ANSWERS WITH RATIONALE Situation 1- As an RN, you assume responsibility for systematically assessing and planning for the needs

of your clients. You admitted Tony to the ward. 1. CORRECT ANSWER: A RATIONALE: Establishing rapport is a process of creating goodwill and trust. It can begin with a greeting (“Good morning Tony”) or a self introduction (“Good morning. I’m Tel, your new nurse”) accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. The nurse must be careful not to overdo this phase; too much superficial talk can arouse anxiety about what is to follow and may appear insincere. SOURCE: Kozier. Fundamentals of Nursing. 7th Edition p. 268 2. CORRECT ANSWER: A RATIONALE: Social data includes the home and neighborhood conditions, family relationships/ friendships, ethnic affiliation, ethnic affiliation and lifestyle (personal habits, diet, sleep/rest patterns, ADLs, recreation). Kozier. Fundamentals of Nursing.7th Edition.p. 263 Perception of illness belongs to the health history. 3. CORRECT ANSWER: A RATIONALE: Kardex provides a concise method of organizing and recording data about a client, making information readily accessible to all members of the health team. It is a series of flip cards usually kept in portable file. It is a way to ensure continuity of care from one shift to another and from one day to the next. It is a tool for Change-of-Shift-report. But endorsement is not simply reciting content of kardex. The health care need of the client is still the primary basis for endorsement. B and C- Progress notes or the Nurse’s note (SOAPIE format) is a component of Problem-oriented medical record (POMR). Data about the client are recorded and arranged according to the source of the information. The record integrates all data about the problem, gathered by the members of the health team. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. pp. 158-161 4. CORRECT ANSWER: A RATIONALE: Involving the client in care planning enhances cooperation. Participation in the determination of goals and objectives increases commitment, transforming them from stated to real goals. It also motivates the patient to assume responsibility for his own care. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.p 299 5. CORRECT ANSWER: A RATIONALE: Primary nursing is a care delivery model designed to maintain continuity of care across shifts, days or visits. The RN assumes responsibility for a caseload of clients overtime. The RN selects the clients for his/her caseload and care for the same clients during their hospitalization or stay in a health care setting. Team Nursing- this model involves the delivery of nursing care by staff of various educational preparations. An RN leads the team composed of other RN’s, and assistive personnel. The team members provide direct client care to group of clients under the direction and coordination of the RN team leader. Case-management- it is care delivery approach that coordinates and links health care services to clients and their families. This involves professional nurse assuming responsibility for client care from admission through and following discharge. Clinicians, either as individuals or as a part of collaborative groups oversee the management of case-type-based care. Functional Nursing- this care delivery model involves the division of tasks, with one nurse assuming responsibility for certain tasks while another nurse assumes responsibility for others. Nurses tend to become highly competent with the tasks that are repeatedly assigned to them. However, functional nursing is task-focused, not clientfocused. There is absence of holistic view of clients, and there is great probability that care becomes mechanical. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. pp. 15-16 Situation 2 - The professional nurse has a major responsibility for enhancing client’s capacity for self-care. 6. CORRECT ANSWER: B RATIONALE: Dorothea Orem developed the Self-Care and Self-Care deficit Theory. She defined self care as the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health and wellbeing. OPTION A: She presented the Adaptation model. She viewed each person as a unified biopsychosocial system in constant interaction with the changing environment. OPTION C: She conceptualized the Behavioral system model. According to Johnson, each person as a behavioral system is composed of seven subsystems namely: ingestive, eliminative, affiliative, aggressive, dependence, achievement, sexual and role identity behavior. OPTION D: She conceptualized the Human Caring model SOURCE: Udan Fundamentals of Nursing 2nd ed. 7. CORRECT ANSWER: A RATIONALE: Demonstration is often used with explanation, so client can learn through cognitive domain. During return demonstration it permits the clients to have hands-on experience or to personally do and explain what the teacher taught. Learning was maximized because clients were actively participating. OPTION B- Role-playing only permits affective and cognitive learning, the participants still can’t learn the skills. OPTION C- Lecture discussion- teacher controls content and pace. Learner is passive; therefore retains less information than when actively participating. OPTION D- Group dynamics- group members learn from one another, learner can obtain assistance from supportive group.

who.Aggregate of all custom. air pollution and utilization of chemicals such as pesticides. general in nature and embodying the aspirations and values of its writers and subjects. there are no future and defined burden. 11. is gravely disabled. and is an extremely controversial course of action. This is because. which focuses responsibility for health on the individual. families and communities. There are several factors in the eco-system which affect this level of functioning. his family and the community. the middle and upper income group has also very pressing health problems such as drug abuse and lifestyle diseases.7th OPTION A: Constitution of the Philippines . See also legal system. acceptable. (http://www. Efforts to train manpower have been done by the government through the National Mental health Programs. A bill of rights sets legal limits on the power of government to prevent public officials from denying liberties and rights to individuals.the menace of pollution has been growing over the years and has greatly affected the health of the people. CORRECT ANSWER: B RATIONALE: The modern concept of health refers to optimum level of individuals. The diseases today are largely man-made. poor garbage OPTION C: Laws of the land . However. but are generally based on a determination that a person is imminently dangerous to self or others. and D are the strategies used in meeting the goal of the primary health care. The hidden burden refers to the burden associated with stigma and violations of human rights and freedoms. Increase of crimes and the lack of safety in streets and and even in the homes are major concerns of society. http://www. differential treatment in various classes of society affects which they possess on the basis of their humanity. Involuntary hospitalization is synonymous with involuntary commitment or involuntary treatment. 13-15 10. people from the lower income groups tend to have proportionately greater number of illnesses and health problems than those in the higher income groups. 461 8. Oppression especially of the poor. this burden has not been efficiently measured.politics greatly influence the social climate in which people live. Socio-economic influence. this burden is difficult to quantify. Examples are safety. CORRECT ANSWER: C RATIONALE: Involuntary hospitalization is a legal procedure used to compel an individual to receive inpatient treatment for a mental health disorder against his or her will. Examples f these are communicable diseases due to poor sanitation. 13. It is generally . and other types of laws of a country applicable to everyone (including the government) within the jurisdiction of its courts. 15 Situation 3. Although obviously substantial. 67-68) 9.Fundamental and entrenched rules governing the conduct of a nation. (Community health nursing services in the department of health Philippines pp. This is a major problem throughout the world. New opportunities for preventive health care are also produced. usage. Environment. CORRECT ANSWER: B RATIONALE: Primary Health Care (PHC) characterized by partnership and empowerment of the people shall permeate as the core strategy in the effective provision of essential health services that are community based. It is usually a short document. SOURCE: Community health nursing services in the department of health Philippines pp. CORRECT ANSWER: C RATIONALE: The undefined burden of mental problems refers to the economic and social burden for families. oppression and people empowerment. or clearly needs immediate care and treatment.Mental health covers the psychosocial concerns of daily living covering the different stages of life. This is because of the lack of quantitative data and difficulties in measuring and CORRECT ANSWER: D RATIONALE: A bill of rights consists of statements of civil liberties and rights that a government may not take away from the people who live under the government's authority. capable of achieving an acceptable level of health and well-being. as many cases remain concealed and unreported. and establishing its concept.businessdictionary.wikipedia. It also recognizes the inter-relationship between health and the overall political. people from the lower income groups tend to have proportionately greater number of illnesses and health problems than those in the higher income groups. and sustainable. Community health nursing services in the department of health Philippines p. smoking. The legal justifications vary somewhat from state to state. which the community and the government can According to literatures. http://www. Heredity. These factors are: Political.businessdictionary. Fundamentals of Nursing.SOURCE: Kozier. This is because. CORRECT ANSWER: C RATIONALE: Socio-economic influence.families from the lower income groups are the ones mostly served in public health services and by the community health nurses. It is a strategy. sociocultural and economic development of society. Again. P. and structure.html 12. communities and countries. character. http://www.html OPTION B: A penal code can be defined as that portion of a state's laws that deal with defining the elements of particular crimes and specifying the punishment for each crime http://en. It includes the full participation and active involvement of the community towards the development of self-reliant people. Political jurisdictions have the power and authority to regulate the environment. statute. However. at a cost. accessible. OPTIONS A.understanding genetically influenced diseases is increased through knowledge about the nature of genetic materials and about the process by which genetic traits are transmitted.families from the lower income groups are the ones mostly served in public health services and by the community health nurses. C. the middle and upper income group has also very pressing health problems such as drug abuse and lifestyle diseases.

Nursing Research Principles and Methods. 734 17. 106 15. CORRECT ANSWER: D .” Confidential information may be revealed only when: ▪ the patient himself/herself permits such revelation as in the case of claim for hospitalization.pdf Situation 5 . 720) The expressive role of the nurse is the variable that can be manipulated (independent variable).wikipedia. ▪ the case is medico-legal which have to be reported to the local police or NBI or constabulary.Communication between patient-nurse and nurse-health team is very important 21. insurance benefits. Patient who will undergo NGT insertion is the subject of the %20Research. The Nurse expressive role is the independent variable. D. questionnaire) to identify flaws or assess time requirements. ▪ the patient is ill of communicable disease and public safety may be jeopardized. CORRECT ANSWER: C RATIONALE: Options A. Reduction of patient’s anxiety is the dependent variable.a last resort used in dealing with a person who is so ill that he/she is unable to use proper judgment or insight in deciding to refuse treatment. the variable that can be measured is the reduction of anxiety. A well-designed experimental study allows the researchers to answer a research question with a high degree of certainty because their conclusions are backed up by concrete data.air.the variable that is believed to cause or influence the dependent variable. ( Therefore. which states that “the privacy of communication and correspondence shall be inviolable except upon lawful order of the court or when public safety and order require otherwise. Reduction of patient’s anxiety is the dependent variable. 728. D. in experimental research. 720) In the above research. the manipulated (treatment) variable. the responding variable. Section 4(1) o the New Constitution. Pretest. CORRECT ANSWER: B Rationale: Independent variable. Experimental study seeks to produce definitive conclusions and measurable results. D. 7th ed. CORRECT ANSWER: B RATIONALE: If researchers have concerns about their study plan. Nursing Research Principles and Methods. among others. SOURCE: Venzon.assessment of the stability of an instrument by correlating the scores obtained on repeated administrations. SOURCE: Polit. they may undertake a pilot study. D. Professional Nursing in the Philippines. Nursing Research Principles and Methods.minddisorders. CORRECT ANSWER: B Rationale: Independent variable. pp. Option C is a responsibility of the nurse during the rehabilitation phase. C. B. (Polit. Test-retest reliability. the manipulated (treatment) variable.a document specifying what the researcher proposes to study.” 16. Experimental or “true” designs are the gold standard for research because these studies attempt to establish causal relationships between two or more factors. 19. p. or the outcome variable. Patients who will undergo NGT insertion is the subject of the study. 51. 197-198 for a complete list of the responsibilities of the nurse in the Mental Health Program of the DOH Situation 4.Quasi-experimental research projects seek to compare two groups of individuals who are thought to have similar characteristics. CORRECT ANSWER: D RATIONALE: Confidential information may also be revealed as provided for by law in Article IV.Descriptive studies are conducted to address the question of why something occurs.the trial administration of a newly developed instrument (ex. (http://en.A research was conducted on “The Effects of the Nurse Expressive Role in the Reduction of Anxiety in Patients who will undergo NGT insertion. SOURCE:http://www. CORRECT ANSWER: A Rationale: Results from experimental studies are primarily concerned with whether or not a treatment works. the explained variable. http://www.Exploratory research is a study that explores the dimensions of a phenomenon or that develops or refines hypotheses about relationships between phenomena. CORRECT ANSWER: C Rationale: The dependent variable is also known as the measured variable. 7th ed.html 14. Patient who will undergo NGT insertion is the subject of the study. expressive role of the nurse is the independent variable. 18. Proposal. in experimental research. 20.the variable that is believed to cause or influence the dependent variable. and D are all responsibilities of the nurse in mental health promotion. p.10th ed. which is a small-scale version or trail run of the major study. and ▪ given to members of the health team if information is relevant to his care.B. Please refer to Community health nursing services in the department of health Philippines pp. p. 7th ed.

Rationale: The second component of the communication process is the message itself – what is actually said or written. Fundamentals of Nursing. Reacting only to the facts are examples of inactive listening. Channel. 424) Empathy is good because it is an expression of understanding of the feelings of the client but the nurse should not be in control of the situation. it is the message that the receiver returns to the sender. CORRECT ANSWER: D Rationale: The characteristics of an effective nurse-client relationship are as follows: an intellectual and emotional bond between the nurse and the patient and is focused on the patient respects the client as an individual. the nurse uses active listening and creates an environment in which the client feels comfortable expressing feelings. example. Avoid preconceived ideas or biases about your client. 7th ed. (http://connection. Researchers might decide purposely to select subjects who are judged to be typical of the population or particularly knowledgeable about the issues under study. 26. tilting your head away from the client. 7th ed. The problem with convenience sampling is that available subjects might be atypical of the population of interest with regard to critical variables. Nursing Research Principles and Methods. 295 A . large organizations that are divided into departments. P. http://www. CORRECT ANSWER: C Rationale: Listening is the most important skill to learn and develop fully in order to collect complete and valid data from your client. Situation 6 . Effective verbal communication is essential to a client interview. respect and acceptance Source: Mastering Fundamentals of Nursing by Quiambao-Udan. ethnic and cultural factors.Purposive sampling is based on the belief that researchers’ knowledge about the population can be used to hand-pick sample members.7th Edition. Your appearance. The goal of the interview process is to elicit as much data about the client’s health status as possible. posture. (Kozier. Becoming an effective listener takes concentration and practice. SOURCE: Polit. in the first stage 10 states in the US were selected using a complex stratification procedure.his ability to participate in his care. The nurse who conducts an observational study of women delivering twins at the local hospital is also relying on a convenience sample. the body language that accompanies the words. 23. A faculty member who distributes questionnaires to nursing students in a class is using convenience sample. Kozier.pdf) Stereotyped communication is not used in a nurse-client and nurse. CORRECT ANSWER: B Rationale: For effective communication. Nonverbal communication is as important as verbal communication. Nursing Research Principles and Methods. In the second stage. CORRECT ANSWER: A Rationale: Nonverbal communication often tells others more about what a person is feeling than what is actually said. Fundamentals of Nursing. C – refers to cluster sampling. or looking blank or inattentive. classrooms within a school system. CORRECT ANSWER: C Rationale: Convenience sampling entails using the most conveniently available people as study participants. Polit. like national and local political boundaries. facial expressions.Anonymity of subjects is preserved in all types of sampling.In clinical nursing research. independent chance of being selected.p.] B. and attitude strongly influence how the client perceives the questions you ask. D. 27.p. Several types of questions and techniques to use during the interview are discussed in the following sections. 775 25.the medium used to convey the message.the you must keep an open mind. and how the message is transmitted. RNs were selected from each state. you need to maintain good eye team communication because it is non-therapeutic. Avoid crossing your arms. To listen effectively. A. The nurse should acknowledge both the positive and the negative comments made the clients. the subjects are generally clients or patients. It involves selection of every kth case from a list or group. Reacting enthusiastically is not the most effective strategy.299 .lww. To listen effectively. smile or display an open.Multistage sampling is best used with populations that are organized into groups. because nonverbal behavior is controlled less consciously than verbal behavior. 422 22. Saunders Q&A review for the NCLEX-RN Exam. Never overlook this type of communication or take it for granted. family relationships and values respects client’s confidentiality focuses on the client’s well-being based on mutual trust. sitting back. p.pdf B. appropriate facial expression. demeanor. 3rd Edition. thinking about other things. D. L. CORRECT ANSWER: D Rationale: Random sampling involves a selection process in which each element in the population has an equal. A. 157 24.refers to systematic sampling. Feedback.rpi.7th Edition. not only in random sampling. 292.refers to simple random sampling C. pp. maintain an open body position (open arms and hands and lean forward). An authoritarian approach is directive and not permissive and will not create an environment for verbal exchange from the client. It is important for the channel to be appropriate for the message and it should help make the intent of the message clearer.

CORRECT ANSWER: B Rationale: Researchers are sometimes able to study the outcomes of “natural experiment” in which a group exposed to natural or other phenomena that have important health consequences are compared with a nonexposed group. Nursing Research Principles and Methods. requiring a team of providers (sometimes called a “code team”) to rush to the specific location and begin immediate resuscitative efforts. CORRECT ANSWER: A Rationale: Recordings need to be brief as well as complete to save time in communication. Before making any entry. who are directly involved in the treatment of the patient are allowed to have free access on the client’s record. C. Observational research. Option C – all entries must be legible and easy to read to prevent interpretation errors. and ethnicity.asp?articlekey=54842&page=2 Situation 8 . 151 Options B. 35. The client is also allowed to have access on the chart with the supervision of the nurse or any of the members of the health team. The nurse should know and use only the approved list of abbreviations at the facility to avoid putting a client at potential risk.nil per os (nothing by mouth) OD.7th Edition.You consider Nurse Crys. and social status. Fundamentals of Nursing. This is essential not only for legal reasons but also for client safety.28. often involving a rigorous and controlled design.asp?articlekey=57667) DNR means Do Not Resuscitate. CORRECT ANSWER: D Rationale: Technically. informed consent is utilized. The signature includes the name and the title. Document the date and time of each recording. The client’s name and the word client are omitted. Option A – The client’s name and identifying information should be stamped or written on each page of the clinical record. Kozier. 726-729 Situation 7. Each recording on the nursing notes is signed by the nurse making it. however the longer the period of time between actual care and charting. 7th Edition. sex. Kozier. This is a specific order not to revive a patient artificially if they succumb to illness.Record management is another responsibility of the nurse 31. (http://www. 263 Informal consent is not an example of a socio-demographic variable. race. orderly reality that can be objectively studied. re nata (as needed) Positivist paradigm is the traditional paradigm iunderlying the scientific approach. Informed consent means that the participants have adequate information regarding the research. If a patient is given a DNR are capable of comprehending the information.medicinenet.7th Edition. CORRECT ANSWER: A Rationale: Prospective participants who are fully informed about the nature of the research and its potential risks and benefits are in position to make rational decisions about participating in the study. A late entry is better than no entry.oculus dextre (right eye) PRN. Such natural experiments are nonexperimental because the researcher does not intervene but simply observes the outcome of an external event or circumstance. symbols and terms that are specified by the agency.pp 341-344 33. Nursing Research Principles and Methods.studies in which data are collected by observing and recording behaviors or activities relating to phenomenon of interest. which assumes that there is fixed. 7th ed. not even a part of a study. check that it is the correct chart. enabling them to consent to or decline participation voluntarily. D. but doctors often use the term as slang for a cardiopulmonary arrest happening to a patient in a hospital or clinic. economic status. The client’s name and the word client are omitted. Recordings need to be brief as well as complete to save time in communication.medicinenet. p 341 32. often associated with quantitative research. the greater the suspicion. Option B – Be timely. p. Fundamentals of Nursing. they are not resuscitated if they are near death and no code blue is called. CORRECT ANSWER: C Rationale: NPO. Many abbreviations are used universally. 180. Fundamentals of Nursing. there's no formal definition for a “Code”. D. the speech therapist and physical therapist. 7th ed. CORRECT ANSWER: D Rationale: Use only commonly accepted abbreviations. Polit. 29. 30. pp. and have the power of free choice. Social data includes educational history. In a study. CORRECT ANSWER: C Rationale: Members of the health care team. Polit. pp. 191. and D are considered if the subjects agreed to participate in the study. CORRECT ANSWER: C Rationale: Characteristics of bureaucratic management: ♥ clear division of labor . chief nurse of your hospital a traditional and bureaucratic leader 36. not informal consent. CORRECT ANSWER: C Rationale: Demographic variables include age. Quantitative research is the investigation of phenomena that lend themselves to precise measurement and quantification. http://www.

and managing planned change. 28 . and grouping activities to meet unit goals. authority is recognized. 5th ed. The conventional term 'laissez-faire” has a lax implication. and rules. leadership style becomes less task focused and more relationship oriented. Situation 9. ♥ selection for employment and promotion based on technical competence. 26-29. SOURCE: predicts which leadership style is most appropriate in each situation based on the level of the followers’ maturity. patient care needs collaboration and team work among members of the health care team. policies. Because it is non-directed leadership. B. promotes autonomy and growth in individual workers. Leadership Roles and Management Functions in Nursing. Leadership Roles and Management Functions in Nursing. Authoritarian leadership results in well-defined group actions that are usually predictable. communicating. As people mature. 271-272. The manager who shuns or ignores an employee is exercising power through punishment. In health care setting. the organizations to which he or she belongs.Punishment or coercive power. or experience. Leadership Roles and Management Functions in Nursing. reducing frustration in the work group and giving members a feeling of security. determining a fiscal course of action. group apathy and disinterest can occur. appropriate for groups that work together fro extended periods. selfmotivation. Nursing audit is in CONTROLLING. such as motivating. C is a case manager. 5th ed. Option A. procedures. suggesting that employees are free to do whatever they want. Democratic leadership. this phase’s functions usually entail human resource management and responsibilities. delegating. so this kind of leadership style is not suitable in health care settings. 29 37. CORRECT ANSWER: A Rationale: The human relations movement began in the 1940s with attention focused on the effect individuals have on the success or failure of an organization. Productivity is usually high. thus limiting the opportunities for arbitrary behavior and personal favoritism. privileges are allotted. pp. fiscal accountability.Your head nurse participated in a 2-week seminar. legal and ethical control. Having critical knowledge allows a manager to gain power over others who need that knowledge. managing conflict.and short. objectives. This style is also called empowering or delegative. ♥ bureaucrats are not free to act in any way they please. B. Situational leadership style. as is the manager who berates or belittles an employee. Organizing includes establishing structure to carry out plans. This type of leadership is particularly effective when cooperation and coordination between groups are necessary.range projections. B is a role of patient advocate. B – refers to scientific management C – refers to bureaucratic management D – refers to laissez-faire management SOURCE: Marquis. and facilitating collaboration. 5th ed. CORRECT ANSWER: D Rationale: Expert power is gained through knowledge. p. and professional and collegial control. and autonomy are reduced. pp. B. Directing sometimes includes several staffing functions.♥ well-defined hierarchy of authority in which superiors are separated from subordinates. Reward power is obtained by the ability to grant favors or reward others with whatever they value. remuneration for work is dispensed. But it is now more constructive to talk of empowerment so that there is no connotation of losing control. This perception could be based on personal charisma. Controlling functions include performance appraisals. Positive leadership through rewards tends to develop a great deal of loyalty and devotion toward leaders. SOURCE: Marquis. 5th ed. CORRECT ANSWER: A Rationale: Laissez-faire .people may develop referent power because others perceive them as powerful. CORRECT ANSWER: D Rationale: A refers to being a change agent. determining the most appropriate type of patient care delivery. Participative decision making is only allowed in Participative Management which was introduced by Mary Parker Follet. Formulating philosophy and vision is in PLANNING. but creativity. expertise. Leadership Roles and Management Functions in Nursing.With this style. carrying out long.306-307 40. You were designated to be the officer-in-charge of your unit. Option B refers to reward power. B. ♥ a system of procedures for dealing with work situations must exist ♥ a system of rules covering the rights and duties of each position must be in place. CORRECT ANSWER: A Rationale: Planning encompasses determining unit philosophy. These are the processes of Nursing Management. In service education programs are included in DIRECTING. is based on fear of punishment if the manager’s expectations are not met. However. the laissez-faire leadership style can be frustrating. pp 50-52 39. B. executives let subordinates make their own decisions. while D basically summarized functions of a nurse manager. goals. or the people with whom he or she associates. 41. Bureaucratic rules provide systematic control of superiors over subordinates. Leadership Roles and Management Functions in Nursing. 51 38. Marquis. and promotions are awarded. 5th ed. on the basis of this hierarchy. The arsenal of rewards that a manager can dispense to get employees toward meeting organizational goals is very broad. the opposite of reward power. Option C.Referent (Charismatic) Power. the way the leader talks or acts. SOURCE: Marquis. quality control. pp.

Leadership Roles and Management Functions in Nursing. examined. are more specific and measurable than goals because they identify how and when the goal is to be accomplished. (3) the foreseeability of harm resulting from failure to meet the standard. committed against a person or property independent of a contract which renders the person who commits it liable for damages in a civil action. and That the plaintiff himself did not engage in any manner that would tend to bring about the injury. CORRECT ANSWER: D Rationale: Performance appraisal. plus the results that are expected for satisfactory job performance. Options B and C are used as resources in attaining the objectives of the unit. and acting or the non-acting of which is the proximate cause of injury to another person or his property. effective staff utilization. http://www. (2) failure to meet the standard of due is an objective regarding unit supplies/ materials E. The question was only referring to nursing unit. or problems that require students to show what they can do. B. observable or retrievable.indiana. Patient classification system (PCS) is a method of determining. 5th ed. D. p. a sound method for budget preparation and defense. CORRECT ANSWER: D Rationale: Patient classification system also known as workload management group patients according to specific characteristics that measure acuity of illness in an effort to determine both the number and mix of the staff needed to adequately care for those patients. SOURCE: Venzon.10th ed. Knowing the objectives of the unit. important that before a patient can be touched.42. exercises. operation or the management systems and procedures of a governmental or non-profit entity to assess whether the entity is achieving economy. (Marquis. and obtainable.patientclassificationsystem. Negligence refers to the commission or omission of an act. These are: That the injury was of such nature that it would not normally occur unless there was a negligent act on the part of someone. treated or subjected to medical/surgical procedures. he must have given consent to this effect. D – Mission of the hospital is so general and broad. pursuant to a duty. generally using structured and professionally adopted methodologies. you can identify what are the things that should be done and how to do it. 178 47.4427471c9d076deddeb3ffdb62108a0c/) Performance audit refers to an examination of a program. p 156 To provide safe nursing care (option D) is the only objective that speaks about patient care. They are the observable behaviors and actions which explain how the job is to be done. Marquis. CORRECT ANSWER: C Rationale: Battery is an intentional. function. (http://www. nurse Nina will assume accountability for her nursing actions.htm 43.160. however. (http://www. 45. validating. 616) Performance assessment is a measure of assessment based on authentic tasks such as activities. p 156 44. are explicit. Leadership Roles and Management Functions in Nursing. The examination is objective and appraisal of how well employees perform the duties of their job as delineated by the job description. 46. that a reasonably prudent person in the same or similar circumstance would or would not do.Professional Nursing in the Philippines. That the injury was caused by an agency within control of the defendant. Objectives. CORRECT ANSWER: D Rationale: Objectives are similar to goals in that they motivate people to a specific end and in Nursing in the Philippines. B. 5th ed. They serve as the means by which the objectives can be met. and monitoring individual patient care requirements over time. p. CORRECT ANSWER: A Rationale: Objectives are similar to goals in that they motivate people to a specific end and in addition. B. observable or retrievable.ascd.htm) Situation 10 . CORRECT ANSWER: B Rationale: The elements of professional negligence: (1) existence of a duty on the part of the person charged to use due care under is an objective for documentation/ charting F. measurable. 161 48. measurable. and obtainable. Marquis. A tort is a legal focuses on the number of nursing staff not on patient care. 5th ed. It is therefore.As a registered nurse. unconsented touching of another person. Assault is the imminent threat to harmful or offensive bodily contact.10th ed. are explicit. A valid and reliable PCS can offer organizations: a way to provide staffing flexibility. CORRECT ANSWER: B Rationale: Res ipsa Loquitor – “the thing speaks for itself Three conditions are required to establish a defendant’s negligence without proving specific conduct. (http://en. and (4) the fact that the breach of this standard resulted in an injury to the plaintiff. efficiency and effectiveness in the employment of available Performance standards provide the employee with specific performance expectations for each major Leadership Roles and Management Functions in Nursing. . SOURCE: balanced patient assignments.

(Burnard.Professional Nursing in the Philippines. and an unintended yet foreseen evil effect--is licit. 8-10 50. then one should not act at all (in that particular circumstance). 126) Justice. nonmaleficence is sometimes interpreted to imply that if one cannot do good without also causing harm. fairly. health education is the major responsibility of the duty to “do no harm” 55. p. CORRECT ANSWER: B Rationale: According to RA 9173 (The Philippine Nursing Act of 2002) Article III Section 9. (Venzon. SOURCE: Venzon.telling the truth. P. Honesty. duress. or policy made by a physician or other care-giver.Professional Nursing in the Philippines. 52. and equally.The principle of beneficence requires us.10th ed." is often considered being an outcome to the principle of beneficence. CORRECT ANSWER: C Rationale: Nonmaleficence.refers to the right to demand to be treated justly. CORRECT ANSWER: C Rationale: Parents. The distinction lies in the fact that the principle of beneficence is stated in a positive form while nonmaleficence is stated in a positive form while non maleficence is stated as an admonition in the negative form to remind health practitioners to do no involves self-determination and freedom to choose and implement one’s decision. pp. 100) Beneficence.the principle of beneficence promotes doing acts of kindness and mercy that directly benefit the patient. Professional Nursing in the Philippines. For a mentally incompetent person. http://www. Option D is an example of negligence. CORRECT ANSWER: D Rationale: Prudence. Professional Nursing in the Philippines. 49. http://www. Beneficence. decision.In RA 9173. that dictates what is best for the patient(s) without considering the patient’s own beliefs and value system and does not respect patient autonomy. (Venzon. p. 174-175 53.Powers and Duties of the Board – the Board shall supervise and regulate the practice of the nursing profession and shall have the following ( Nurses are obliged to do good.permits us to live with good sense and perspective.html#beneficence Autonomy. Nonmaleficence.10th ed.asp 54. SOURCE: Venzon.sewanee. http://www. do no harm. In this respect.ascensionhealth. Considered in its own right. involves self-determination and freedom to choose and implement one’s decision. unless a court of law orders to the contrary. constraint or coercion. 163 Option C is an example of some way the principle of nonmaleficence is similar to the principle of beneficence.being truthful.10th ed. 99) Situation 12 . p. or what will further the patient's interest.10th ed. that is. free from deceit. CORRECT ANSWER: B Rationale: Double-effect. duties and functions: issue. Beneficence.asp Justice. Professional and Ethical Issues in Nursing. Resourcefulness. or someone standing in their behalf. 99) Paternalism in the context of health care is constituted by any action. fairly. http://www. or a government. Professional Nursing in the Philippines.ascensionhealth. CORRECT ANSWER: C Rationale: As a nurse. Reliability. suspend or revoke certificates of registration for the practice of nursing.asp Veracity. P 251 Situation11. Source: Mastering Fundamentals of Nursing by Quiambao-Udan. to do good.Professional Nursing in the Philippines. and stealing. p. to implement actions that benefit clients and their support persons. constraint or coercion. trustworthy and upright in one’s dealings with others as well as refraining from lying. cheating.commonly translated as "first. the consent must be taken from the parents or legal guardian.their right to decide whether or not to undergo any health care intervention – even where a refusal may result in harm or death to themselves or a fetus. other things being equal.SOURCE: Venzon. we are bound to respect the patients’ or clients’ autonomy .means doing good. pp.10th ed. CORRECT ANSWER: D Rationale: Autonomy. (Venzon.10th is dependability and involves one’s use of sound judgment based upon careful observation and an understanding of any given situation in which one is required to act. rule. . provided there is a due proportion between the intended good and the permitted evil. and involves self-determination and freedom to choose and implement one’s decision. 3rd ed. Nonmaleficence. p.The role of the Nurse is bounded by several ethico-moral responsibilities 51. free from deceit. constraint or coercion. duress. free from deceit. gives the consent to medical or surgical treatment of a An action that is good in itself that has two effects--an intended and otherwise not reasonably attainable good effect. it shares the same characteristics of beneficence considered as a middle principle.Professional Nursing in the Philippines. duress.refers to the right to demand to be treated justly.involves a person’s ability to recognize and deal promptly and effectively with difficulties or problems that arise.10th ed.ascensionhealth. 103) Autonomy. Guides one’s action of here and now.

Fundamentals of Nursing. CORRECT ANSWER: D Rationale: The best way to disseminate information to the publicis by television followed by radio.Professional Nursing in the /stem/specific/epithelial) Macrophage: A type of white blood that ingests (takes in) foreign and leukocytes into the interstitial spaces. tissues can't 61. if not all. This responsibility encompasses promotion of alleviation of suffering. clinically manifested by the characteristic inflammatory signs of swelling and pain. This marked increase in blood supply is referred to as hyperemia and is responsible for the characteristic signs of redness and heat. SOURCE: Kozier. the release of chemical mediators. Essentially epidemiology patterns depend upon these factors which influence the probability of contact between an infectious agent and a susceptible host. prevention of illness.wikipedia. This is how the DOH establish its IEC Programs other than publishing posters. lasting only a few moments.medterms. CORRECT ANSWER: A Rationale: Stress launches a sequence of events that constrict blood vessels and deprive the tissues of oxygen.You took over the nursing care of Paolo with an infected wound. Wound healing places additional demands on the body. CORRECT ANSWER: A Rationale: at the start of the first stage of inflammation. lipids. (http://cmbi. dead phagocytic cells.p. CORRECT ANSWER: B Rationale: According to Philippine Nursing Act of 2002 Article VI Section 28.Scope of Nursing. 63-64) . proteins. assistance towards a peaceful death shall be his/her obligation. or being aware.blogspot. Also. epithelial tissues contain stem cells.56. (Public health nursing in the Philippines p.asp?articlekey=4561 Platelets or thrombocytes are the cell fragments circulating in the blood that are involved in the cellular mechanisms of primary hemostasis leading to the formation of blood clots http://en. constriction of the blood vessels occurs at the site of (http://www. .p 285) The by-laws of the PNA is about the guiding rules of or the principles by which the PNA must operate or function. Green defined health education as “any combination of learning experience designed to facilitate voluntary adoptions of behaviors conducive to health. A change in any of the component will alter an existing equilibrium to increase or decrease the frequency of the disease. and restoration of health. http://www. Oxygen activates the inflammatory cells of the immune system that help healing. CORRECT ANSWER: A Rationale: Cognitive domain pertains to the mental processes of knowing. He is an accountant and asks nurse Jarred about his condition 60. wound healing is delayed. Blood brings oxygen and nourishment to the wound. However. (Venzon. Explaining the rationale for taking new medications shows that the client has understood why he/she is taking the medication. consisting of fluid that escaped from the blood vessels. Without sufficient oxygen.7th Edition.the initial constriction is rapidly followed by dilation of small blood vessels. and dead tissue cells and products that they release. http://www. They are responsible for normal tissue renewal or for regeneration following damage. Fundamentals of Nursing. Clients require a diet rich in protein. CORRECT ANSWER: D Rationale: Option D encompasses all the choices given. Malnourished clients may require time to improve their nutritional status for faster wound healing.htm) In ischemia. Options B and D . 59. CORRECT ANSWER: D Rationale: The present epidemiology approach is based on the interaction of the host. there is a restriction of blood supply. the inflammatory exudate is produced. Vitamins A and C. and the release of histasmine. families and communities.medterms. The result of this altered permeability is an outpouring of fluid. Option C – affective domain 58.10th ed. filled with neutrally-staining granules. carbohydrates. specifically a form of granulocyte. http://pinoybsn.sciencedaily.psychomotor domain. 634 63. leaflets. () The Code of Ethics for Nurses as promulgated by the BON states that the primary responsibility of the Filipino registered nurse is to preserve health at all cost. Thus more blood flows to the injured area. 862 62.It shall be the duty of the nurse to: Provide health education to individuals. when the foregoing are not Vascular permeability increase at the injured site with the dilation of the vessels in response to cell death. and brochures.asp?articlekey=4238 Neutrophil: A type of white blood cell. (Public health nursing in the Philippines pp. tiny sacs of enzymes that help the cell to kill and digest microorganisms it has engulfed by phagocytosis.7th Edition. An emerging new way to disseminate is through the internet.html Situation13. oxygen derivatives like bleach and peroxide are part of the arsenal of noxious products that these cells use to kill the bacteria in wounds. CORRECT ANSWER: D Rationale: Most. the causative agent. In the second stage of inflammation. and minerals. perceiving. 61) 57. Source:Kozier. and the environment. therefore when there is ischemia. Macrophages are key players in the immune response to foreign invaders such as infectious microorganisms.

cannot walk properly Lips-dry.7th Edition. proteins. not chapped or cracked Mouth and oral membranes-reddish pink mucous membranes Nails-firm. which are thought to irritate the nerve endings. Kozier. CORRECT ANSWER: A Rationale: SIGNS OF GOOD NUTRITION Alert. A sample of his daily diet (Option B) and foods he ate yesterday (Option C) only provides information about the types of foods eaten but not the quantities. some fat under skin Lips-smooth.or angular lesions at corners of mouth. underdeveloped. scaly.wikipedia. the nurse compares the total 24-hour fluid output measurement with the total fluid intake measurement and compares both to previous measurements. This prevents contamination of urethral meatus and vaginal orifice by microorganisms from the anus. 634) Situation 14 . poor tone. Option C is also wrong because foods served at fast food chains are high in fat. The result of this is altered permeability is an outpouring of OPTION B – decrease in fat and increase in carbohydrates is good but protein intake must be increased also because protein is essential for cell growth. including an adequate amount of water. OPTIONC. (http://en. scars. humped back Muscles-Flaccid.7th Edition. sunken chest. ice cream and cream soup are examples of full liquid. The client’s usual body weight better reflects weight change and the possibility of malnutrition. therefore option D is incorrect. the duration of the change. Offer a wide variety of foods. The nurse should describe any weight loss or gain. some of the fluid filtered in the kidneys are reabsorbed and used by the body and some are excreted through urine. Nurse Nancy attended to his needs. p. http://www. p. low-fat dairy products. Options B and C refers to the attributes of the host. Situation 15 . good color. "wasted" appearance. Kozier.As a graduate of BSN program. serotonin. moist. and cachectic Weight-overweight or underweight Posture-sagging shoulders. Porridge contains oats and rice.Option A refers to the agent. 65. 1193 67.Although the proportion of body water decreases as age increases.7th Edition. 1373-1374 OPTION A – Not all fluid intake becomes urine output. apathetic. good tone. tender. A healthy diet consist fruits and vegetables. CORRECT ANSWER: D Rationale: Accurate assessment of the client’s height. CORRECT ANSWER: D RATIONALE: the measurement and recording of all fluid intake and output (I&O) during a 24-hour period provides important data about the client’s fluid and electrolyte balance. 1201 69. Fundamentals of Nursing. and prostaglandin). These data are not reliable in determining the level of nutrition of the client. The pain is caused by the pressure of accumulating fluid on local nerve endings and the chemical mediators. Although the client’s current body weight can be compared with an ideal body weight. (Kozier. Usually this involves consuming necessary nutrients by eating the appropriate amounts from all of the food groups.Lucky is a college student who went to a clinic for check up. use front to back technique.p. the release of chemical mediators (Bradykinin. To determine whether the fluid output is proportional to fluid intake or whether there are any changes in the client’s fluid status. ink SIGNS OF POOR NUTRITION Listless. 64. such as grains. we can still measure accurately the intake and output of the patient. and usual body weight is essential. and leukocytes (white blood cells) into the interstitial spaces. and lean meat or beans. fissures.pp.pdf 66. swollen. Fundamentals of Nursing. you are expected to demonstrate basic nursing skills for safe and quality Kozier. and the release of histamine. firm. current body weight. therefore it can’t be classified as liquid. Fundamentals of Nursing. redness and swelling. CORRECT ANSWER: B RATIONALE: When performing perineal care in a female client. arms and legs straight Muscles-well developed. clinically manifested by the characteristic inflammatory signs of swelling (edema) and pain. age and body build Posture-erect. and whether the weight change was intentional or unintentional. 70. vegetables and fruits. 7th Edition. CORRECT ANSWER: D Rationale: Vascular permeability increases at the injured site with the dilation of the vessels in response to cell death. the IBW is based on healthy people and does not account for changes in the client’s body composition that accompany illness or reflect any changes in weight. Fundamentals of Nursing. responsive Weight is normal for height. CORRECT ANSWER: A RATIONALE: Maintaining a healthy diet is the practice of making choices about what to eat with the intent of improving or maintaining good health. Cleanse perineum with . CORRECT ANSWER: A RATIONALE: Gelatin is classified as a clear liquid.

nature. so it is best not to touch it. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. Wholly Compensatory. . To Rogers. • Retract the skin laterally. To seal the drug deep into the muscles and prevent permanent staining of the skin. moisture supports bacterial growth. She defined self-care as “the practice of activities that individuals initiate and perform on their own behalf in maintaining Instruct the client not to wash. the distinctive properties of the whole are significantly different from those of its parts. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan.when the nurse is expected to accomplish all the patient’s therapeutic self-care or to compensate for the patient’s inability to engage in self-care or when the patient needs continuous guidance in self-care. unitary man is an energy field in constant interaction with the environment. Situation 16 . Source: Mastering Fundamentals of Nursing by Quiambao-Udan. Rinse the area with copious amount of water to remove soap adequately and prevent irritation of the perineal area. 271 75. (5) Apply thin layer of petroleum jelly to lips to prevent drying or cracking. She focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. 296. Hold retraction of skin until the needle is withdrawn. CORRECT ANSWER: B RATIONALE: Mouth care for unconscious client: (1) Place in side-lying position to prevent aspiration. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. Theory of the Unitary Man (Martha Rogers) .advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values. bandages and ointments can affect the test results. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. (3) Use padded tongue blade to open the mouth. Faye Abdellah introduced Patient-Centered Approaches to Nursing Model.html Scratching the test site will cause an infection. pp. • Do not massage the site of injection. the distinctive properties of the whole are significantly different from those of its rub or scratch the injection site.soap/antiseptic solution. p.A significant milestone influencing the development of nursing concepts and theories was the establishment of the Journal of Nursing Research. so it will not pull when the legs move. 2. pp. Dry perineum thoroughly.htm. 360 74. p. so it is important to keep the skin clear and uncovered (long sleeves and jumpers [sweaters] can be worn) http://www.masongross. and that an adaptive mechanism appears to counteract the immunosuppressive effects of chronic irradiation. Supportive-Educative. Furthermore.tract technique)•Used for parenteral iron preparation. B. Florence Nightingale developed and described the first theory of nursing. (4) Brush teeth and gums. Dorothea Orem developed the Self-Care and self Care Deficit Theory. using toothbrush or soft sponge-ended swab. 16-19) 77. CORRECT ANSWER: D RATIONALE: Male: laterally upward over the lower abdomen to prevent penoscrotal pressure. beliefs and practices) to improve or maintain a health condition.” She conceptualized three nursing systems as follows: 1. 299) 71. CORRECT ANSWER: C RATIONALE: Self-Care Deficit Theory (Dorothea Orem) . inject the medication slowly. 73. sensation and emotion.when both nurse and patient engage in meeting self-care needs.she defined self-care as “the practice of activities that individuals initiate and perform on their own behalf in maintaining life. She identified 21 nursing problems. Several nursing theorists have published the framework for practice according to their perspective nursing theory. She asserted that human beings are more than and different from the sum of their parts. 76. CORRECT ANSWER: D RATIONALE: Martha Rogers conceptualized the Science Of Unitary Human Beings. p. Usually the test is interpreted after 30 minutes except the Mantoux test (which is checked after 24 or 48 hours). she believed that human being is characterized by the capacity for abstraction and imagery. 290) 72. language and thought.the system that requires assistance in decision making. and D all pose danger to the safety of the client. She defined nursing as service to individuals and families. Female: inner aspect of the thigh. CORRECT ANSWER: D RATIONALE: IM injection (Z. (Transcultural Nursing Model (Madeleine Leininger) . 287-288.rutgers.unitary man is an energy field in constant interaction with the environment. Only option B provides a safe environment for clients. 3. She asserted that human beings are more than and different from the sum of their parts. http://www. Notes on Nursing: What It Is. CORRECT ANSWER: B RATIONALE: Options A. Include the inner thigh. health and well-being. Bandaids. (2) Have suction apparatus readily available. The site should be kept dry. behavior control and acquisition of knowledge and skills. therefore to society. What It Is Not. health and well-being. To prevent irritation of the site and to prevent leakage into subcutaneous. Partially Compensatory. CORRECT ANSWER: A RATIONALE: It was concluded that even suberythemal doses of UV significantly reduce delayed type hypersensitivity responses to purified protein derivative.

http://www. CORRECT ANSWER: B RATIONALE: When assessing the abdomen. punishment or reward. the individual is concerned about maintaining the expectations of the family. 593) It is not necessary to wear gloves in assessing abdomen except if the patient has drainage in the abdomen. She identified 21 nursing problems. 2. children interpret these in terms of the physical consequences of their actions. our focus is the safety of the patient. namely: 1. children are responsive to cultural rules and labels good and bad. acquiring personal standards. At the second level. communication. These involve respect for other humans and belief that relationships are based on mutual trust. The goal attainment theory is based on personal and interpersonal systems. Schulman and Mekler. reproduction and mastery of human system. Accordingly Roy believed that adaptive human behavior is directed as an attempt to maintain homeostasis or integrity of the individual by conserving energy and promoting the survival.7th Edition. including interaction. draping the client and positioning. i. 90 years old who recently experienced a CVA. growth. The environment needs to be well-lighted and the equipment should be organized for use. Freud. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel motility and thus heighten bowel sounds.. and what will happen during the examination. growth and development.conceptualized the Behavioral System Model. Psychologically preparing the client is just like getting an informed consent from the client. SOURCE: Kozier. Fundamentals of Nursing. transaction. At first level called the premoral or the preconventional level. However. OPTION B: Physical preparation of the client includes emptying the bladder before the examination if it is required. the nurse performs inspection first. She contended that the person as an adaptive system. it is a rule that patient should be dealt first before the equipments. OPTION C: it is important to prepare the environment before starting the assessment. (Kozier. They believed that morality has two components. The nurse should explain when and where it will take place.she viewed each person as a unified biopsychosocial system in constant interaction with a changing environment. Identified 14 basic needs. 525-526 82.p. Fundamentals of Nursing. the aforementioned authors asserted that the theory of moral development is based on three foundations. OPTION A: in establishing priorities. . 79. the conventional level. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan.muw.believed that morality is a measure of how people treat fellow humans and that a moral child is one who strives to be kind and just. developing emphatic reactions. establishing goals. as follows: internalizing parental standards of right and wrong.pp. Virginia Henderson. therefore to society. 16-20) 80. In order to provide proper care. He focused on the reasons for the making of a decision. pp. CORRECT ANSWER: D Rationale: The nurse should give highest priority to the psychological preparation of the client. or conscience. Erickson’s theory on the development of virtues or unifying strengths of the “good man” suggests that moral development continues throughout life. Noel. Assessment is also not apart of the above theory. not on the morality of the decision itself. which they believed can be taught. She defined nursing as service to individuals and families. percussion.Adaptation Theory (Sister Callista Roy) . This is not as important as preparing the client psychologically. creating false results. pp. CORRECT ANSWER: B RATIONALE: Kohlberg suggested 3 levels of moral development. stress.7th Edition. groups or nation and sees this as a right. Sister Callista Roy. role. Furthermore. people make an effort to define valid values and principles without regard to outside authority or to the expectations of others. you need to do a physical assessment 81. The strength of the superego depends on the intensity of the child’s feelings of aggression or attachment toward the model parent rather than on the actual standards of the parent. He believed that if the conflicts of each psychosocial development stages are favorably resolved. CORRECT ANSWER: C RATIONALE: King's Goal Attainment Theory involves the nurse and the patient mutually communicating information. pp. functions as a whole through interdependence of its parts. followed by'S. She viewed each person as a unified biopsychosocial system in constant interaction with a changing environment. autonomous.Nurse Jill is in the ward and was given a patient.introduced The Nature of Nursing Model. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. and taking action to obtain goals. 17-20) 78. time and space. then an ‘ego-strength’ or virtue emerges. As nurses.htm Technical skills and environmental management skills are not mentioned in Imogene King’s Goal Attainment Theory. the person acting must be fair or Justin the sense that the person considers the rights of others without prejudice or favoritism. This is done to lessen anxiety and to gain the patient’s cooperation.introduced Patient-Centered Approaches to Nursing Model. Most people need an explanation of the physical examination. The room should be warm enough to be comfortable for the client. At this level. the intention of the person acting must be good in the sense that the goal of the act is the well-being of one or more people.presented the Adaptation Model. or principled level.believed that the mechanism for right and wrong within the individual is the superego. why is it important.e. 23-24 Situation 17 . and/or palpation. At the third level called the postconventional. He hypothesized that a child internalizes and adopts the moral standards and character or character traits of the model parent through the process of identification. Dorothy Johnson. (Source: Mastering Fundamentals of Nursing by Quiambao-Udan. CORRECT ANSWER: C RATIONALE: Faye Abdellah.

values. preferences.absent A weak.lww. or some attribute of the client. what the client will do. SOURCE: Kozier. 2. Changing the client’s position is an intervention. (http://connection. effortless breathing.pdf) OPTIONS A. for example. any part of the client. CORRECT ANSWER: D RATIONALE: Romberg's test is a neurological test that is used to assess the dorsal columns of the spinal cord. Attend to client first before the equipment. bounding 2+ . must be used. Stand close by as a precaution in order to stop the person from falling over and hurting themselves. such as administer. p. Verb. (http://en. these data should be analyzed for a nurse to formulate a nursing diagnosis. then instructs the client to stand with feet and shoulder-width apart and bend forward slowly to touch the toes.both refer to data gathered through assessment. Watch the movement of the body in relation to a perpendicular object behind the subject. Subjective data provide clues to possible physiologic. 85. desires. Breathing that is normal in rate and depth is called eupnea.weak. Assess first clients who are unstable and needing nursing care. deep. The depth of a person’s respirations can be established by watching the movement. The subject.'s_test) Option A and B refers to Forward Bend Test. It is the clinical act of identifying problems. thready pulse reflects a decreased stroke volume. personal information. as occurs with hemorrhagic shock. this is used in screening for scoliosis. or shallow.normal 1+ . such as the client’s pulse or urinary output. 5. 6. feelings. learn. (Kozier. These types of data can be elicited and verified only by the client. The verb specifies an action the client is to perform. Respiratory depth is generally described as normal. is the client. and D are all examples of objective data. show. Mastering Fundamentals of Nursing by Quiambao-Udan. CORRECT ANSWER: C RATIONALE: Diagnosing is a process which results to a diagnostic statement or nursing diagnosis.full. ideas. 4. 187 The nurse should first assess the condition of the patient before notifying the physician so that the nurse can give a clear picture of the status of the patient to the physician. 88. assessment comes first before intervention. 3. Verbs that denote directly observable behaviors. The pulse force is recorded using a three-point scale: 3+ .p. They also provide the nurse with information that may reveal a client’s risk for a problem as well as areas of strengths or the client. perceptions. Subjective data consist of: sensations or symptoms. To diagnose in nursing. Assessing the client will help the nurse decide what appropriate interventions should be done. Fundamentals of Nursing. p. 87. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. beliefs. Conditions or modifiers. thready 0 . Criterion of desired performance. Two of these are the amount of effort a client must exert to breathe and the sound of breathing. p. These criteria may specify time or speed. walk. Conditions or modifiers may be added to the verb to explain the circumstances under which behavior is to be performed. Maslow’s Heirarchy of Needs.The nursing process is an immeasurable tool used by the nurse for proper intervention. accuracy. Actual problems are usually more important than potential problems. sometimes irregular swaying and even toppling over occurs. 506 84. .7th Edition. Airway. CORRECT ANSWER: B RATIONALE: Collecting subjective data is an integral part of nursing health assessment.Place small pillows beneath the knees and the head to reduce tension in the abdominal muscles. Situation 18 . CORRECT ANSWER: A RATIONALE: Respiratory quality or character refers to those aspects of breathing that are different from normal.wikipedia. it means to analyze assessment information and derive meaning from this analysis. A positive sign is noted when a swaying. 176) OPTION A-possible health risk or potential health problem is an example of nursing diagnosis. a noun. and Circulation. or experience. CORRECT ANSWER: C RATIONALE: Goal/desired outcome statements should usually have the following components: Subject. The examiner is behind the standing client. 7. 89. Fundamentals of Nursing. CORRECT ANSWER: B RATIONALE: the force of the pulse shows the strength of the heart’s stroke volume. psychological. [1] which are essential for joint position sense (proprioception).3rd Edition. Safety of the patient always. 594) 83. The respiratory rate is normally described in breaths per minute. CORRECT ANSWER: B RATIONALE: in establishing priorities for client care these should be considered: 1. and sociologic problems. Ask the subject to stand erect with feet together and eyes closed. C. OPTIONS B and D. 7th Edition. SOURCE: Carolyn Jarvis Physical Exam and Health The Nursing Process (ADOPIE). 86.

p. CORRECT ANSWER: C RATIONALE: The nurse acts as a change agent when assisting others. 39) Anastacia Giron-Tupaz. 13 OPTION A: Communicator. such as clinical care. p. Implementation.html) 94. To be effective. nurses identify client problems and then communicate these verbally or in writing to other members of the health team. The nurse manager delegates nursing activities to ancillary workers and other nurses and supervises and evaluates their performance. To establish a time-achievement criterion. and protects the client’s rights. gives reward fairly.There are different roles of a nurse can assume in various health care setting where competency as well as knowledge is of importance.Nursing as a profession has various historical perspective and theoretical foundation that can be applied in health care is an example of a managerial role of the nurse Situation 20 . and extrapersonal in nature. 43-45 95. develops staff. Udan. clients. Performing bedside nursing care is a caregiver role. A sense of history gives you better understanding of nursing as a profession. if it is not helping a client return to health. CORRECT ANSWER: A RATIONALE: You can never provide nursing care if you don’t know what are the needs of the client. monitors operations. p. CORRECT ANSWER: C RATIONALE: Evaluation. How can you provide an effective postural drainage if you do not know where is the bulk of the patient’s secretion.distance. set standards of performance and design staff schedule. 40) Clara Barton. p. CORRECT ANSWER: A RATIONALE: the nurse manager coordinates and delegates patient care. 2nd Ed.pp. 7th Edition. SOURCE: (Mastering Fundamentals of Nursing by Quiambao-Udan.pain is less than or equal to 3 on a 0-10 pain scale 90. p.founder of the Philippine Nurses Association. healthy lifestyle. Its purpose is to carry out planned nursing interventions to help the client attain goals and achieve optimal level of health. Nurses are continually dealing with change in the age of client population. Mastering Fundamentals of Nursing. (http://pinoybsn. the nurse needs to ask “How long?” To establish an accuracy criterion. Assessment. that is. CORRECT ANSWER: D RATIONALE: In promotion of health nurses assist individuals in increasing well being and attain self-actualization. pp.html) 92. In the role of the communicator. ensures that the client’s needs are met. gives directions. OPTION B: The caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client’s dignity. immunization. 93. 13. (Mastering Fundamentals of Nursing by Quiambao-Udan. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. to make modifications in their own behavior. and represents both staff members and administration as needed. 18) . CORRECT ANSWER: C Rationale: As a client advocate. Nurses also often act to make changes in a system. and changes in medications are just a few of the changes nurses deal with daily.blogspot. pp. pp 302-303 assessing the client’s response to nursing interventions and then comparing the response to predetermined standards or outcome collecting. 91.Client Verb. SOURCE: (http://pinoybsn. She asserted that nursing is a unique profession in that it is concerned with all the variables affecting an individual’s response to stresses. Planning. SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. 31) Betty Neuman. To safely practice nursing is not a role of the nurse but a duty of the nurse. the nurse promotes what is best for the client. which are intrapersonal. involve the client and his family in planning. 96.these two are not the responsibilities of a nurse OPTION D. OPTION D: Registered nurses are bound to safely practice nursing in any health care setting and in giving care to all clients. The purpose of this is to appraise the extent to which goals and outcome criteria of nursing care have been achieved. (Mastering Fundamentals of Nursing by Quiambao-Udan.founded the American Red Cross. the best description of a care provider is the accurate and prompt determination of the client’s needs to be able to render safe and effective nursing care. Health promotion activities include exercise.proposed the Health Care System model. 175-183 Situation 19 putting the nursing care plan into action.involves determining beforehand the strategies or course of action to be taken before implementation of nursing care.upgraded the practice of nursing and made nursing an honorable profession. validating.7th Edition. self responsibility and other factors that minimize if not totally eradicate risks and threats of health. Therefore. CORRECT ANSWER: A RATIONALE: Florence Nightingale. the nurse asks “How Well?” SOURCE: Kozier. organizing and recording data about the client’s health status. The nurse plans. Kozier. Fundamentals of Nursing. Fundamentals of 10-11 OPTIONS A and B. interpersonal. (Mastering Fundamentals of Nursing by Quiambao-Udan.will state Condition. good food. and quality.

otherwise known as Republic Act 877. Act 2808 was passed. This act provided for the examination and registration of nurses in the Philippine Islands. on June 19. 1953. 137 100. Raised in England in an atmosphere of culture and affluence. The first law that had to do with the practice of nursing was contained in Act No. However. which regulated the practice of medicine. CORRECT ANSWER: B RATIONALE: Florence Nightingale was born on May 12.10th ed. CORRECT ANSWER: A RATIONALE: in 1919. provisions regarding nursing schools and colleges.10th ed. examination. registration of nurses including sundry provisions relative to the practice of nursing. P 137 99. 98. Congress enacted The Philippine Nursing Law.97. 1820 in Florence. Provisions included the organization of the Board of Examiners for nurses. it was in 1920 that the first board examination in the Philippines was given. CORRECT ANSWER: C RATIONALE: Contemporary Nursing – this covers the period after World War II to the present. 2493 of 1915.p. SOURCE: Venzon. SOURCE: Venzon. CORRECT ANSWER: A RATIONALE: In 1919. Scientific and technological developments as well as social changes mark this period. a board of examiners for nurses.Professional Nursing in the Philippines. Republic Act 877 otherwise known as The Philippine Nursing Law.Professional Nursing in the Philippines. Italy. This was known as the First True Nursing Law. . Act 2808 was passed. among others. It created. This was known as The First True Nursing Law.

Sign up to vote on this title
UsefulNot useful