parents may explain that the preschooler may be too grown up for the crib rather
than state that her baby sister will use the old bed. Stating the latter is a direct route to sibling rivalry and jealousy. Assure the preschooler that she is not
being replaced.
(Pillitteri, 5th ed, pg 901)

62. Parents of school-age children often mention behavioral issues or conflicts during yearly health visits. Some parents feel they are
losing contact with their children during these years. This can cause them to misinterpret a normal change in behavior, especially if
they are not prepared for what to expect from their child. A mother tells the nurse that her daughter has become quite a collector, filling her
room with Beanie babies, dolls, and stuffed animals. The nurse recognizes that the child is developing:
A. Object permanence
B. Post-conventional thinking
C. Concrete operational thinking
D. Pre-operational thinking

RATIONALE:
OPTION C: As the school-age child develops concrete operational thinking, he/she learns several new concepts; one of these is the concept of
Class Inclusion.
Class Inclusion is the ability to understand that objects can belong to more than one classification. The school-age child can categorize
items in many ways (e.g., stones and shell can be differentiated by shapes, sizes, and textures). The ability to classify objects leads to the
collecting activities of the school-age period; they become more selective and discriminating in their collections.
OPTION A: refers to the cognitive development of the infant;
OPTION B: refers to moral, not cognitive, development;
OPTION D: refers to the cognitive development of the toddler and preschool child.
Reference: Pillitteri, Adele, Maternal and Child Health Nursing, 2003, pp.884-885.
KOHLBERGs DEVELOPMENT OF MORAL REASONING
LEVEL 1
PRECONVENTIONAL
Common from 4-10 years
STAGE 1
Punishment and Obedience Orientation
- reflexes cause actions
- behavior is motivated by fear of punishment
I must follow the rules otherwise I will be punished
LEVEL 2
Common from age 10-13
years and into adulthood

LEVEL 3
Can occur from
adolescence onwards

CONVENTIONAL LEVEL
STAGE 3
Good Boy Nice Girl Orientation
- seeks good relations and approval of family group;
orientation to interpersonal relations of mutuality
- behavior motivated by expectations of others;
strong desire for approval and acceptance
I must follow the rules so I will be accepted
POST-CONVENTIONAL LEVEL
STAGE 5
Social Contract Orientation
- concerned with individual rights and legal contract;
social contract; utilitarian lawmaking perspective
- behavior is motivated by respect for universal laws
and moral principles; guided by internal set of
values
I must follow rules as there are reasonable laws for
it.

STAGE 2
Instrumental Relativist Orientation
- Conforms to obtain rewards or favors
- Behavior is motivated by egocentrisms and
concern for self.
I must follow the rules for the reward and favor it
gives.
STAGE 4
Society Maintaining Orientation
- obedience to law and order and society;
maintenance of social order shows respect for
authority (motivation of behavior)
I must follow rules so there is order in the society.
STAGE 6
Universal Ethical Principle Orientation
- higher law and conscience orientation
- orientation to internal decisions of conscience but
without clear rationale or universal principles
- behavior is motivated by internalized principles of
honor, justice and respect for human dignity;
guided by the conscience.
I must follow rules because my conscience tells
me.

63. The developmental milestones of the toddler years are less numerous but no less dramatic than those of the infant year, because this
is a period of slow and steady, not sudden growth. Cara takes pride in new accomplishments and wants to do everything independently. Mother
Belle tells the Nurse that she has problems with regard to Carlas frequent replies of NO! The nurse explained to Mother Belle that this is normal for
her age and that there is nothing to worry about. With this situation, what do you think is the developmental task of Carla based on Eriksons
Psychosocial theory?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
C. Industry vs. inferiority
D. Autonomy vs. Shame and Doubt
RATIONALE:
The situation above illustrates a child under Autonomy Vs. Shame and Doubt stage of childhood. Toddlers under this stage are self-governing or
independent. If parents recognize toddlers need to do what they are capable of doing, are their own pace and in their own time, then children develop a
sense of being able to control their muscles and impulses during this time. Trust vs. Mistrust is seen in infants where he or she learns to love and be loved.
Erikson defines the developmental task of the preschool period as learning Initiative vs. Guilt. Learning initiative is learning how to do things. Industry vs.
Inferiority or accomplishment rather than inferiority is viewed by Erikson as a developmental task of the school-age period. During school-age, children
learn how to do things well.
Discomforts during the childhood years sometimes can be inevitable because some of them are parts of growing up. It can be a physical discomfort or it can
be psychological. Both can be distressing to the child. Dissatisfaction, irritation, and fear are some of the common causes of childhood discomfort. A

Mothers class was held in the Barangay Kinaykay Health Station with the topic about the common causes of Children Discomforts. The participants also
brought with them their children.
64. Attachment and trust are the key developmental issues of infancy and the infant-career dyad is pivotal. The physical examination of a

young infant (less than 5 months of age) is relatively straightforward and can usually proceed in a cephalocaudal manner. The
examination of older infants will require flexibility in the examination sequence. During their break time from the program, one mother
approached a student inside the Barangay Health Station and asked if its alright to have her take the vital signs of her child. So the student nurse took
her paraphernalia. She is aware that children are very much fearful when it comes to taking their vital signs so she must take into consideration the
proper arrangement on gathering data. Arrange the following in an order that would be less traumatic to the child.
1. Blood Pressure
2. Temperature
3. Respiratory rate
4. Heart rate
A.
B.
C.
D.

3, 4, 2, 1
3, 4, 1, 2
3, 1, 4, 2
3, 2, 4, 1

RATIONALE:
In taking the vital signs of a child, it should be arranged in a manner that would be less stressful. It should be arranged from the least invasive procedure to
the most invasive. The following is the correct arrangement on gathering the Vital Signs of a child:
1. Respiratory rate- Should be taken first. Besides it being the least invasive of all the procedure, it is one of the most easily disturbed vital sign when
the child begins to cry.
2. Heart rate- is the next in line. It is also easily interrupted.
3. Temperature- temperature taking is considered by a child as invasive and should be measured second to the last. So even if the child cries, the
temperature will not be that affected.
4. Blood pressure- is the most invasive of all the procedure and must be taken last so that the duration of the childs stress would not be lengthened.
Taking it earlier than the other vital signs would lengthen the stress duration of the child thus exhausting him.
65. Children enter the school-age period with the ability to trust others and with a sense of respect for their own worth. Nurse Joelle has been a
school nurse for three years now. She is assessing appropriate development among the grade school pupils. Which of the following types of play will
she expect from grade school pupils?
A. They enjoy playing by themselves.
B. They play alongside, but do not share toys.
C. They play by the rules and with leadership.
D. They abide by rules that will either make them winners or losers.
RATIONALE:
PLAYS APPROPRIATE FOR AGE:
Infants: Solitary Play- self is the interest of activities. (Option A)
Toddlers: Parallel Play- plays alongside, but NOT with another. (Option B)
Preschool: Associative Play- plays in random without group goal
School Age: Cooperative Play- Organized with rules and leadership (Option C)
Adolescents: Competitive Play- with win-lose type of rules (Option D)
Grade school pupils are mostly aged 7- 12 years old which puts them on the school age bracket.
(ULG by Balita, pg 250)
66. Hypothyroidism results from suboptimal levels of thyroid hormone. Its most common cause in adults is Hashimotos disease, in which the
immune system attacks the thyroid gland. Mrs. Roosevelt, 54 years old, was diagnosed with autoimmune thyroiditis. She was rushed to the ER due
to worsening symptoms. Nurse Diego is preparing to assess Mrs. Roosevelt. She expects to find signs and symptoms of hypothyroidism which will
appear as:
1. Heat intolerance
2. Diarrhea
3. Bradycardia
4. Coarse and dry skin
5. Somnolence
6. Decreased appetite
A.
B.
C.

2,3,5 and 6
3,4,5 and 6
All except 5

D.

1, 2,3 and 4

RATIONALE:
Early symptoms of hypothyroidism are nonspecific, but extreme fatigue makes it difficult for the person to complete a full days work or participate in usual
activities. Reports of hair loss, brittle nails, and dry skin are common, and numbness and tingling of the fingers may occur. On occasion, the voice may
become husky, and the patient may complain of hoarseness. Menstrual disturbances such as menorrhagia or amenorrhea occur, in addition to loss of libido.
Severe hypothyroidism results in a subnormal temperature and pulse rate. The patient usually begins to gain weight even without an increase in food intake.
Hair thins and falls out; the face becomes expressionless and masklike. The patient often complains of being cold even in a warm environment. Speech is
slow, the tongue enlarges, and hands and feet increase in size. The patient frequently complains of constipation. Deafness may also occur.
(Brunner, 10th ed, pg 1216)
67. The primary objective in the management of hypothyroidism is to restore a normal metabolic state by replacing the missing hormone. Mrs.
Roosevelt is prescribed with Levothyroxine (Synthroid) to manage her symptoms. Before administering the drug, aside from verifying the physicians
order, there is also a need to perform which of the following:
A. Take the weight of the client
B. Advise the client to stay in bed
C. Take the temperature and respiratory rate
D. Take the BP and the pulse rate
RATIONALE:
Levothyroxine contains thyroid hormone indicated for hypothyroidism. Thyroid hormones enhance the cardiovascular effects of catecholamines which may
cause angina or cardiac dyrhythymias. It is important to check the clients cardiovascular status such as BP and pulse rate.
Any patient who has had hypothyroidism for a long period is almost certain to have elevated serum cholesterol levels, atherosclerosis, and coronary artery
disease. As long as metabolism is subnormal and the tissues, including the myocardium, require relatively little oxygen, a reduction in blood supply is
tolerated without overt symptoms of coronary artery disease. When thyroid hormone is administered, however, the oxygen demand increases, but oxygen
delivery cannot be increased unless, or until, the atherosclerosis improves. This occurs very slowly, if at all. The occurrence of angina is the signal that the
oxygen needs of the myocardium exceed its blood supply.
(Brunner, 10th ed, pg 1217)
68. Hyperthyroidism is the second most prevalent endocrine disorder, after diabetes mellitus. It results from an excessive output of thyroid
hormones caused by abnormal stimulation of the thyroid glands by circulating immunoglobulins. Rihanna was recently diagnosed with Graves
disease. She presents with weight loss, bulging eyes, warm, moist skin, apical rate of 90 bpm, and BP of 140/80. Laboratory results show increased T3
and T4. She was ordered to undergo radioactive iodine therapy the following day. The following statements are true about radioactive iodine therapy,
except:
A. The radioactive iodine is absorbed by the thyroid gland where it destroys thyroid cells.
B. It takes about a month before symptoms of hyperthyroidism subside.
C. Rihanna will receive the radioactive iodine intravenously.
D. It is a recommended treatment for the elderly.
RATIONALE:
The goal of radioactive iodine therapy is to destroy the overactive thyroid cells. The radioactive isotope of iodine is concentrated in the thyroid gland, where it
destroys thyroid cells without jeopardizing other radiosensitive tissues. The patient is instructed about what to expect with this tasteless, colorless
radioiodine, which may be administered by the radiologist. A single oral dose of the agent is administered.
Use of radioactive iodine is the most common treatment in elderly patients. After treatment with radioactive iodine, the patient is followed closely until the
euthyroid state is reached. In 3 to 4 weeks, symptoms of hyperthyroidism subside. The patient is observed for signs of thyroid storm; propranolol is useful in
controlling these symptoms.
(Brunner, 10th ed, pg 1222)
69. Treatment of hyperthyroidism is directed toward reducing thyroid hyperactivity to relieve symptoms and remove the cause of important
complications. Treatment depends on the cause of the hyperthyroidism and may require a combination of therapeutic approaches. The
physician reminds you to monitor Mrs. Castillo closely because her treatment has just started a week ago. She is very vulnerable to the effects of
medication that she is taking. Which of the following symptoms experienced by Mrs. Castillo must be reported without delay?
A. Menstrual disturbances such as menorrhagia or amenorrhea
B. Pain in the center of the chest
C. A decrease in the blood pressure
D. Abdominal pain, yellowish discoloration of skin and eyes
RATIONALE
Any patient who has had hypothyroidism for a long period is almost certain to have elevated serum cholesterol, atherosclerosis, and coronary artery disease.
As long as metabolism is subnormal and the tissues, including the myocardium, require relatively little oxygen, a reduction in blood supply is tolerated
without overt symptoms of coronary artery disease. When thyroid hormone is administered, the oxygen demand increases, but oxygen delivery cannot be
increased unless, or until, the atherosclerosis improves. This occurs very slowly, if at all. The occurrence of angina is the signal that the oxygen needs
of the myocardium exceed its blood supply. Angina or dysrhythmias can occur when thyroid replacement is initiated because thyroid hormones
enhance the cardiovascular effects of catecholamines. The nurse must also be alert for signs of angina, especially during the early phase of treatment; if
detected, it must be reported and treated at once to avoid a fatal myocardial infarction.

Menstrual disturbances are common findings in a patient with a thyroid dysfunction. Hypertension is expected rather than hypotension. Signs of liver failure
may occur in later phases of treatment. (Brunner 2010, 1257-1258)
70. Thyroidectomy was once the primary method of treating hyperthyroidism; today, surgery is reserved for special circumstances for example,
in pregnant women allergic to antithyroid drugs, patients with large goiters, or patients unable to take antithyroid agents. Nurse Taylor is
caring for a 50-year-old female client who is being discharged after undergoing a subtotal thyroidectomy. Nurse Taylor is preparing to give discharge
instructions to the client and her family. Which of the following instructions from Nurse Taylor would be a cause of concern?
1. Report signs and symptoms of hypoglycemia.
2. Take thyroid replacement medications as ordered.
3. Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, dry skin, and report these to the
physician.
4. Recognize the signs of dehydration.
5. Carry injectable dexamethasone at all times.
A.
B.
C.
D.

Only 5
All except 2
1, 3, and 5
All except 2 and 3

RATIONALE:
After the removal of the thyroid gland, the client needs to take thyroid replacement medication. The client also needs to report such changes as lethargy,
restlessness, cold sensitivity, and dry skin, which may indicate the need for higher dosage of medication.
Option 1- the thyroid gland does not regulate blood glucose levels, therefore signs and symptoms of hypoglycemia arent relevant for this client.
Option 4- Dehydration is more of a complication of diabetes insipidus
Option 5- Dexamethasone is a steroid used to diagnosis cushings syndrome. This is not relevant for the clients case.
71. Diabetes mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood resulting from defects in insulin
secretion, insulin action, or both. Seneca Crane, 43 years old, is diagnosed with diabetes mellitus type 2. His doctor advised him to manage this
through a balance of diet, exercise, frequent monitoring, and medications. Seneca went for a jogging the whole afternoon. His wife checked is blood
glucose afterwards and found it to be at the level of 45 mg/dL. You are aware that by this time, Seneca would be manifesting which signs and
symptoms?
A. Coma, anxiety, confusion, headache, and cool, moist skin
B. Kussmauls respirations, dry skin, hypotension, and bradycardia
C. Polyuria, polydipsia, hypotension, and hypernatremia
D. Polyuria, polydipsia, polyphagia, and weight loss
RATIONALE:
Signs and symptoms of hypoglycemia include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures.
In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated, resulting in a surge of epinephrine and norepinephrine.
This causes symptoms such as sweating, tremor, tachycardia, palpitation, nervousness, and hunger.
In moderate hypoglycemia, the fall in blood glucose level deprives the brain cells of needed fuel for functioning. Signs of impaired function of the CNS may
include inability to concentrate, headache, lightheadedness, confusion, memory lapses, numbness of the lips and tongue, slurred speech, impaired
coordination, emotional changes, irrational or combative behavior, double vision, and drowsiness.
In severe hypoglycemia, CNS function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia. Symptoms may
include disoriented behavior, seizures, difficulty arousing from sleep, or loss of consciousness, and coma.
Option B- are symptoms of diabetic ketoacidosis
Option C- are symptoms of diabetes insipidus
Option D- are classic signs of diabetes mellitus
(Brunner, 10th ed, pg 1179)
72. Nutrition, meal planning, and weight control are the foundation of diabetes management. The most important objectives of which are control
of total caloric intake to attain or maintain blood glucose levels. Mr. Delgado, 56 years old, is recently diagnosed with diabetes mellitus type 2.
Nurse Lara is instructing discharge instructions to him and his wife. He is wondering about the many changes this will bring to his diet. Nurse Lara
appropriately responds to Mr. Delgados concerns if she mentions which of the following?
A. It is recommended that you receive more calories from protein.
B. You better avoid alcohol starting today, Mr. Delgado.
C. You can still eat sugar-free products for as long as you want.
D. Eating raw foods is better than eating cooked ones to lower glycemic response.
RATIONALE:
One of the main goals of diet therapy in diabetes is to avoid sharp, rapid increases in blood glucose levels after food is eaten. Ways to do so are the
following:
Combining starchy foods with protein- and fat-containing foods tends to slow their absorption and lower the glycemic response.
In general, eating foods that are raw and whole results in a lower glycemic response than eating chopped, pureed, or cooked foods.
Eating whole fruit instead of drinking juice decreases the glycemic response because fiber in the fruit slows absorption.

Adding foods with sugars to the diet may produce a lower glycemic response if these foods are eaten with foods that are more slowly absorbed.
Option A- The caloric distributing currently recommended is higher in carbohydrates than in fat and protein. 50- 60% from carbohydrates, 20- 30% from fat,
and 10- 20% from protein.
Option B- Alcohol consumption may lead to excessive weight gain, hyperlipidemia, and hyperglycemia. Diabetics can still drink alcohol in moderation (one
alcoholic beverage per day for women and two per day for men). Lower-calorie or less sweet drinks (light beer, dry wine) is advised.
Option C- Foods labeled sugarless of sugar-free may still provide calories equal to those of sugar-containing products. Patients must not consider them free
foods to be eaten in unlimited quantity, because they can elevate blood glucose levels.
(Brunner, 11th ed, pg 1358)
73. SIADH is often of nonendocrine origin; for instance, the syndrome may occur in patients with bronchogenic carcinoma in which malignant
lung cells synthesize and release ADH. Nurse Lexie is caring for Benj who is diagnosed with syndrome of inappropriate antidiuretic hormone
secretion (SIADH) caused by his brain tumor. Benjs laboratory results reveal a serum sodium level of 123 mEq/L and urine specific gravity of 1.038.
Nurse Lexie is aware that which of the following health educations would help prevent complications associated with SIADH?
A. You should learn how to inject Vasopressin on yourself now Benj. Let me teach you.
B. You should restrict your sodium intake to 1 gm/day.
C. You should restrict your fluid intake to 800 mL/day.
D. You should elevate your head to 90 degrees always.
RATIONALE:
Excessive release of ADH disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free
water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day of less than a liter per
day.
Option A- Vasopression is administered to clients with diabetes insipidus, a condition in which circulating ADH is deficient.
Option B- The clients sodium is low at 125 mEq/L and, therefore, shouldnt be restricted. Clients with SIADH retain fluids and develop dilutional
hyponatremia.
Option D- Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion
worsening the clients condition.
(Brunner, 11th ed, pg 1448)
74. Diabetes insipidus is a disorder of the posterior lobe of the pituitary gland that is characterized by the deficiency of ADH. Camille, 24 years
old, was diagnosed with a pituitary tumor. She has undergone a transphenoidal hypophysectomy. The postoperative nursing orders included monitoring
for signs of complication such as diabetes insipidus. Which of the following assessment would the nurse report as a possible manifestation of this
complication?
A. Increasing urine output with specific gravity of 1.030
B. Drinking more than 5L of fluid within the shift
C. Presence of glucose in the urine
D. Diaphoresis and complaints of headache
RATIONALE:
DI is characterized by polydipsia and large volumes of dilute urine. Without the action of ADH on the distal nephron of the kidney, an enormous daily output
of very dilute, water-like urine with a specific gravity of 1.001 to 1.005 occurs. The urine contains no abnormal substances such as glucose and albumin.
Because of the intense thirst, the patient tends to drink 2 to 20 liters of fluid daily and craves cold water.
Option A- specific gravity of 1.030 indicates the urine is concentrated
Option C- there is no glucose in urine
Option D- not relevant findings to DI
(Brunner, 11th ed, pg 1447)
75. Pituitary tumors are usually benign, although their location and effects on hormone production by target organs can cause life-threatening
effects. Jelena whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary
tumor, which necessitates a transphenoidal hypophysectomy. The evening before the surgery, Nurse Justine reviews preoperative and postoperative
instructions given to Jelena earlier. Which postoperative instruction should Nurse Justine emphasize?
A. You must lie flat for 24 hours after surgery.
B. You must avoid coughing, sneezing, and blowing your nose.
C. You must report ringing in your ears immediately.
D. You will expect an incision in your nasal mucosa.
RATIONALE:
After a transphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the
surgical graft used to close the wound and to avoid increase in ICP.
Option A- the HOB must be elevated, not kept flat, to prevent tension or pressure on the suture line.
Option C- assessment of visual acuity and visual fields, not auditory assessment, is required because of the anatomic proximity of the pituitary
gland to the optic chiasm.
Option D- Incision in transphenoidal hypophysectomy is under the upper lip, not in the nasal mucosa.
(Brunner, 11th ed, pg 2189)

76. Pheochromocytoma is a tumor that is usually benign and originates from the chromaffin cells of the adrenal medulla. It may occur in any
age but its peak incidence is between 40 and 50 years of age. Pedro Russo, 45 years old, came to the ER due to headache and blurred vision. He
has a history of pheochromocytoma. Further assessment showed BP of 203/110 mmHg, diaphoresis, and PR of 111 bpm. He is admitted due to acute
hypertensive crisis. To reverse this, Nurse Gideon expects to administer which drug?
A. Phentolamine (Regitine)
B. Methyldopa (Aldomet)
C. Mannitol (Osmitrol)
D. Felodipine (Plendil)
RATIONALE:
Pheochromocytoma causes excessive production of epinephrine and norepinephrine, natural catecholamines that raise the blood pressure. Phentolamine,
an alpha-adrenergic blocking agent given by IV bolus or drip, antagonizes the bodys response to circulating epinephrine and norepinephrine, reducing blood
pressure quickly and effectively.
Option B- although methyldopa is an antihypertensive agent available in parenteral form, it isnt effective in treating hypertensive emergencies.
Option C- Mannitol, a diuretic, isnt used to treat hypertensive emergencies
Option D- Felodipine, an antihypertensive agent, is available only in extended-release tablets and therefore doesnt reduce blood pressure quickly
enough to correct hypertensive crisis.
(Brunner, 10th ed, pg 1236)
77. Cushings syndrome results from excessive adrenocortical activity. This syndrome may result from excessive administration of
corticosteroids or ACTH or from hyperplasia of the adrenal cortex. Nurse Juliet is assessing Mrs. Cruise who is diagnosed with Cushings
syndrome. Which of the following assessment findings would Nurse Juliet report to the physician immediately?
A. Pitting edema of the legs
B. An irregular pulse rate
C. BP of 150/90
D. Frequent urination
RATIONALE:
Because Cushings syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia.
Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician.
Indicators of Cushings syndrome include an increase in serum sodium and blood glucose levels and decrease in serum potassium, a reduction in the
number of blood eosinophils, and disappearance of lymphoid tissue.
Option A- Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention
Option C- hypertension is an expected manifestation of Cushings syndrome
Option D- frequent urination is not very specific to Cushings disease
(Brunner, 11th ed, pg 1480)
78. Adrenocortical insufficiency occurs when adrenal cortex function is inadequate to meet the patients need for cortical hormones.
Autoimmune or idiopathic atrophy of the adrenal glands is responsible for 80-90% of the cases. Ariana, 32 years old, has Addisons disease.
She is rushed to the ER due to extreme weakness and confusion. Further assessment findings reveal pallor, rapid weak pulse, rapid shallow
respirations, hypotension, and cyanosis. Her daughter said that she just came back from a rock climbing competition. Upon arrival of Arianas
laboratory results, Nurse Vicky would expect to find which data?
A. Low BUN
B. Sodium of 150 mEq/L
C. Blood glucose of 180 mg/dL
D. Potassium of 6 mEq/L
RATIONALE:
The patient is experiencing Addisonian crisis, a complication of Addisons disease. Physical and psychological stressors may precipitate an addisonian crisis
such as exposure to cold, overexertion, infection, and emotional distress. Signs and symptoms of addisonian crisis are often the manifestations of circulatory
shock with cyanosis. In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion (aldosterone promotes sodium reabsorption
and potassium secretion).
Option A- BUN increases as the glomerular filtration rate is reduced due to decreased circulation to kidneys
Option B- instead of hypernatremia, there is hyponatremia caused by reduced aldosterone secretion
Option C- instead of hyperglycemia, there is hypoglycemia due to reduced cortisol secretion leading to impaired glyconeogenesis and a reduction
of glycogen in the liver and muscle.
(Brunner, 11th ed, pg 1478)
79. Acute renal failure is a reversible clinical syndrome where there is a sudden and almost complete loss of kidney function over a period of
hours to days with failure to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasis. Nurse Shamcey is caring
for several clients in the medical ward. One of her patients has had scanty urine output for 8 hours now. The physician evaluated the client for renal
failure. Nurse Shamcey is aware that which of the following may trigger a renal failure of intrarenal cause?
A. Bacterial meningitis leading to septic shock
B. Benign prostatic hyperplasia
C. Angina treated with nitroglycerin

D.

CT scan with contrast media

RATIONALE:
Renal failure of intrarenal cause results from damage to the kidney, such as from nephrotoxic injury caused by contrast media, antibiotics, corticosteroids, or
bacterial toxins.
Option A- Septic shock is of prerenal cause where there is hypoperfusion of the kidneys resulting from massive vasodilation
Option B- BPH is of postrenal cause which is a result of an obstruction somewhere distal to the kidneys
Option C- Nitroglycerin causes vasodilation resulting in hypoperfusion of kidneys. It is of prerenal cause.
Major categories of ARF:
Prerenal ARF (hypoperfusion of kidney)
Hemorrhage (Option D)
GI losses
Impaired cardiac performance (MI, heart failure, cardiogenic shock)
Vasodilation (sepsis or anaphylaxis)
Intrarenal ARF (actual damage to kidney tissue)
Nephrotoxic agents (aminoglycosides, radiocontrast agents)
Prolonged renal ischemia
Infectious processes (acute pyelonephritis, AGN)
Burns and crush injuries
BT reactions
Postrenal ARF (obstruction to urine flow)
Urinary tract obstruction (calculi, tumor, BPH, blood clots)
(Brunner, 11th ed, pg 1522)
80. Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the bodys ability to maintain metabolic
and fluid and electrolyte balance fails, resulting in uremia or azotemia. Chito, a 56-year-old diabetic, has recently been treated for chronic renal
failure. He decided on a kidney transplant next month. For the meantime, he has been cleared for discharge. In providing discharge teaching, Nurse
Farah should reinforce which dietary instruction?
A. Be sure to eat meat at every meal.
B. Eat plenty of bananas.
C. Increase your carbohydrate intake.
D. Drink plenty of fluids, and use a salt substitute.
RATIONALE:
Extra carbohydrates are needed to prevent protein catabolism. Calories are supplied by carbohydrates and fat to prevent wasting. In a client with CRF,
unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as
amino acids and ammonia. Therefore, the client must limit intake of sodium, meat (high in protein), bananas (high in potassium), and fluid (failing kidneys
cant excrete fluids adequately).
Option A- Protein is restricted because urea, uric acid, and organic acidsthe breakdown products of dietary and tissue proteinsaccumulate
rapidly in the blood when there is impaired renal clearance. The allowed protein must be of high biologic value (dairy products, eggs, meats) but
not in every meal.
Option B- Dietary intervention is necessary with deterioration of renal function and includes careful regulation of protein intake, fluid intake to
balance fluid losses, sodium intake to balance sodium losses, and some restriction of potassium. At the same time, adequate caloric intake and
vitamin supplementation must be ensured.
Option D- Usually, the fluid allowance is 500 to 600 mL more than the previous days 24-hour urine output. Salt substitutes are high in potassium
and should be avoided.
(Brunner, 11th ed, pg 1530)
81. Glomerulonephritis is an inflammation of the glomerular capillaries. Acute glomerulonephritis is more common in children older than 2
years of age, but it can occur at nearly any age. Two weeks after being diagnosed with a streptococcal infection, Miranda Kerr develops fatigue,
low-grade fever, and shortness of breath. Nurse Candice auscultates bilateral crackles and observes neck vein distension. Urinalysis reveals RBCs,
WBCs, and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which
nursing action should Nurse Candice not take?
A. Provide a high-protein, low-carbohydrate diet
B. Limit fluid intake to 1L per day
C. Weigh the client daily.
D. Place the client on bed rest.
RATIONALE:
AGN is caused by group A beta hemolytic streptococcus. The primary presenting features are hematuria, oliguria, proteinuria, increased BUN and
creatinine, edema, and hypertension. Patients with circulatory overload may experience dyspnea, engorged neck veins, cardiomegaly, and pulmonary
edema.

Option A- Dietary protein is restricted when renal insufficiency and nitrogen retention (elevated BUN) develop. Sodium is restricted when the
patient has hypertension, edema, and heart failure. Carbohydrates are given liberally to provide energy and reduce the catabolism of protein.
Option B- Fluids are given according to the patients fluid losses and daily body weight. The client already has circulatory overload due to edema
so fluids must be limited to less than 1L per day.
Option C- Intake and output are carefully measured and recorded and weight measured daily.
Option D- The nurse immediately must enforce bed rest to ensure a complete recovery and help prevent complications
(Brunner, 11th ed, pg 1518)
82. Nephrolithiasis refer to stones (calculi) in the kidney. Stones are formed when substances such as calcium oxalate, calcium phosphate, and
uric acid increase. Chris Stark came to the ER due to severe left flank pain, nausea, and vomiting. Imaging studies were ordered and showed renal
calculi in his left kidney. He is scheduled to undergo extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which
instruction?
A. Take you temperature every 4 hours.
B. Increase your fluid intake to 2- 3 L per day.
C. Apply an antibacterial dressing to the incision daily.
D. Be aware that your urine will be cherry-red for 5- 7 days.
RATIONALE:
Increasing fluid intake flushes the renal calculi fragments through- and prevents obstruction of- the urinary system. Measuring temperature every 4 hours
isnt needed. Lithotripsy doesnt require an incision. Hematuria may occur for a few hours after lithotripsy but should then disappear.
ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney. After the stones are fragmented to the size of grains of sand, the
remnants of the stones are spontaneously voided. So, fluid intake must be increased. In ESWL, a high-energy amplitude of pressure, or shock wave, is
generated by the abrupt release of energy and transmitted through water and soft tissues. When the shock wave encounters a substance of different
intensity (a renal stone), a compression wave causes the surface of the stone to fragment. Repeated shock waves focused on the stone eventually reduce it
to many small pieces. These small pieces are excreted in the urine, usually without difficulty.
(Brunner, 11th ed, pg 1593)
83. Urinary incontinence is involuntary loss of urine from the bladder. Urinary incontinence affects people of all ages but is particularly common
among the elderly. A female client reports to Nurse Lance that she experiences a loss of urine when she coughs and jogs. Assessment reveals no
nocturia, burning discomfort when voiding, or urine leakage before reaching the bathroom. Nurse Lance explains to the client that this type of problem
is called:
A. Functional incontinence
B. Reflex incontinence
C. Stress incontinence
D. Overflow incontinence
RATIONALE:
Stress incontinence is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure (sneezing,
coughing, or changing position). It predominately affects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and
pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base.
Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. The patient is aware of the need to void
but is unable to reach a toilet in time. An uninhibited detrusor contraction is the precipitating factor. This can occur in a patient with neurologic
dysfunction that impairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction.
Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. This
commonly occurs in patients with spinal cord injury because they have neither neurologically mediated motor control of the detrusor nor sensory awareness
of the need to void.
Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder. Such overdistention results from the bladders inability
to empty normally, despite frequent urine loss.
Functional incontinence refers to those instances in which lower urinary tract function is intact but other factors, such as severe cognitive impairment (eg,
Alzheimers dementia), make it difficult for the patient to identify the need to void or physical impairments make it difficult or impossible for the patient to
reach the toilet in time for voiding.
(Brunner, 11th ed, pg 1579)
84. Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract (the normal urinary tract is sterile above the
urethra). UTIs are generally classified as infections involving the upper or lower urinary tract. Fergie sought admission due to painful urination,
fever and chills. Urine culture showed bacteria in the urine. She was diagnosed with UTI and started with co-trimoxazole 500 mg, TID for 7 days. Nurse
Jesse would provide which medication instruction?
A. Take the medication with food
B. Drink at least 8 glasses of fluid daily.
C. Avoid taking antacids during co-trimoxazole therapy.
D. Dont be afraid to go out in the sun.

RATIONALE:
When receiving a sulfonamide such as co-trimoxazole, the client should drink at least 8 glasses of fluid daily to maintain a urine output of at least 1,500
ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits.
For maximum absorption the client should take the drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with
the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during the therapy.
85. Patients with acute uncomplicated pyelonephritis are usually treated as outpatients if they are not dehydrated, not experiencing nausea or
vomiting, and not showing signs or symptoms of sepsis. In addition, they must be responsible and reliable to ensure that all medications are
taken as prescribed. The doctor orders co-trimoxazole (Bactrim) and phenazopyridine hydrochloride (Pyridium) for Benjamin Button. All but one of the
following are the therapeutic effects of these combination of drugs, except:
A. Pain relief and decreased WBC count.
B. Equal fluid intake an output.
C. Polyuria with a reddish stain
D. Increased complaints of bladder spasm after 20 minutes.
RATIONALE:
OPTION A: This combinations therapeutic effect includes pain relief and a decreased WBC count; phenazopyridine is an analgesic, and co-trimoxazole is
an antibiotic.
NOTE: For outpatients, a 2-week course of antibiotics is recommended because renal parenchymal disease is more difficult to eradicate than mucosal
bladder infections. After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks if evidence of a relapse is seen. A follow-up
urine culture is done 2 weeks after completion of antibiotic therapy to document clearing of the infection.
OPTION B: The drugs dont affect fluid intake and output; however, because co-trimoxazole is a sulfa preparation, the patients fluid intake should be
increased to prevent crystallization in the urine.
OPTION C: Phenazopyridine causes a reddish stain in the urine, but this effect has no therapeutic value.
OPTION D: The patients complains of bladder spasm should decrease, not increase, after administration of phenazopyridine.
86. The nurse-client relationship is the foundation on which psychiatric nursing is established. It is a relationship in which mutual learning
occurs. Nurse Dee Dee is caring for Dexter who has antisocial personality disorder. During a one-on-one interaction, Dexter talked about his past
girlfriends and suddenly puts his arm around Nurse Dee Dees shoulder. What would be the nurses most appropriate response that conveys
unconditional acceptance?
A. Dexter, I understand how you feel but this isnt right. Im going to leave now and maybe return tomorrow.
B. Dexter, stop that! Whats gotten into you? Dont even think about it. Okay?
C. Hey! I am leaving and I wont come back. You better not do this again
D. Dexter, do not place your hand on me. We are talking about your past relationships and that does not require you to touch me. Now, lets
continue.
RATIONALE:
The nurse who does not become upset or respond negatively to a clients outbursts, anger, or acting out conveys acceptance to a client. This means
avoiding judgments of the person, no matter what the behavior. In accepting inappropriate behavior, the nurse must set boundaries by being clear and firm.
This does not mean acceptance of the inappropriate behavior but acceptance of the person as worthy.
Option A- Leaving the client and threatening not to return does not convey acceptance.
Option B- Threatening the client does not convey acceptance. The nurse also fails to address the inappropriate behavior. The nurse shows anger
and is judging the client.
Option C- Leaving the client does not convey acceptance.
(Videbeck, 4th ed, pg 86)
87. One tool that is useful in learning more about oneself is the Johari window, which creates a word portrait of a person in four areas and
indicates how well that person knows himself and communicates with others. Before interacting with her clients, Nurse Johara strives to increase
her self-awareness. She creates a Johari window to discover more about herself. Nurse Johara is cognizant that all of the following are true about the
Johari window, aside from:
A. In quadrant 2, qualities are known only to others.
B. Smaller quadrant 1 means she has more insights about herself.
C. Arena is increased by group discussions.
D. Private quadrant can be reduced by self disclosure.
RATIONALE:
One tool that is useful in learning more about oneself is the Johari window, which creates a word portrait of a person in four areas and indicates how well a
person knows himself or herself and communicates with others.

Quadrant 1: Open/public self: qualities one knows about oneself and others also know

Quadrant 2: Blind/unaware self: qualities known only to others

Quadrant 3: Hidden/private self: qualities known only to oneself

Quadrant 4: Unknown: an empty quadrant to symbolize qualities as yet undiscovered by oneself or others

Larger quadrant 1 indicates that the nurse is open to others; a smaller quadrant 1 means that the nurse shares little about herself. Arena is increased by
group disclosures and soliciting feedbacks from others. Public quadrant is enlarged for better communication. Blind quadrant is reduced by dialogue. Private
quadrant is reduced by self disclosure.
(ULG by Balita, pg 114; Videbeck, 4th ed pg 88)
88. Professional boundaries limit and outline expectations for appropriate professional relationships with patients. Psychiatric Nurse Detty is
sharing her experience with the head nurse regarding violations against professional boundaries with a patient. She desires to be well-acquainted with
the topic so she asks the head nurse about this. Which of the following will the head nurse site as a nurse abiding by the principles of professional
boundaries?
A. Nurse Lara who shares the details of her divorce with the patient
B. Nurse Sara who shares how she dealt with a similar situation with the patient
C. Nurse Mara who repeatedly requests to be assigned to a patient named Tom Cruise
D. Nurse Tara who agrees to date her patient but only after discharge
RATIONALE:
Boundary crossings can threaten the integrity of the nurse-patient relationship. Nurses must gain self-awareness and insight to be able to recognize when
professional integrity is being compromised. Concerns regarding professional boundaries are commonly related to the following issues: self-disclosure, giftgiving, touch, and friendship or romantic associations.
Nurse Abbys action is acceptable since self-disclosure on the part of the nurse is only appropriate when it is judged that the information may therapeutically
benefit the patient, and not the nurse.
Certain warnings that indicate that professional boundaries of the nurse-patient relationship may be in jeopardy:
Favoring a clients care over that of another (Option C)
Keeping secrets with a client
Changing dress style for working with a particular client
Swapping client assignments to care for a particular client
Giving special attention or treatment to one client over others
Spending free time with a client
Frequently thinking about the client when away from work
Sharing personal information or work concerns with the client (Option A)
Receiving of gifts from or continued contact/ communication with the client after discharge (Option D)
(Townsend, 5th ed, pg 114-115)
89. The therapeutic interpersonal relationship is the means by which the nursing process is implemented. Through the relationship, problems
are identified and resolution is sought. Monica is a new psychiatric nurse in the unit. She understands that one of the most important tools used in
the psychiatric setting is the development of a therapeutic relationship with the client. Furthermore, Monica identifies which of the following nurses as
not accomplishing the task associated with the orientation phase of relationship development?
A. Nurse Hero who formulates a therapeutic contract with the client.
B. Nurse Xiah who interviews the client regarding his illness.
C. Nurse Micky who begins to set goals for the client.
D. Nurse Max who explores the clients feelings regarding the interaction.
RATIONALE:
The orientation phase is the introductory phase. This is where the nurse and the client become acquainted. The goal of this phase is to establish trust and
rapport and formulate contract for intervention. One of tasks is to set goals that are mutually agreeable to the nurse and client. To make this possible, goals
are set together with the client and not the nurse alone.
Tasks of the Orientation phase:

Creating an environment for the establishment of trust and rapport

Establishing a contract

Gathering assessment information to build a strong client database

Identifying the clients strengths and limitations

Formulating nursing diagnoses

Setting goals that are mutually agreeable to the nurse and client

Developing a plan of action that is realistic for meeting the established goals

Exploring feelings of both the client and nurse


(Townsend, 5th ed, pg 112)
THERAPEUTIC NURSING PROCESS
ORIENTATION PHASE
(Teach them)
Trust and Rapport
Environment (Therapeutic)
Assess clients strengths and weaknesses
Contract (therapeutic)
Help communicatie

WORKING PHASE
(Provide therapeutic Experience )
Promote positive self concept
Realistic goal setting
Organize support system
Verbalize feelings (encourage)
Implement action plan

TERMINATION PHASE
(Take Pride)
Promote self care
Recognize increasing anxiety
Increase independence
Demonstrate emotional stability
Environmental support

Develop positive coping behaviors


Evaluate the results of plan of action
90. Therapeutic communication is an interpersonal interaction between the nurse and client during which the nurse focuses on the needs of the
client to promote an effective exchange of information between them. Nurse Jesse is caring for Jessa, a schizophrenic patient who is about to be
discharged. Nearing the end of the shift, Nurse Jesse begins to initiate termination of the relationship. During this time, Jessa asks her if she would go
out on a date with him. Nurse Jesses response would be to:
A. Ask the head nurse to be transferred to another client.
B. Discuss the boundaries of the relationship with the client
C. Tell the client that such behavior is inappropriate
D. Inform the patient that the hospital policy prohibits staff to date clients
RATIONALE:
The nurse-client relationship is one with professional, not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
Also, the nurse should deal with socially unacceptable behavior nonjudgementally and matter-of-factly. This means making factual statements with no
overtones of scolding and not talking to the client as if he were a naughty child.
Asking to be transferred to another client will favor mistrust in the client, which will make it difficult for him to trust other caregivers in the future. And, in the
clients present state of mind, it is doubtful that he adheres to the rules. (Videbeck, 4th ed, p. 284-285)
91. Goals of therapeutic communication include establishing rapport, actively listening, gaining the clients perspective, exploring the clients
thoughts and feelings, and guiding the client in problem-solving. During a nurse-client interaction, Fina says to Nurse Danica, I got two to three
jobs and worked so hard just to put my husband through college, and as soon as he graduated, he left me for some girl. I hate him! In fact, I hate all
men. Theyre all the same. Nurse Danica responds empathetically by saying which of the following?
A. I see youre very angry now. This is a normal response to your loss.
B. I know youre depressed now Fina, but you will feel better in time.
C. I understand you completely. My husband divorced me too.
D. I know what you mean. Men can be so insensitive.
RATIONALE:
Empathy is the ability of the nurse to perceive the meanings and feelings of the client and communicate that understanding to her. Being able to put herself
in the clients shoes is one of the essential skills a nurse must develop. Sympathy is showing feelings of concern or compassion. This way, the nurse may
project her personal concerns onto the client, thus inhibiting the clients expression of feelings. Empathy is being objective while sympathy is being
subjective. Empathy is I see you are sadhow can I help?, while sympathy is, I feel so sorry for you.
Option B- giving false reassurance and assuming she is depressed are non-therapeutic
Option C- focusing on the nurse instead of the client is the drawback of being sympathetic.
Option D- Agreeing and making stereotyped comments is non-therapeutic
(Videbeck 5th ed, pg 85)
92. Anxiety disorders are diagnosed when anxiety no longer functions as a signal of danger or motivation for needed change but becomes
chronic and permeates major portions of the clients life, resulting in maladaptive behavior and emotional disability. Which of the following
choices would be an accurate clinical picture of a person with panic disorder?
A. Atejay was invited to a party, but just the thought of going makes her severely anxious. I might spill my food, or say something wrong in front of
everyone, she thought. She decided not to go to the party and stay at home instead.
B. Princesnel is always late for work because he repeatedly goes back to her house to make sure that her TV is unplugged. She continually misses
the bus for work because of this.
C. Lesley has stopped going to the grocery store because the last time she was there, she suddenly felt her heart pounding out of her chest and
she was running out of air. That was the fourth time that had happened in a month.
D. Adriana works on the 24th floor of an office building, but being inside the elevator makes her feel an overwhelming need to run and escape. She
climbs up and down the stairs everyday instead.
RATIONALE:
Panic disorder is characterized by recurrent, unexpected panic attacks that cause constant concern. A panic attack is the sudden onset of intense
apprehension, fearfulness or terror associated with feelings of impending doom. A person with panic disorder experiences the emotional and physiologic
responses of panic anxiety without a stimulus. Also, the memory of the panic attack coupled with the fear of having more can lead to avoidance behavior.
Choice A is an example of a person with social phobia (anxiety provoked by certain types of social performance). Choice B is OCD (Miyagi has a
compulsion that is an example of a checking ritual). Choice D is an example of a specific phobia (Akane has a situational phobia, which is fear of being in a
specific situation which in this case is being inside an elevator).
Source: Psychiatric Mental Health Nursing by Videbeck, 3rd ed., pp. 252, 255, 258, 263-264
93. Anxiety is a vague feeling of dread and apprehension; it is a response to external or internal stimuli that can have behavioral, emotional,
cognitive, and physical symptoms. Totz, a senior nursing student, has an upcoming exam the following day. He is already anxious and is cramming
through his lessons and notes. Despite this, he exhibits increased alertness and feels like he can absorb everything. You classify Totz to be in what
level of anxiety?
A. Mild
B. Moderate
C. Severe

D.

Panic

RATIONALE:
In Mild anxiety sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect himself or herself.
Mild anxiety often motivates people to make changes or to engage in goal-directed activity. For example, it helps students to focus on studying for an
examination.
In Moderate anxiety the person becomes nervous or agitated. The person can still process information, solve problems, and learn new things with
assistance from others. He or she has difficulty concentrating independently but can be redirected to the topic
As the person progresses to severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease
significantly. A person with severe anxiety has trouble thinking and reasoning. Muscles tighten and vital signs increase. The person paces; is restless,
irritable, and angry; or uses other similar emotionalpsychomotor means to release tension. In panic, the emotionalpsychomotor realm predominates with
accompanying fight, flight, or freeze responses.
(Videbeck, 4th ed, pg 243)
94. Nurses encounter anxious clients and families in a wide variety of situations. They must assess the persons anxiety level because that
determines what interventions are likely to be effective. If you are assigned to a client with a panic disorder, all of the following should be included
in your plan of care except:
A. Stay with the client during a panic attack and offer reassurance of safety and security.
B. During a panic attack, the nurse should make sure to provide a thorough explanation of the situation to the client.
C. The clients room must be kept dim and the dcor should be minimal.
D. Use a non-threatening, matter-of-fact approach when conversing with the client.
RATIONALE:
Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences. In an intensely anxious situation, the client is unable to
comprehend anything but the most elemental communication. Stay with the client and offer reassurance of safety and security. Do not leave the client in
panic anxiety alone. The client may fear for his or her life. Presence of a trusted individual provides a feeling of security and assurance of personal safety.
Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor). A stimulating environment may increase level of anxiety. Maintain a
calm, nonthreatening, matter-of-fact approach. Anxiety is contagious and may be transferred from staff to client or vice versa. Client develops a feeling of
security in the presence of a calm staff person.
Source: Essentials of Psychiatric Mental Health Nursing by Townsend, 5th ed., pp. 440-441
LEVEL OF ANXIETY
1. MILD
2. MODERATE
3. SEVERE
4. PANIC

GOAL OF NURSING MANAGEMENT


To assist client to tolerate some anxiety
To reduce anxiety by helping client understanding its cause and by identifying a way
of controlling it.
To help the client channel anxiety and lower it to a moderate or mild level.
To be supportive and protective

95. Antianxiety drugs are among the most widely prescribed medications today. A wide variety of drugs from different classifications
have been used in the treatment of anxiety and insomnia. Benzodiazepines have proved to be the most effective in relieving anxiety
and are the drugs most frequently prescribed. A newly-diagnosed patient is prescribed with chlordiazepoxide (Librium) for his anxiety. Which
of the following health education statements should be excluded by the nurse?
A. Move slowly when sitting up or standing.
B. If there are signs of early bruising or bleeding, inform the doctor immediately.
C. This drug is only for short-term use. After the prescribed period, you must immediately discontinue drug use.
D. Avoid taking the medication with alcohol or antihistamines.
RATIONALE:
Benzodiazepines can produce drug dependence, and an abrupt discontinuation of the drug could produce a withdrawal syndrome which is
potentially lethal. Discontinuing chlordiazepoxide (Librium) requires gradual tapering of dose. Sedation and dizziness are side effects of the drug,
and orthostatic hypotension could worsen these and predisposes the patient to falls. Thrombocytopenia is a common adverse reaction which must
be immediately reported. Benzodiazepines also potentiate the sedative effect of alcohol and antihistamines, so they must not be taken at the same
time.
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing ; Nursing Spectrum Drug Handbook, 2010
96. Obsessions are unwanted, intrusive persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress while
compulsions are unwanted repetitive behavior patterns or mental acts. Mrs. Damon was diagnosed with obsessive-compulsive disorder 2 months
ago. She has a habit of washing and scrubbing her hands for so many hours and counting her books in the shelf every day. Nurse Matt is aware that
the most likely reason she exhibits these behaviors is that they:
A. Relieve her anxiety
B. Reduce the probability of infection
C. Give her a feeling of control over her life
D. Increase her self-concept

RATIONALE:
OCD is characterized by obsessions and compulsions. Compulsions Unwanted repetitive behavior patterns or mental acts (e.g., praying, counting, repeating
words silently) that are intended to reduce anxiety, not to provide pleasure or gratification. They may be performed in response to an obsession or in a
stereotyped fashion. Usually, the theme of the ritual is associated with that of the obsession. The individual recognizes that the behavior is excessive or
unreasonable but, because of the feeling of relief from discomfort that it promotes, is compelled to continue the act.
(Townsend, 5th ed, pg 449)
97. OCD is diagnosed only when these thoughts, images, and impulses consume the person or he is compelled to act out the behaviors to a
point at which they interfere with personal, social, and occupational function. Mrs. Damon has just been admitted to the psychiatric unit after
being found locked in her home for two days. She has been continuously scrubbing and scrubbing her hands and kept repeating to herself, I cant miss
anything! I must get off all the germs. The initial care plan for Mrs. Damon who obsessively washes her hands would include which of the following
nursing actions?
A. Keep her bathroom locked so she cannot wash her hands all the time.
B. Structure her schedule so that she has plenty of time for washing her hands.
C. Gradually decrease time for washing her hands.
D. Explain her behavior to her, since she is probably unaware that it is maladaptive.
RATIONALE:
The goal in caring for clients with OCD aims that the client is able to maintain anxiety at a manageable level without resorting to the use of ritualistic
behavior. In the beginning of treatment (initial), allow plenty of time for rituals. To deny clients this activity may increase the anxiety and cause the client to
panic. Do not be judgmental or verbalize disapproval of behavior. Provide structured schedule of activities for client, including adequate time to for
completion of rituals to provide a feeling of security to the anxious client.
Option A- prohibiting the ritual this early in the treatment further increases anxiety
Option C- not appropriate in early treatment but effective in later treatment. The client must learn relaxation techniques first before eliminating the
rituals. Also, the client must be willing to make changes in his or her behavior before gradually reducing rituals.
Option D- The client is aware of the maladaptive behavior, but does it anyway because it can reduce her anxiety.
(Townsend, 5th ed, pg 453)
98. Posttraumatic Stress Disorder (PTSD) can occur in a person who has witnessed an extraordinarily terrifying and potentially deadly event.
After the traumatic event, the person re-experiences all or some of it through dreams or nightmares. Hidalgo, an ex-military soldier, is
diagnosed with PTSD. He experiences a nightmare during his first night in the hospital. He looks frantic and agitated. He explains to the nurse that he
was dreaming about gunfire all around and people being killed. The nurses most appropriate intervention initially is:
A. Administer alprazolam prn for anxiety.
B. Call the physician and report the incident.
C. Stay with Hidalgo and reassure him of his safety.
D. Have Hidalgo listen to a tape of relaxation exercises.
RATIONALE:
During periods of flashbacks and nightmares, the nurse must stay with the client. Offer reassurance of safety and security and that these symptoms are not
uncommon following a trauma of the magnitude he has experienced. Presence of a trusted individual may calm fears for personal safety and reassure client
that he is not going crazy.
The nurse must calm the client first before any other interventions to promote clients safety.
(Townsend, 5th ed, pg 459)

NURSING INTERVENTIONS FOR PATIENTS WITH PTSD:


1. Assign the same staff as often as possible.
2. Use a nonthreatening, matter of-fact, but friendly approach.
3. Respect clients wishes regarding interaction with individuals of opposite sex at this time (especially important if the trauma was rape).
4. Be consistent; keep all promises; convey acceptance; spend time with client.
5. Stay with client during periods of flashbacks and nightmares. Offer reassurance of safety and security and that these symptoms are not
uncommon following a trauma of the magnitude he or she has experienced.
6. Obtain accurate history from significant others about the trauma and the clients specific response.
7. Encourage the client to talk about the trauma at his or her own pace. Provide a nonthreatening, private environment, and include a significant
other if the client wishes. Acknowledge and validate clients feelings as they are expressed.
8. Discuss coping strategies used in response to the trauma, as well as those used during stressful situations in the past. Determine those that
have been most helpful, and discuss alternative strategies for the future. Include available support systems, including religious and cultural
influences. Identify maladaptive coping strategies (e.g., substance use, psychosomatic responses) and practice more adaptive coping
strategies for possible future post-trauma responses.
9. Assist the individual to try to comprehend the trauma if possible. Discuss feelings of vulnerability and the individuals place in the world
following the trauma.
99. The psychosocial theory seeks to explain why certain persons exposed to massive trauma develop PTSD and others do not. Variables
include characteristics that relate to the traumatic experience, the individual, and the recovery environment. Nurse Marie is caring for Cleto
who has PTSD. During an episode of flashback, Nurse Marie says, I know youre frightened Cleto, but youre in a safe place. Im Marie and Im here
with you. You are in the hospital. This is your room. Do you feel the chair youre sitting on? Nurse Marie is doing which of the following techniques?

A.
B.
C.
D.

Distraction
Reality orientation
Relaxation
Grounding

RATIONALE:
Grounding techniques are helpful to use with the client who is dissociating or experiencing a flashback. Grounding techniques remind the client that he or
she is in the present, is an adult, and is safe. Validating what the client is feeling during these experiences is important: I know this is frightening, but you
are safe now. In addition, the nurse can increase contact with reality and diminish the dissociative experience by helping the client focus on what he or she
is currently experiencing through the senses: Do you feel your arm on the chair? or Do you feel the watch on your wrist? The nurse repeats this
reorienting information as needed. Asking the client to look around the room encourages the client to move his or her eyes and avoid being locked in a daze
or flashback.
(Videbeck, 4th ed, pg 206)
100. Behavioral therapy focuses on teaching what anxiety is, helping the client to identify anxiety responses, teaching relaxation techniques,
setting goals, discussing methods to achieve those goals and helping the client to visualize phobic situations. Mercedes is afraid to ride
elevators and instead, resorts to climbing 26 flights of stairs just to reach her office. She decided to seek assistance from a therapist to overcome her
fear. Mercedes is exposed to images and vivid descriptions of an elevator for prolonged periods of time until it no longer produces anxiety. The
therapist using what kind of treatment modality on Mercedes?
A. Individual Psychotherapy
B. Cognitive therapy
C. Systematic desensitization
D. Implosion therapy
RATIONALE:
Implosion therapy or flooding is a kind of behavior therapy in which the client must imagine situations or participate in real-life situations that she finds
frightening for a prolonged period of time. A session is terminated until the feared object no longer produces anxiety. It is rapid and the client is confronted
with the feared object without using relaxation training.
Option A- Individual psychotherapy focuses on helping patients understand the hypothesized unconscious meaning of the anxiety, the symbolism
of the avoided situation, the need to repress impulses, and the secondary gains of the symptoms.
Option B- Cognitive therapy strives to assist the individual to reduce anxiety responses by altering cognitive distortions.
Option C- Systematic desensitization is another kind of behavior therapy where the client is gradually exposed to the phobic stimulus, either in
real or imagined situation. The individual is instructed in the art of relaxation using techniques most effective for him or her (e.g., progressive
relaxation, mental imagery, tense and relax, meditation). When the individual has mastered the relaxation technique, exposure to the phobic
stimulus is initiated.
(Townsend, 5th ed, pg 462- 464)